Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty: An Updated Meta-Analysis of Randomized Trials

doi:10.1016/j.jacc.2013.04.025

Journal of the American College of Cardiology

Volume 62, Issue 16, 15 October 2013, Pages 1409-1418

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Objectives

This meta-analysis was designed to update data on clinical outcomes with aspiration thrombectomy or mechanical thrombectomy before primary percutaneous coronary intervention (PCI) compared with conventional primary PCI alone.

Background

The clinical efficacy of thrombectomy in acute myocardial infarction (AMI) remains uncertain.

Methods

Clinical trials that randomized AMI patients to aspiration (18 trials, n = 3,936) or mechanical thrombectomy (7 trials, n = 1,598) before PCI compared with conventional PCI alone were included.

Results

The weighted mean duration of clinical follow-up was 6 months. Aspiration thrombectomy vs. conventional primary PCI (18 trials, n=3,936): Major adverse cardiac events (MACE) (risk ratio [RR]: 0.76; 95% confidence interval [CI]: 0.63 to 0.92; p = 0.006) and all-cause mortality (RR: 0.71; 95% CI: 0.51 to 0.99; p = 0.049) were significantly reduced with aspiration thrombectomy. Beneficial trends were noted for recurrent MI (p = 0.11) and target vessel revascularization (p = 0.06). Final infarct size (p = 0.64) and ejection fraction (p = 0.32) at 1 month were similar. ST-segment resolution (STR) at 60 min (RR: 1.31; 95% CI: 1.16 to 1.48; p < 0.0001) and Thrombolysis In Myocardial Infarction blush grade (TBG) 3 post-procedure (RR: 1.37; 95% CI: 1.19 to 1.59; p < 0.0001) were both improved with aspiration thrombectomy. Mechanical thrombectomy vs. conventional primary PCI (7 trials, n = 1,598): there was no difference between the mechanical thrombectomy and conventional primary PCI arms in the incidence of MACE (RR: 1.10; 95% CI: 0.59 to 2.05; p = 0.77), mortality (p = 0.57), recurrent MI (p = 0.32), target vessel revascularization (p = 0.19), or final infarct size (p = 0.47). A benefit in STR at 60 min (RR: 1.25; 95% CI: 1.06 to 1.47; p = 0.007), but not TBG 3 (RR: 1.09; 95% CI: 0.86 to 1.38; p = 0.48) was noted.

Conclusions

Thrombectomy during AMI by manual catheter aspiration, but not mechanically, is beneficial in reducing MACE, including mortality, at 6 to 12 months compared with conventional primary PCI alone.

Key Words

meta-analysis

mortality

myocardial infarction

outcomes

thrombectomy

Abbreviations and Acronyms

creatine kinase

CMR

cardiac magnetic resonance imaging

delayed enhancement

MACE

major adverse cardiac event(s)

PCI

percutaneous coronary intervention

SPECT

single-photon emission computed tomography

STEMI

ST-segment elevation myocardial infarction

WMD

weighted mean difference

Cited by (0)

: Dr. Kumbhani has received honoraria from the American College of Cardiology and Somahlutions. Dr. Bavry has received research support from Eli Lilly and Novartis; is a consultant for Boehringer-Ingelheim; and has received honoraria from the American College of Cardiology. Dr. Bangalore serves on the advisory board for Daiichi Sankyo and Boehringer-Ingelheim. Dr. Bhatt is a member of the advisory board at Elsevier Practice Update Cardiology and Medscape Cardiology; serves on the board of directors at the Boston Veterans Affairs Research Institute and the Society of Chest Pain Centers; is Chair of the American Heart Association Get With the Guidelines Science Subcommittee; has received honoraria from the American College of Cardiology (Editor, Clinical Trials, Cardiosource), Duke Clinical Research Institute (clinical trial steering committees), Slack Publications (Chief Medical Editor, Cardiology Today Intervention), and WebMD (CME steering committees); is a Senior Associate Editor of the Journal of Invasive Cardiology; serves on the Data Monitoring Committee of the TOTAL trial; has received research grants from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, sanofi-aventis, and The Medicines Company; and participates in unfunded research with FlowCo, PLx Pharma, and Takeda. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.