Presentation on theme: "‘SMASH IT!’ Mark Mason Interventional Cardiologist Harefield Hospital"— Presentation transcript:
1 ‘SMASH IT!’ Mark Mason Interventional Cardiologist Harefield Hospital Royal Brompton and Harefield NHS Trust
2 BackgroundCoronary occlusion in AMI comprises a variable amount of thrombusEvidence suggests that the degree of thrombus burden has an influence on prognosis (JACC 2007;50:573-83)Simply balloon dilating and stenting seems counter-intuitive in this contextDo mechanical devices offer any greater thombus clearance than simple aspiration devices, and do they confer any clinical benefit?
3 ThromCat ‘Smash and suck’ type device High pressure jets ‘smash’ and internal ‘Archimedes screw’ draws in the debrisDoesn’t require large permanent console- pack contains all that’s needed (other than some saline)
4 ThromCatSafety study presented at EuroPCR demonstrating safety and efficacyNo randomised controlled trialsRelatively easy to use (I said relatively!)Good anecdotal results
5 X-Sizer ‘Suck and smash’ type device Helical cutter in tip generates a vacuum and then acts as an ‘Archimedes screw’ to break up the thrombus and draw it inAgain, no large console- all required equipment contained in disposable pack
6 X-Sizer Randomised controlled data available- X AMINE ST trial (JACC 2005;46(2):246-52):201 pts with AMI randomised to X-Sizer vs. conventional PCISignificantly higher overall ST resolution and >50% ST resolutionSignificant reduction in distal embolisationNo difference in TIMI score, myocardial blush, or 6 month event rates
7 Angiojet ‘Smash and suck’ type device Requires large permanent console with additional disposable catheters
8 AngioJet Catheter- Mechanism of Action Saline jets travel backwards at half the speed of sound to create a low pressure zone.Thrombus is drawn into the catheter where it is fragmented by the jets and evacuated from the body.
9 Angiojet Data variable- In the Angiojet group! WHY? AiMI trial (JACC 2006;48(2):244-52)Angiojet vs. conventional PCI:Higher final infarct sizeLower TIMI 3 rateHigher MACEHigher 30-day mortalityIn the Angiojet group!WHY?Patients enrolled post-angio and did not require angiographic evidence of thrombus!Clearly cannot support routine use in AMI patients
10 So what are we supposed to do? De Luca et al- meta-analysis of 21 studies involving ‘rheolytic thrombectomy’ devices, simple aspiration devices, and distal protection devices (Am Heart J 2007;153(3):343-53)Improved TIMI grade, better myocardial blush grade, reduced distal embolisation, no difference in mortalityNo evidence that use of these devices confers a survival benefit (?TAPAS)
11 Should we bother at all then? Mortality is obviously important, butit is also commonly measured because it is an easy ‘hard’ endpoint to assessThe long term impact of significant infarcts is clear to us as clinicians, butfew have the will, nor the resources, to assess the morbidity associated with such scenarios
12 Do we use them or not? All three devices appear to be safe Routine use in AMI/rescue cannot be justifiedIMHO, they remain a useful adjunct to conventional modalities in highly selected cases and may make a differenceNo evidence exists to guide the choice of device