1. Is the Debate Over? Routine Thrombus Aspiration in STEMI (From TAPAS to INFUSE-AMI to TASTE to TOTAL)
Stefan James
Professor of Cardiology
Uppsala Clinical Research Centre Uppsala University Uppsala, Sweden

2. Potential conflicts of interest
AstraZeneca Pharmaceuticals Institutional Research grants/ consultant/Honoraria
The Medicines Company Research grant/ consultant/ Honoraria
Jansen consultant/ Honoraria
Bayer consultant/ Honoraria
Thermo Fisher Consultant/ Honoraria
Swedish Research Council Research grant
Swedish Heart and Lung Foundation Research grant
Strategic Research Council Research grant

3. Impact of Macroscopic Distal Emboli
Proximal LCX filling defect at primary PCI site
Distal thromboemboli
Distal embolization occurred in 15% patients after primary PCI 
↓ ST resolution
↑ Infarct size
↑ Mortality
What is the impact of macroscopic dital embolization. Distal embolization is related to reduced myocardial reperfusion, more extensive myocardial damage and a poor prognosis. Therefore, additional pharmacological interventions and mechanical devices should be studied to prevent and treat distal embolization.
Henriques JPS et al. EHJ 2002;23:1112-7

4. Macroscopic embolic debris is retrieved in >75% of primary PCI cases
How common is distal embolization: macroscopic embolic debris as you can see in these patients is retrieved in more that 75 % of primary PCI-cases.
The concept of thrombus aspiration prior to primary PCI in STEMI is intuitive and “feels right”

5. No evidence of reduction in Infarct Size
These are results from three trials assessing infarct size in thrombus aspiration vs. Controls.
P=0.004
P=0.20
P=0.46
Rescue catheter
Export catheter
Export catheter
Kaltoft A et al.
Circ 2006;114:40-47
Sardella G et al.
JACC 2009;53:309–15
Svilaas T et al.
NEJM 2008;358; 5

6. INFUSE-AMI - Primary powered endpoint -
Median [IQR]
17.0%
[9.0, 22.8]
Median [IQR]
17.3%
[7.1, 25.5]
P=0.51
N=452
All anterior MI
Sx-hosp <4 hrs
TIMI 0-2
Infarct size, %LV
Aspiration
N=229
No aspiration
N=223
Stone GW et al. JAMA 2012;307:

7. TAPAS: 1,071 pts
30 days
4.0% vs. 2.1% P=0.07
Time (days)
Mortality (%)
Conventional PCI
Thrombus-Aspiration
100
200
300
400 2 4 6 8 10 12
1 year
7.6% vs. 4.0%
P=0.04
A large confirmatory trial is needed (small trials with unexpected large effect sizes, need to be replicated)
Vlaar et al. Lancet 2008;371:

8. All-cause mortality 1,071 pts
HR up to 1 year 0.94 (0.78 – 1.15), P=0.57
HR up to 30 days 0.94 ( ), P=0.63
N Engl J Med Oct 24;369(17):
N Engl J Med Sep 18;371(12):

9. Reinfarction Stent thrombosis TASTE, N= 7.244 2.7
HR 1 year 0.97 (0.73 – 1.28), P=0.81
HR 1 year 0.84 (0.50 – 1.40), P=0.51
HR 30 days 0.61 ( ), P=0.09
HR 30 days 0.47 ( ), P=0.06
N Engl J Med Oct 24;369(17):
N Engl J Med Sep 18;371(12):

10. All-cause mortality at 1 year
Results consistent across major subgroups.
N Engl J Med Oct 24;369(17):
N Engl J Med Sep 18;371(12):

11. TOTAL, N=10.732
1er Endpoint: risk of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days
Patients with STEMI were assigned to primary PCI with or without thrombectomy
At 180 days: there was no significant between-group difference in the primary outcome of death or cardiovascular events.
N Engl J Med; Volume 372(15): , 2015

12. TOTAL, N=10.732
Patients in the thrombectomy group had a higher rate of stroke at 30 days.
N Engl J Med; Volume 372(15): , 2015

13. TOTAL, N=10.732

14. TASTE and TOTAL TASTE, N= 7.244 TOTAL, N=10.732
CV death, recurrent myocardial infarction, cardiogenic shock, or heart failure within 180 days

15. Johnson, Vizzi, Strange Baumbach
Residual thrombus burden
Johnson, Vizzi, Strange Baumbach
EuroIntervention 2014;10:

16. Bhindi et al European Heart Journal (2015) 36, 1892–1900
TOTAL OCT-substudy
Culprit lesion thrombus burden after thrombus aspiration
Pre-stent
Post-stent
Bhindi et al European Heart Journal (2015) 36, 1892–1900

17. Distal Embolization During Primary PCI
DE occurred in 30/450 pts (6.7%) after primary PCI with thrombus aspiration, and in 26/433 pts (6.0%) after primary PCI w/o aspiration
Timing of first embolization
Present on initial angiogram
After guidewire passage
After aspiration or balloon
After stent
Fokkema M et al. Eur Heart J. 2009;30:908-15

18. Conclusions
The concept of thrombus aspiration prior to primary PCI in STEMI is intuitive and “feels right” Data from two major RCT patients show that routine aspiration does not reduce infarct size, MI, stent thrombosis, heart failure or mortality Routine thrombus aspiration is not beneficial in any investigated subgroup Thrombus aspiration is associated with an increased risk of stroke Routine aspiration should not be performed