1. Is There a Role for Aspiration in STEMI?
David A. Cox, MD FSCAI FACC
Lehigh Valley Health Network
Director, Cardiovascular Research Institute
Associate Director of Cardiac Catheterization Laboratory
Allentown, PA
CRT 2017

2. Disclosures
Advisory Board: Abbott Vascular Medtronic,Inc Boston Scientific
Speaker: Medicure

3. Thanks to all of you…

4. Happy CardioVascular Professionals Week!

5. Now what?

7. Mechanical Aspiration

8. Mechanical Aspiration

9. Manual Aspiration

10. Gotta Help to Remove!

11. You know….Removing Clot
Decrease DISTAL EMBOLI
Lessen NO-REFLOW
Decrease STENT THROMBOSIS

12. But….

15. Lots of papers in this area

16. Not all clinical trials are correct

17. AngioJet Rheolytic Thrombectomy18

18. “Don’t bring a knife to a gunfight”

19. Sully: US Air Flt 1549

20. Angiojet: First Class Rx

21. Thrombectomy 2011 I
IIa
IIb
III
Aspiration thrombectomy is reasonable for patients undergoing primary PCI. B 22

23. Why Angiojet Rarely Used?
Set up more complex
Heart Block, hypotension
Deaths in AiMI often related to procedural complications
Manual Aspiration…must be better

24. Aspiration Thrombectomy 2013
IIa
IIb
III B
Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI.

25. Manual Thrombectomy

26. Tale of 3 Trials
TAPAS
TASTE
TOTAL

27. TAPAS: 1,071 pts with STEMI undergoing PCI randomized in the ER to aspiration (Export) vs. control
Myocardial Blush (1 EP)
ST-segment Resolution
P<0.001
P<0.001
Thrombus
aspiration
Conventional
PCI
Thrombus
aspiration
Conventional
PCI
Svilaas T et al. NEJM 2008;358;

28. TAPAS: 1,071 pts with STEMI undergoing primary PCI randomized in the ER to manual aspiration (Export) vs. control
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
Vlaar et al. Lancet 2008;371:

29. Ole Fröbert, MD, PhD - on behalf of the TASTE investigators
UCR
Uppsala Clinical Research Center
Thrombus Aspiration in ST- Elevation myocardial infarction in Scandinavia (TASTE trial):
Results and Methodology of a Registry based Randomized Clinical Trial (RRCT)
Ole Fröbert, MD, PhD - on behalf of the TASTE investigators
Departement of Cardiology
Örebro University Hospital
Sweden

30. TASTE and previous studies

31. All-cause mortality at 30 days
HR 0.94 ( ), P=0.63
Per protocol analysis based on actual treatment:
HR 0.88 ( ), P=0.38
Fröbert, O. et al. N Engl J Med 2013; 369:

32. TASTE vs. TAPAS

33. TASTE 12 mo: NO BENEFIT

34. TOTAL Recruitment from 87 sites in 20 countries
Europe
5617
North America
3863
Asia Pacific
865
South America
387
10,732 patients randomized between August 2010 and July 2014

35. Primary Outcome (CV death, MI, Shock or CHF) at 1 year

36. Primary Outcome (CV death, MI, Shock or CHF) at 1 year

37. Primary Outcome at 1 year
Thrombectomy
(N=5033) (%)
PCI alone
(N=5030) (%) HR
95% CI p
CV death, MI, shock or
class IV heart failure
395 (7.8)
394 (7.8)
1.00
(0.87 – 1.15)
0.99
CV death
179 (3.6)
192 (3.8)
0.93
(0.76 – 1.14)
0.48
Recurrent MI
125 (2.5)
118 (2.3)
1.05
( )
0.68
Cardiogenic Shock
95 (1.9)
105 (2.1)
0.90
(0.68 – 1.19)
0.47
Class IV heart failure
106 (2.1)
96 (1.9)
1.01
(0.83 – 1.45)
0.50

38. Safety Outcomes at 1 year
Thrombectomy
(N=5033) (%)
PCI alone
(N=5030) (%) HR
95% CI p
Stroke at 1 year
60 (1.2)
36 (0.7)
1.66
(1.10 – 2.51)
0.015
Stroke or TIA at 1 year
73 (1.4)
44 (0.9)
1.6 5
(1.14 – 2.40)
0.008
Landmark Analyses
Stroke 180 days to 1 year
7 (0.1)
10 (0.2)
0.7 0
(0.27 – 1.83)
0.46

39. Site Primary PCI Volume: Tertile 1 2450 8.1 8.4 Tertile 2 2139 8.4 7.8
Thrombectomy (%)
PCI Alone (%)
P (INTERACTION)
OVERALL
10064
7.8
7.8
TIMI Thrombus Grade: ≥3
8983
8.0
8.2
<3
1073
6.0
4.9
0.407
TIMI Thrombus Grade: ≥4
7919
8.4
8.5
<4
2137
5.8
5.5
0.759
Symptom Onset:
<6 hrs
8416
7.6
7.4
6-12 hrs
1645
9.3
10.2
0.480
Initial TIMI Flow:
0-1
7453
8.3
8.6
2-3
2517
6.8
5.7
0.195
Site Primary PCI Volume:
Tertile 1
2450
8.1
8.4
Tertile 2
2139
8.4
7.8
Tertile 3
5475
7.5
7.6
0.823
MI Type:
Anterior
4017
9.7
10.1
Non-Anterior
6039
6.7
6.3
0.509
Age:
≤65 yrs
6662
5.5
5.1
>65 yrs
3401
12.6
13.1
0.375
Favours Thrombectomy
Favours PCI Alone
0.5
1.0
2.0

40. 2015 ACC/AHA/SCAI Focused Update on Primary PCI for Patients with STEMI: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
Developed in Collaboration with the American College of Emergency Physicians
© American College of Cardiology Foundation, American Heart Association, and Society for Cardiovascular Angiography and Interventions

41. Aspiration Thrombectomy
COR
LOE
Recommendations
IIb
C-LD
The usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established.1
III: No Benefit A
Routine aspiration thrombectomy before primary PCI is not useful.2
1. Modified recommendation from 2013 guideline (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI)
2. New recommendation

42. Routine Aspiration in ALL STEMI’s

43. Don’t believe everything you hear….

44. Use what works for you! Selective Thrombectomy