TOTAL Randomized trial of manual aspiration Thrombectomy + PCI vs. PCI Alone in STEMI (TOTAL) SS Jolly, JA Cairns, S Yusuf, B Meeks, J Pogue, MJ Rokoss, S Kedev, L Thabane, G Stankovic, R Moreno, A Gershlick, S Chowdhary, S Lavi, K Niemelä, PG Steg, I Bernat, Y Xu, WJ Cantor, C Overgaard, C Naber, AN Cheema, RC Welsh, OF Bertrand, A Avezum, R Bhindi, S Pancholy, SV Rao, MK Natarajan, JM ten Berg, O Shestakovska, P Gao, P Widimsky, V Džavík on behalf of the TOTAL Investigators

TOTAL Disclosures TOTAL trial was funded by: Canadian Institutes of Health Research Canadian Network and Centre for Trials Internationally (CANNeCTIN) Medtronic Inc.

TOTAL Rationale for Thrombectomy Major Limitation of Primary PCI: Distal Embolization and Reduced Flow Hypothesis: Aspiration thrombectomy may reduce embolization and improve clinical outcomes

TOTAL Background Large effect size in TAPAS (2008)No difference in TASTE (2013) Vlaar PJ, et al. Lancet 2008;371: Frobert O, et al. N Engl J Med Lagerqvist B, et al. N Engl J Med TAPAS trial (N=1071) showed a large benefit vs. TASTE (N=7244) showed no benefit of thrombus aspiration

TOTAL The TOTAL Trial Study Design PCI Alone (only bailout thrombectomy) Routine Upfront Manual Thrombectomy followed by PCI Primary Outcome: CV death, MI, cardiogenic shock and class IV heart failure ≤180 days Safety Outcome: Stroke ≤30 days 1:1 Randomization between strategies Bailout Thrombectomy allowed if PCI alone strategy fails: Persistent TIMI 0 or 1 flow with large thrombus after balloon pre-dilatation Persistent large thrombus after stent deployment at target lesion STEMI* with Primary PCI ≤12 hours of symptom onset Sample size of 10,700 for 80% power to detect a 20% Relative Risk Reduction

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

TOTAL TOTAL Trial Flow and Adherence 10,732 enrolled and randomized Cross-over to Thrombectomy as initial strategy in 69 (1.4%) Bailout Thrombectomy in 355 (7.1%) Crossover to PCI alone in 230 (4.6%) TOTAL 5033 Manual Thrombectomy 5030 PCI Alone 5030 included in analysis5033 included in analysis 10,066 underwent PCI for STEMI

TOTAL Baseline Characteristics Thrombectomy N=5033 PCI alone N=5030 Mean Age61.0 years Male76.8%78.2% Killip Class ≥24.3%4.2% Anterior MI39.0%40.9% Symptom onset to hospital arrival*128 min120 min Door to Device time53.0 min *P=0.024

TOTAL PCI Procedural Details Thrombectomy N=5033 PCI alone N=5030 Pre PCI TIMI 0 flow66.3%67.8% TIMI thrombus grade ≥390.8%89.1% Unfractionated Heparin80.8%81.6% Bivalirudin18.7%17.3% Upfront Glycoprotein IIb/IIIa**22.7%25.4% Drug Eluting Stents44.7%45.0% Radial Access68.3%68.2% **P=0.0002

TOTAL PCI Variables and Surrogate Outcomes Thrombectomy N=5033 PCI alone N=5030 P PCI Procedure time (median) 39 min35 min<0.001 Direct Stenting38.3%21.3%<0.001 Final TIMI 3 flow*93.1% 0.12 Distal Embolization*1.6%3.0%<0.001 ST segment Resolution <70%*27.0%30.2%<0.001 * Investigator Reported Outcomes. Core laboratory analysis is ongoing.

TOTAL Primary Outcome Day 180 Thrombectomy (N=5033) (%) PCI alone (N=5030) (%) HR95% CIp CV death, MI, shock or class IV heart failure 347 (6.9%)351 (7.0%) CV death157 (3.1%)174 (3.5%) Recurrent MI99 (2.0%)92 (1.8%) Cardiogenic Shock92 (1.8%)100 (2.0%) Class IV heart failure98 (1.9%)90 (1.8%)

TOTAL Safety Outcomes Thrombectomy (N=5033) (%) PCI alone (N=5030) (%) HR95% CIp Stroke within 30 days33 (0.7%)16 (0.3%) Stroke or TIA within 30 days42 (0.8%)19 (0.4%) Stroke within 180 days52 (1.0%)25 (0.5%)

TOTAL Time to Stroke Months of Follow-up Cumulative % of Stroke Thrombectomy PCI alone Hazard ratio, 2.08 (95%CI, ); P=0.0021

TOTAL Outcomes at 30 days Thrombectomy (N=5033) (%) PCI alone (N=5030) (%) HR95% CIp CV Death, MI, shock or class IV heart failure 281 (5.6%)287 (5.7%) Stent Thrombosis59 (1.2%)69 (1.4%) Target Vessel Revascularization126 (2.5%)132 (2.6%)

TOTAL Subgroup Analysis Primary Outcome

TOTAL 16 Limitations Operators not blinded Slightly lower use of GP IIb/IIIa inhibitors in Thrombectomy group Strategy trial of routine thrombectomy Cannot rule out a benefit of selective thrombectomy Control Arm had Bailout thrombectomy (7%) when PCI alone strategy failed Not designed to test effectiveness of bailout. Clinical judgement still needed. Stroke findings are unexpected Requires confirmation in other studies Analyses are ongoing to understand etiology

TOTAL Conclusions Routine thrombectomy compared to PCI alone with only bailout thrombectomy did not reduce CV death, MI, shock or heart failure within 180 days Routine thrombectomy was associated with increased risk of stroke within 30 days TOTAL and TASTE emphasize the need to conduct large randomized trials of common interventions even when small trials appear positive

TOTAL Available Online at

TOTAL Acknowledgements Steering Committee A. AvezumM.K. Natarajan I. BernatK. Niemelä O. BertrandS. Pancholy R. BhindiS.V. Rao W.J. CantorM. Rokoss B. MeeksG. Stankovic A. GershlickP.G. Steg S. KedevJ.M. ten Berg R. MorenoR.C. Welsh C.K. NaberP. Widimsky Y. Xu Data Monitoring Committee G. Wyse (Chair) J.P. Bassand D. Bhatt M. LeMay G. Wells J. Pogue (DMC statistician) Angiographic Core Lab C. Overgaard, V. Sharma, W. Chan, F. Fuchs, J. Chiha, T. Hamid, S. Bui, M. Sibbald, V. Džavík ECG Core Lab M. Eskola, K. Nikus, J. Koivumäki, K. Niemelä PHRI Project Office Study Team B. Meeks (Program Manager) S. Ahmad (Research Coordinator) M. Lawrence L. Floyd M. McClelland M. Wild S. Batey A. Fatima Statisticians J. Pogue O. Shestakovska P. Gao Adjudication Committee M. Rokoss (Chair), A. Avezum, K. Bainey, P. Domsik, G. Ducrocq, M. Eskola, G. Fodor, P. Hajek, B. Hart, P. Kanjana, J. Karasconyi, K. Kervinen, T. Lai, D. Mancevski, L. Morillo, A. Neskovic, K. Ng, K. Niemelä, W. Oczkowski, G. Oliveira, M. Pan, P. Paulu, D. Petrovska- Cvetskovska, I. Plaza, H. Romppanen, J.D. Schwalm, A. Shoamanesh, T. Sotirov, D. Topic, N. Valettas, K. Vondrak, P. Widimský, V. Zenios Quality Assurance Committee C. Ainsworth, D. Al Khdair, A. Alazzoni, N. Ali, A. Al-Saleh, A. Avezum, F. Botto, W. Chan, J. Cohen, M. Eskola, F. Fuchs, A. Gangasandra Basavaraj, P. Hajek, V. Hsieh, K. Jolly, K. Kervinen, J. Manolakos, M. Natarajan, G. Oliveira, J. Paikin, S. Pandie, P. Paulu, S. Pizzale, M. Rokoss, J.D. Schwalm, K. Shufelt, T. Sotirov, D. Topic, M. Tsang, N. Valettas, K. Vondrak, D. Wright Executive Committee S.S. Jolly (co-Principal Investigator) V. Džavík (co-Principal Investigator) J.A. Cairns L. Thabane S. Yusuf

TOTAL TOTAL Investigators from 87 sites in 20 countries AUSTRALIACANADAFINLANDNETHERLANDSUNITED KINGDOM A. RahmanS. JollyK. NiemeläJ.M. ten BergA. Gershlick R. BhindiA. FungH. RomppanenNEW ZEALANDS. Chowdhary J. WeaverA. CheemaFRANCEG. DevlinA. Jain AUSTRIAO. BertrandG. SiderisSERBIAN. Curzen I. LangV. DžavíkP.G. StegG. StankovicM. El-Omar BELGIUMS. KassamN. DelarcheSOUTH KOREAM. Seddon S. PourbaixA. Della SiegaF. SchieleW. KimJ. Shannon BRAZILT. CiezaS. MarliereS. Jin LeeR. Oliver M. Andre TebetS. LaviGERMANYM-H. JeongJ. Gunn A. KormannN. NadeemN. WernerS-H. KimS. Hetherington A. ZagoR. WelshC. NaberSPAINK. Grosser P. CaramoriW. CantorM. GreifJ. MauriJ. Glover V. LimaL. BilodeauJ. TorzewskiN. VazquezUSA M.A. dos SantosR. LeungGREECEB. Garcia del BlancoN. Patel A. AbizaidJ. CharaniaD. AlexopoulosA. BethencourtI.J. Sarembock CHINACZECH REPUBLICA.ZiakasR. MorenoJ. Blankenship Y. XuP. HajekHUNGARYA. Iniguez RomoD. Lasorda J. QiuV. KockaI.UngiJ. Escaned BarbosM. Sheldon S. LiuP. CervinkaB. MerkelyH. Tizon-MarcosS. Pancholy H. LuoI. BernatMACEDONIAC. Devireddy D. HorakS. KedevS. Singh