1. 第八届西部长城心脏病学会议
李妍,副主任医师，副教授，硕士研究生导师。陕西西安西京医院心内科副主任。中华医学会陕西分会会员、中国女医师协会青年委员。在心血管权威杂《Circulation》杂志及国家核心期刊发表专业论著30余篇。多次主持参与国家级及省部级科研项目。
李 妍

2. Management Strategies of Acute Thrombus-containing Lesions
Yan Li, MD, PhD
Associate Professor of Cardiology
Vice-director of Department of Cardiology
Fourth Military Medial University
Xi,an China

3. Thrombus Presence in STEMI
Angiographic thrombus is evident in over 70% of STEMI Patients

7. Thrombus: the Problem
No reflow
Worse outcomes

8. Routine Use of Thrombus Aspiration or Not?

9. Manual Thrombus Aspiration
EXPORT Catheter
PRONTO Catheter
DIVER catheter
FETCH-2
ELIMINATE
THROMBUSTER

10. Mechanical Thrombectomy
RESCUE CATHETER
ANGIOJET-XMI
Ev3 (EndiCOR) X-sizer

11. Manual Thrombectomy in STEMI
WHY?
Cheap
User-Friendly
Safe
Procedural/Clinical benefits

13. Thrombectomy and myocardial perfusion

14. 1-year Clinical Outcomes

16. Benefits in ST-Segment resolution and thrombus burden
P =
Log Odds ratio
Thrombus (%)
De Luca G et al. Int J Cardiol 2012

17. TASTE trial enrollment flow chart
Enrolled in Denmark
N=247
All patients with STEMI in Sweden and Iceland undergoing
primary or rescue PCI. N= *)
Enrolled in TASTE
N=7259
Not enrolled
N=4697
Erroneous enrollments
N=15
Randomized in TASTE
N=7244
N=3621 assigned
to thrombus aspiration
N=3623 assigned
to conventional PCI
N=3399 underwent
thrombus aspiration
N=222 underwent
conventional PCI
N=3445 underwent
conventional PCI
N=178 underwent
thrombus aspiration
N=1162 underwent
thrombus aspiration
N=3535 underwent
conventional PCI
N=3621 were
followed up
N=3623 were
followed up
N=1162 were
followed up
N=3535 were
followed up 17

18. Baseline clinical characteristics18

19. Baseline procedural characteristics19

20. Post randomization characteristics (1)20

21. Post randomization characteristics (2)21

22. 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 22

23. Reinfarction at 30 days HR 0.61 (0.34 - 1.07), P=0.09
Per protocol analysis based on actual treatment:
HR 0.67 ( ), P=0.19 23

24. Additional results 24

25. 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
TASTE
TAPAS 25

26. Selected population (Bias???)
TASTE Limitations
Selected population (Bias???)
Conducted as registry
No event adjudication
No data verification
No centralized coreLab
Short-term follow-up

27. Mechanical reperfusion strategy for STEMI in 2013
Preprocedure TIMI 0-1 After crossing the occlusion
Manual Thrombectomy
Large thrombus burden
Angioget
TIMI 2-3 flow
Direct stenting if anatomically feasible
TIMI 0-1 flow
Predilatation
Mechanical reperfusion strategy for STEMI in 2013
Preprocedual TIMI 2-3 before or after crossing the occlusion
Small thrombus burden
Manual thrombectomy

28. Intravenous, Intracoronary or intralesion IIb/IIIa inhibitor ?

31. INFUSE-AMI Aspiration and or IL Abciximab Infusion for Thrombus Removal in STEMI
?Proof of Concept
Early
Total Occlusion
Solid endpoint
ClearWay Infusion catheter
Aspiration
Thrombectomy

32. INFUSE-AMI Trial 452 pts with anterior STEMI Manual aspiration
Anticipated Sx to PCI <5 hrs, TIMI 0-2 flow in prox or mid LAD
Primary PCI with bivalirudin anticoagulation
Pre-loaded with aspirin and
clopidogrel 600 mg or prasugrel 60 mg
Stratified by symptoms to angio <3 vs ≥3 hrs, and prox vs mid LAD occlusion R
1:1
Manual aspiration
No aspiration R
1:1 R
1:1
IL Abcx
No Abcx
IL Abcx
No Abcx
Primary endpoint: Infarct size at 30 days (cMRI)
2º endpoints: TIMI flow, blush, ST-resolution, MACE (30d, 1 yr)
Stone, GW et al, JAMA. 2012;307(17);

33. INFUSE AMI: ST Resolution at 60 minutes
P=NS
Stone, GW et al, JAMA. 2012;307(17);

34. INFUSE-AMI MRI at 30 Days IL

35. INFUSE-AMI

36. Mesh-covered Stent or DES ?

37. MGuard & MGuard Prime STENT MGuard MGuard Prime MATERIAL
Stainless steel
Cobalt chromium
STRUT THICKNESS
100m
80m
CROSSING PROFILE mm mm
MICRONET
PET
FIBER DIAMETER
20M
PORE SIZE M
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38. Jain and Rothman. JACC 2011;58;e39
Novel Stent Designs
(Mesh-Covered Stent)
Thrombus trapped
behind the mesh
Jain and Rothman. JACC 2011;58;e39

39. Death Time-to-Event curve1 2 3 4 5
Months 6 7 8 9 10 11 12
217
214
209
206
126
216
210
207
123
Number at risk:
MGuard
BMS/DES
P= 0.09
HR: 0.28 [95% CI: 0.06, 1.36]
1.0%
3.3%
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RESULTS 39

40. Death or MI Time-to-Event curve
DEATH/MI (%) 1 2 3 4 5
Months 6 7 8 9 10 11 12
217
212
207
205
125
216
209
208
206
123
Number at risk:
MGuard
BMS/DES
2.3%
3.7%
P= 0.04
HR: 0.62 [95% CI: 0.20, 1.89]
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RESULTS 40

41. Deferred PCI or Primary PCI ?

42. Deferred PCI – Randomized Trial
Allcomers – STEMIs assessed for eligibility
N = 411 (March – Nov 2012)
310 excluded
Enrolment
TIMI 3 flow asap thrombectomy +/- POBA
Randomized n=101
Deferred stenting
hrs later, n = 52
Usual care
Immediate PCI, n = 49
Berry al. TCT 2013

43. Deferred PCI – Randomized Trial
Immediate stenting
Deferred stenting
p = 0.008
p = 0.006 33
p = 0.054 29 % 14 10 6 2
Berry al. TCT 2013

44. Case PCI Strategy in patient with acute inferior wall myocardial infarction

45. History Male，65 years old
Chest pain and distress 4 years ,aggrevating for 13 hours. CABG 7 years ago, 1 vein graft to LCX and LIMA to LAD.
HR 77 bpm，BP 110/70mmHg, no murmur and
ECG：AMI (inferior wall)
Killip I
OMI (anterior wall)
UCG：EF 50%, OMI(anterior wall )
Lab test: cTnI 30ng/mL
CK308IU/L CKMB 44ng/ml

46. Angiography

47. Patent LIMA and Vein Graft to LAD and LCX

48. No graft to RCA

49. Acute thrombotic lesion
Lesion Analysis
Short stump blunt end
No visible colaterals
No side branch and visible bridge vessels
Acute thrombotic lesion

50. Recanalization with GW
GC : JR4
GW: Runthrough NS
Occluded RCA with large thrombus burden
Export catheter aspiration

51. Intra-lesion IIb/IIIa Inhibitor
IL: Intra-lesion bolus of Tirofiban( 8mL)
was administered.
IV： Tirofiban 4mL/h

52. RCA Primary POBA
Pre-dilatation with 2.0X20mm balloon

53. Intracoronary Sodium Nitroprusside
IV: Tirofiban 4mL/h
IC: Sodium nitroprusside
400ug
Blood flow: TIMI 2-3

54. 5 days later, re-check angiography
IV: Tirofiban 4mL /h for 3 days
Blood flow TIMI 3

55. Stenting with 3.5X28 DES @ 16atm
No reflow or slow flow
Blood flow TIMI 3

56. Final Results

57. Thrombus aspiration
Intra-lesion infusion of IIb/IIIa inhibitor
Primary POBA
Deferred PCI

58. Conclusions
Aspiration thrombectomy – although currently no prove in adequately powered multicenter trial that thrombectomy reduces clinical endpoints, the routine use of manual thrombectomy is still a very appealing strategy
IIb/IIIa inhibitor: IV, IC, IL - via guiding catheter no benefit - via Clearway-catheter infarct size reduction but no benefit on reperfusion measures. Clinical outcome?
Mesh-covered stent - improvement in ST-segment resolution, but higher MACE at 12 months (wait for MASTER-II)
Deferring PCI + pharmacotherapy - Interesting concept, reduces thrombus and improves flow