1. Thrombectomy: beneficial (if ever) only in highly selected patients Prof. Imad Sheiban University of Turin, Turin, Italy

2. CASE STUDY: ANTERIOR STEMI baseline angio

3. CASE STUDY: ANTERIOR STEMI wiring and predilation with NC balloon at 30 ATM undilatable and calcific culprit lesion: 2 NC Mercury 2.5x10 balloons had to be burst @30 ATM to open it

4. CASE STUDY: ANTERIOR STEMI final result after stenting 2 BMS (3.0x18 @ 18 ATM and 2.75x28 @16 ATM)

5. CASE STUDY: ANTERIOR STEMI final result after stenting 2 BMS (3.0x18 @ 18 ATM and 2.75x28 @16 ATM) WHAT IS THE ROLE OF THROMBECTOMY IN SUCH A PATIENT? NONE

6. FANCY DEVICES ROUTINELY USEFUL OR POINTLESS BUT IN HIGHLY SELECTED PATIENTS?

7. THE REMEDIA TRIAL Burzotta et al, JACC 2005

8. THE REMEDIA TRIAL No data on device-related dissections. Failure to deliver Diver CE: 1/48. Cross-over to no thrombectomy: 2/48. Burzotta et al, JACC 2005

9. THE DEAR-MI TRIAL Silva-Orrego et al, JACC 2006

10. THE DEAR-MI TRIAL Failure to deliver Pronto: 12/74 Silva-Orrego et al, JACC 2006

11. THE TAPAS TRIAL

12. Svilaas et al, NEJM 2008 No device-related dissections despite inclusion of 500 patients. (???) No data on failure to deliver Export. Cross-over to no thrombectomy: 54/502.

13. THE TAPAS TRIAL Vlaar et al, Lancet 2008

14. THE TAPAS TRIAL Can we believe this impact on survival? Guess not: stents were never proven capable of improving survival in STEMI; it usually takes much >1000 pts to prove mortality benefit in STEMI (e.g. GISSI enrolled 16000 pts to prove thrombolysis was better than placebo).

15. WHAT ABOUT ANGIOJET? NO WAY! AiMI trial – 480 patients with STEMI

16. ANY SYNTHESIS POSSIBLE?

17. Burzotta et al, EHJ 2009

18. ANY SYNTHESIS POSSIBLE? All survival benefit driven only by TAPAS trial Burzotta et al, EHJ 2009

19. CAN WE CONCLUDE SO FAR THAT ROUTINE THROMBECTOMY IS BENEFICIAL?

20. death ↑ VERDICT CAN WE CONCLUDE SO FAR THAT ROUTINE THROMBECTOMY IS BENEFICIAL? VERDICT

21. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESS baseline angio in acutely occluded SVG

22. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESS angio after guidewire crossing

23. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESS thrombectomy with 6 Fr Diver CE

25. THE ONLY ROLE OF THROMBECTOMY DEVICES IS INCREASING PROCEDURAL SUCCESS final results after DES implantation 3.5x23 mm DES @ 18 ATM

26. TAKE HOME MESSAGES Active thrombectomy is too expensive and not risk-beneficial and thus should be discouraged in most cases Manual thrombectomy can be attempted in selected cases with large thrombus burden in proximal lesions were lack of support or risk of dissection are not major issues Most cases of STEMI can be managed with a highly selective use of manual thrombectomy, keeping balloon and stenting as the procedural workhorses

27. Thank you for your attention For these and further slides on these topics feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html http://www.metcardio.org/slides.html