Deferred stenting in acute ST elevation myocardial infarction
2016; Elsevier BV; Volume: 388; Issue: 10052 Linguagem: Inglês
10.1016/s0140-6736(16)31739-1
ISSN1474-547X
Autores Tópico(s)Cardiac Imaging and Diagnostics
ResumoWe read with interest the Article by Henning Kelbæk and colleagues (May 28, p 2199)1Kelbæk H Høfsten DE Køber L et al.Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial.Lancet. 2016; 387: 2199-2206Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar who did the DANAMI 3-DEFER trial and concluded that deferred stenting in acute ST-segment elevation myocardial infarction (STEMI) does not reduce the occurrence of death, heart failure, myocardial infarction, and repeat revascularisation. The referred study by Cafri and colleagues2Cafri C Svirsky R Zelinher J et al.Improved procedural results in coronary thrombosis are obtained with delayed percutaneous coronary interventions.J Invasive Cardiol. 2004; 16: 69-71PubMed Google Scholar does not enter into this context because by definition, patients having primary angioplasty in the setting of acute STEMI were excluded by Cafri and colleagues. We were the first to introduce the concept of a minimalist immediate mechanical intervention (MIMI) using the simple guide wire or a very small balloon in an emergency to reopen an infarct-related artery with a thrombolysis in myocardial infarction (TIMI) grade 0 flow in patients with an acute STEMI, and to postpone stenting the following days in stable conditions.3Isaaz K Robin C Cerisier A et al.A new approach of primary angioplasty for ST-elevation acute myocardial infacrtion based on minimalist immediate mechanical intervention.Coron Artery Dis. 2006; 17: 261-269Crossref PubMed Scopus (51) Google Scholar In the DANAMI 3-DEFER trial,1Kelbæk H Høfsten DE Køber L et al.Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial.Lancet. 2016; 387: 2199-2206Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar deferred stent implantation was done at a mean of 48 h. This delay is probably too short to allow both spontaneous structural modifications and anti-thrombotic treatment to act on thrombus in all cases. To admit that thrombus was totally absent in all patients at control angiogram is difficult. In our original work,3Isaaz K Robin C Cerisier A et al.A new approach of primary angioplasty for ST-elevation acute myocardial infacrtion based on minimalist immediate mechanical intervention.Coron Artery Dis. 2006; 17: 261-269Crossref PubMed Scopus (51) Google Scholar 17 (33%) of 52 patients with deferred stenting received a stent at a mean of 6 days because of persistent substantial thrombus at previous control coronary angiogram. In the DANAMI 3-DEFER trial,1Kelbæk H Høfsten DE Køber L et al.Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial.Lancet. 2016; 387: 2199-2206Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar the objective of the initial intervention was to restore and stabilise a TIMI 2–3 flow. Therefore, a substantial proportion of patients with deferred stenting can be assumed to have been left with a TIMI 2 flow during a mean of 48 h, whereas 589 (96%) of 612 patients with immediate stenting had a TIMI 3 flow.1Kelbæk H Høfsten DE Køber L et al.Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial.Lancet. 2016; 387: 2199-2206Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar The fact that a postintervention TIMI 2 flow does not result in a benefit as great as that of a TIMI 3 flow in terms of clinical outcome is well known,4Christopher P Cannon CP. Importance of TIMI 3 flow.Circulation. 2001; 104: 624-626Crossref PubMed Scopus (38) Google Scholar, 5Ndrepepa G Mehilli J Schulz S et al.Prognostic significance of epicardial blood flow before and after percutaneous coronary intervention in patients with acute coronary syndromes.J Am Coll Cardiol. 2008; 52: 512-517Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar representing a bias that might have penalised the deferred stenting group. Also, in our experience of MIMI in the past 14 years, we found that a TIMI 2 flow after MIMI is a factor of reocclusion. Finally, 131 (22%) of 603 patients in the deferred stenting group had immediate stenting (crossovers) in the DANAMI 3-DEFER trial.1Kelbæk H Høfsten DE Køber L et al.Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial.Lancet. 2016; 387: 2199-2206Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar In our own work,3Isaaz K Robin C Cerisier A et al.A new approach of primary angioplasty for ST-elevation acute myocardial infacrtion based on minimalist immediate mechanical intervention.Coron Artery Dis. 2006; 17: 261-269Crossref PubMed Scopus (51) Google Scholar we also found that a stable TIMI 3 flow using MIMI could not be achieved in 16 (17%) of 93 cases. These patients with failed MIMI should have been excluded from the final analysis comparing immediate with deferred stenting in the DANAMI 3-DEFER trial.1Kelbæk H Høfsten DE Køber L et al.Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial.Lancet. 2016; 387: 2199-2206Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar We believe that deferred stenting cannot be proposed in all patients and should not be recommended in patients who cannot achieve a stable TIMI 3 flow with MIMI. By contrast, deferred stenting should be proposed for patients with a stable TIMI 3 flow obtained with MIMI and who have a large thrombus burden. However, sufficient time should elapse before stenting to ensure total removal of thrombus burden. Further randomised trials are needed to assess this concept. We declare no competing interests. Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trialIn patients with STEMI, routine deferred stent implantation did not reduce the occurrence of death, heart failure, myocardial infarction, or repeat revascularisation compared with conventional PCI. Results from ongoing randomised trials might shed further light on the concept of deferred stenting in this patient population. Full-Text PDF Deferred stenting in acute ST elevation myocardial infarction – Authors' replyWe thank Karl Isaaz and Antoine Gerbay for their interest in our work assessing the effect of deferred stent implantation in patients with ST-segment elevation myocardial infarction who are having primary percutaneous coronary intervention.1 Additionally, we acknowledge their pioneership of the minimalistic approach to reduce the negative effect of thrombus embolisation while securing the coronary blood flow during percutaneous coronary intervention in the acute state of a myocardial infarction. Full-Text PDF
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