Response by Jolly et al to Letters Regarding Article, “Thrombus Aspiration in ST-Segment-Elevation Myocardial Infarction: An Individual Patient Meta-Analysis: Thrombectomy Trialists Collaboration”
2017; Lippincott Williams & Wilkins; Volume: 135; Issue: 22 Linguagem: Inglês
10.1161/circulationaha.117.028198
ISSN1524-4539
AutoresSanjit S. Jolly, Stefan James, Vladimír Džavík, John A. Cairns, Ole Frøbert,
Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoHomeCirculationVol. 135, No. 22Response by Jolly et al to Letters Regarding Article, "Thrombus Aspiration in ST-Segment-Elevation Myocardial Infarction: An Individual Patient Meta-Analysis: Thrombectomy Trialists Collaboration" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Jolly et al to Letters Regarding Article, "Thrombus Aspiration in ST-Segment-Elevation Myocardial Infarction: An Individual Patient Meta-Analysis: Thrombectomy Trialists Collaboration" Sanjit S. Jolly, MD, MSc, Stefan James, MD, PhD, Vladimír Džavík, MD, John A. Cairns, MD and Ole Frøbert, MD, PhD Sanjit S. JollySanjit S. Jolly From McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (S.S.J.); Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Sweden (S.J.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (V.D.); University of British Columbia, Vancouver, Canada (J.A.C.); and Örebro University, Faculty of Health, Department of Cardiology, Södra Grev Rosengatan, Örebro, Sweden (O.F.). , Stefan JamesStefan James From McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (S.S.J.); Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Sweden (S.J.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (V.D.); University of British Columbia, Vancouver, Canada (J.A.C.); and Örebro University, Faculty of Health, Department of Cardiology, Södra Grev Rosengatan, Örebro, Sweden (O.F.). , Vladimír DžavíkVladimír Džavík From McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (S.S.J.); Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Sweden (S.J.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (V.D.); University of British Columbia, Vancouver, Canada (J.A.C.); and Örebro University, Faculty of Health, Department of Cardiology, Södra Grev Rosengatan, Örebro, Sweden (O.F.). , John A. CairnsJohn A. Cairns From McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (S.S.J.); Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Sweden (S.J.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (V.D.); University of British Columbia, Vancouver, Canada (J.A.C.); and Örebro University, Faculty of Health, Department of Cardiology, Södra Grev Rosengatan, Örebro, Sweden (O.F.). and Ole FrøbertOle Frøbert From McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (S.S.J.); Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Sweden (S.J.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (V.D.); University of British Columbia, Vancouver, Canada (J.A.C.); and Örebro University, Faculty of Health, Department of Cardiology, Södra Grev Rosengatan, Örebro, Sweden (O.F.). Originally published30 May 2017https://doi.org/10.1161/CIRCULATIONAHA.117.028198Circulation. 2017;135:e1103–e1104In Response:Karamasis and colleagues describe their own registry of patients with ST-segment–elevation myocardial infarction undergoing thrombus aspiration in whom they performed serial ECGs and showed worsening in ST-segment elevation in 13.5% of cases after the first wire passage, in 19.7% of cases after thrombus aspiration, and in 12.5% of cases at the end of the procedure. Thus, >50% ST-segment resolution occurred in 15.2% after wire passage, in 21.8% after thrombus aspiration, and in 44.3% at the end of the procedure.1 However, without a control group for comparison, one should be cautious about the interpretation of these results. Thrombus aspiration devices may cause transient reductions in flow after thrombus aspiration, which may be related to disruption of culprit plaque or distal embolization.Although we agree that thrombus aspiration can in some cases "effectively remove thrombus and re-establish flow," evidence is still needed that it also improves clinical outcomes safely. Last, we agree with Karamasis and colleagues that future trials are needed and should focus on patients with high thrombus burden.Jurado-Román and colleagues try to explain the fact that thrombus aspiration improves reperfusion parameters but not clinical outcomes in our meta-analysis.2 They argue that this may be due to the low rate of angiographic thrombus observed in the TAPAS trial (Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction).3 In addition, in TAPAS and TOTAL (A Trial of Routine Aspiration Thrombectomy With Percutaneous Coronary Intervention [PCI] Versus PCI Alone in Patients With ST-Segment Elevation Myocardial Infarction [STEMI] Undergoing Primary PCI), angiographic thrombus grade was evaluated before wire crossing, so in the two thirds of patients with an initially occluded vessel, some may have recanalized with wire crossing with less residual thrombus. However, the TASTE (Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia) investigators evaluated thrombus grade after wire crossing and found no difference in clinical outcomes with thrombus aspiration in the subgroups with high and low thrombus burden.4As for selection bias, informed consent was a requirement for randomization in these trials. In ST-segment–elevation myocardial infarction, a substantial proportion of patients are unable to consent because of severe pain and clinical instability. In TASTE, 76.9% of all patients potentially eligible for enrollment underwent randomization, increasing the external validity of TASTE.Last, Jurado-Román et al state that the stroke rate in TOTAL continued to increase between 30 and 180 days. A landmark analysis of ischemic stroke from the TOTAL trial shows only a significant increase from 0 to 48 hours and no statistically significant increase during time periods beyond 48 hours.5Shah asserts that the increase in stroke observed in this meta-analysis is driven predominantly by the TOTAL trial. It should be noted that meta-analyses before TOTAL were the first to suggest a potential increase in stroke with thrombus aspiration.6 Shah incorrectly states that there were significant differences in baseline risk factors for stroke between the thrombus aspiration group and PCI alone in TOTAL that account for the difference. This was not the case; factors such as age, sex, diabetes mellitus, prior stroke, and peripheral arterial disease were not different between the groups.7 Furthermore, in a multivariable analysis accounting for these variables, thrombus aspiration was an independent predictor of stroke.5 The finding of an increased rate of stroke in the subgroup with high thrombus burden adds biological plausibility to these findings. However, future trials will need to assess whether newer technologies can improve outcomes such as mortality without increasing the risk of stroke.Sanjit S. Jolly, MD, MScStefan James, MD, PhDVladimír Džavík, MDJohn A. Cairns, MDOle Frøbert, MD, PhDDisclosuresDuring the conduct of the TOTAL trial, Dr Jolly received an institutional research grant from Medtronic. During the conduct of the TASTE trial, Dr James received institutional research grants from Medtronic, Vascular Solutions, and Terumo Inc. Thereafter, he has received institutional research grants from Boston Scientific, Abbot Vascular, AstraZeneca, and The Medicines Company. He has received honoraria from AstraZeneca, The Medicines Company, Bayer, and Boston Scientific. The other authors report no conflicts.FootnotesCirculation is available at http://circ.ahajournals.org.References1. Russhard P, Al Janabi F, Parker M, Clesham GJ. Patterns of ST segment resolution after guidewire passage and thrombus aspiration in primary percutaneous coronary intervention (PPCI) for acute myocardial infarction.Open Heart. 2016; 3:e000430. doi: 10.1136/openhrt-2016-000430.CrossrefMedlineGoogle Scholar2. Jolly SS, James S, Džavík V, Cairns JA, Mahmoud KD, Zijlstra F, Yusuf S, Olivecrona GK, Renlund H, Gao P, Lagerqvist B, Alazzoni A, Kedev S, Stankovic G, Meeks B, Frøbert O. Thrombus aspiration in ST-segment-elevation myocardial infarction: an individual patient meta-analysis: Thrombectomy Trialists Collaboration.Circulation. 2017; 135:143–152. doi: 10.1161/CIRCULATIONAHA.116.025371.LinkGoogle Scholar3. Svilaas T, Vlaar PJ, van der Horst IC, Diercks GF, de Smet BJ, van den Heuvel AF, Anthonio RL, Jessurun GA, Tan ES, Suurmeijer AJ, Zijlstra F. Thrombus aspiration during primary percutaneous coronary intervention.N Engl J Med. 2008; 358:557–567. doi: 10.1056/NEJMoa0706416.CrossrefMedlineGoogle Scholar4. Fröbert O, Lagerqvist B, Olivecrona GK, Omerovic E, Gudnason T, Maeng M, Aasa M, Angerås O, Calais F, Danielewicz M, Erlinge D, Hellsten L, Jensen U, Johansson AC, Kåregren A, Nilsson J, Robertson L, Sandhall L, Sjögren I, Ostlund O, Harnek J, James SK; TASTE Trial. Thrombus aspiration during ST-segment elevation myocardial infarction.N Engl J Med. 2013; 369:1587–1597. doi: 10.1056/NEJMoa1308789.CrossrefMedlineGoogle Scholar5. Jolly SS, Cairns JA, Yusuf S, Meeks B, Gao P, Hart RG, Kedev S, Stankovic G, Moreno R, Horak D, Kassam S, Rokoss MJ, Leung RC, El-Omar M, Romppanen HO, Alazzoni A, Alak A, Fung A, Alexopoulos D, Schwalm JD, Valettas N, Džavík V; TOTAL Investigators. Stroke in the TOTAL trial: a randomized trial of routine thrombectomy vs. percutaneous coronary intervention alone in ST elevation myocardial infarction.Eur Heart J. 2015; 36:2364–2372. doi: 10.1093/eurheartj/ehv296.CrossrefMedlineGoogle Scholar6. Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta-analysis of randomized trials.Eur Heart J. 2008; 29:2989–3001. doi: 10.1093/eurheartj/ehn421.CrossrefMedlineGoogle Scholar7. Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ, Kedev S, Thabane L, Stankovic G, Moreno R, Gershlick A, Chowdhary S, Lavi S, Niemelä K, Steg PG, Bernat I, Xu Y, Cantor WJ, Overgaard CB, Naber CK, Cheema AN, Welsh RC, Bertrand OF, Avezum A, Bhindi R, Pancholy S, Rao SV, Natarajan MK, ten Berg JM, Shestakovska O, Gao P, Widimsky P, Džavík V; TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy.N Engl J Med. 2015; 372:1389–1398. doi: 10.1056/NEJMoa1415098.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Nayak K, Skupin A, Schempp T, Garberich R, Bhavnani S and Henry T (2021) Machine learning for holistic visualization of STEMI registry data, Journal of Biomedical Informatics, 10.1016/j.jbi.2021.103869, 121, (103869), Online publication date: 1-Sep-2021. Januszek R, Siudak Z, Malinowski K, Wojdyła R, Mika P, Wańha W, Kameczura T, Surdacki A, Wojakowski W, Legutko J and Bartuś S (2020) Aspiration Thrombectomy in Patients with Acute Myocardial Infarction—5-Year Analysis Based on a Large National Registry (ORPKI), Journal of Clinical Medicine, 10.3390/jcm9113610, 9:11, (3610) May 30, 2017Vol 135, Issue 22 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.028198PMID: 28559506 Originally publishedMay 30, 2017 PDF download Advertisement
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