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Published on: May 28, 2019
Effect of Coronary Thrombectomy in Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction
Makoto Suzuki1, Tetsuya Sumiyoshi2, Hideki Miyachi3
1Department of Cardiovascular Medicine, Sakakibara Heart Institute, Tokyo, Japan; Tokyo CCU Network Scientific Council, Tokyo, Japan.
Insights
Pre-percutaneous coronary intervention (PCI) thrombectomy did not improve optimal coronary reflow or reduce in-hospital mortality in patients with cardiogenic shock complicating ST-elevation myocardial infarction (STEMI). New strategies are needed for this critical condition.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Research
Background:
- Optimal coronary reflow is crucial for improving clinical outcomes in patients with cardiogenic shock complicating ST-elevation myocardial infarction (STEMI).
- The potential benefit of pre-percutaneous coronary intervention (PCI) coronary thrombectomy in achieving optimal reflow in this high-risk population remains unclear.
Purpose of the Study:
- To investigate whether pre-PCI coronary thrombectomy improves optimal coronary reflow and reduces in-hospital mortality in patients with STEMI complicated by cardiogenic shock.
- To evaluate the effectiveness of coronary thrombectomy in achieving Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 post-PCI.
Main Methods:
- A retrospective analysis of 180 patients with STEMI and cardiogenic shock (TIMI flow grade 0) from the Tokyo CCU Network Scientific Council (2009-2011).
- Patients were divided into those who underwent coronary thrombectomy (n=128) and those who did not (n=52).
- Outcomes assessed included achievement of TIMI flow grade 3 and in-hospital mortality, with subgroup analysis for patients in profound shock requiring mechanical circulatory support.
Main Results:
- Coronary thrombectomy was performed in 71% of patients, with overall in-hospital mortality at 41%.
- Thrombectomy did not significantly improve the achievement of optimal coronary reflow (65% vs. 58%, p=0.368) or reduce in-hospital mortality (42% vs. 37%, p=0.484).
- In patients with profound shock, thrombectomy also showed no significant difference in optimal reflow (56% vs. 47%, p=0.518) or mortality (58% vs. 65%, p=0.601).
Conclusions:
- Pre-PCI coronary thrombectomy has limitations in achieving optimal coronary reflow in patients with STEMI and cardiogenic shock.
- The findings suggest a need for novel strategies to improve outcomes in this critically ill patient group.
- Multivariate analysis identified hemoglobin concentration as a significant factor associated with optimal coronary reflow, but not thrombectomy or mechanical support.
Abstract:
Optimal coronary reflow is the critical key issue to ameliorate clinical outcomes in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction (Shock-STEMI). We investigated our hypothesis that pre-percutaneous coronary intervention (PCI) procedural coronary thrombectomy may provide clinical advantages to attempt optimal coronary reflow in patients with Shock-STEMI. Of 7,650 patients with acute myocardial infarction registered in the Tokyo CCU Network Scientific Council from January 2009 to December 2011, a total of 180 consecutive patients (144 men, 68 ± 13 years) with Shock-STEMI who showed pre-PCI procedural Thrombolysis in Myocardial Infarction flow grade 0 (absent initial coronary flow) were recruited. Achievements of post-PCI procedural Thrombolysis in Myocardial Infarction flow grade 3 (optimal coronary reflow) and also in-hospital mortality were evaluated in those in accordance with and without coronary thrombectomy. Coronary thrombectomy was performed in 128 patients with Shock-STEMI (71% of all). Overall in-hospital mortality was 41% and that in anterior Shock-STEMI with a necessity of mechanical circulatory support increased by 59% (i.e., profound shock). Coronary thrombectomy did not affect any improvements in the achievement of optimal coronary reflow (65% vs 58%, p = 0.368) and in-hospital mortality (42% vs 37%, p = 0.484) in these patients. Even when focused on 76 patients with profound shock, neither an achievement of optimal coronary reflow (56% vs 47%, p = 0.518) nor in-hospital mortality (58% vs 65%, p = 0.601) were different between with and without coronary thrombectomy. Multivariate logistic analysis did not demonstrate any association of coronary thrombectomy (p = 0.798), left main Shock-STEMI (p = 0.258), and use of mechanical circulatory support (p = 0.119) except a concentration of hemoglobin (for each 1 g/dl increase, odds ratio 1.247, 95% confidence interval 1.035 to 1.531, p = 0.019) with optimal coronary reflow. In conclusion, pre-PCI procedural coronary thrombectomy may have serious limitations on attempting optimal coronary reflow that indicates a necessity of promising strategies for this critical illness.
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