1. JOURNAL CLUBDr Awadhesh Kumar Sharma

2. INTRODUCTION Primary percutaneous coronary intervention (pPCI) is highly effective in restoring a normal Thrombolysis In Myocardial Infarction (TIMI) flow in patients with ST segment elevation acute myocardial infarction (STEMI). But a relevant proportion of patients (approx 15%) shows a poor myocardial reperfusion, which strongly correlates with larger infarct size and worse clinical outcome. Thrombectomy devices aim at improving myocardial reperfusion by preventing distal thrombus embolization during pPCI.

3. After controversial results of the initial studies, 2 recent randomized single-center studies demonstrated a significant benefit of thrombus aspiration on clinical outcome although not on infarct size. Currently, magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) is the best method to assess infarct size. (TAPAS): a 1-year follow-up study. Lancet 2008;371:191520. JETSTENT trial. J Am Coll Cardiol 2010;56:1298 306

4. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration duringPercutaneous coronary intervention in Acute myocardial infarction Study(TAPAS): a 1-year follow-up study Findings Cardiac death at 1 year was 36% (19 of 535 patients) in the thrombus aspiration group and 67% (36 of 536) in the conventional PCI group (hazard ratio [HR] 193; 95% CI 111 337; p=0020). 1-year cardiac death or non-fatal reinfarction occurred in 56% (30 of 535) of patients in the thrombus aspiration group and 99% (53 of 536) of patients in the conventional PCI group (HR 181; 95% CI 116284; p=0009). Interpretation Compared with conventional PCI, thrombus aspiration before stenting of the infarcted artery seems to improve the 1-year clinical outcome after PCI for ST-elevation myocardial infarction. Lancet 2008;371:191520.

5. TAPAS: 1-Year Results Trial design: Patients with ST-elevation myocardial infarction were randomized to thrombus aspiration prior to PCI (n = 535) or standard PCI without aspiration (n = 536) and followed for 1 year. Results All-cause mortality: 4.7% vs. 7.6% (p = (p = 0.042) (p = 0.05) 0.042), respectively Cardiac death: 3.6% vs. 6.7% (p = 0.02), 4.7 7.6 respectively 8 Reinfarction: 2.2% vs. 4.3% (p = 0.05),% 2.2 4.3 respectively 4 Conclusions In earlier presentation of TAPAS, thrombus aspiration 0 Reinfarction during acute MI improved reperfusion All-cause mortality All-cause mortality Re-infarction Extended follow-up to 1 year demonstrates that this strategy reduces death and MI Thrombus Standard PCI aspiration Vlaar PJ, et al. Lancet 2008;371:1915-20

6. Comparison of AngioJet Rheolytic Thrombectomy Before Direct Infarct ArteryStenting With Direct Stenting Alone in Patients With Acute MyocardialInfarctionThe JETSTENT Trial Results From December 2005 to September 2009, 501 patients were randomly allocated to RT before DS or to DS alone. The ST- segment resolution was more frequent in the RT arm as compared with the DS alone arm: 85.8% and 78.8%, respectively (p = 0.043), while no difference between groups were revealed in the other surrogate end points. The 6-month major adverse cardiovascular events rate was 11.2% in the thrombectomy arm and 19.4% in the DS alone arm (p = 0.011). The 1-year event- free survival rates were 85.2 2.3% for the RT arm, and 75.0 3.1% for the DS alone arm (p = 0.009). Conclusions Although the primary efficacy end points were not met, the results of this study support the use of RT before infarct artery stenting in patients with acute myocardial infarction and evidence of coronary thrombus. JETSTENT trial. J Am Coll Cardiol 2010;56:1298 306

7. The aim of the study The aim of this study was to assess the impact of thrombectomy, either manual or rheolytic, on myocardial reperfusion and infarct size in patients with high thrombotic burden.

8. Methods Study design and patients- A multicenter prospective randomized study Assigned patients in a 1:1 ratio to either thrombectomy as an adjunct to pPCI (Group T) or standard pPCI without thrombectomy (Group S)

9. Inclusion criteria Age >/= 18 years; STEMI (new ST-segment elevation of >1 mm in at least 2 contiguous leads or new left bundle branch block) within 12 h of symptom onset TIMI thrombus grade >3 after diagnostic angiography according to Sianos et al. Reference diameter of the infarct related artery >/= 3.0 mm at visual estimate Sianos G, Papafaklis MI, Daemen J, et al. Angiographic stent thrombosis after routine use of drug-eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden. J Am Coll Cardiol 2007;50:573 83.

10. Exclusion criteria Previous infarct in the same ventricular wall; Cardiogenic shock; Severe liver/renal failure; Contraindications to abciximab; and Contraindications to MRI. Recent PCI (1/2 but