A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction

Loubeyre, Christophe; Morice, Marie‐Claude; Lefèvre, Thierry; Piéchaud, Jean-François; Louvard, Yves; Dumas, Pierre

doi:10.1016/s0735-1097(01)01701-6

Cited by 204 publications

(122 citation statements)

References 32 publications

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“…In the postconditioned group, within 1 minute of reflow after the direct stenting, the angioplasty balloon was positioned just upstream of the implanted stent (so that it would not be damaged and to prevent possible thrombi embolization during in-stent balloon reinflation) and reinflated 4 times for 1 minute with low-pressure (4 to 6 atm) inflations, each separated by 1 minute of reflow (Figure 1). 16 This sequence of 4 brief episodes of ischemia-reperfusion was chosen arbitrarily because we recently demonstrated that a similar regimen triggers postconditioning in the rabbit heart. 17 When the balloon was positioned just upstream of the implanted stent in the postconditioned group, care was taken not to encompass a coronary branch.…”

Section: Experimental Protocolmentioning

confidence: 99%

Postconditioning the Human Heart

et al. 2005

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Background-In animal models, brief periods of ischemia performed just at the time of reperfusion can reduce infarct size, a phenomenon called postconditioning. In this prospective, randomized, controlled, multicenter study, we investigated whether postconditioning may protect the human heart during coronary angioplasty for acute myocardial infarction. Methods and Results-Thirty patients, submitted to coronary angioplasty for ongoing acute myocardial infarction, contributed to the study. Patients were randomly assigned to either a control or a postconditioning group. After reperfusion by direct stenting, control subjects underwent no further intervention, whereas postconditioning was performed within 1 minute of reflow by 4 episodes of 1-minute inflation and 1-minute deflation of the angioplasty balloon. Infarct size was assessed by measuring total creatine kinase release over 72 hours. Area at risk and collateral blood flow were estimated on left ventricular and coronary angiograms. No adverse events occurred in the postconditioning group. Determinants of infarct size, including ischemia time, size of the area at risk, and collateral flow, were comparable between the 2 groups. Area under the curve of creatine kinase release was significantly reduced in the postconditioning compared with the control group, averaging 208 984Ϯ26 576 compared with 326 095Ϯ48 779 (arbitrary units) in control subjects, ie, a 36% reduction in infarct size. Blush grade, a marker of myocardial reperfusion, was significantly increased in postconditioned compared with control subjects: 2.44Ϯ0.17 versus 1.95Ϯ0.27, respectively (PϽ0.05). Conclusions-This

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Section: Experimental Protocolmentioning

confidence: 99%

Postconditioning the Human Heart

et al. 2005

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“…Direct stenting without predilation may decrease embolization and the incidence of the no-reflow phenomenon. 2,3 More specific approaches to the problem of microvessel embolization during PCI include thrombectomy by different techniques and the use of anti-embolic protection devices. One randomized trial has reported rheolytic thrombectomy to be effective in decreasing embolization in patients who underwent PCI on venous grafts or native coronary vessel with massive thrombosis 4 ; however, few data exist on the effectiveness of rheolytic thrombectomy in the setting of AMI.…”

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confidence: 99%

Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction

Antoniucci¹,

Valenti²,

Migliorini³

et al. 2004

The American Journal of Cardiology

155

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This randomized trial compared rheolytic thrombectomy before direct infarct artery stenting with direct infarct artery stenting alone in 100 patients with a first acute myocardial infarction (AMI). The primary end point of the study was early ST-segment elevation resolution, and the secondary end points were corrected Thrombolysis In Myocardial Infarction (TIMI) frame count, infarct size, and 1-month clinical outcome. The primary end point rates were 90% in the thrombectomy group and 72% in the placebo group (p ‫؍‬ 0.022). Randomization to thrombectomy was independently related to the primary end point (odds ratio 3.56, p ‫؍‬ 0.032). M acro-and microembolization during percutaneous coronary intervention (PCI) is frequent and may result in the obstruction of the microvessel coronary network. 1 In the setting of acute myocardial infarction (AMI), PCI-related embolization results in a decreased efficacy of mechanical reperfusion and myocardial salvage. Direct stenting without predilation may decrease embolization and the incidence of the no-reflow phenomenon. 2,3 More specific approaches to the problem of microvessel embolization during PCI include thrombectomy by different techniques and the use of anti-embolic protection devices. One randomized trial has reported rheolytic thrombectomy to be effective in decreasing embolization in patients who underwent PCI on venous grafts or native coronary vessel with massive thrombosis 4 ; however, few data exist on the effectiveness of rheolytic thrombectomy in the setting of AMI. 5,6 This randomized trial assessed the efficacy of rheolytic thrombectomy before direct infarct artery stent implantation in patients who underwent PCI for AMI.• • • Criteria for enrollment included chest pain persisting Ͼ30 minutes associated with an ST-segment elevation of Ն0.1 mV in Ն2 contiguous electrocardiographic leads. The exclusion criteria included (1) previous myocardial infarction, (2) administration of fibrinolytic therapy, (3) bundle branch block or ventricular pacing on the baseline electrocardiogram preventing analysis of the ST-segment changes, (4) infarct-related artery (IRA) diameter Ͻ2.5 mm on visual angiographic assessment, and (5) inability to obtain informed consent. Patients with cardiogenic shock due to predominant ventricular failure were included, as were patients with high-risk coronary anatomy. After coronary angiography, eligible patients were randomly assigned to direct IRA stenting alone or thrombectomy before stenting. Computer-generated sequences and assignments using a closed envelope system were used to perform randomization. Thrombectomy was accomplished with the second-generation rheolytic thrombectomy 4Fr catheter (AngioJet, Possis Medical, Minneapolis, Minnesota). Two types of stents were used: a tubular closed-cell carbon-coated stent (Techno, Sorin, Saluggia, Italy) and a tubular open-cell stent (Zeta, Guidant, Santa Clara, California). All patients received abciximab (ReoPro, Centocor, Malvern, Pennsylvania), if not contraindicated, immediately before the ...

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“…Direct stenting without predilatation also was more frequent after thrombus aspiration, which may have contributed to the favorable results. 107 Infarct size was not measured in this study. Thus, these results require confirmation in a multicenter randomized trial (with infarct size determination) before they can be considered definitive.…”

Section: Stone Interventional Strategies In Stemi 559mentioning

confidence: 88%

Angioplasty Strategies in ST-Segment–Elevation Myocardial Infarction

Stone

2008

Circulation

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A s reviewed in part I of this report, 1 primary PCI without antecedent fibrinolytic therapy has become widely accepted as the preferred reperfusion modality for patients with ST-segment-elevation myocardial infarction (STEMI) presenting at suitably equipped tertiary facilities. However, primary percutaneous coronary intervention (PCI) is not offered at Ն50% of US hospitals, and many of those that do are unable to offer primary PCI as an around-the-clock service. Primary PCI also is less widely available in many other countries than in the United States. Thus, fibrinolytic therapy continues to be administered to many patients with STEMI. 2,3 Given the relatively low rates of successful reperfusion with fibrinolysis, 4,5 revascularization often is required afterward, the indications for and outcomes of which are critically evaluated here. The impact of individual operator and institutional volumes on PCI outcomes is reviewed. Evidencebased recommendations for selecting among the various reperfusion therapy options are then offered for the patients with STEMI presenting at centers with and without interventional capabilities, with distinctions drawn where the evidence-based recommendations in this article differ substantially from recently updated task force guidelines of the American College of Cardiology (ACC) and American Heart Association (AHA). 5 Finally, recent and ongoing investigations to further improve outcomes after catheter-based reperfusion therapy are summarized. Angioplasty After Fibrinolytic TherapyPCI after fibrinolytic therapy in STEMI may be performed in a variety of settings: (1) rescue PCI after failed fibrinolysis in patients with ongoing symptoms, myocardial injury, or persistent coronary occlusion, typically initiated within 60 to 120 minutes after fibrinolytic administration; (2) immediate PCI (also known as facilitated PCI), performed within several hours after fibrinolytic administration, regardless of whether clinical or ECG evidence of ongoing myocardial injury is present; (3) delayed routine PCI, in which patients who are stable for several days after fibrinolytic administration undergo angiography and PCI, regardless of the presence or absence of ischemia or myocardial viability; and (4) delayed selective angioplasty, in which only patients with spontaneous or inducible ischemia after fibrinolysis undergo catheterization and PCI when appropriate.Similar to primary PCI, each of these interventional strategies describes an approach of angiography followed by triage to angioplasty, coronary artery bypass graft surgery, or medical therapy, a decision based on the coronary anatomy, left ventricular function, and other patient-related factors. However, PCI is performed in Ϸ80% to 90% of angiographically screened patients requiring revascularization. Rescue PCIRescue PCI refers to the strategy of urgent catheterization after fibrinolytic therapy has clinically failed to restore reperfusion of the infarct artery. Patients in whom fibrinolysis fails to restore patency of the infarct-related a...

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A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction

Abstract: In selected patients with AMI, direct stenting can be applied safely and effectively. This strategy may result in a significant reduction of microvascular injury, as suggested by improved ST-segment resolution after reperfusion with major potential clinical consequences.

Cited by 204 publications

References 32 publications

Postconditioning the Human Heart

Postconditioning the Human Heart

Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction

Angioplasty Strategies in ST-Segment–Elevation Myocardial Infarction

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