No-reflow after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction : an angiographic core laboratory analysis of the TOTAL Trial
d'Entremont, Marc-André Alazzoni, Ashraf Dzavik, Vladimir Sharma, Vinoda Overgaard, Christopher B Lemaire-Paquette, Samuel Lamelas, Pablo Cairns, John A Mehta, Shamir R Natarajan, Madhu K
d'Entremont, Marc-André
Alazzoni, Ashraf
Dzavik, Vladimir
Sharma, Vinoda
Overgaard, Christopher B
Lemaire-Paquette, Samuel
Lamelas, Pablo
Cairns, John A
Mehta, Shamir R
Natarajan, Madhu K
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Affiliation
Sherbrooke University Hospital Center; McMaster University; Cleveland Clinic Abu Dhabi; Sandwell and West Birmingham NHS Trust; et al.
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Publication date
2023-08-07
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Abstract
Background: The optimal strategy to prevent no-reflow in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) is unknown. Aims: We aimed to examine the effect of thrombectomy on the outcome of no-reflow in key subgroups and the adverse clinical outcomes associated with no-reflow. Methods: We performed a post hoc analysis of the TOTAL Trial, a randomised trial of 10,732 patients comparing thrombectomy versus PCI alone. This analysis utilised the angiographic data of 1,800 randomly selected patients. Results: No-reflow was diagnosed in 196 of 1,800 eligible patients (10.9%). No-reflow occurred in 95/891 (10.7%) patients randomised to thrombectomy compared with 101/909 (11.1%) in the PCI-alone arm (odds ratio [OR] 0.95, 95% confidence interval [CI]: 0.71-1.28; p-value=0.76). In the subgroup of patients who underwent direct stenting, those randomised to thrombectomy compared with PCI alone experienced less no-reflow (19/371 [5.1%] vs 21/216 [9.7%], OR 0.50, 95% CI: 0.26-0.96). In patients who did not undergo direct stenting, there was no difference between the groups (64/504 [12.7%] vs 75/686 [10.9%)], OR 1.18, 95% CI: 0.82-1.69; interaction p-value=0.02). No-reflow patients had a significantly increased risk of experiencing the primary composite outcome (cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA Class IV heart failure) at 1 year (adjusted hazard ratio 1.70, 95% CI: 1.13-2.56; p-value=0.01). Conclusions: In patients with STEMI treated by PCI, thrombectomy did not reduce no-reflow in all patients but may be synergistic with direct stenting. No-reflow is associated with increased adverse clinical outcomes.
Citation
d'Entremont MA, Alazzoni A, Dzavik V, Sharma V, Overgaard CB, Lemaire-Paquette S, Lamelas P, Cairns JA, Mehta SR, Natarajan MK, Sheth TN, Schwalm JD, Rao SV, Stankovic G, Kedev S, Moreno R, Cantor WJ, Lavi S, Bertrand OF, Nguyen M, Couture ÉL, Jolly SS. No-reflow after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: an angiographic core laboratory analysis of the TOTAL Trial. EuroIntervention. 2023 Aug 7;19(5):e394-e401. doi: 10.4244/EIJ-D-23-00112
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Article