AIMS: Manual thrombectomy has been proposed as a strategy to reduce thrombus burden during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, the effectiveness of manual thrombectomy in reducing thrombus burden is uncertain. In this substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial, we compared the thrombus burden at the culprit lesion using optical coherence tomography (OCT) in patients treated with thrombectomy vs. PCI-alone. METHODS AND RESULTS: The TOTAL trial (N = 10 732) was an international, multicentre, randomized trial of thrombectomy (using the Export catheter, Medtronic Cardiovascular, Santa Rosa, CA, USA) in STEMI patients treated with primary PCI. The OCT substudy prospectively enrolled 214 patients from 13 sites in 5 countries. Optical coherence tomography was performed immediately after thrombectomy or PCI-alone and then repeated after stent deployment. Thrombus quantification was performed by an independent core laboratory blinded to treatment assignment. The primary outcome of pre-stent thrombus burden as a percentage of segment analysed was 2.36% (95% CI: 1.73-3.22) in the thrombectomy group and 2.88% (95% CI: 2.12-3.90) in the PCI-alone group (P = 0.373). Absolute pre-stent thrombus volume was not different (2.99 vs. 3.74 mm(3), P = 0.329). Other secondary outcomes of pre-stent quadrants of thrombus, post-stent atherothrombotic burden, and post-stent atherothrombotic volume were not different between groups. CONCLUSION: Manual thrombectomy did not reduce pre-stent thrombus burden at the culprit lesion compared with PCI-alone. Both strategies were associated with low thrombus burden at the lesion site after the initial intervention to restore flow.

Cardiology Department Patras University Hospital Patras Greece

Department of Cardiology Clinical Center of Serbia and Medical Faculty University of Belgrade Belgrade Serbia

Department of Cardiology London Health Sciences Centre London ON Canada

Division of Cardiology Vancouver General Hospital University of British Columbia Vancouver BC Canada

Heart Hospital Tampere University Hospital and School of Medicine University of Tampere Tampere Finland

Medicine Charles University Prague and University Hospital Kralovske Vinohrady Prague Czech Republic

Peter Munk Cardiac Centre University Health Network Toronto ON Canada

Population Health Research Institute and Department of Medicine McMaster University and Hamilton Health Sciences David Braley Cardiac Vascular and Stroke Research Institute 237 Barton St E Hamilton ON Canada L8L 2X4

Rouge Valley Health System Centenary Cardiac Care Program Toronto ON Canada

Royal North Shore Hospital Sydney and University of Sydney Sydney Australia

Southlake Regional Health Centre University of Toronto Newmarket ON Canada

St Michael's Hospital Toronto ON Canada

Eur Heart J. 2019 Oct 7;40(38):e14-e16. doi: 10.1093/eurheartj/ehv231. PubMed

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