Adjunctive devices in primary or rescue PCI: a meta-analysis of randomized trials.
OBJECTIVE
To overview and summarize the results emerging from the studies on adjunctive devices (AD) with theoretical anti-embolic properties in patients with ST-elevation acute myocardial infarction (STEMI) undergoing percutaneous coronary interventions (PCI).


BACKGROUND
A series of small-to-medium size randomized studies have compared different AD with standard PCI (SP) in the setting of STEMI. The reported results are conflicting.


METHODS
Eighteen prospective randomized studies on 3180 STEMI patients comparing AD with SP were identified and entered the meta-analysis. Pre-specified angiographic, electrocardiographic (absence of ST-segment resolution, STR) and early (up to 30 days) clinical end-points were assessed.


RESULTS
AD were associated with lower rates of angiographically evident distal embolization: OR (95% CI): 0.54 (0.37-0.81). Analyses of angiographic and electrocardiographic reperfusion showed striking heterogeneity among studies and an overall trend toward better results with AD: OR (95% CI) 0.76 (95% CI 0.51-1.12) for TIMI<3, 0.53 (0.37-0.76) for myocardial blush grade (MBG)<3, 0.60 (0.45-0.78) for absence of STR. Subgroup analysis according to the type of AD for the end-point of no STR showed concordant absence of benefit in studies testing distal protection devices, positive results being confined to the studies using thrombectomy devices (OR 0.46, 95% CI 0.32-0.66). However, the possibility of a "small study" bias within thrombectomy studies cannot be discharged (significant heterogeneity and positive Egger's test). Early major adverse cardiac events were not different between AD and SP.


CONCLUSIONS
AD use may be associated with reduced rate of angiographic distal embolization, and improved MBG 3 and STR rates. However, efficacy might vary with the type of device employed. Moreover, early clinical outcome is not modified suggesting that further, larger, studies are needed to assess the clinical impact of AD.


CONCLUSIONS
We conducted a meta-analysis of 18 prospective randomized trials comparing adjunctive devices (AD) with standard PCI in the setting of STEMI. The use of AD was associated with lower rates of (angiographically evident) distal embolization. Analyses of angiographic and electrocardiographic reperfusion showed striking heterogeneity and an overall trend toward better results with AD. Subgroup analysis suggested that different types of device may have different effects. Early major adverse cardiac events were similar between AD and SP.
Burzotta
Francesco
F
Institute of Cardiology, Catholic University of the Sacred Heart, Via Prati Fiscali 158, 00141 Rome, Italy. f.burzotta@rm.unicatt.it
Testa
Luca
L
Giannico
Floriana
F
Biondi-Zoccai
Giuseppe G L
GG
Trani
Carlo
C
Romagnoli
Enrico
E
Mazzari
Mario
M
Mongiardo
Rocco
R
Siviglia
Massimo
M
Niccoli
Giampaolo
G
De Vita
Maria
M
Porto
Italo
I
Schiavoni
Giovanni
G
Crea
Filippo
F
D015906:Angioplasty, Balloon, Coronary / Q000295:instrumentation* / Q000379:methods; D006328:Cardiac Catheterization; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000502:physiology; D003328:Coronary Thrombosis / Q000517:prevention & control*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D015201:Meta-Analysis as Topic; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D011446:Prospective Studies; D019736:Prostheses and Implants; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012720:Severity of Illness Index; D015607:Stents; D016019:Survival Analysis; D016896:Treatment Outcome; D014654:Vascular Patency