title: Culprit lesion thrombus burden after manual thrombectomy or percutaneous coronary intervention-alone in ST-segment elevation myocardial infarction: the optical coherence tomography sub-study of the TOTAL (ThrOmbecTomy versus PCI ALone) trial.
abstract: OBJECTIVE
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Royal North Shore Hospital, Sydney, and University of Sydney, Sydney, Australia.
authors.forename: Ravinay
authors.initials: R
authors.lastname: Bhindi
authors.affiliation: Heart Hospital, Tampere University Hospital and School of Medicine, University of Tampere, Tampere, Finland.
authors.forename: Olli A
authors.initials: OA
authors.lastname: Kajander
authors.affiliation: 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.
authors.forename: Sanjit S
authors.initials: SS
authors.lastname: Jolly
authors.affiliation: Rouge Valley Health System Centenary, Cardiac Care Program, Toronto, ON, Canada.
authors.forename: Saleem
authors.initials: S
authors.lastname: Kassam
authors.affiliation: Department of Cardiology, London Health Sciences Centre, London, ON, Canada.
authors.forename: Shahar
authors.initials: S
authors.lastname: Lavi
authors.affiliation: Heart Hospital, Tampere University Hospital and School of Medicine, University of Tampere, Tampere, Finland.
authors.forename: Kari
authors.initials: K
authors.lastname: Niemelä
authors.affiliation: Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Anthony
authors.initials: A
authors.lastname: Fung
authors.affiliation: St. Michael's Hospital, Toronto, ON, Canada.
authors.forename: Asim N
authors.initials: AN
authors.lastname: Cheema
authors.affiliation: 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.
authors.forename: Brandi
authors.initials: B
authors.lastname: Meeks
authors.affiliation: Cardiology Department, Patras University Hospital, Patras, Greece.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Alexopoulos
authors.affiliation: Medicine, Charles University in Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
authors.forename: Viktor
authors.initials: V
authors.lastname: Kočka
authors.affiliation: Southlake Regional Health Centre, University of Toronto, Newmarket, ON, Canada.
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Cantor
authors.affiliation: Heart Hospital, Tampere University Hospital and School of Medicine, University of Tampere, Tampere, Finland.
authors.forename: Timo P
authors.initials: TP
authors.lastname: Kaivosoja
authors.affiliation: 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.
authors.forename: Olga
authors.initials: O
authors.lastname: Shestakovska
authors.affiliation: 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.
authors.forename: Peggy
authors.initials: P
authors.lastname: Gao
authors.affiliation: Department of Cardiology, Clinical Center of Serbia, and Medical Faculty, University of Belgrade, Belgrade, Serbia.
authors.forename: Goran
authors.initials: G
authors.lastname: Stankovic
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
authors.forename: Vladimír
authors.initials: V
authors.lastname: Džavík
authors.affiliation: 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 shetht@mcmaster.ca.
authors.forename: Tej
authors.initials: T
authors.lastname: Sheth
mesh_terms: D003324:Coronary Artery Disease / Q000601:surgery; D003328:Coronary Thrombosis / Q000601:surgery*; D017281:Cost of Illness; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000601:surgery*; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D012307:Risk Factors; D015607:Stents; D017131:Thrombectomy / Q000379:methods*; D061665:Time-to-Treatment; D041623:Tomography, Optical Coherence
keywords: Myocardial infarction; Optical coherence tomography; STEMI; Thrombectomy; Thrombus