title: Myocardial blush and microvascular reperfusion following manual thrombectomy during percutaneous coronary intervention for ST elevation myocardial infarction: insights from the TOTAL trial.
abstract: Thrombectomy during primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) has been thought to be an effective therapy to prevent distal embolization and improve microvascular perfusion. The TOTAL trial (N = 10 732), a randomized trial of routine manual thrombectomy vs. PCI alone in STEMI, showed no difference in the primary efficacy outcome. This angiographic sub-study was performed to determine if thrombectomy improved microvascular perfusion as measured by myocardial blush grade (MBG).
  
  
  
  Of the 10 732 patients randomized, 1610 randomly selected angiograms were analysable by the angiographic core laboratory. Primary outcomes included MBG and post-PCI thrombolysis in myocardial infarction (TIMI) flow grade. Secondary outcomes included distal embolization, PPCI complications, and each component of the complications. The primary end point of final myocardial blush (221 [28%] 0/1 for thrombectomy vs. 246 {30%} 0/1 for PCI alone group, P = 0.38) and TIMI flow (712 [90%] TIMI 3 for thrombectomy vs. 733 [89.5%] TIMI 3 for PCI alone arm, P = 0.73) was similar in the two groups. Thrombectomy was associated with a significantly reduced incidence of distal embolization compared with PCI alone (56 [7.1%] vs. 87 [10.7%], P = 0.01). In multivariable analysis, distal embolization was an independent predictor of mortality (HR 3.00, 95% CI 1.19-7.58) while MBG was not (HR 2.73, 95% CI 0.94-5.3).
  
  
  
  Routine thrombectomy during PPCI did not result in improved MBG or post-PCI TIMI flow grade but did reduce distal embolization compared with PCI alone. Distal embolization and not blush grade is independently associated with mortality.
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: Vinoda
authors.initials: V
authors.lastname: Sharma
authors.affiliation: The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, Hamilton, ON, Canada.
authors.forename: Sanjit S
authors.initials: SS
authors.lastname: Jolly
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: Tahir
authors.initials: T
authors.lastname: Hamid
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: Divyesh
authors.initials: D
authors.lastname: Sharma
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: Joseph
authors.initials: J
authors.lastname: Chiha
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: William
authors.initials: W
authors.lastname: Chan
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: Felipe
authors.initials: F
authors.lastname: Fuchs
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: Sanh
authors.initials: S
authors.lastname: Bui
authors.affiliation: The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, Hamilton, ON, Canada.
authors.forename: Peggy
authors.initials: P
authors.lastname: Gao
authors.affiliation: Rouge Valley Health System, Toronto, ON, Canada.
authors.forename: Saleem
authors.initials: S
authors.lastname: Kassam
authors.affiliation: CK Hui Heart Centre, Edmonton, AB, Canada.
authors.forename: Raymond C M
authors.initials: RC
authors.lastname: Leung
authors.affiliation: KrajskáNemocnice Liberec, Liberec, Czech Republic.
authors.forename: David
authors.initials: D
authors.lastname: Horák
authors.affiliation: Heart Centre, Kuopio University Hospital, Kuopio, Finland.
authors.forename: Hannu O
authors.initials: HO
authors.lastname: Romppanen
authors.affiliation: Central Manchester Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
authors.forename: Magdi
authors.initials: M
authors.lastname: El-Omar
authors.affiliation: Central Manchester Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
authors.forename: Saqib
authors.initials: S
authors.lastname: Chowdhary
authors.affiliation: Clinical Center of Serbia, Department of Cardiology, Medical Faculty, University of Belgrade, Belgrade, Serbia.
authors.forename: Goran
authors.initials: G
authors.lastname: Stanković
authors.affiliation: University Clinic of Cardiology, Sts. Cyril and Methodius University, Skopje, Macedonia.
authors.forename: Saško
authors.initials: S
authors.lastname: Kedev
authors.affiliation: The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, Hamilton, ON, Canada.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Rokoss
authors.affiliation: The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, Hamilton, ON, Canada.
authors.forename: Tej
authors.initials: T
authors.lastname: Sheth
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4.
authors.forename: Vladimír
authors.initials: V
authors.lastname: Džavík
authors.affiliation: Peter Munk Cardiac Centre, University Health Network, 6 Eaton North Room 232, Toronto, ON, Canada Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4 chris.overgaard1@gmail.com.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Overgaard
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D006801:Humans; D009203:Myocardial Infarction; D062645:Percutaneous Coronary Intervention; D000072657:ST Elevation Myocardial Infarction; D017131:Thrombectomy; D016896:Treatment Outcome
keywords: Myocardial Blush Grade; STEMI; Thrombectomy