An end to the routine use of manual thrombectomy in STEMI?

Earlier this month the results of long awaited TOTAL trial were presented at the ACC meeting and simultaneously published in NEJM. TOTAL is the largest randomised trial to date which investigated the routine upfront manual thrombectomy with PCI alone in STEMI. 10,732 patients with STEMI undergoing primary PCI were randomised. The primary outcome was a composite of death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days. The key safety outcome was stroke within 30 days. Manual aspiration thrombectomy was associated with lower rates of incomplete ST-segment resolution and distal embolization, however, this did not alter the clinical outcome. The primary outcome was 6.9% with thrombectomy and 7.0% with PCI alone (HR 0.99; 95% CI 0.85-1.15). More importantly, this finding was consistent across all pre-specified subgroups, including in patients with large thrombus burden. Although, incidence of safety outcome of stroke was statistically lower in PCI alone group, both at 30 days and 180 days, the trial was underpowered to detect this difference and this finding may be due to chance alone. There are several caveats in this trial. First, it was an open design which may have introduced a selection bias. Second, the inclusion of some patients with a low thrombus burden that would be less responsive to thrombectomy and lastly authors did not study the effect of selective use of thrombectomy versus no t...
Source: Doc2Doc BMJ Cardiology - Category: Cardiology Authors: Source Type: forums