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Chapter 1

The Thrombotic AMI Lesion: Lessons from Pathology more...

Chapter 2

Electrocardiographic Identification of the Culprit Lesion in ST-Segment Elevation Myocardial more...

Chapter 3

The Role of Thrombolysis in the Era of STEMI Interventions more...

Chapter 4

STEMI Interventions: A Review of Relevant Clinical Trials more...

Chapter 5

Updated Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction more...

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Chapter 9
Role of Thrombectomy in ST-Elevation Myocardial Infarction: Emerging Evidence
Joseph M. Sweeny, MD, Annapoorna S. Kini, MD, FACC, Samin K. Sharma, MD, FACC

Introduction
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion modality in patients presenting with ST-segment elevation myocardial infarction (STEMI). The timely re-establishment of antegrade coronary blood flow reduces infarct size, enhances myocardial perfusion, attenuates adverse LV remodeling and reduces long-term mortality. However, despite successful recanalization of the epicardial vessel with TIMI 3 flow, optimal myocardial reperfusion is not achieved in a significant percentage of STEMI patients, portending an unfavorable outcome. Distal embolization with subsequent microvascular obstruction in STEMI is an important determinant in poor tissue reperfusion, in up to 16% of patients undergoing primary PCI for STEMI, and is associated with increased infarct size, reduced recovery of ventricular function as well as increased mortality. Preventing embolization of thrombotic and atherosclerotic debris is an attractive strategy aimed at improving myocardial reperfusion and survival after AMI. Several adjunctive antithrombotic therapies as well as a wide array of mechanical thrombectomy and distal protection devices have been developed and evaluated in clinical studies for their role in preventing distal embolization. In particular, a number of clinical studies have evaluated the role and efficacy of thrombectomy devices in the setting of STEMI. Until recently, many of these investigations have been small and underpowered for clinical endpoint analysis and consequently have demonstrated disparate results. However, promising data from three recent randomized clinical trials (JETSTENT, TAPAS and EXPIRA) as well as three large meta-analyses have established the role of thrombectomy for STEMI. Accordingly, such data supports the recent Class IIa recommendation for aspiration thrombectomy put forward by the 2009 focused update on AHA/ACC guidelines for the management of patients with ST-elevation myocardial infarction. This chapter will focus on the current patterns for use of thrombectomy mechanical (manual and mechanical/rheolytic aspiration), provide a description of commonly used thrombectomy devices and briefly discuss emerging evidence from retrospective analyses and prospective clinical trials regarding optimal patient selection for mechanical thrombectomy. Lastly, a simplified decision algorithm that incorporates clinical and angiographic characteristics (thrombus burden) based on our institutional experience and published data has been included to provide a useful approach to integrate thrombectomy into routine clinical practice for treating patients with STEMI.

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