Coronary interventions

No-reflow after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: an angiographic core laboratory analysis of the TOTAL Trial

EuroIntervention 2023;19:e394-e401. DOI: 10.4244/EIJ-D-23-00112

Marc-André d'Entremont
Marc-André d'Entremont1,2, MD, MPH; Ashraf Alazzoni3, MD; Vladimir Dzavik4, MD; Vinoda Sharma5, MBBS; Christopher B. Overgaard6, MD; Samuel Lemaire-Paquette1, MSc; Pablo Lamelas7, MD; John A. Cairns8, MD; Shamir R. Mehta2,9, MD, MSc; Madhu K. Natarajan2,9, MD, MSc; Tej N. Sheth2,9, MD; John-David Schwalm2,9, MD, MSc; Sunil V. Rao10, MD; Goran Stankovic11, MD; Sasko Kedev12, MD; Raul Moreno13, MD; Warren J. Cantor6, MD; Shahar Lavi14, MD; Olivier F. Bertrand15, MD, PhD; Michel Nguyen1, MD; Étienne L. Couture1, MD, MPH; Sanjit S. Jolly2,9, MD, MSc
1. Sherbrooke University Hospital Center (CHUS), Sherbrooke, QC, Canada; 2. Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada; 3. Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE; 4. Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; 5. Birmingham City Hospital, University of Birmingham, Birmingham, UK; 6. Southlake Regional Health Centre, University of Toronto, Toronto, ON, Canada; 7. Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina; 8. Vancouver Coastal Health Research Institute, Vancouver, BC, Canada; 9. Hamilton Health Sciences, Hamilton, ON, Canada; 10. New York University Langone Health, New York, NY, USA; 11. Department of Cardiology, University Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia; 12. University Clinic of Cardiology, Ss. Cyril and Methodius University, Skopje, Republic of North Macedonia; 13. University Hospital La Paz, Madrid, Spain; 14. London Health Sciences Centre, London, ON, Canada; 15. Quebec Heart and Lung Institute, Quebec City, QC, Canada

Background: The optimal strategy to prevent no-reflow in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) is unknown.

Aims: We aimed to examine the effect of thrombectomy on the outcome of no-reflow in key subgroups and the adverse clinical outcomes associated with no-reflow.

Methods: We performed a post hoc analysis of the TOTAL Trial, a randomised trial of 10,732 patients comparing thrombectomy versus PCI alone. This analysis utilised the angiographic data of 1,800 randomly selected patients.

Results: No-reflow was diagnosed in 196 of 1,800 eligible patients (10.9%). No-reflow occurred in 95/891 (10.7%) patients randomised to thrombectomy compared with 101/909 (11.1%) in the PCI-alone arm (odds ratio [OR] 0.95, 95% confidence interval [CI]: 0.71-1.28; p-value=0.76). In the subgroup of patients who underwent direct stenting, those randomised to thrombectomy compared with PCI alone experienced less no-reflow (19/371 [5.1%] vs 21/216 [9.7%], OR 0.50, 95% CI: 0.26-0.96). In patients who did not undergo direct stenting, there was no difference between the groups (64/504 [12.7%] vs 75/686 [10.9%)], OR 1.18, 95% CI: 0.82-1.69; interaction p-value=0.02). No-reflow patients had a significantly increased risk of experiencing the primary composite outcome (cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA Class IV heart failure) at 1 year (adjusted hazard ratio 1.70, 95% CI: 1.13-2.56; p-value=0.01).

Conclusions: In patients with STEMI treated by PCI, thrombectomy did not reduce no-reflow in all patients but may be synergistic with direct stenting. No-reflow is associated with increased adverse clinical outcomes.

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