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.

Sign in to read and download the full article

Forgot your password?

No account yet?
Sign up for free!

Create my pcr account

Join us for free and access thousands of articles from EuroIntervention, as well as presentations, videos, cases from PCRonline.com

drug-eluting stentstemithrombus-containing lesion
Read next article
Biodegradable or durable polymer drug-eluting stents in patients with coronary artery disease: ten-year outcomes of the randomised NEXT Trial

Latest news