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Controversies in primary percutaneous coronary intervention

Timely and effective primary percutaneous coronary intervention (PPCI) is a life-saving intervention in patients with evolving ST-elevation myocardial infarction (STEMI). Thanks to national cardiology societies, enthusiastic »national champions« and »Stent for life« initiative launched by EAPCI a few years ago, PPCI is becoming a predominant reperfusion strategy in a majority of European countries.

  • Selective use of drug-eluting stents: Pro, presented by G De Luca (Novara, IT) - Slides, Rebuttal Slides
  • Selective use of drug-eluting stents: Contra, presented by H Suryapranata (Nijmegen, NL) - Slides, Rebuttal Slides
  • Systematic manual thrombose aspiration: Contra, presented by L Thuesen (Aarhus N, DK) - Slides, Rebuttal Slides
  • Systematic manual thrombose aspiration: Pro, presented by F Burzotta (Roma, IT) - Slides, Rebuttal Slides
Acute Coronary Syndromes (ACS)

The primary aim of PPCI is not limited to the restoration of coronary patency but rather to achieving effective myocardial reperfusion indicated by early and complete ST elevation resolution and optimal myocardial blush. Since "slow and no-reflow" is usually provoked by distal embolization of culprit thrombus/plaque, manual catheter aspiration appeared as an attractive and simple adjunct to conventional PPCI. Indeed, it has been demonstrated that aspiration prior to definite intervention which is usually stenting, improves myocardial reperfusion and is likely, as indicated by well-known TAPAS study, to increase survival.

The usual dilemma of a practicing interventionalist after successfully passing a guidewire down the infarct related artery is whether to use manual aspiration systematically in all patients or only in selected patients with angiographically obvious thrombotic burden. On one hand, one has to admit that angiography is rather insensitive for thrombus evaluation and despite low thrombus score, significant amount of aspirate may be obtained.

On the other hand, "unnecessary" aspiration with no or little aspirate may result only in rare but possible procedural complications such as dissection and spasm of infarct related artery. Since appropriate studies have not been done to answer this important question, proportion of manual aspiration varies significantly between interventional cardiologists. There are several ongoing randomized trials powered also for clinical outcome endpoints which will help us to use this, I believe, essential intervention during PPCI, in the best interest of our patients.

Another burning question in the PPCI field is the utilization of DES instead of BMS to reduce restenosis rate without compromising the efficacy and safety of PPCI. Randomized studies in selected patients with STEMI undergoing PPCI have confirmed the validity of hypothesis. Despite these studies, the interventional community is divided and DES penetration in PPCI vary from 0 to almost 100%. "Defenders of BMS" strategies argue that BMS restenosis is significantly less frequent after PPCI as compared to elective PCI and that one should focus toward optimal reperfusion and stent sizing and not a remote issue of restenosis. It is true also that the benefits in reduction of restenosis after PPCI are mainly driven by restenosis-high risk subgroups including patients with diabetes and patients who need longer stents of smaller diameter.

On the other hand, "DES defenders" believe that available randomized trials with up to 4 years of follow up are sufficient to demonstrate that we can safely and effectively achieve both goals already during index intervention-optimal myocardial reperfusion and reduced target vessel revascularization.

Again, further randomized trials including EXAMINATION which is being presented during this ESC congress, will shed more light to answer the important question of selective or systematic use of DES in the setting of PPCI.




Controversies in primary percutaneous coronary intervention

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.