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Novel adjunctive therapies in primary percutaneous coronary intervention

Acute Coronary Syndromes (ACS)

Optimizing prehospital organisation has reduced referral delay for patients with STEMI, while better mechanical devices and antithrombotic therapy have improved procedural outcomes.
The purpose of the present session was to describe the role of thrombus and reperfusion injury in ST-elevation myocardial infarction and their management to improve outcome beyond the open coronary artery.

Ulf Landmesser (Zurich, CH) reviewed stem cell therapy by demonstrating the results of experimental and early clinical experiences of stem cell therapy. Using surrogate endpoints, these studies demonstrated a reduction of infarct size averaging 3% of left ventricular (LV) mass and a subsequent improvement of LV ejection fraction averaging 3-4%.
We await the results of the Bami trial to clarify whether these improvements will translate into a clinical benefit. Current experimental and preclinical work focus on optimizing preparation of progenitor cells to promote homing and stimulate regeneration.

David Erlinge (Lund, SE) reviewed different modalities for cardioprotection including pharmacological and mechanical cardioprotection by postconditioning and remote conditioning, as well as cooling. Cyclosporine is the only pharmacological agent with a documented clinical effect. Postconditioning yields inconsistent results for reducing infarct size. Remote conditioning achieved by inflating a blood pressure cuff on the upper arm 4 times for 5 minutes to 200 mmHg has shown an increment of myocardial salvage when given in the ambulance during transportation to primary angioplasty.
Most recently this has translated into a reduction of major cardiovascular events at 4-year follow-up. Cooling by infusion of cold saline into the inferior caval vein has demonstrated a reduction in infarct size in a preliminary study. The infusion has to be initiated before opening of the coronary artery. Results of the larger CHILL-MI study will be presented shortly.

Greg Stone (New York, US) presented results from intracoronary administration of abciximab, adenosine and supersaturated oxygen. While abciximab administrated intracoronarily seems to yield inconsistent reduction of infarct size, administration via a dedicated intraluminal catheter appears to yield more promising results. Intracoronary adenosine may have some potential, and supersaturated oxygen achieved by saturation in a dedicated oxygenator and administered via a dedicated catheter appears to reduce infarct size in a preclinical setting.
These modalities are truly novel and clinical outcome studies are at planning stage.

Rajesh Kharbandha (Oxford, UK) reviewed mechanical thrombectomy in the light of the TASTE trial presented during the ESC meeting.
While early proof of content studies showed discrepancies in effects on surrogate endpoints, including myocardial salvage and infarct size, the TAPAS trial demonstrated a clinical effect on mortality in 1,071 patients. The TASTE trial included more than 7000 patients with registry-based outcomes and demonstrated no effect on mortality when thrombectomy is used on a routine basis.
The challenge remains to clarify whether any beneficial effect can be achieved in selected high-risk patients and how to identify those patients.


Session Title: Novel adjunctive therapies 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.