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(Circulation. 2008;118:1810-1816.)
© 2008 American Heart Association, Inc.

Interventional Cardiology

Presence of Older Thrombus Is an Independent Predictor of Long-Term Mortality in Patients With ST-Elevation Myocardial Infarction Treated With Thrombus Aspiration During Primary Percutaneous Coronary Intervention

Miranda C.A. Kramer, MD; Allard C. van der Wal, MD, PhD; Karel T. Koch, MD, PhD; Johanna P.H.M. Ploegmakers, BSc; René J. van der Schaaf, MD; José P.S. Henriques, MD, PhD; Jan Baan, Jr, MD, PhD; Saskia Z.H. Rittersma, MD, PhD; Marije M. Vis, MD; Jan J. Piek, MD, PhD; Jan G.P. Tijssen, PhD; Robbert J. de Winter, MD, PhD

From the Departments of Cardiology (M.C.A.K., K.T.K., R.J.v.d.S., J.P.S.H., J.B., S.Z.H.R., M.M.V., J.J.P., J.G.P.T., R.J.d.W.) and Pathology (A.C.v.d.W., J.P.H.M.P.), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.

Correspondence to Robbert J. de Winter, MD, PhD, FESC, Professor of Clinical Cardiology, Department of Cardiology, B2–137, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; or PO Box 22660, 1100 DD Amsterdam, the Netherlands. E-mail r.j.dewinter{at}amc.uva.nl

Received March 19, 2008; accepted August 29, 2008.

Background— Routine thrombus aspiration is frequently used during primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction to prevent distal embolization. Recently, evidence of clinical benefit was published. In 50% of the ST-elevation myocardial infarction patients with an onset of symptoms <12 hours before, thrombi were shown to be >1 day old. This observation illustrates that plaque rupture and coronary occlusion are significantly separated in time. In the present study, we correlate the presence of fresh versus older thrombus with long-term mortality.

Methods and Results— Thrombus aspiration was performed in 1315 patients treated with primary percutaneous coronary intervention with 3 devices (Rescue, Export, and Proxis). Aspirated material was fixed in formalin and processed for histopathology. If possible, thrombus age was classified as either fresh only (<1 day) or older (>1 day). We identified fresh thrombus in 552 patients and older thrombus in 372 patients. The cumulative Kaplan-Meier estimate of all-cause mortality at 4 years was significantly higher in patients with older thrombus (16.0%) compared with patients with fresh thrombus (7.4%), with a hazard ratio of 1.82 (95% confidence interval, 1.17 to 2.85; P=0.008). Multivariate analysis identified the presence of older thrombus, in addition to other established predictors, as an independent predictor (hazard ratio, 1.83; 95% confidence interval, 1.14 to 2.93; P=0.01) of long-term mortality.

Conclusion— Our study demonstrates that the presence of older thrombus, in addition to other established predictors, is an independent predictor of long-term mortality in patients with ST-elevation myocardial infarction treated with thrombus aspiration during primary percutaneous coronary intervention.

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CLINICAL PERSPECTIVE

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