TATORT-NSTEMI: Still No Role for Thrombus Aspiration in NSTEMI

Longer follow-up from the TATORT-NSTEMI trial testing thrombus aspiration in NSTEMI confirms the study’s primary 6-month results—there is no benefit to performing thrombus aspiration prior to PCI in this group of patients.

The lack of benefit in NSTEMI echoes that already seen in STEMI patients in the large, randomized TASTE and TOTAL trials.  Recent guideline updates for STEMI patients undergoing PCI from both Europe and the United States now recommend against aspiration thrombectomy for STEMI. Whether thrombus aspiration may play a role in NSTEMI patients has not been as widely studied, although the 6-month results from TATORT-NSTEMI signaled no benefit to the procedure.

Roza Meyer-Saraei, PhD, of University Heart Centre Luebeck in Germany, and colleagues reported the 12-month results from TATORT-NSTEMI on November 19, 2015, in the European Heart Journal: Acute Cardiovascular Care.

In a press release accompanying the release of the 12-month TATORT-NSTEMI findings, senior author Holger Thiele, MD, also of  University Heart Centre Luebeck, notes that guidelines do not currently include  recommendations on thrombectomy use in NSTEMI, because these patients had not previously been studied.

“For patients with NSTEMI, there [have been] no data at all. Based on the negative results of our trial and also from the STEMI trials, we currently do not recommend to use aspiration thrombectomy on a routine basis,” Thiele explained to TCTMD in an email.

As previously reported by TCTMD, TATORT-NSTEMI randomized 460 patients 1:1 to thrombectomy plus PCI or standard PCI. The primary endpoint of microvascular obstruction assessed by cardiac magnetic resonance within 4 days after randomization did  not differ between the thrombectomy and standard PCI groups (1.7 percent LV vs. 1.6 percent LV, respectively; P = .65). Early imaging results also showed no differences in parameters such as infarct size or TIMI flow. Six-month follow-up revealed no disparities in the combined clinical endpoint between the thrombectomy and the standard PCI group (P = .85).

Now, with an additional 6 months of follow-up, researchers continue to see no differences in clinical outcomes, with similar MACE, NYHA class, and QoL between groups at 12 months.

Thiele doesn’t rule out using thrombectomy in “very select” cases.

“I personally believe that it should be reserved for no-reflow after PCI or large persistent thrombus after PCI,” he said. That limited usage may be hard for some interventionalists to accept, given the intuitive appeal of removing thrombus prior to revascularization, although Thiele said he believes the results from the STEMI trials are slowly sinking in.

“Current practice is currently changing in STEMI, although my impression is that many interventional cardiologists still believe in aspiration thrombectomy,” Thiele commented. “I am sure that the numbers will go down and that, based on the AHA/ACC guidelines which were changed for STEMI recently, it will only be used for bail-out situations. The same applies for NSTEMI patients based on our TATORT-NSTEMI trial.”

Source: 
Meyer-Saraei R, de Waha S, Eitel I, et al. Thrombus aspiration in non-ST-elevation myocardial infarction: 12-month clinical outcome of the randomised TATORT-NSTEMI trial. Eur Heart J Acute Cardiovasc Care 2015:Epub before print.

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