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Original Investigation
January 9, 2019

Association of Physician Variation in Use of Manual Aspiration Thrombectomy With Outcomes Following Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: The National Cardiovascular Data Registry CathPCI Registry

Author Affiliations
  • 1Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 4Duke Clinical Research Institute, Duke University, Durham, North Carolina
  • 5Center for Interventional Vascular Therapy, Division of Cardiology, Department of Medicine, Columbia University, New York, New York
  • 6Associate Editor, JAMA Cardiology
  • 7Center for Healthcare Delivery Innovation, Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
  • 8St Luke's Mid America Heart Institute, University of Missouri, Kansas City
JAMA Cardiol. Published online January 9, 2019. doi:10.1001/jamacardio.2018.4472
Key Points

Question  What are the temporal trends and clinical benefits of manual aspiration thrombectomy use during primary percutaneous coronary intervention for ST-elevation myocardial infarction?

Findings  In this cohort study of 683 584 primary percutaneous coronary interventions, aspiration thrombectomy use increased from 2009 to 2011, followed by a decline through 2016. Aspiration thrombectomy use was associated with no difference in mortality, a small increase in in-hospital stroke, and no difference in cumulative events at 180 days.

Meaning  Aspiration thrombectomy use is declining nationwide, with trends in use corresponding with evolving trial data; there was no clinical benefit of selective aspiration thrombectomy use during primary percutaneous coronary intervention for ST-elevation myocardial infarction.

Abstract

Importance  Following negative randomized clinical trials, US guidelines downgraded support for routine manual aspiration thrombectomy (AT) during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). However, some PCI operators continue to endorse a clinical benefit with AT use despite the lack of supportive data.

Objective  To examine temporal trends and comparative outcomes of AT use during pPCI for STEMI.

Design, Setting, and Participants  Retrospective cohort study of the National Cardiovascular Data Registry (NCDR) CathPCI Registry from July 1, 2009, to June 30, 2016, to assess temporal trends and in-hospital outcomes associated with AT use. To evaluate outcomes through 180 days, a subanalysis was conducted among Centers for Medicare and Medicaid Services–linked patients from July 1, 2009, through December 31, 2014. The comparative effectiveness analysis was performed using instrumental variable analyses to account for treatment selection bias. The instrumental variable was operator’s preference to use AT during pPCI. Data were analyzed between February 1, 2017, and April 1, 2018.

Exposures  Aspiration thrombectomy use during pPCI for STEMI.

Main Outcomes and Measures  Primary outcomes included in-hospital stroke and death. Secondary outcomes included heart failure, stroke, all-cause rehospitalization, and death through 180 days of follow-up.

Results  Among all pPCIs performed (683 584), the mean (SD) age of patients was 61.7 (12.8) years, 489 257 were male (71.6%), and 596 384 were white (87.2%). Among patients undergoing pPCI, AT use increased from 2009 through 2011, with peak use of 13.8%. This was followed by a decline of more than 9%, reaching 4.7% by mid-2016. Overall, AT was used in 10.8% of pPCIs (lowest operator group median, 0%; highest operator group median, 33.8%). After instrumental variable analysis, AT use was associated with no difference in in-hospital death (adjusted absolute risk difference, −0.18%; 95% CI, −0.53% to 0.16%; P = .29) and a small increase in in-hospital stroke (adjusted RD, 0.14%; 95% CI, 0.01%-0.30%; P = .03). Among Centers for Medicare and Medicaid Services–linked patients, AT use was not associated with differences in death, heart failure, stroke, or rehospitalization at 180 days.

Conclusions and Relevance  In this large, nationwide analysis, AT use during STEMI pPCI declined by more than 50% since 2011, with use as of mid-2016 at less than 5%. Selective AT use was associated with a small excess risk of in-hospital stroke and no difference in other outcomes through 180 days of follow-up.

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