Why the study?
Does left ventricular unloading with delayed reperfusion improve safety and reduce infarct size compared to immediate reperfusion in patients with anterior STEMI without cardiogenic shock?
Population
50 patients with anterior ST-segment-elevation myocardial infarction (STEMI) without cardiogenic shock
Comparison
Left ventricular unloading using the Impella CP… vs Left ventricular unloading using the Impella CP…
Design
RCT, randomized
Follow-up
30 days
Key result
LV unloading with a 30-minute delay before reperfusion was safe and feasible in anterior STEMI, with similar 30-day MACCE rates compared to immediate reperfusion (12% vs 8%, P=0.99).
Authors
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Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“As a clinician, I’m going to continue using Impella in cardiogenic shock. In anterior STEMIs, I don’t think we’ll be using this technology.”
“Our findings do not support the routine use of a left-ventricular transaxial flow pump followed by a 30-minute waiting period before performing PCI, as opposed to performing immediate PCI without the heart pump.”
“If you take a patient with STEMI and if you unload the ventricle, you decrease wall stress, decrease myocardial oxygen demand and increase coronary perfusion, but you do a lot more. You provoke a whole series of cardioprotective reflexes that actually reduce reperfusion injury and apoptosis. It totally changes the transcriptome of the patient while you've got left ventricular unloading, but this concept has never been tested. As interventional cardiologists, we are pretty good at opening the epicardial coronary artery, but we're not so good at salvaging myocardium. As a result, we end up with high incidence of death and heart failure hospitalizations.”
Not indicated to delay PCI for LV unloading in anterior STEMI; leaves open benefit in larger confirmatory trials.
RCT (n=50)
randomized
Yes
Does left ventricular unloading with delayed reperfusion improve safety and reduce infarct size compared to immediate reperfusion in patients with anterior STEMI without cardiogenic shock?
Absolute Event Rate: 12% vs 8%
p-value: p=0.99
In patients with anterior STEMI without cardiogenic shock, left ventricular unloading with Impella CP and a 30-minute delay before reperfusion is feasible and safe, supporting the need for a larger pivotal trial.
Kapur et al. (2019) conducted an RCT in Anterior ST-Segment-Elevation Myocardial Infarction (STEMI) (n=50). LV unloading with delayed reperfusion (U-DR) vs. LV unloading with immediate reperfusion (U-IR) was evaluated on Composite of major adverse cardiovascular and cerebrovascular events at 30 days (p=0.99). LV unloading with a 30-minute delay before reperfusion was safe and feasible in anterior STEMI, with similar 30-day MACCE rates compared to immediate reperfusion (12% vs 8%, P=0.99).