Author + information
- Brahim Harbaoui, MD, MSc∗ (, )
- Eric Eeckhout, MD, PhD,
- Olivier Muller, MD, PhD and
- Pierre Lantelme, MD, PhD
- ↵∗Cardiology Department, Lausanne University Hospital (CHUV), Rue du Bugnon, Lausanne, Switzerland 1011
Deferred stenting (DS) in the setting of ST-segment elevation myocardial infarction (STEMI) has been the subject of numerous controversies, but the current view is that DS should be restricted to very selected cases, as demonstrated once again by Lønborg et al. (1). Notwithstanding, it is widely acknowledged that thrombus plays a key role in the pathophysiology of STEMI, and the size and composition of thrombus may affect the results of primary percutaneous coronary intervention, given the risk of distal embolization. The ratio of plaque to thrombus is highly variable among culprit lesions; it is also highly variable with time, and this represents the conceptual basis of the DS strategy. Despite the overall negative results of this study in terms of microvascular obstruction (1), we think that there is still a place for a “tailored DS strategy,” provided that thrombus-laden lesions can be selected. In this respect, Lønborg et al. (1) showed a highly significant interaction between DS and lesion length that may represent an interesting parameter for selection of patients who are potentially eligible for DS.
This finding is perfectly in line with our observation that, in patients with STEMI who are treated with DS, the longer the culprit lesion, the greater is its shortening with time (2). In particular, for lesions longer than 23.7 mm (very close to the 24-mm cutoff reported by Lønborg et al. ), this shortening could reach more than 7 mm (2). Within such a brief time frame, this result clearly implies that the length of the lesion is associated with thrombus content. The paper by Loøborg et al. (1) strongly fuels the hypothesis of a prognostic advantage of DS in the presence of a long lesion, probably through thrombus regression. Although it is a post hoc analysis with all the inherent limitations of such a study, we find this result extremely promising for tailoring the best strategy during primary percutaneous coronary intervention. However, we acknowledge that routine DS in all patients with STEMI is probably not an option. We believe that further adequately designed clinical trials that have an evaluation of thrombotic load and lesion length as their basis should be encouraged.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
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