Clinical trial NCT03950310: Laser Atherectomy for ST Elevation Myocardial Infarction
Official title: Evaluation of Myocardial Salvage by Scintigraphy After Excimer Laser Coronary Angioplasty and Percutaneous Coronary Intervention With Biodegradable-polymer Platinum Chromium Everolimus-eluting Stent in the Patients With Anterior ST Elevation Myocardial Infarction
Study type: INTERVENTIONAL
Overall status: TERMINATED
Phase: NA
Conditions: STEMI - ST Elevation Myocardial Infarction
Keywords: ELCA
STEMI
Myocardial Salvage
Lead sponsor: Tokai University
Sponsor class: OTHER
First posted: 2019-05-15
Enrollment: 142
Sex: ALL
Minimum age (years): 21
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The objectives of this study are to observe and examine prospectively whether excimer laser coronary angioplasty (ELCA) and percutaneous coronary intervention with biodegradable-polymer platinum chromium everolimus-eluting stent may improve the myocardial salvage in the patients with anterior ST elevation myocardial infarction (STEMI) using the myocardial scintigram (acute-phase I123-BMIPP and chronic-phase 99mTc-tetrofosmin), and to clarify the myocardial protective effect of excimer laser in the patients with anterior STEMI.

Detailed description: The clinical result of catheter treatment in the patients with acute myocardial infarction in these several decades improved because of progress of early reperfusion therapy and stent treatment technique. However, the no-reflow phenomenon is still remaining as a problem, which is involved in a decrease in left ventricular function and worsening of prognosis. It is considered that the no-reflow phenomenon is induced by atherosclerotic and thrombotic emboli, endothelial dysfunction of capillary vessels, free radicals and cytokine. The treatment combining the peripheral protection and thrombus aspiration aiming at prevention of no-reflow is expected to reduce no-reflow and the infarct size and has been conducted on the patients with acute myocardial infarction. However, a lot of randomized studies have been conducted, so far, which do not lead to reduction of infarct size and improvement of survival rate, and the efficacy has not been demonstrated.

Some explanations have been suggested for this phenomenon:

1. The operation method of device is complicated, and it is difficult to acquire the treatment technique.
2. Giant thrombus and solid lesion could not be aspirated effectively.
3. A lot of randomized studies have not focused on the "patients with anterior descending lesion of thrombolysis in myocardial infarction (TIMI) grade 0/1, of which the time from onset to treatment is within 6 hours," considered to have the largest benefit of prevention of no-reflow.

In recent years in Japan, excimer laser coronary angioplasty (ELCA) has been used in the patients with acute coronary syndrome (ACS), and not only debulking of arteriosclerotic lesion but also thrombolytic effect have been reported. In the Camel trial and Utility of Laser for Transcatheter Atherectomy Multicenter Analysis around Naniwa (ULTRAMAN) registry, the efficacy and safety in ACS have been reported, but the infarct size has not been evaluated.

This time in this study, it is considered that verification whether or not ELCA is able to improve the myocardial salvage in anterior ST elevation myocardial infarction (STEMI) using myocardial scintigram (acute-phase BMIPP and chronic-phase TF) will provide the useful information helpful for selection of treatment to medical care staffs and patients for future patients suffering from ACS and will be able to contribute to further improvement of medical science and medical practice.

MRI will be performed twice at 5-9 days and at 6 months post index ST elevation myocardial infarction to assess myocardial damage and functional variables, which details will be described in the following outcome measurement section.

Eligibility criteria: Inclusion Criteria:

* Patients to whom PCI treatment for anterior STEMI is indicated \[Main selection criteria\]
* First-episode anterior STEMI patients within 6 hours of onset that satisfy electrocardiogram criteria
* Patients who are 21 years of age or older at the time of consent acquisition
* Patient who the patient himself agreed in writing

Exclusion Criteria:

* Patients presenting cardiac shock at the time of visit
* Patients whose target lesions are left main trunk, circumflex, right coronary artery, distal anterior descending branch
* Patients who have TIMI 2, 3 at the initial imaging
* Patients with a reference vessel diameter of 2.5 mm or less
* Patients determined to lack consent ability for mental or other reasons
* Patient who is judged inappropriate by research researcher or research sharing doctor

The inclusion and exclusion criteria for the MRI will follow the main study, but in addition, will exclude following conditions.

* Atrial fibrillation subject at the timing of MRI scan
* Internally implanted devices such as pacemakers or ICDs
* Subject that is allergic to Gadolinium,
* Subject with claustrophobia
* Pregnancy

Primary outcomes:
measure: myocardial salvage (17 segment model) by SPECT
timeFrame: 3 day to 6 month
measure: Myocardial Salvage index (17 segment model) by SPECT
timeFrame: 3 day to 6 month
Secondary outcomes:
measure: Myocardial scar amount assessment by MRI
timeFrame: 5-9 days and 6 month
measure: Microvascular obstruction assessment by MRI
timeFrame: 5-9 days and 6 month
measure: Myocardial salvage assessment by MRI
timeFrame: 5-9 days and 6 month
measure: Ejection fraction assessment by MRI
timeFrame: 5-9 days and 6 month
measure: Gray zone assessment by MRI
timeFrame: 5-9 days and 6 month
measure: Left ventricular ejection fraction by TF scintigraphy at 6 months
timeFrame: 5-7 month
measure: Left ventricular volume (ml) by TF scintigraphy at 6 months
timeFrame: 5-7 month
measure: Left ventricular end-diastolic volume (ml) by TF scintigraphy at 6 months
timeFrame: 5-7 month
measure: Left ventricular end-systolic volume (ml) by TF scintigraphy at 6 months
timeFrame: 5-7 month
measure: Intra-stent tissue volume by OCT
timeFrame: at the end of procedure and 1-year
measure: Myocardial salvage [total perfusion defect (TPD) model] by SPECT
timeFrame: 3 day to 6 month
measure: Myocardial salvage index (%) [total perfusion defect (TPD) model] by SPECT
timeFrame: 3 day to 6 month
measure: Major adverse cardiovascular events (MACE) at 12 months
timeFrame: 12 months
measure: Major adverse cardiovascular events (MACE) at 36 months
timeFrame: 36 months
measure: Major adverse cardiovascular events (MACE) at 60 months
timeFrame: 60 months
measure: Cardiac death at 12 months
timeFrame: 12 months
measure: Cardiac death at 36 months
timeFrame: 36 months
measure: Cardiac death at 60 months
timeFrame: 60 months
Other outcomes:
Locations:
city: Isehara
country: Japan
facility: Tokai University School of Medicine
state: Kanagawa
Study officials:
References:
citation: Giugliano RP, Braunwald E; TIMI Study Group. Selecting the best reperfusion strategy in ST-elevation myocardial infarction: it's all a matter of time. Circulation. 2003 Dec 9;108(23):2828-30. doi: 10.1161/01.CIR.0000106684.71725.98. No abstract available.
citation: Tanaka A, Kawarabayashi T, Nishibori Y, Sano T, Nishida Y, Fukuda D, Shimada K, Yoshikawa J. No-reflow phenomenon and lesion morphology in patients with acute myocardial infarction. Circulation. 2002 May 7;105(18):2148-52. doi: 10.1161/01.cir.0000015697.59592.07.
citation: Gupta S, Gupta MM. No reflow phenomenon in percutaneous coronary interventions in ST-segment elevation myocardial infarction. Indian Heart J. 2016 Jul-Aug;68(4):539-51. doi: 10.1016/j.ihj.2016.04.006. Epub 2016 Apr 19.
citation: Morishima I, Sone T, Okumura K, Tsuboi H, Kondo J, Mukawa H, Matsui H, Toki Y, Ito T, Hayakawa T. Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction. J Am Coll Cardiol. 2000 Oct;36(4):1202-9. doi: 10.1016/s0735-1097(00)00865-2.
citation: Ito H, Maruyama A, Iwakura K, Takiuchi S, Masuyama T, Hori M, Higashino Y, Fujii K, Minamino T. Clinical implications of the 'no reflow' phenomenon. A predictor of complications and left ventricular remodeling in reperfused anterior wall myocardial infarction. Circulation. 1996 Jan 15;93(2):223-8. doi: 10.1161/01.cir.93.2.223.
citation: De Luca G, Ernst N, Zijlstra F, van 't Hof AW, Hoorntje JC, Dambrink JH, Gosslink AT, de Boer MJ, Suryapranata H. Preprocedural TIMI flow and mortality in patients with acute myocardial infarction treated by primary angioplasty. J Am Coll Cardiol. 2004 Apr 21;43(8):1363-7. doi: 10.1016/j.jacc.2003.11.042.
citation: Rezkalla SH, Kloner RA. No-reflow phenomenon. Circulation. 2002 Feb 5;105(5):656-62. doi: 10.1161/hc0502.102867. No abstract available.
citation: Stone GW, Webb J, Cox DA, Brodie BR, Qureshi M, Kalynych A, Turco M, Schultheiss HP, Dulas D, Rutherford BD, Antoniucci D, Krucoff MW, Gibbons RJ, Jones D, Lansky AJ, Mehran R; Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) Investigators. Distal microcirculatory protection during percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: a randomized controlled trial. JAMA. 2005 Mar 2;293(9):1063-72. doi: 10.1001/jama.293.9.1063.
citation: Ikari Y, Sakurada M, Kozuma K, Kawano S, Katsuki T, Kimura K, Suzuki T, Yamashita T, Takizawa A, Misumi K, Hashimoto H, Isshiki T; VAMPIRE Investigators. Upfront thrombus aspiration in primary coronary intervention for patients with ST-segment elevation acute myocardial infarction: report of the VAMPIRE (VAcuuM asPIration thrombus REmoval) trial. JACC Cardiovasc Interv. 2008 Aug;1(4):424-31. doi: 10.1016/j.jcin.2008.06.004.
citation: Vlaar PJ, Svilaas T, van der Horst IC, Diercks GF, Fokkema ML, de Smet BJ, van den Heuvel AF, Anthonio RL, Jessurun GA, Tan ES, Suurmeijer AJ, Zijlstra F. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008 Jun 7;371(9628):1915-20. doi: 10.1016/S0140-6736(08)60833-8.
citation: Jolly SS, Cairns JA, Yusuf S, Meeks B, Pogue J, Rokoss MJ, Kedev S, Thabane L, Stankovic G, Moreno R, Gershlick A, Chowdhary S, Lavi S, Niemela K, Steg PG, Bernat I, Xu Y, Cantor WJ, Overgaard CB, Naber CK, Cheema AN, Welsh RC, Bertrand OF, Avezum A, Bhindi R, Pancholy S, Rao SV, Natarajan MK, ten Berg JM, Shestakovska O, Gao P, Widimsky P, Dzavik V; TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015 Apr 9;372(15):1389-98. doi: 10.1056/NEJMoa1415098. Epub 2015 Mar 16.
citation: Frobert O, Lagerqvist B, Olivecrona GK, Omerovic E, Gudnason T, Maeng M, Aasa M, Angeras O, Calais F, Danielewicz M, Erlinge D, Hellsten L, Jensen U, Johansson AC, Karegren A, Nilsson J, Robertson L, Sandhall L, Sjogren I, Ostlund O, Harnek J, James SK; TASTE Trial. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med. 2013 Oct 24;369(17):1587-97. doi: 10.1056/NEJMoa1308789. Epub 2013 Aug 31.
citation: Stone GW, Dixon SR, Grines CL, Cox DA, Webb JG, Brodie BR, Griffin JJ, Martin JL, Fahy M, Mehran R, Miller TD, Gibbons RJ, O'Neill WW. Predictors of infarct size after primary coronary angioplasty in acute myocardial infarction from pooled analysis from four contemporary trials. Am J Cardiol. 2007 Nov 1;100(9):1370-5. doi: 10.1016/j.amjcard.2007.06.027. Epub 2007 Aug 17.
citation: Nikolsky E, Stone GW, Lee E, Lansky AJ, Webb J, Cox DA, Brodie BR, Turco MA, Rutherford BD, Kalynych AM, Antoniucci D, Krucoff MW, Gibbons RJ, Fahy M, Mehran R. Correlations between epicardial flow, microvascular reperfusion, infarct size and clinical outcomes in patients with anterior versus non-anterior myocardial infarction treated with primary or rescue angioplasty: analysis from the EMERALD trial. EuroIntervention. 2009 Sep;5(4):417-24. doi: 10.4244/eijv5i4a66.
citation: Topaz O, Minisi AJ, Bernardo NL, McPherson RA, Martin E, Carr SL, Carr ME Jr. Alterations of platelet aggregation kinetics with ultraviolet laser emission: the "stunned platelet" phenomenon. Thromb Haemost. 2001 Oct;86(4):1087-93.
citation: Topaz O, Bernardo NL, Shah R, McQueen RH, Desai P, Janin Y, Lansky AJ, Carr ME. Effectiveness of excimer laser coronary angioplasty in acute myocardial infarction or in unstable angina pectoris. Am J Cardiol. 2001 Apr 1;87(7):849-55. doi: 10.1016/s0002-9149(00)01525-3.
citation: Nishino M, Mori N, Takiuchi S, Shishikura D, Doi N, Kataoka T, Ishihara T, Kinoshita N; ULTRAMAN Registry investigators. Indications and outcomes of excimer laser coronary atherectomy: Efficacy and safety for thrombotic lesions-The ULTRAMAN registry. J Cardiol. 2017 Jan;69(1):314-319. doi: 10.1016/j.jjcc.2016.05.018. Epub 2016 Jul 2.
citation: Rawlins J, Din JN, Talwar S, O'Kane P. Coronary Intervention with the Excimer Laser: Review of the Technology and Outcome Data. Interv Cardiol. 2016 May;11(1):27-32. doi: 10.15420/icr.2016:2:2.