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A Randomized Controlled Trial

Gregg W. Stone, MD; John Webb, MD; David A. Cox, MD; Bruce R. Brodie, MD; Mansoor Qureshi, MD; Anna Kalynych, MD; Mark Turco, MD; Heinz P. Schultheiss, MD; Daniel Dulas, MD; Barry D. Rutherford, MD; David Antoniucci, MD; Mitchell W. Krucoff, MD; Raymond J. Gibbons, MD; Denise Jones, BSN; Alexandra J. Lansky, MD; Roxana Mehran, MD; for the Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) Investigators

JAMA. 2005;293:1063-1072.

Context  Atheromatous and thrombotic embolization during percutaneous coronary intervention (PCI) in acute myocardial infarction is common and may result in microcirculatory dysfunction, the prevention of which may improve reperfusion success, reduce infarct size, and enhance event-free survival.

Objective  To determine whether protection of the distal microcirculation from thromboembolic debris liberated during primary PCI results in improved reperfusion and decreased infarct size.

Design, Setting, and Patients  Prospective randomized controlled trial at 38 academic and community-based institutions in 7 countries enrolling 501 patients aged 18 years or older with ST-segment elevation myocardial infarction (STEMI) presenting within 6 hours of symptom onset and undergoing primary PCI or rescue intervention after failed thrombolysis.

Interventions  Patients were randomized between May 20, 2002, and November 21, 2003, to receive PCI with a balloon occlusion and aspiration distal microcirculatory protection system vs angioplasty without distal protection.

Main Outcome Measures  Coprimary end points were ST-segment resolution (STR) measured 30 minutes after PCI by continuous Holter monitoring and infarct size measured by technetium Tc 99m sestamibi imaging between days 5 and 14. Secondary end points included major adverse cardiac events.

Results  Among 252 patients assigned to distal protection, aspiration was performed in 97% (242/251), all angioplasty balloon inflations were fully protected in 79% (193/245), and visible debris was retrieved from 73% (182/250). Complete STR was achieved in a similar proportion reperfused with vs without distal protection (63.3% [152/240] vs 61.9% [148/239], respectively; absolute difference, 1.4% [95% confidence interval, –7.7% to 10.5%; P = .78]), and left ventricular infarct size was similar in both groups (median, 12.0% [n = 229] vs 9.5% [n = 208], respectively; P = .15). Major adverse cardiac events at 6 months occurred with similar frequency in the distal protection and control groups (10.0% vs 11.0%, respectively; P = .66).

Conclusions  A distal balloon occlusion and aspiration system effectively retrieves embolic debris in most patients with acute STEMI undergoing emergent PCI. Nonetheless, distal embolic protection did not result in improved microvascular flow, greater reperfusion success, reduced infarct size, or enhanced event-free survival.

Author Affiliations: Columbia University Medical Center and Cardiovascular Research Foundation, New York, NY (Drs Stone, Lansky, and Mehran); St Paul’s Hospital, Vancouver, British Columbia (Dr Webb); Mid Carolina Cardiology, Charlotte, NC (Dr Cox); Moses Cone Hospital, Greensboro, NC (Dr Brodie); St Joseph Mercy Hospital, Ypsilanti, Mich (Dr Qureshi); Crawford Long Hospital, Atlanta, Ga (Dr Kalynych); Washington Adventist Hospital, Tacoma Park, Md (Dr Turco); University Hospital Benjamin Franklin, Berlin, Germany (Dr Schultheiss); Mercy Hospital, Coon Rapids, Minn (Dr Dulas); St Luke’s Hospital, Kansas City, Mo (Dr Rutherford); Policlinico Careggi, Florence, Italy (Dr Antoniucci); Duke University Medical Center, Durham, NC (Dr Krucoff); Mayo Clinic Foundation, Rochester, Minn (Dr Gibbons); Medtronic Corp, Santa Rosa, Calif (Ms Jones).

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