Possible Advantages of Deferred Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction Patients With Moderate-to-High Thrombus Burden

Document Type : Original Article


Cardiology Department, Ain Shams University, Abbasia, Cairo, Egypt.


Background:Primary percutaneous coronary intervention is the standard of care for ST-elevation myocardial infarction (STEMI). However, the proper management of the culprit artery with residual moderate-to-high thrombus burden after the initial restoration of flow is still unclear.
Methods:One hundred patients with STEMI underwent primary percutaneous coronary intervention, through which the operators managed to establish thrombolysis in myocardial infarction (TIMI) II–III flow with minimal manipulation but with residual moderate-to-high thrombus burden in the culprit artery. The patients were categorized into 2 equal groups. Group A consisted of patients who underwent immediate stenting, and Group B was comprised of patients for whom the intervention was deferred. After 24 to 48 hours, coronary angiography was repeated in Group B, and stenting was done when needed. The patients had pre-discharge echocardiography and were followed for 4 weeks for major adverse cardiac events (MACE); additionally, echocardiography was repeated 1 month after discharge
Results:There was no difference between the 2 groups regarding the TIMI flow of the culprit artery at the end of the revascularization procedure. There was a significant difference between the groups concerning the need for coronary stenting, which was lower in the deferral group (100% of the patients had stents in Group A vs 58% in Group B; P = 0.000). No significant difference was observed between the immediate and the deferral groups apropos the in-hospital morbidity/mortality or left ventricular function. At follow-up, there was no difference between the 2 groups vis-à-vis MACE and left ventricular function.
Conclusions: Deferred stenting is beneficial in reducing the need for stenting and the associated mortality/morbidity. (Iranian Heart Journal 2021; 22(1): 26-32)


Gibson CM, de Lemos JA, Murphy SA et al., (2001).  Combination therapy with abciximab reduces angiograhically evident thrombus in acute myocardial infarction – a TIMI 14 substudy. Circulation 103,2550–2554.
Carrick D, Oldroyd KG, McEntegart M, et al., (2014):A randomized trial of deferred stenting versus immediate stenting to prevent no- or slow-reflow in acute ST-segment elevation myocardial infarction (DEFER-STEMI). J Am Coll Cardiol; 63:2088–2098.
Jianzhong Qiao, MD, Lingxin Pan, MD, Bin Zhang, MD et al., (2017): Deferred Versus Immediate Stenting in Patients with ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis – Journal of the American Heart Association; Vol. 6, No. 3
O’Gara PT, Kushner FG, Ascheim DD, et al., (2013): ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol; 61:485–510.
 Fokkema ML, Vlaar PJ, Svilaas T, et al., (2009): Incidence and clinical consequences of distal embolization on the coronary angiogram after percutaneous coronary intervention for ST-elevation myocardial infarction. Eur Heart J; 30:908–915.
 Ke D, Zhong W, Fan L, et al., (2012): Delayed versus immediate stenting for the treatment of ST-elevation acute myocardial infarction with a high thrombus burden. Coron Artery Dis; 23:497–506.
 Pascal J, Veugeois A, Slama M, et al., (2016): Delayed stenting for ST-elevation acute myocardial infarction in daily practice: a single center experience. Can J Cardiol; 32:988–995.
 Kelbæk H, Høfsten DE, Køber L, et al., (2016): Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial. Lancet; 387:2199–2206.
 Belle L, Motreff P, Mangin L, et al., (2016):Comparison of immediate with delayed stenting using the minimalist immediate mechanical intervention approach in acute ST-segment-elevation myocardial infarction: the MIMI Study. Circ Cardiovasc Interv.; 9:e003388.
Rao AK, Pratt C, Berke A, et al., (1988): Thrombolysis in Myocardial Infarction (TIMI) Trial—phase I: hemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase. J Am Coll Cardiol; 11:1–11.
Mehran R, Rao SV, Bhatt DL, et al., (2011): Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation; 123:2736–2747.
Harbaoui B, Courand PY, Besnard C, et al., (2015): Deferred vs immediate stenting in ST elevation myocardial infarction: potential interest in selected patients. Presse Med; 44:e331–e339.
Kelbæk H, Engstrøm T, Ahtarovski KA, et al., (2013): Deferred stent implantation in patients with ST-segment elevation myocardial infarction: a pilot study. EuroIntervention; 8:1126–1133.
Bethke A, Halvorsen S, Bøhmer E, et al., (2015): Myocardial perfusion grade predicts final infarct size and left ventricular function in patients with ST-elevation myocardial infarction treated with a pharmaco-invasive strategy (thrombolysis and early angioplasty). EuroIntervention; 11:518–524.
Freixa X, Belle L, Joseph L, et al., (2013): Immediate vs delayed stenting in acute myocardial infarction: a systematic review and meta-analysis. EuroIntervention; 8:1207–1216.
Zalewski J, Nycz K, Przewlocki T, et al., (2011):Evolution of myocardial perfusion during primary angioplasty in spontaneously reperfused infarct-related artery: impact on long-term clinical outcomes and left ventricular function recovery. Int J Cardiol; 147:25–31.
Lønborg J, Engstrøm T, Ahtarovski KA, et al.Myocardial Damage in Patients With Deferred Stenting After STEMI: A DANAMI-3–DEFER Substudy. J Am Coll Cardiol 2017;69:2794-804.