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This editorial refers to ‘Randomized study to assess the effect of thrombus aspiration on flow area in patients with ST-elevation myocardial infarction: an optical frequency domain imaging study—TROFI trial’, by Y. Onuma et al. , doi:10.1093/eurheartj/ehs456 Microvascular perfusion after primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) has been clearly linked to mortality.1 It seems logical that by removing thrombus prior to PCI, thrombectomy could prevent distal embolization, improve microvascular perfusion and improve outcomes in STEMI.The early small randomized clinical trials of distal protection devices combined with aspiration failed to show improvements in surrogate outcomes of ST segment resolution or infarct size.2 As a result, many questioned the concept that by preventing distal embolization during primary PCI, one could improve clinical outcomes. The concept gained new momentum with the publication of the TAPAS trial, a single-centre trial comparing thrombectomy with the Export catheter (Medtronic CardioVascular, Santa Rosa, CA, USA) vs. PCI alone in STEMI ( n = 1072).3 This trial showed not only an improvement in the primary outcome of myocardial blush grade but a nearly 50% reduction in mortality at 1 year.3,4 Subsequent meta-analyses of small trials that were dominated …

Another chapter in the story of thrombectomy in ST-elevation myocardial infarction: a story not yet finished