Primary percutaneous coronary intervention (PPCI) is increasingly seen as the treatment of choice in acute myocardial infarction (AMI). Compared with thrombolysis, with PPCI recanalisation of the vessel is almost guaranteed, and, with elimination of the culprit epicardial stenosis, the risk of reocclusion is greatly reduced. There is, however, one advantage to thrombolysis: if it successfully restores epicardial flow, it can penetrate distal to the lesion and lyse further small microthrombi in the downstream myocardial bed. The effects of thrombus embolisation continue to be a problem in patients undergoing PPCI, in whom angiographic evidence of embolisation occurs in up to 15%,1 and are clearly related to adverse clinical and functional outcome.2 3 Once present, angiographic no-reflow, the end result of distal embolisation, is difficult to treat and disheartening for the operator.

In this issue of the journal, Reho and colleagues describe the successful use of a filter embolic protection device to retrieve clot during PPCI in a patient with high thrombus burden (see image on page 10.1136/hrt.2007.123273).4 They do not, however, simply leave the device distal to the thrombus during PCI. Instead, they pull back the open filter across the lesion and use the filter to “fish out” the thrombus, before recapturing the …