急诊心脏介入治疗中无复流现象预防措施的效果观察

目的 探讨ST段抬高型急性心肌梗死患者行急诊经皮冠脉介入治疗术(PCI)出现无复流现象的原因及预防措施.方法 选择ST段抬高型急性心肌梗死患者202例,无急诊PCI治疗禁忌证,随机分为3组,分别给予常规PCI治疗、血栓抽吸和冠脉内注入血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂后PCI等不同的治疗,监测患者PCI治疗后血浆脑钠肽前体(pro-BNP)和PCI术后冠脉造影TIMI血流分级,记录患者住院时间和28 d死亡率.结果 三组患者间发病至梗死相关血管开通时间、总平均住院时间、PCI治疗术后28d死亡率差异无统计学意义.常规PCI治疗组无复流现象的发生率高于血栓抽吸组和冠脉内注入血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂组,并且血浆pro-BNP明显高于后者.结论 心肌梗死患者PCI术后无复流的发生与冠脉内微血栓形成有关,通过血栓抽吸和冠脉内注入血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂的方法可以有效减少无复流的发生.     

No-reflow phenomenon occurring during elective angioplasty performed due to in-stent restenosis -- a case report

The no-reflow phenomenon is an impairment of microcirculation after successful percutaneous coronary interventions (PCI). The no-reflow phenomenon is usually observed during acute myocardial infarction. This case-report describes no-reflow phenomenon in a patient undergoing elective PCI in the right coronary artery, occluded due to restenosis in implanted stent. After deflation of balloon during angioplasty in restenosed stent, no-reflow phenomenon occurred, followed by asystolia. The patient was successfully resuscitated. During resuscitation procedures, abciximab was administered what improved myocardial perfusion. This case demonstrates that no-reflow phenomenon can be a serious problem during elective PCI, leading even to a cardiac arrest. It shows also the necessity for administration of drugs improving tissue perfusion when no-reflow phenomenon occurs.     

超选择性冠脉内注射硝普钠对急性心肌梗死急诊冠状动脉介入治疗中无再流现象的作用

目的:评价超选择性冠状动脉内注射硝普钠对急性心肌梗死(AMI)患者急诊经皮冠状动脉介入(PCI)治疗中梗死相关动脉(IRA)无复流现象的作用。方法:选择AMI急诊PCI后再通的IRA存在无复流现象者43例。21例患者经血栓抽吸导管超选择性梗死相关冠状动脉内注射法,22例患者采用常规指引导管内注射方法。药物均采用硝普钠100μg,2 s内"弹丸式"快速注射完毕。10 min后复查冠状动脉造影,评定冠状动脉血流TIMI分级及校正TIMI帧数(cTFC)。结果:两组均可明显改善急诊PCI后的无再流现象,超选择组所有患者梗死相关血管IRA血流恢复TIMIⅢ级,cTFC帧数由用药前的(84±7)帧降至(26±6)帧,与常规组相比较差异有统计学意义(P0.01)。结论:超选择性IRA内快速注射硝普钠100μg能更有效地改善AMI急诊PCI中无再流现象。     

The thrombus laden coronary artery--forget the fancy stuff, just aspirate it!

"No-reflow" is an important complication of percutaneous coronary intervention (PCI) in the setting of acute myocardial infarction and is associated with worse outcomes. Visible thrombus on the angiogram is a significant risk factor for "no-reflow". A variety of strategies have been employed to prevent this phenomenon including intracoronary vasodilators and distal protection systems. Randomized trials have not revealed any superiority of distal protection devices despite the theoretical rationale to their use. We describe a case of a thrombus-laden right coronary artery in which PCI would have likely resulted in significant "no-reflow". A simple aspiration catheter was used to significantly reduce the thrombus burden. Subsequent stenting was performed with no adverse events. This case illustrates the benefit of a less fancy approach to the thrombus-filled coronary artery - just aspirate it! Randomized trials are needed to test the role of simple aspiration prior to stenting in thrombus-laden coronary arteries.     

冠状动脉介入术后无再流现象的防治进展

急性心肌梗死患者行经皮冠状动脉介入术(PCI)时,无再流现象的发生严重影响了再通治疗的成功率。因此,改善心肌再灌注,减少无再流现象的发生率成为当今PCI治疗的新热点。本文主要对PCI后无再流现象的预防和治疗进展及存在问题进行综述。     

血栓抽吸导管在冠脉介入治疗中对血栓病变TIMI血流的影响

目的:探讨血栓抽吸导管在经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)中对于血栓病变TIMI血流的影响。方法:对我院1年来急性冠脉综合征(ACS)冠状动脉造影(CAG)显示靶病变相关血管(target-related artery,TRA)血栓负荷的患者48(男35,女13)例,年龄(58±8)岁,随机分成试验组(血栓抽吸+PCI,n=25)与对照组(直接PCI,n=23)。收集所有病例的临床和CAG资料,对比两组患者PCI术中相关血管心肌梗死溶栓试验(thrombolysis in myocardial infarction,TIMI)血流情况。结果:试验组患者PCI术中无复流及慢血流发生率明显低于对照组(0%vs.17%,P0.05),两组患者PCI术后TIMIⅢ级血流无显著差异。结论:对于冠脉有血栓负荷病变进行血栓抽吸可以明显改善ACS患者IRA远端的前向血流,降低无复流现象的发生。     

血栓抽吸联合冠状动脉内注射替罗非班对ST段抬高型患者无复流和心功能的影响

目的探讨替罗非班冠状动脉给药联合血栓抽吸与替罗非班静脉给药对ST段抬高型急性心肌梗死（STEMI）患者直接冠状动脉介入术（PCI）后冠脉灌注和心功能的疗效差异。方法纳入2008年2月～2012年4月STEMI患者86例（TIMI血流≤1级）,随机分为实验组（n=43）和对照组（n=43）。对照组术前即开始静脉应用替罗非班,实验组则在PCI术中直接向梗死相关动脉（IRA）注射替罗非班并联合血栓抽吸。比较两组患者术后TIMI血流分级,检测术前、术后1周及6个月的血浆N-端脑钠肽前体（NT-proBNP）水平并采用超声心动图测定左室舒张末期容积（LVEDV）、左室收缩末期容积（LVESV）、左室射血分数（LVEF）、左室舒张末期容积指数（LVEDVI）;评价心功能并观察术后6个月内两组患者心血管事件的发生率。结果①实验组术后达到TIMI血流3级比例高于对照组（92.90%vs.66.17%,P〈0.05）;②术后1周及术后6个月实验组和对照组比较,NT-proBNP水平均显著下降（P〈0.01）,LVEF显著升高（P〈0.05）,LVESV、LVEDV、LVEDVI显著减少（P〈0.05）;③术后6个月内实验组心绞痛、心力衰竭等心血管事件发生率显著降低（P〈0.05）。结论 PCI术中IRA注射替罗非班联合血栓抽吸较静脉注射替罗非班可降低急诊PCI术中无复流的发生,改善血流再灌注,提高整体预后。     

血小板分布宽度对急性心肌梗死冠状动脉介入治疗中无复流的预测价值

目的:研究血小板分布宽度(PDW)对ST段抬高型心肌梗死(STEMI)患者直接经皮冠状动脉介入治疗(PCI)中无复流的预测价值。方法:回顾性分析118例发病12h内接受直接PCI的STEMI连续病例,根据直接PCI术中无复流的发生情况分为无复流组(33例)和正常血流组(85例)。比较2组患者的临床资料、实验室检查结果以及直接PCI结果,应用受试者工作曲线(ROC曲线)分析入院时PDW对无复流发生的预测价值。结果:无复流组患者入院时PDW水平明显高于正常血流组[(16.7±2.3)%∶(15.1±2.2)%,P<0.01]。应用ROC曲线分析PDW对无复流的预测价值,曲线下面积0.726(95%可信区间0.608～0.844,P<0.01)。当截点值为16.45%时,入院时PDW对直接PCI术中无复流进行预测的敏感性和特异性分别为80.0%和72.4%。结论:STEMI患者入院时PDW水平是直接PCI术中发生无复流的预测因素,并具有较好的敏感性和特异性。     

血栓抽吸导管在急性心肌梗死患者治疗中的临床应用

目的评估ZEEK血栓抽吸导管在急性心肌梗死患者治疗中的临床应用。方法将316例行急诊介入治疗的急性心肌梗死患者分为两组,其中使用ZEEK血栓抽吸导管127例患者作为ZEEK组,未使用ZEEK血栓抽吸导管189例患者作为对照组。观察无复流发生率、术后ST段下降率、住院病死率及左心室射血分数等。结果ZEEK组4例发生无复流,发生率为3.1%,住院期间无死亡。对照组189例中有18例发生无复流,发生率9.5%,死亡6例(3.2%)。两组患者的无复流发生率、ST段下降率、住院病死率及心功能均具有显著差异(P<0.05)。结论急性心肌梗死在急诊介入治疗中,应用ZEEK血栓抽吸导管可以降低无复流发生率和住院病死率。     

An unusual no-reflow phenomenon due to neointimal tissue embolization during drug eluting balloon intervention in stent restenosis: A case report

Acute coronary syndrome is one of the leading causes of death worldwide. Percutaneous coronary intervention (PCI), along with various devices, have been technically developed to dramatically improve mortality risk in patients with acute myocardial infarction. However, no-reflow phenomenon still remains a problematic complication during a PCI, even in the era of drug eluting stents. There are various hypotheses and mechanisms for no-reflow phenomenon, but none have been confirmed. Treatment for no-reflow phenomenon also depends on various underlying conditions, but have not yet shown effective improvement. We presented a case of no-reflow phenomenon caused by an unusual cause.     

经皮冠状动脉介入术中无复流治疗的进展

经皮冠状动脉介入治疗（PCI）已经是治疗冠心病的重要手段,但无复流现象却严重影响PCI近期和远期预后。目前治疗无复流的方法很多,但效果尚不理想。本文就PCI中无复流的治疗进展作一综述。     

经皮冠状动脉介入治疗术后的无再流现象

无再流现象 (no reflowphenomenon)是指冠状动脉闭塞 ,血流中断后重新恢复血流 ,却无心肌组织的有效灌注的现象 ,可发生于溶栓治疗及经皮冠状动脉介入治疗 (PCI)术后。本文就PCI术后无再流现象的发生情况、机制、检测、预防和处理等方面的研究进展进行了综述。     

急性心肌梗死直接介入治疗后无复流的血管因素

目的:探讨急性ST段抬高型心肌梗死(STEAMI)患者直接经皮冠状动脉内介入治疗(percutaneous coronary intervention,PCI)后与无复流有关的血管因素。方法:回顾性分析410例STEAMI患者直接PCI后的临床和造影资料,无复流患者51例,由其余359例直接PCI后TIMI3级血流者中随机抽取60例作为正常血流组。结果:无复流的发生率为12.44%。:两组在几乎完全闭塞、血栓、钙化、长病变等造影发现的罪犯血管形态学改变存在显著性差异。结论:STEAMI患者如果在造影时发现罪犯血管存在几乎完全闭塞、血栓、钙化、长病变等形态学改变,则直接PCI后无复流的发生率明显著增加。     

Usefulness of preprocedural N-terminal pro-brain natriuretic peptide in predicting angiographic no-reflow phenomenon during stent implantation in patients with ST-segment elevation acute myocardial infarction

The no-reflow phenomenon after primary percutaneous coronary intervention (PCI) is associated with larger infarct size, worse functional recovery, and higher incidence of complication after acute ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the relation between preprocedural N-terminal pro-brain-type natriuretic peptide (NT-pro-BNP) and angiographic no-reflow phenomenon. We measured preprocedural serum NT-pro-BNP level in 159 consecutive patients with acute STEMI (aged 63 +/- 12 years; 72% men) before PCI. Angiographic no-reflow after PCI was defined as Thrombolysis In Myocardial Infarction (TIMI) flow grade <3. Baseline characteristics, including time from chest pain onset, between the no-reflow (n = 67) and normal-reflow groups (n = 92) were similar. NT-pro-BNP was significantly higher in the no-reflow group than the normal reflow group (1,982 +/- 3,314 vs 415 +/- 632 pg/ml; p = 0.005). Also, high-sensitivity C-reactive protein, monocytes, and troponin-T were significantly higher in the no-reflow group than the normal-reflow group. In the no-reflow group, NT-pro-BNP was much higher in patients with TIMI flow grade 0 (n = 41; 2,290 +/- 3,495 pg/ml) than those with TIMI grade 1 or 2 (n = 26; 1,575 +/- 2,340 pg/ml), but without significant difference. The area under the receiver-operating characteristic curve for NT-pro-BNP was 0.78, and the optimal cut-off value identified using receiver-operating characteristic curve analysis was 500 pg/ml. At the standard cut-off value of >500 pg/ml, increased NT-pro-BNP showed a high probability of no-reflow phenomenon (odds ratio 4.42, 95% confidence interval 1.15 to 17.00, p = 0.028). In conclusion, preprocedural NT-pro-BNP may be a strong predictor of the development of no-reflow phenomenon after PCI in patients with acute STEMI.     

主动脉内球囊反搏治疗急性心肌梗死急诊冠状动脉介入治疗术后无复流现象的临床研究

目的:探讨主动脉内球囊反搏(IABP)在急性心肌梗死(AMI)急诊冠状动脉介入治疗(PCI)术后无复流(NR)现象中的治疗作用.方法:分析自2006-01-2010-08期间因AMI行PCI术后NR患者30例资料,采用单双日法分组方法将其中16例运用 IABP治疗,其余未用IABP的14例为对照组,观察术后10 d内心肌损伤标志物、脑钠肽(BNP)及血管活性物质恢复情况.心肌损伤标志物包括肌红蛋白、肌酸激酶同工酶(CK-MB)、肌钙蛋白I(cTnI);血管活性物质指标包括肾素活性(PRA)、血管紧张素Ⅱ(AngⅡ)、醛固酮(ALD)、肾上腺素(E)、去甲肾上腺素(NE);治疗10 d后应用彩色超声心动图测量患者左房内径、左室内径、左室射血分数(LVEF);并随访3个月、6个月左房内径、左室内径、LVEF变化情况.结果:IABP治疗组患者血管活性物质及心肌损伤标志物指标时间-浓度曲线显示指标下降明显快于对照组,2组间血管活性物质及心肌损伤标志物与对照组相比,2组下降幅度差异有统计学意义(P<0.05);IABP组BNP峰值较对照组提前,IABP治疗组BNP指标时间-浓度曲线显示指标下降明显快于对照组,2组间BNP指标下降与对照组相比差异无统计学意义(P>0.05);超声心动图测量2组患者10 d、3个月及6个月时左房内径、左室内径及LVEF差异有统计学意义(P<0.05).结论:IABP能够加速降低AMI急诊PCI术后发生NR患者升高的交感神经系统、RAS系统激素及心肌损伤标志物的水平;使BNP峰值提前并改善10 d、3个月及6个月时左房内径、左室内径及射血分数值.     

Usefulness of adjunctive pulse infusion thrombolysis after failed aspiration for massive intracoronary thrombus

Slow/no-reflow phenomenon during emergent percutaneous coronary intervention in patients with ST-elevation myocardial infarction (STEMI) results in a poor prognosis. A high thrombus burden was an independent predictor of angiographic slow/no-reflow phenomenon. We experienced a case of a STEMI patient with massive intracoronary thrombus. In our case, a massive red thrombus was aspirated easily by adjunctive pulse infusion thrombolysis (PIT) after failed aspiration. Adjunctive pulse infusion thrombolysis after failed aspiration might be a useful strategy to prevent the slow/no-reflow phenomenon in STEMI patients with massive intracoronary thrombus.     

Application of intra-aortic balloon pumping on no-reflow phenomenon in primary PCI for STEMI

background To investigate the effect of intra-aortic balloon pumping (IABP) on no-reflow phenomenon in primary percutaneous coronary intervention (PCI) for ST-Elevation Myocardial Infarction (STEMI). Methods Clinical data of 22 acute myocardial infarction patients after PCI with angiographic no-reflow phenomenon were retrospectively analyzed between January 2006 and December 2009.12 patients underwent IABP, other 10 patients as control group. We observed difference of cardiac structure, brain natriuretic pe...     

Clinical significance of intra-aortic balloon pumping on no-reflow phenomenon of primary percutaneous coronary intervention for acute myocardial infarction

Background Percutaneous coronary intervention(PCI) is used as a treatment for acute myocardial infarction(AMI),and one of its major complications is the angiographic no-reflow phenomenon(NR).Although intra-aortic balloon pumping(IABP) is sometimes used in such patients to increase the diastolic coronary blood flow,there is little available information regarding the effects of IABP on the angiographic no-reflow phenomenon.Method Twenty-two AMI patient with NR were performed primary PCI between January 2006 a...     

Depletion of antioxidants is associated with no-reflow phenomenon in acute myocardial infarction

BACKGROUND: No-reflow phenomenon is observed in approximately one-third of patients after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and is associated with poor functional and clinical outcomes. On the other hand, the formation of free radicals in vasculature exerts deleterious effects on coronary microcirculation. HYPOTHESIS: We hypothesized that redox state in coronary circulation may play a crucial role in no-reflow phenomenon in AMI. METHODS: Consecutive 26 patients with first AMI who underwent primary PCI < 24 h after onset were enrolled. Before PCI, blood samples were obtained from coronary sinus to measure plasma or serum antioxidative vitamins (vitamin C, vitamin E, and beta-carotene) and antioxidative enzymes (extracellular glutathione peroxidase [GPX], superoxide dismutase, and catalase). After PCI, the corrected Thrombolysis In Myocardial Infarction (TIMI) frame count (CTFC) was measured in the target vessel. Patients with TIMI < or = 2 flow despite an optimal PCI result were designated as no-reflow group (Group NR, n = 6) and the others as reflow group (Group R, n = 20). RESULTS: Levels of vitamin C, vitamin E, and GPX before PCI were significantly lower in Group NR than in Group R. The CTFC correlated inversely with levels of vitamin C, vitamin E, and GPX (p < 0.05). CONCLUSIONS: Depletion of antioxidants is associated with no-reflow phenomenon in AMI. These findings strongly suggest that the redox state in coronary circulation plays an important role in the pathogenesis of no-reflow phenomenon.     

冠状动脉无复流现象的当前认识

经皮冠状动脉介入治疗（PCI）是急性ST段抬高性心肌梗死患者的首选治疗策略。虽然PCI后冠脉血流恢复，但仍经常观察到无复流现象，并且与较差的临床预后有关。导致该现象的病因机制复杂且相互关联，对这些机制的进一步认识有助于制定个性化的预防和治疗策略。可以使用冠脉造影、心肌对比超声及心脏磁共振等技术诊断无复流。许多药物可能改善实验室和临床无复流，但一些药物尚未明确地改善临床结果。