应用 Albunex结合经胸多普勒超声评估无复流时冠脉血流速度模式变化的实验研究

目的应用Albunex进行心肌声学造影结合经胸多普勒冠脉血流显像观察犬急性心肌缺血再灌注时梗死相关动脉(IRA)血流灌注模式的变化,探讨该变化与心肌微血管损害之间的关系.方法健康杂种犬19只,均结扎左前降支(LAD)60min,而后分别再灌注60min(n=6),120 min(n=6)和180 min(n=7).LAD结扎后经静脉弹丸式注射Albunex进行MCE检查,MCE显示的低灌注区为危险区(RAMCE),再灌注后MCE检查确定的低灌注区为无复流区(NRAMCE).若NRAMCE/RAMCE比值大于或等于25%时认为发生了无复流现象;若NRAMCE/RAMCE比值小于25%时认为心肌复流.多普勒超声使用冠脉血流程序检测IRA血流动力学各项指标.结果2只犬在实验中死亡,其余17只犬均完成实验方案.复流组共有7支犬,无复流组共有10支犬.再灌注60min时,PVs,VTIs,cFDs,PVd,VTId,cFDd,DDR,cDDD在复流组有所变化,但与基础状态相比较差异无显著意义(P值均＞0.05);而无复流组的PVs,VTIs,cFDs,PVd,VTId,cFDd均明显减小(P值均＜0.05),舒张期最显著的变化是减速度(DDR)明显增大(P＜0.01),减速时间(DDD)显著减小(P＜0.01).结论微血管床的损害可以影响心外膜冠脉血流动力学.这种变化可能主要是通过增加微血管阻力,降低冠脉灌注压的途径来实现的.经胸多普勒超声结合Albunex注射进行心肌声学造影可以无创性评估无复流时梗死相关动脉血流速度模式变化.     

CHA2DS2-VASc score predicts the slow flow/no-reflow phenomenon in ST-segment elevation myocardial infarction patients with multivessel disease undergoing primary percutaneous coronary intervention

ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) have a higher incidence of slow-flow/no-reflow (SF-NR) phenomenon during primary percutaneous coronary intervention (PPCI) than those with single vessel disease. Currently, no effective tools exist to predict the risk of SF-NR in this population. The present study aimed to evaluate whether CHA₂DS₂-VASc score can be used as a simple tool to predict this risk.This study consecutively included STEMI patients hospitalized in Beijing Anzhen Hospital from January 2005 to January 2015. Among these patients, 1032 patients with MVD were finally enrolled. Patients were divided into SF-NR (+) group and SF-NR (–) group according to whether SF-NR occurred during PPCI. SF-NR was defined as the thrombolysis in myocardial infarction (TIMI) grade ≤2.There were 134 patients (13%) in the SF-NR (+) group. Compared with the SF-NR (–) group, patients in the SF-NR (+) group are elder, with lower left ventricular ejection fraction and higher CHA₂DS₂-VASc score. Multiple logistic regression analysis indicated that CHA₂DS₂-VASc score ≥3 (odds ratio [OR], 2.148; 95% confidence interval [CI], 1.389–3.320; P = .001), current smoking (OR, 1.814; 95% CI, 1.19–2.764; P = .006), atrial fibrillation (OR, 2.892; 95% CI, 1.138–7.350; P = .03), complete revascularization (OR, 2.307; 95% CI, 1.202–4.429; P = .01), and total length of stents ≥40 mm (OR, 1.482; 95% CI, 1.011–2.172; P = .04) were independent risk factors of SF-NR. The incidence of SF-NR in patients with CHA₂DS₂-VASc score ≥3 was 1.7 times higher than that in patients with CHA₂DS₂-VASc score <3. Additionally, patients with CHA₂DS₂-VASc score ≥3 plus ≥2 risk factors have 3 times higher incidence of SF-NR than those with CHA₂DS₂-VASc score ≥3 plus 0 to 1 risk factor.CHA₂DS₂-VASc score ≥3 can be used as a simple and sensitive indicator to predict SF-NR phenomenon and guide the PPCI strategy in STEMI patients with MVD.     

D-二聚体/纤维蛋白原比值对老年ST段抬高型心肌梗死患者经皮冠状动脉介入治疗术中慢血流/无复流的预测价值

目的]探讨D-二聚体/纤维蛋白原比值(DFR)对老年急性ST段抬高型心肌梗死(STEMI)患者经皮冠状动脉介入治疗(PCI)术中慢血流/无复流(SF/NRF)的预测价值。[方法]回顾性分析240例接受急诊PCI的老年STEMI患者,依据术后冠状动脉远端血流情况分为SF/NRF组(42例)和非SF/NRF组(198例),比较两组患者基线资料、介入相关指标、DFR等,分析SF/NRF的影响因素及DFR对SF/NRF的预测价值。[结果]SF/NRF组心功能Killip 2～3级、肌酸激酶同工酶峰值、心肌肌钙蛋白I峰值、D-二聚体、纤维蛋白原和DFR均显著高于非SF/NRF组(P＜0.05)。SF/NRF组症状发作到首份心电图时间显著长于非SF/NRF组,术前TIMI血流0级比例显著高于非SF/NRF组(P＜0.05),而有创收缩压、有创舒张压显著低于非SF/NRF组(P＜0.05)。多因素回归分析显示症状发作到首份心电图时间和DFR是SF/NRF的独立预测因素。ROC曲线分析显示,当DFR＞0.28时,DFR对SF/NRF的预测价值较高,曲线下面积为0.818(95%CI 0.763～0.864,P＜0.01),灵敏度为73.81%,特异度为75.76%。[结论]DFR对老年STEMI患者PCI术中SF/NRF的发生具有较高的预测价值。     

Pathophysiology,Diagnosis, and Management of Coronary No-Reflow Phenomenon

Coronary no-reflow phenomenon is a lethal mechanism of ongoing myocardial injury, following successful revascularization of an infarct-related coronary artery. Incidence of this phenomenon is high following percutaneous intervention, and is associated with adverse in-hospital and long-term outcomes. Several mechanisms such as ischemia-reperfusion injury and distal microthromboembolism in genetically susceptible patients and those with preexisting endothelial dysfunction have been implicated. However, the exact mechanism in humans is still poorly understood. Several investigative and treatment strategies within and outside the cardiac catheterization laboratory have been proposed, but have not uniformly shown success in reducing mortality or in preventing adverse left ventricular remodeling resulting from this condition. The aim of this article is to provide a brief and concise review of the current understanding of the pathophysiology, clinical predictors, and investigations and management of coronary no-reflow phenomenon.     

早期应用替罗非班对ST段抬高性心肌梗死患者行急诊经皮冠状动脉介入治疗后的疗效简

目的 探讨早期应用替罗非班对ST段抬高性心肌梗死（ST segment elevation myocardial infarction,STEMI）患者急诊经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗疗效的影响.方法 自2009年1月至2012年1月,将186例接受急诊PCI治疗的STEMI患者分为2组：A组为实验组,为早期应用替罗非班的患者共95例,均于PCI治疗前使用;B组为对照组,常规治疗组,未使用替罗非班的患者共91例.分析两组PCI治疗前、后的临床状况、造影血流情况[心肌梗死溶栓（thrombolysis in myocardial infarction,TIMI）血流分级、TIMI心肌灌注分级（TIMI myocardial perfusion,TMP）]及出血事件.记录住院期间及随访6个月内的主要心血管事件的发生率.结果 所有患者均成功行急诊PCI治疗.两组间的基础临床情况及术前造影情况比较,差异无统计学意义（P＞0.05）.与B组比较,A组PCI治疗后TIMIⅢ级血流的比例（96.5％ vs.81.2％,P＜0.05）、TMPⅡ级以上血流的比例（96.8％ vs.84.2％,P＜0.05）均明显增高,发生无复流现象的比例（5.6％ vs.13.2％,P＜0.05）则明显减少,差异均有统计学意义.两组住院期间主要心血管事件、出血事件的发生率比较,差异无统计学意义（P＞0.05）.而在随访的6个月期间内,A组主要心血管事件较B组明显减少,差异有统计学意义（P＜0.01）.结论 在STEMI急诊PCI治疗患者中,早期应用替罗非班能有效预防无复流现象的发生,改善靶血管前向血流,挽救更多存活心肌及改善预后.     

Embolic Protection Devices in Saphenous Vein Graft and Native Vessel Percutaneous Intervention: A Review

The clinical benefit of percutaneous intervention (PCI) depends on both angiographic success at the site of intervention as well as the restoration of adequate microvascular perfusion. Saphenous vein graft intervention is commonly associated with evidence of distal plaque embolization, which is correlated with worse clinical outcomes. Despite successful epicardial intervention in the acute MI patient treated with primary PCI, distal tissue perfusion may still be absent in up to 25% of cases [1-3]. Multiple devices and pharmacologic regimens have been developed and refined in an attempt to protect the microvascular circulation during both saphenous vein graft intervention and primary PCI in the acute MI setting. We will review the evidence for various techniques for embolic protection of the distal myocardium during saphenous vein graft PCI and primary PCI in the native vessel.     

丹酚酸B镁对兔急性心梗再灌注后无复流心肌损伤的保护作用

目的 评价丹酚酸B镁（salvianolic acid B,Sal-B）对兔急性心肌梗死再灌注后心肌损伤的保护作用。方法 新西兰大白兔40只随机分成4组,即假手术组、心肌缺血再灌注（myocardial ischemia/reperfusion,MI/R）、再灌注低剂量组（Sal-B20 mg·kg^-1组）、再灌注高剂量组（Sal-B 60 mg·kg^-1组）,每组10只。假手术组只开胸不结扎,其余3组结扎左室缘支90 min,切断结扎线120 min,建立MI/R模型。各组分别于结扎左心室缘支前5 min、结扎后90 min、再灌注120 min时取血,检测肌酸激酶同工酶（CK-MB）、心肌肌钙蛋白I （cTnI）,并评估缺血范围、无复流范围及梗死区心肌范围。结果 结扎90 min后,MI/R组、Sal-B 20 mg·kg^-1组和Sal-B 60 mg·kg^-1组3组之间CK-MB、cTnI水平差异无统计学意义。再灌注120 min后,Sal-B 60 mg·kg^-1组的血清CK-MB、cTnI水平显著低于MI/R组、Sal-B 20 mg·kg^-1组,差异有统计学意义（P<0.05）。各组染色所测的冠脉结扎区心肌缺血范围基本一致。与MI/R组、Sal-B 20 mg·kg^-1组比,Sal-B 60 mg·kg^-1组可以显著减少无复流面积（P<0.05）和梗死面积（P<0.05）,MI/R组和Sal-B 20 mg·kg^-1组之间差异无统计学意义。结论 Sal-B 60 mg·kg^-1能在一定程度上减轻心肌细胞结构损伤,缩小心肌梗死面积,减轻无复流的发生。     

尼可地尔对猪急性心肌梗死再灌注后无再流的影响

目的评价尼可地尔防治猪急性心肌梗死(AMI)再灌注后无再流的作用。方法中华小型猪24只,随机分成对照组、尼可地尔组和假手术组,每组8只。结扎冠状动脉(冠脉)3h、松解1h制备AMI再灌注模型。AMI前后和再灌注后均行血流动力学测定和心肌声学造影(MCE)检查,最终行病理学分析。结果1与AMI前相比,对照组AMI后3h左室收缩压(LVSP)、心排血量(CO)和左室内压最大收缩和舒张变化速率(±dp/dtmax)均显著下降(P<0.05或P<0.01),左室舒张末压(LVEDP)显著升高(P<0.01);再灌注后1h仅LVSP显著恢复(P<0.05),±dp/dtmax继续显著下降(P均<0.05)。尼可地尔组AMI后3h各项指标变化与对照组相同;但再灌注后1hLVSP、LVEDP、±dp/dtmax和CO均恢复,差异有显著性(P<0.05),且比对照组更显著(P均<0.05)。2对照组MCE和病理染色所测冠脉结扎区心肌范围(LA%)高度一致(P>0.05),再灌注后无再流范围(ANR%)分别为(78.50±4.35)%和(82.30±1.90)%,心肌坏死范围(NA%)为(98.50±1.35)%。尼可地尔组LA%虽与对照组相当(P均>0.05),但两方法所测ANR%和NA%均显著小于对照组(P<0.05或P<0.01)。3对照组再灌注即刻和再灌注后1h冠脉血流量(CBV)仅占AMI前的50.6%和45.8%(P均<0.01);尼可地尔组CBV分别提高到69.4%和67.9%,均比对照组显著增加(P均<0.01)。结论尼可地尔能有效防治AMI再灌注后无再流,改善其心功能,缩小梗死面积。