心肌缺血再灌注中的棘手问题及对策

目的:探讨心肌缺血再灌注研究中的一些棘手问题,以及目前应对这些问题的主要临床辅助策略。方法:通过查阅近几年发表的有关心肌缺血再灌注研究的文献,分析该研究领域的研究现状。结果:再灌注是恢复缺血心肌血流供应的有效手段。研究发现,冠状动脉闭塞后60～90 min实施再灌注能够有效挽救缺血心肌。再灌注可以引起心律失常、微循环紊乱、受损心肌细胞死亡,导致再灌注损伤;而不利的心肌重塑则是急性心肌梗死患者主要的死亡原因之一。常规即时再灌注的实施、减轻再灌注损伤和防止不利的心肌重塑等是现在临床治疗面临的难题。采取预处理、活化再灌注损伤救援激酶、干细胞治疗等辅助措施有望解决这些难题。结论:心肌缺血再灌注虽是恢复缺血心肌血液供应最有效的手段之一,然而,再灌注引起的损伤及不利的重塑也是急需解决的难题,再灌注治疗联合辅助措施有望为解决这一问题带来突破。

Important Issues and Relative Approaches in Myocardial Ischemic Reperfusion

Objective: To discuss some unresolved problems in myocardial ischemia/reperfusion research and to review some approaches for successfully combining adjuvant therapies with coronary artery opening. Method : The researches in myocardial ischemia/reperfusion in recent years were reviewed. Result: Reperfusion can produce significant salvage of ischemic myocardium. According to reports, the operation was carried out in 60-90 min for effective reperfusion and optimal myocardial salvage which conveys decreased short-term and long-term mortality compared with longer ischemic times. Reperfusion has negative effects on ischemic myocardium, which collectively are referred to as myocardial reperfusion injury,which complicates with arrhythmias, microcirculatory disturbances and progression to cell death of critically injured cardiomyocytes. Progressive unregulated remodeling is the important mortality in acute myocardial infarction. The development of clinical care systems that can routinely deliver very timely coronary opening and reperfusion,the limitation of myocardial reperfusion injury,the strategies to retard adverse remodeling are the difficult issues in reperfusion. Promising approaches are being explored including pre-conditioning and post-conditioning,activators of the reperfusion injury salvage kinase pathway and stem cell therapy. Conclusion : Myocardial reperfusion after ischemia is a double-bladed sword: the advantages mixed up with the problems. These challenges could be overcome by combining adjuvant therapies with reperfusion.