血栓抽吸导管“一抽一推”在急诊冠脉介入中的应用

目的探讨单纯使用血栓抽吸导管“一抽一推（抽吸血栓，推注替罗非班）”在急性sT段抬高型心肌梗死（sTEMI）急诊“再灌注”治疗中的有效性和安全性。方法回顾2009年1月至2012年12月所收治因急性STEMI行急诊冠脉介入治疗，并符合纳入条件的梗死相关动脉（IRA）高血栓负荷患者，其中32例为导管抗栓组，均是经导管进行血栓抽吸并推注ⅡbIIIa受体拮抗剂替罗非班（国产欣维宁）后IRA血流已达TIMI3级者；另28例为静脉抗栓组，是经使用血栓导管抽吸，同时经静脉通路推注IIbⅢa受体拮抗剂替罗非班，即刻冠脉IRA血流也达到了TIMI3级者。观察两组术后即刻的MBG分级，以及两组术前及术后肌酸激酶一同工酶（CK—MB）、肌钙蛋白T（cTnT）、高敏c反应蛋白（hs-CRP）、N末端B型利钠肽原（NT-proBNP）的峰值，术后1．5h心电图sT段恢复（STR）比率，化验术前及术后1周的外周血白细胞计数；比较术后10—14d（择期PCI之前）的心脏超声指标左心室射血分数【LVEF）和左心室舒张末期内径（LVEDd）的变化；比较两组消化道出血及主要心『lIL管事件（MACE）发生率。结果冠脉造影MBG分级：2级所占比例导管抗栓组低于静脉抗栓组（P〈0．05），而3级所占比例导管抗栓组则高于静脉抗栓组（P〈0．05）。发病10-14d检查心脏超声指标LVEDd值导管组明显小于静脉抗栓组（P〈O．05），而LVEF值导管抗栓组则明显高于静脉抗栓组（P〈0．05）。术前CK—MB、NT—proBNP、hs—CRP及白细胞计数等指标两组比较差异无统计学意义（P〉0．05）；而术后心肌酶CK—MB、cTnT、NT—proBNP、hs—CRP、白细胞计数等指标，导管组均优于静脉抗栓组。术后消化道出m及MACE事件两组比较差异无统计学意义（P〉0．05）。结论对高血栓负荷的STEMI患者在进行急诊导管血栓抽吸即刻从中推注1Ibma受体拮抗剂替罗非班，即用“一抽一推”法能较好地恢复心肌再灌注，减轻心肌损伤，近期有效且安全。

The application of "both aspiration and injection" by thrombus aspiration catheter during emergency percutaneous coronary intervention in patients with acute STEMI

Objective To evaluate the efficacy and safe of “both aspiration and injection” using only thrombus aspiration catheter during emergency percutaneous coronary intervention for myocardium reperfusion in patients with acute ST-elevation myocardial infarction （STEMI）. Methods Of the patients with acute STEMI hospitalized from January 2009 to December 2012, which were found in IRA with high thrombus burden and underwent conventional the procedures of emergency percutaneous coronary intervention （PCI）, 32 cases of them were taken for catheter anti-thrombus group, because their IRA were achieved TIMI 3 grades in coronary flow only us- ing catheter thrombus aspiration repeatedly and followed simuhaneously by injecting II b m a receptor antagonist tirofiban through the same catheter, the other 28 cases of them were taken for intravenous anti-thrombus group, their IRA were equally achieved instantly TIMI 3 grades only using catheter thrombus aspiration repeatedly but followed simultaneously by injecting tirofiban intravenous. Immediate myocardium blush grades （MBG） were carefully observed after implanting stents in 2 groups. It was also observed that basic value and peak of creatine kinase isoenzyme（CK-MB）, high sensitivity Creactive protein（hs-CRP） and N-terminal pro-B type brain natriuretic peptide （NT-proBNP） before and after the procedure. Electrocardiogram S-T segment recovery （STR） 1.5 hour after the procedure was recorded, leukocytes count was detected before and 1 week after the procedure. Heart ultrasound indexes left ventricular ejection fraction （LVEF） and left ventricular end diastolic dimension（LVEDd）were measured at 10-14 days after the procedure （before elective PCI ）, alimentary tract hemorrhage was observed peropeative period and major adverse cardiovascular events（MACE） duration of hospital stay. Results The proportion of MBG 2 grade was lower in catheter anti-thrombus group than intravenous group（P〈O.05）, and oppositely MBG 3 grade was higher in catheter anti-thrombus group than intravenous group （P〈0.05）. LVEDd and LVEF were better in catheter anti-thrombus group than intravenous group （P〈0.05）. There were not significant difference in CK-MB, NT-proBNP, hs-CRP and leukocytes count before the procedure （P〉0.05）. After the procedure, my- ocardial enzyme series CK-MB, cTnT, heart function index NT-proBNP, inflammation marker hs-CRP, leukocytes count, all they were better in catheter anti-thrombus group than intravenous anti-thrombns group （P〈0.05）. The incidence rate of alimentary tract hemorrhage was similar in the two groups （P〉0.05） per-opeative period. MACE was not found in the two groups during hospital stay. Conclusion It is effective and safe in the short term to apply a method of “both aspiration（thrombus） and injection（tirofiban ）” by the thrombus aspiration catheter during emergency percutaneous coronary intervention for recovery myocardium reperfusion and reducing myocardium injury in patients with acute STEMI of high thrombus burden.