急性冠状动脉综合征的介入治疗

急性冠状动脉综合征 ( ACS)是一组冠状动脉粥样硬化斑块破裂、血栓形成或血管痉挛而致急性或亚急性心肌缺血的临床综合征。目前 ,根据患者心电图 ST段是否抬高而将其分成 ST段抬高的 ACS,即 ST段抬高的急性心肌梗死( STEMI)和无 ST段抬高的 ACS,后者包括不稳定性心绞痛( U A)和无 ST段抬高的心肌梗死 ( NSTEMI)。 U A/ NSTEMI又合称为不稳定性冠状动脉疾病 ( UCAD)。1　 UA/ NSTEMI的介入治疗U A/ NSTEMI患者的处理有两种不同的策略 ,即早期保守治疗和早期有创治疗。前者的原则是 ,患者仅反复缺血 (静息时或稍活动…     

常规急诊及尿激酶溶栓失败后补救性冠脉介入治疗急性心肌梗死的疗效

目的:评价急性ST段抬高型心肌梗死(STEMI)常规急诊及尿激酶溶栓失败后行补救性经皮冠状动脉介入治疗(PCI)的近期疗效及安全性。方法:回顾分析2006年6月～2009年12月在我院因急性STEMI而行急诊PCI术的134例患者的基本资料(包括溶栓失败行急诊补救性PCI患者),及其术后30d内的主要终点事件(包括全因死亡、再梗死)以及严重出血性并发症的发生情况。结果:急诊PCI术患者共计134例,其中17例(12.68%)因外院尿激酶溶栓失败转入我院行补救性PCI。134例中30d内共7例(5.22%)发生主要终点事件,死亡6例(4.48%)。多因素Logistic分析显示冠状动脉TIMI血流≤1级和主要终点事件明显相关(OR=60.98,P<0.05)。3例(2.24%)发生严重出血性并发症。单因素Logistic分析显示补救性PCI术与严重出血并发病无显著相关(P>0.05)。结论:急性ST段抬高型心肌梗死尿激酶溶栓失败后行补救性经皮冠状动脉介入治疗安全、有效。     

直接冠状动脉介入治疗支架内血栓形成的发生率、危险因素及预后

目的分析过去5年期间常规开展ST段抬高性心肌梗死(STEMI)直接经皮冠状动脉介入治疗(PCI)支架内血栓形成的发生率、危险因素以及对预后的影响.方法 1999年3月至2004年2月5年期间常规对311例STEMI患者经股动脉或桡动脉施行直接PCI.男250例,女61例,平均年龄60.4岁(26～85岁).围手术期采用阿司匹林、氯吡格雷或噻氯匹定、肝素进行标准的三联抗血小板/抗凝治疗.对全部患者随访两个月以上.结果直接PCI手术操作成功率99%(308/311).8例发生9例次支架内急性/亚急性或后期血栓形成,发生率为2.6%(8/308).其中急性血栓形成5例,亚急性或后期血栓形成3例.这8例患者均有血栓形成的多个高危因素.8例中住院死亡3例,其余5例有明显的左心室收缩功能障碍.结论 STEMI直接PCI后的血栓形成发生率较高,小直径的长支架和缺乏有效的抗血小板治疗可能是血栓形成的主要危险因素,血栓形成患者的死亡率高,临床长期预后差.     

32例急性ST段抬高型心肌梗死急诊介入治疗临床观察

目的评价急性ST段抬高型心肌梗死(STEMI)患者急诊介入治疗的临床疗效及安全性。方法2005年6月～2008年9月共32例急性ST段抬高型心肌梗死在我院行急诊直接PCI治疗,观察介入治疗效果,患者主要心脏不良事件(MACE,包括死亡、非致命性再梗死、靶血管再血管化治疗)的发生率。结果PCI成功率为87.5%,术后住院期间死亡2例,MACE发生率为6.25%;出院后临床随访30例患者,随访时间3～39个月,无死亡和再发心肌梗死发生,5例患者在术后10～12月时行冠状动脉造影复查,未发现支架内再狭窄。结论急性STEMI患者行急诊直接PCI治疗,有较好的临床疗效,在充分给予阿司匹林、氯吡格雷和肝素进行抗血小板和抗凝治疗基础上,联合使用替罗非班可显著降低直接PCI术后不良心脏事件的发生。     

急性心肌梗死急诊冠状动脉介入治疗后支架内急性血栓形成的原因及处理二例分析

由于围手术期抗凝/抗血小板药物的应用,急性心肌梗死急诊冠状动脉介入治疗(PCI)后支架内急性血栓形成已经大大减少.本文报告两例急诊PCI后支架内急性血栓形成,以提高将来识别和处理这种情况的能力.过去4年间成功地对195例急性ST段抬高性心肌梗死(STEMI)患者施行直接PCI,但是术后有2例(1%)发生支架内急性血栓形成.     

药物涂层支架内血栓形成特点分析

目的 探讨冠状动脉造影证实的药物涂层支架(DES)内血栓形成患者的临床特点.方法 回顾性收集我中心2005年3月至2009年3月冠状动脉造影证实的支架内血栓形成患者的临床情况、造影结果、经皮冠状动脉介入治疗(PCI)过程、抗血小板治疗等资料,分析支架内血栓形成特点和治疗及预后情况.结果 20例冠状动脉造影证实的支架血栓形成患者,发生率为 1.03%(20/1946),均表现为ST段抬高性心肌梗死(STEMI),所有患者均为DES[其中18例(90.0%)为西罗莫司及其衍生物涂层支架(SES),2例(10.0%)为紫杉醇涂层支架(PES)].10例(50.0%)为亚急性支架血栓形成,1例(5.0%)为晚期支架血栓形成,9例(45.0%)为极晚期ST;3例(15.0%)再次发生支架血栓形成,1例(5.0%)2支血管同时发生支架血栓形成.所有患者均接受正规的氯吡格雷+阿司匹林抗血小板治疗1年,9例(45.0%)极晚期支架血栓形成均在停用氯吡格雷后发生.12例(60.0%)患者为长支架(支架长度≥30 mm)置入,其中8例(40.0%)患者为串联支架置入;10例(50.0%)亚急性支架血栓形成患者再次PCI时均接受球囊扩张,1例(5.0%)晚期支架血栓形成患者也接受球囊扩张,9例(45.0%)极晚期支架血栓形成患者再次PCI时,5例(25.0%)患者只接受球囊扩张;随访结果显示,2例(10.0%)患者院内死亡,1例(5.0%)患者因反复支架内血栓形成而接受冠状动脉旁路移植术.结论 支架内血栓形成少见,支架内血栓形成常导致STEMI;支架血栓形成与长支架置入和急诊PCI治疗有关;多数支架内血栓形成可通过球囊扩张治疗;某些患者存在多支血管同时、多次发生支架血栓形成的风险.

Abstract：

Objective To analyze the clinical characteristics and outcomes of angiographically confirmed drug-eluting stent thrombosis (ST). Methods All the angiographically confirmed ST was enrolled in the study from March 2005 to March 2009. Clinical data, angiographic outcomes, procedures of PCI, and anti-platelet treatment of ST were retrospectively collected. Results Total 20 cases of ST included 18 cases (90.0%) of sirolimus and derives eluting stents and 2 cases (10.0%) of paclitaxel eluting stent. Ten (50.0%) stent thromboses were subacute, 1 (5.0%) were late, and 9 (45.0%) were very late. ST reoccurred in 3 cases and occurred simultaneously in two arteries in 1 case. All the cases presented with ST-segment elevation myocardial infarction (STEMI). ST occurred in 16 cases after emergency PCI and 4 cases after selective PCI. Nine late stent thrombosis occurred after clopidogrel cessation. Long stents (stent length ≥ 30 mm) were implanted in 12 cases (60.0%), of which overlap stents were implanted in 8 cases (40.0%).Balloon angioplasty was used in 16 cases (80.0%). The 2 patients died from STEMI during hospitalization and 1 patient accepted coronary artery bypass graft for repetitive ST. Conclusions Angiographically confirmed ST appears rarely, but most frequent ST presents with STEMI. ST is related with long stent implantation and emergency PCI. Balloon angioplasty is frequently used for ST. Some patients have the risk of multiple arteries and repetitive ST.     

老年急性冠脉综合征患者介入治疗的临床分析

目的:探讨老年急性冠脉综合征(ACS)患者接受经皮冠状动脉介入治疗(PCI)的临床价值.方法:70岁以上老年ACS患者50例,对持续性胸痛伴(或)ST段抬高心肌梗死患者(AMI 2例,UA2例)行急诊PCI;对非ST段抬高ACS患者经规范内科治疗病情平稳1周后行PCI.结果:对70支罪犯血管进行PTCA术后置入81枚支架.49例患者随访8～24个月无心绞痛发作;1例术后2个月冠脉造影显示支架内再狭窄,经支架内再支架置入术后随访5个月无心绞痛发作.结论:对老年ACS患者及时进行PCI可获得良好效果,临床安全程度高.     

雷帕霉素药物洗脱支架治疗急性心肌梗死六个月随访结果

目的探讨雷帕霉素药物洗脱支架（Cypher）在急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗（PCI）中应用的安全性和有效性.方法选择2002年11月至2004年12月间的急性ST段抬高心肌梗死患者168例,于发病12 h内行急诊PCI治疗,于梗死相关血管的靶病变置入Cypher支架.记录1个月和6个月随访终点时的主要心脏不良事件（包括死亡、再发心肌梗死、靶血管再成形等）发生率、支架内血栓发生率、支架内再狭窄发生率.结果 168例患者急诊PCI治疗均获得成功.168支梗死相关血管的171处罪犯病变共置入175枚Cypher支架,未发生与介入治疗有关的并发症.1个月随访终点时死亡3例（死亡率1.8%）;支架内亚急性血栓1例;主要心脏不良事件发生率2.4%.6个月随访终点时死亡4例（死亡率2.4%）;主要心脏不良事件发生率4.2%;支架内血栓发生率1.2%;支架内再狭窄发生率1.8%.结论药物洗脱支架（Cypher）在急性ST段抬高心肌梗死急诊PCI中应用与普通支架一样有较强的安全性和有效性,并可以明显降低再狭窄率.     

国产药物洗脱支架在急性冠状动脉综合征急诊介入治疗中的近中期效果评价

目的:评价国产药物支架在急性冠状动脉综合征(ACS)急诊介入治疗(PCI)中的安全性和有效性。方法:51例ACS患者,其中ST段抬高型心肌梗死27例,非ST段抬高型心肌梗死14例,不稳定型心绞痛(BraunwaldⅢ级)10例,在对罪犯血管行PCI过程中置入国产药物洗脱支架———Firebird支架。结果:51例患者PCI治疗均获得成功。共治疗罪犯血管51支,置入Firebird支架63枚。1例STEMI患者出现无复流现象,4例应用主动脉内气囊反搏术,2例发生穿刺部位血肿。无其他严重并发症。随访3～6个月,所有患者未发生严重心血管事件;25例(49.02%)患者术后6个月行冠状动脉造影复查,无一例发生支架内再狭窄。结论:国产药物洗脱支架在ACS急诊PCI中安全、有效,近、中期效果良好。     

急诊经皮冠状动脉介入术开通梗死相关血管时程变化对急性ST段抬高型心肌梗死早期预后的影响

目的:观察急诊经皮冠状动脉介入术(PCI)开通梗死相关血管的时程变化对急性ST段抬高型心肌梗死(STEMI)住院期间死亡率及心肌梗死后30 d内心血管事件发生率的影响.方法:急性STEMI患者213例,根据症状发生至第1次球囊扩张的时间分为3组:＜180 min组(A组,27例),180～360 min组(B组,83例),＞360 min组(C组,103例).观察各组术后30 d内主要心血管不良事件的发生率,包括心源性死亡、非致死性心肌梗死、急性亚急性支架内血栓形成.结果:症状发生到第1次球囊扩张的时间中位数为(355.3±223)min,C组老年患者(≥75岁)及女性患者相对多见,前壁梗死和心源性休克发生率较高.住院总心源性死亡率为13.6%,C组住院期间死亡率(17.5%)明显高于A组(3.7%)和B组(12.1%);急性心肌梗死的并发症心源性休克显著影响死亡率(36.5%).随访30 d,心源性休克、≥75岁高龄、女性患者心血管事件发生率显著升高.多因素回归分析显示时间延迟>360 min是影响急性STEMI早期预后的独立危险因素.结论:急诊PCI时间的延迟显著影响急性STEMI早期预后.急诊PCI时间延迟超过6h是影响早期预后的独立危险因素.     

Coronary Sarcoidosis Presenting as Acute Coronary Syndrome

Sarcoidosis is a systemic disorder of uncertain etiology characterized by noncaseating granulomatous inflammation. The disease often involves the heart on autopsy, but the antemortem diagnosis of cardiac sarcoidosis is frequently missed. Cardiac involvement usually includes granulomatous inflammation or fibrosis of the myocardium, conduction system, or pericardium. We now describe a case of epicardial coronary involvement by sarcoidosis, where the diagnosis was made by surgical biopsy of the coronary artery in an African American man presenting with acute coronary syndrome and recurrent symptomatic restenosis following coronary intervention. The case extends the spectrum of common cardiac syndromes that cardiac sarcoidosis can masquerade as and highlights the importance of maintaining a high index of suspicion for early recognition and instituting specific treatment that might improve prognosis. A review of the literature also suggests the need for improvement in diagnostic approaches and prospective clinical trials to establish the best management strategy for this disease. Copyright © 2009 Wiley Periodicals, Inc.     

Coronary Atherosclerotic Precursors of Acute Coronary Syndromes

Background

The association of atherosclerotic features with first acute coronary syndromes (ACS) has not accounted for plaque burden.

Coronary Thromboembolism with Fatal Outcome Following Coronary Angiography

ABSTRACT A case of fatal thromboembolic occlusion of the left coronary artery at selective coronary arteriography is described. The course of events and the findings at autopsy suggest that thrombotic material was deposited on one intravascular catheter and transferred to a second catheter inserted over the same guide wire. Contrast injection through the second catheter into the left coronary ostium resulted in immediate and fatal occlusion of the two major branches of the left coronary artery.     

Spontaneous Multivessel Coronary Spasm During Diagnostic Coronary Angiography

Acute vasospastic angina, formerly known as Prinzmetal angina, is characterized by transient electrocardiographic changes that are not related to exertion. Its atypical presentation makes it difficult to establish the diagnosis, so it is probably underrecognized and therefore mismanaged. We treated a 49-year-old woman who presented with a 2-day history of chest pain associated with palpitations. Abnormal radionuclide stress test results prompted diagnostic coronary angiography, during which the patient reported chest pain and became hemodynamically unstable. Active coronary vasospasm at multiple sites was treated with intracoronary nitroglycerin and nicardipine, leading to immediate recovery.Our case highlights the importance of accurate, timely diagnosis of vasospastic angina, and of early recognition and management of spontaneous coronary spasm during angiography.     

Coronary collaterals

A 79-year-old man with onset of typical angina pectoris wasreferred to our institution for suspected coronary artery disease.We performed non-invasive coronary angiography using