老年急性ST段抬高心肌梗死急诊介入治疗后心肌组织水平再灌注不良的发生率及其对临床预后的影响

目的探讨老年急性心肌梗死（acute myocardial infarction,AMI）-急诊经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗后心肌组织水平再灌注状态不良的发生率及其对近、远期临床预后的影响。方法回顾性收集398例老年急性ST段抬高心肌梗死（ST-elevationmyocardi-alinfarction,STEMI）行急诊PCI治疗患者的临床资料、冠状动脉造影资料与心电图,以ST段回落程度与TIMI心肌灌注（TIMIMyocardialPerfusion,TMP）分级等指标评估心肌组织水平再灌注状态,患者分为4组,A组为ST段回落率〉50%并且术后TMP分级为Ⅲ级;B组为ST段回落率〈50%而术后TMP分级=Ⅲ级;C组为术后TMP分级≤Ⅱ级而ST段回落率〉50%;D组为ST段回落率〈50%并且术后TMP分级≤Ⅱ级。分析心肌组织水平再灌注不良患者的发生率及其对近远期预后的影响。结果 STEMI急诊PCI术后梗死相关血管（infarctionrelatedartery,IRA）前向血流达到TIMIⅢ级而TMP分级为Ⅱ级以下者占37.2%,心电图ST段回落小于50%者占37.2%,均接近1/3。12.5%的患者具有远端栓塞。术后ST段回落率〉50%并且TMP分级为Ⅲ级者占总人数的39.8%,ST段回落率〈50%,并且术后TMP分级≤Ⅱ级占总人数的14.3%。心肌组织灌注状态不良者与心肌组织灌注状态良好者相比平均住院日更长,左室EF值更低,梗死后心绞痛发生率更高,远端栓塞发生率更高,IABP辅助应用比率更大,心功能恶化、心脏性死亡更高。与D组相比,随访期间MACE的发生风险在C组为43%（P=0.11）,在B组为24%（P〈0.01）,在A组为2.7%（P〈0.01）。结论老年急性心肌梗死行急诊PCI治疗后IRA再通者仅有不到40%的患者其心肌组织水平得到了良好的再灌注,其近、远期预后较好,而剩余约60%的患者其心肌组织水平存在不同程度的再灌注障碍,其中有大概约超过10%的患者其心肌组织水平存在较差的再灌注状态,这些患者在住院期间以及远期随访期间有着极高的MACE发生风险。     

糖化血红蛋白对直接冠状动脉介入术后心肌组织灌注的影响

目的:观察糖化血红蛋白(HbA1c)水平对急性心肌梗死(AMI)患者接受直接冠状动脉介入(PCI)术后心肌组织灌注的影响。方法:选择因AMI行直接PCI的患者492例,根据HbA1c水平将所有患者分为HbA1c≥6.5%组189例和HbA1c<6.5%组(对照组)303例。通过观察TIMI心肌灌注(TMP)分级、心肌blush分级(MBG)及术后ST段回落率(STR),评价2组患者的术后心肌组织灌注及预后。结果:与对照组比较,HbA1c≥6.5%组的病变血管数、术中出现无复流/慢血流比例、住院期间病死率及梗死相关动脉开通时间显著增加,而术后达到TIMI血流3级、MBG 3级、TMP 3级和STR的比例及LVEF均明显降低(均P<0.05)。多因素分析结果显示,HbA1c≥6.5%是影响术后STR(OR=2.156,95%CI:1.057～4.328,P=0.036)及住院期间病死率(OR=1.021,95%CI:0.418～2.412,P=0.022)的独立危险因素。结论:HbA1c升高的AMI患者心肌组织灌注较差,住院期间病死率高。应重视这些高危患者,并尽早处理,从而改善患者的预后。     

血栓抽吸导管对急性心肌梗死患者心肌灌注水平影响的临床研究

目的分析在血栓负荷较大的急性心肌梗死(AMI)患者行急诊PCI中,应用抽吸导管对心肌再灌注的影响及安全性。方法选择经急诊冠状动脉造影显示血栓负荷较大的AMI患者36例作为血栓抽吸组,另选同期采用常规PCI的AMI患者36例作为对照组,比较2组的血栓负荷、TIMI分级、TIMI心肌灌注(TMP)分级、心肌酶峰值、ST段回落幅度、LVEF、住院期间心血管不良事件。结果血栓抽吸组患者经抽吸后血栓负荷明显降低;血栓抽吸组患者TIMI分级和TMP分级明显优于对照组,差异有统计学意义(P0.01);血栓抽吸组患者较对照组肌酸激酶、肌酸激酶同工酶峰值明显降低,术后1 h ST段回落百分比明显增高,LVEF明显升高,左心室舒张末内径明显下降,差异有统计学意义(P0.01)。结论在血栓负荷较重的AMI患者行急诊PCI时,应用血栓抽吸导管安全可行,可显著改善梗死相关血管前向血流情况,改善心肌再灌注,减少无复流现象和心肌酶的释放。     

血小板平均容积对老年急性心肌梗死患者急诊介入治疗后心肌灌注不良的预测

目的探讨急性心肌梗死(AMI)患者急诊PCI术前血小板平均容积(MPV)水平与术后心肌灌注情况之间的关系。方法选择AMI并接受急诊PCI的老年患者273例,根据术后心肌呈色分级(MBG)分为灌注良好组(MBG 3级)159例和灌注不良组(MBG 0~2级)114例。比较2组入院时血常规等情况,分析急诊PCI术后心肌灌注不良的相关因素。结果灌注不良组MPV[(11.2±1.4)fl vs(9.4±1.2)fl]及白细胞计数[(11.2±1.0)×109/L vs(10.1±1.3)×109/L]较灌注良好组明显增高(P0.01)。多因素logistic回归分析显示,MPV(OR=2.409,95%CI:1.640~3.539,P0.01)和白细胞计数(OR=1.683,95%CI:1.107~2.558,P0.05)是急诊PCI术后心肌灌注不良的预测因素;相关分析显示,MPV和白细胞计数分别与急诊PCI术后MBG(r=-0.616,P0.01;r=-0.449,P0.05)和左心室射血分数(r=-0.671,P0.01;r=-0.265,P0.05)呈负相关。结论在接受急诊PCI术成功开通梗死相关血管的老年AMI患者中,其MPV和白细胞计数越高,术后心肌灌注情况越差。     

急性心肌梗死经皮冠状动脉介入治疗后心肌灌注的方法评价

目的　联合应用TIMI心肌灌注分级 (TMP)、校正的TIMI画面记帧 (CTFC)、心电图ST段变化 (sumSTR)方法评价急性心肌梗死 (AMI)急诊经皮冠状动脉介入治疗 (PCI)后心肌灌注程度 ,探讨心肌灌注程度对临床预后的影响。方法　 77例AMI患者PCI后即刻采用TMP CTFC、TMP sumSTR、CTFC sumSTR三种联合方法评价心肌灌注程度 ,PCI术后 1个月检查双核素心肌灌注显像 ,记录 6个月心脏事件。结果　评价心肌灌注程度 ,与双核素心肌灌注显像对比 ,TMP sumSTR敏感性 86 7%、特异性 85 7%、准确性 86 2 % ;TMP CTFC敏感性 80 %、特异性 77 1%、准确性 78 5 % ;多变量回归分析TMP 0 / 1级 sumSTR <30 %为 6个月心脏事件的独立危险因子 (OR=2 1 5 ,95 %可信区间 2 7～ 6 5 7,P =0 0 0 3) ;Kaplan Meier分析曲线显示TMP sumSTR方法评价的心肌灌注不良组 6个月心脏事件高于心肌灌注良好组 (P <0 0 5 )。结论　TMP sumSTR、TMP CTFC能更好的评价心肌灌注程度 ;TMP sumSTR可预测 6个月心脏事件。     

血栓抽吸术联合PCI治疗急性心肌梗死的疗效

目的观察血栓抽吸(TA)联合冠状动脉介入术(PCI)治疗急性心肌梗死(AMI)伴有血栓负荷病变的疗效及安全性。方法选取70例(年龄≥65岁)经冠状动脉造影证实冠脉血栓负荷病变患者,在AMI常规治疗基础上均应用盐酸替罗非班治疗,并随机分为TA联合PCI组(45例)和单纯PCI组(25例)。TA联合PCI组加用DiverC.E.血栓抽吸装置。比较两组病人一般发病资料和TIMI血流分级、ST段抬高和回落百分比、心肌显色分级、左心室射血分数(LVEF)、主要心血管不良事件(MACE)。结果两组心肌梗死溶栓治疗TIMI血流分级、ST段抬高和回落百分比(sumSTR)、心肌显色分级(MBG)、LVEF比较具有统计学差异(P<0.05);住院期间TA联合PCI组MACE发生率较单纯PCI组低。结论 TA联合血小板膜受体拮抗剂是治疗AMI伴有血栓负荷病变有效的手段,能够更大程度改善冠脉血流和梗死区域的心肌灌注,挽救濒死心肌,减少MACE事件发生,改善急性ST段抬高型心肌梗死血栓负荷病变患者的左室功能,改善预后。     

血栓抽吸联合替罗非班对急性ST段抬高心肌梗死患者心肌再灌注的影响

目的 探讨急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗（PCI）中联合应用ZEEK血栓抽吸导管和替罗非班对心肌组织灌注及临床预后的影响.方法 84例经冠脉造影证实为血栓负荷病变的急性ST段抬高心肌梗死患者随机分为血栓抽吸＋替罗非班42例（A组）和标准PCI 42例（B组）,比较两组患者手术后即刻梗死相关动脉（IRA）的心肌梗死溶栓（TIMI）血流、心肌灌注分级（MBG）、心电图ST段回落百分比、左心室射血分数（LVEF）及住院期间主要心脏不良事件（MACE）和出血性并发症发生率.结果 A组术后即刻TIMI血流、MBG、ST段抬高回落百分比及LVEF均明显优于B组（P〈0.05）,两组住院期间的MACE发生率及出血并发症比较差异无统计学意义（P〉0.05）.结论 在急性心肌梗死急诊PCI中联合使用ZEEK导管血栓抽吸和替罗非班安全可行,可有效清除冠状动脉内血栓,改善心肌组织灌注和术后心脏功能,并且不增加主要心脏不良事件的发生率.     

单支冠状动脉慢性完全闭塞病变介入治疗术后影响预后因素

目的：探讨单支冠状动脉慢性闭塞（CCTO）病变介入治疗术后临床预后的影响因素.方法：回顾分析2006年10月～2013年2月因单支主要冠状动脉CCTO病变在我院行经皮冠状动脉介入治疗（PCI）的患者资料,筛选预测主要不良心脏事件（MACE：心因性死亡、再发心绞痛、非致命性心肌梗死或心力衰竭）的危险因子.结果：130例患者平均中位年龄为68岁,男性占76.9％.86例（66.2％）被成功开通闭塞血管.平均随访23月,40例（30.8％）发生MACE事件,PCI失败并不增加MACE事件的发生（P=0.205）,多因素Logistic回归分析显示慢性肾脏疾病（CKD）≥3期和MACE事件独立相关（OR值1.55,95％可信区间1.07～2.24,P=0.02）.结论：肾功能失代偿（CKD≥3期）可预测单支主要冠状动脉慢性闭塞病变患者PCI术后的远期不良预后,成功的PCI治疗可能不能减少此类患者主要不良心脏事件的发生.     

慢性完全闭塞病变血运重建后围术期心肌梗死发生率及危险因素分析

目的 采用慢性完全闭塞病变学术联盟（CTO-ARC）专家共识定义,按照CTOARC围术期心肌梗死（PMI）标准,评价慢性完全闭塞（CTO）病变行经皮冠状动脉介入治疗（PCI）PMI的发生率,并对相关危险因素进行分析。方法 根据CTO-ARC标准,回顾性分析首都医科大学附属北京安贞医院冠心病中心自2019年1—6月所有通过PCI成功完成血运重建的CTO病变患者的临床基线特征、造影结果以及手术操作特点,应用多因素Logistic回归分析识别PMI的独立危险因素。结果 纳入通过PCI成功完成血运重建的CTO病变415例,PMI发生率4.8%。经多因素Logistic回归分析,供血血管闭塞（OR 48.818,95%CI 2.365～1 007.888,P=0.012）、边支血管损伤（OR 20.332,95%CI 4.439～93.132,P<0.01）、术后心肌梗死溶栓治疗试验（TIMI）血流分级<Ⅲ级（OR 33.310,95%CI6.209～178.689,P<0.01）及支架长度（OR 1.020,95%CI1.005～1.035,P=0.011）与CTO病变血运重...     

血栓抽吸装置在急性ST段抬高型心肌梗死患者中临床疗效的Meta分析

目的系统评价血栓抽吸装置在急性ST段抬高型心肌梗死患者中的临床疗效。方法计算机检索The Cochrane Library、PubMed、EMbase、中国期刊全文数据库、万方数据库,检索急性ST段抬高型心肌梗死冠脉支架介入治疗应用血栓抽吸装置与单纯冠脉支架介入治疗的随机对照研究(RCT)。按照纳入与排除标准,由两位研究者独立进行文献筛选、资料提取和方法学质量评价后,采用RevMan5.0软件进行Meta分析。结果最终纳入22个随机对照研究,共5177例患者,研究分为抽吸组与PCI组。Meta分析结果显示抽吸组出院后主要心血管不良事件明显低于PCI组(OR=0.78,95%CI:0.62~0.99,P=0.04)。抽吸组与PCI组术后死亡率差异无统计学意义(OR=0.92,95%CI:0.65~1.31,P=0.64),但随访时间在180天至365天抽吸组术后死亡率明显低于PCI组(OR=0.63,95%CI:0.42~0.94,P=0.02)。抽吸组术后心肌灌注3级高于PCI组(OR=2.03,95%CI:1.37~3.0,P=0.004);术后TIMI3血流高于PCI组(OR=1.31,95%CI:1.11~1.54,P=0.001)。结论血栓抽吸装置可明显改善急性ST段抬高型心肌梗死患者术后心肌血流再灌注,降低术后180天至365天的死亡率,减少出院后主要心血管不良事件的发生。     

Triple origin of left coronary arteries from right coronary artery: Unusual case of single coronary artery

A rare case of coronary anomaly is presented: all of the coronary arteries originated from a single ostium located in the right coronary cusp. No clinical evidence of coronary pathology was recognized until the age of 57 years when the patient was found to have coronary obstructive disease. The single coronary artery had a main branch corresponding to the usual dominant right coronary artery. Three other branches separated from this and vascularized the areas normally receiving the circumflex and ramus medianus, the left anterior descending, and a large septal branch.     

Implication of transstenotic coronary pressure gradient measurement during coronary angioplasty

The aim of this study was to establish a criterion for the success of an angioplasty based upon pressure gradients across coronary lesions. Sixty-two percutaneous transluminal coronary angioplasties (PTCA) in 56 patients with isolated left anterior descending artery disease were examined. Pressure gradients measured before and after PTCA were expressed as normalized mean pressure gradients (NMPG) computed by dividing mean pressure gradient by mean aortic or proximal coronary artery pressure. Angiographic severity was expressed as percentage area stenosis (AS) calculated from diastolic caliper measurements of diameter of each lesion and the nearest normal adjacent segment in at least two projections. The relationship between AS and NMPG was nonlinear with a steep increase in gradients beyond a critical value of AS of about 60%. This relationship was unaffected by angiographically visualized collaterals. All except one of 65 coronary stenotic lesions with NMPG of more than 0.32 had an AS of more than 60%. Only three of 57 coronary stenoses with NMPG of less than 0.32 had severe AS (p < 0.001). The results indicate that NMPG is a reliable, practical guide to the severity of coronary stenosis and is therefore a useful measurement for assessing either the success or the residual stenosis during PTCA.     

Left main stem coronary artery dissection during coronary angiography

This paper describes a case of dissection of the main stem of the left coronary artery during coronary angiography with an uneventful clinical course. As far as we know, only one comparable case has been reported before. A brief survey of the pertinent literature is presented. Some possible pathogenetic factors are considered. No specific preventive or therapeutic measurement can be recommended.     

The incidence of coronary anomalies on routine coronary computed tomography scans

The incidence of coronary anomalies (CCAs) in a typical angiographic study was 1.3%.1 Studies have been conducted on CCAs using conventional invasive coronary angiography in highly selected groups of patients but these studies may not reflect the true incidence of CCAs.Although the majority of CCAs are benign and incidentally detected during conventional angiography, certain CCAs may cause syncope, heart failure or sudden death, especially among young athletes.2,3 The US National Registry of Sudden Death in Athletes at the Minneapolis Heart Institute Registry found that CCAs were the second most common cause of sudden cardiac death (out of 17% of the population who died of cardiac-related causes).4Although conventional invasive coronary angiography is considered the gold standard for the diagnosis of CCAs, transthoracic two-dimensional echocardiography, transoesophageal echocardiography, magnetic resonance imaging and multi-slice computed tomography (MSCT) can all identify for diagnosis, CCAs in certain groups of patients.5-10 Transthoracic twodimensional echocardiography may depict the origin of the coronary arteries, especially the left main artery, but successful detection of coronary anomalies depends on the age and size of the patient.5,6Transoesophageal echocardiography has an increased success rate of identifying coronary anomalies in comparison with two-dimensional echocardiography. Nevertheless, the position of the transducer, cardiac motion, and the curvilinear course of the vessel all affect visualisation of coronary anomalies. Moreover, transoesophageal echocardiography is a semi-invasive method and is time consuming.6,7Magnetic resonance (MR) imaging provides an accurate assessment of the course of anomalous coronary arteries.8,9 However, this technique cannot be performed in patients with pacemakers, certain types of arrhythmias or defibrillating devices, and it may be difficult to perform in claustrophobic patients. Furthermore, the spatial resolution of MR imaging is substantially inferior to that of the newest generation of CT scanners.10Myocardial bridging (MB) is defined as the compression of a coronary artery during systole while it is normal in diastole. MB has been linked to serious cardiac events.11 The incidence of myocardial bridging in the population varies substantially according to invasive coronary angiography (13%) and autopsy (15–85%).12,13 The reported incidence of MB has increased up to 44% when using 64-MSCT.14 Because of its ability to cause serious cardiac events, diagnosing MB is clinically important.MSCT is a minimally invasive method that provides excellent temporal and spatial resolution of the coronary arteries. There have been a limited number of studies evaluating CCAs and MB with 64-MSCT. The aim of this study was to assess the incidence of CCAs and MB using 64-MSCT in a relatively large population.     

Association of coronary calcification with obstructive disease in coronary arteries in Indian patients

A total of 1150 consecutive patients (1052 males and 98 females; age 51.2 +/- 10.1 years) with suspected coronary artery disease (Group I) were subjected to fluoroscopy for detection of coronary artery calcification (CAC) and coronary angiography. Another group (Group II) of 120 patients (95 males and 25 females; age 51.4 +/- 9.4 years) catheterized for cardiac diseases other than coronary artery disease (CAD) were subjected to the same protocol of fluoroscopy and coronary angiography to exclude incidental CAD in view of their age. CAC was present in 240 patients (20.0%) in Group I. Of these, 200 (83.4%) had triple-vessel disease (TVD); 20 (8.3%) had double-vessel disease (DVD); 19 (7.9%) had single-vessel disease (SVD); and 37 (15.4%) patients had left main coronary disease (LMCAD). Only one of these patients had insignificant CAD considered as "normal" coronary arteries (NC). Incidence of LMCAD, TVD, DVD, SVD, and NC in patients without CAC was 4.4%, 56.3%, 18.2%, 14.0%, and 11.5%, respectively. Incidence of CAC in patients with LMCAD, TVD, DVD, SVD, and NC was 48.1%, 28.1%, 10.8%, 13.0%, and 1.0% respectively. In Group II (n = 120), 24 patients (20%) had CAD, CAC was present in 5 patients with CAD (20.9%), and in two patients without CAD (2%). CAC is relatively uncommon in Indian CAD patients. Its presence, however, indicates severe multivessel disease.     

The disappearing coronary stenosis: reemphasizing the importance of excluding coronary vasospasm before coronary intervention.

We describe a case of resting angina with multiple angiographic stenoses that were highly suitable for stenting. These classic lesions resolved after intracoronary nitroglycerin while positioning a stent. This case reemphasizes the need to exclude vasospasm prior to any interventional coronary procedure.     

Percutaneous transluminal coronary angioplasty of a right coronary artery arising from the left main coronary artery

Angioplasty of anomalous coronary arteries presents unique technical challenges. Correct guiding catheter selection is important to ensure adequate access to the anomalous vessel and to provide support to cross the lesion. A case of successful PTCA of a lesion in an anomalous right coronary artery arising from the left main coronary artery is presented. © 1993 Wiiey-Liss, Inc.     

冠状动脉造影检查在冠心病诊断中作用的再探讨

目的探讨冠状动脉造影（CAG）检查在诊断冠心病中作用,就其对多年来被认为是金标准作用进行再探讨。方法对138例怀疑有冠心病的患者,均经普通ECG,动态ECG,活动平板和CAG。结果只有71例患者的冠状动脉造影检查符合目前冠心病标准,其余67例患者冠状动脉未达标（轻度-中度狭窄,或完全正常或仅见散在斑块形成）。结论冠心病的诊断是一个较为复杂的问题,CAG检查是诊断冠心病的一个重要依据,有相当比例的冠心病患者（CAG）无明显异常。     

Detection of impaired coronary flow reserve in coronary artery disease using transthoracic echocardiographic assessment of coronary sinus blood flow

In order to establish whether coronary flow reserve (CFR) can be measured by transthoracic echocardiography (TTE) with pulse wave Doppler echocardiography, 14 patients with coronary artery disease (CAD) and 12 normal subjects were studied. Coronary sinus blood flow was measured at rest and 2 minutes after intravenous injection of 0.56 mg/kg dipyridamole (DP). CFR was calculated as the DP to rest flow ratio. Patients with CAD were found to have significantly decreased CFR when compared to normal subjects. These findings suggest that TTE may be useful in diagnosing CAD.     

Sudden coronary death

Many reports have described the amounts of atherosclerotic plaque in victims of sudden coronary death, defining the number of coronary arteries narrowed at some point greater than 75% in cross-sectional area (XSA). In order to quantitate more precisely the amount and distribution of plaque, 70 victims of sudden coronary death aged 22-81 years (mean 50) were studied. The four major epicardial coronary arteries (left main, left anterior descending, left circumflex, and right) from each of 70 victims were cut into 5-mm segments (average 50 per patient) and a histologic section prepared from each segment. The amount of luminal narrowing by plaque was categorized into five groups (0-25%, 26-50%, 51-75%, 76-95%, 96-100%). Of 3,484 five-mm segments, 950 (27%) were narrowed 76-100% in XSA. Comparison of 31 previously symptomatic victims (angina pectoris and/or myocardial infarction) to 39 victims who had been asymptomatic disclosed a higher mean percent of severely narrowed segments (30% vs. 25%, p = less than 0.005) and a lower mean percent of minimally narrowed segments in the symptomatic group. Comparison of the 31 patients with a healed myocardial infarction at necropsy with 39 patients with no left ventricular scar disclosed a higher mean percent of segments severely narrowed (33% vs. 24%, p = less than 0.001) and a lower mean percent of segments narrowed minimally in those with a left ventricular scar (13% vs. 26%, p = less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)