心肌梗死行冠状动脉介入治疗后无复流现象临床分析

目的探讨急性ST段抬高型心肌梗死患者行急诊冠状动脉介入术治疗后无复流现象的影响因素及对预后的影响。方法行急诊冠状动脉介入治疗的急性ST段抬高型心肌梗死患者385例,根据治疗后TIMI血流情况分为无复流组（TIMIO～2级）及TIMI3级组,记录2组住院期间不良事件发生情况,分析无复流现象的影响因素及对预后的影响。结果本组患者行急诊冠状动脉介入术后无复流发生率为40％;应激性高血糖、高尿酸血症、高敏C反应蛋白〉3mg／L是急诊冠状动脉介入术后无复流现象发生的独立危险因素;无复流现象可增加患者住院期间病死率及复合终点事件发生率。结论急诊冠状动脉介入术治疗急性ST段抬高型心肌梗死患者后无复流现象发生率高,无复流现象可增加心血管不良事件发生率。     

急性心肌梗死PCI术后发生无复流患者的护理

急诊经皮冠状动脉介入治疗（PCI）是急性心肌梗死（AM1）治疗中重要的再灌注方法,其目的是使因血栓闭塞的冠状动脉迅速再通,并实现心肌组织的有效再灌注,减少心肌的坏死面积。但在临床研究中发现,虽然造影显示心外膜血管已开通,但仍有10％～30％病例心肌组织无灌注或灌注不良,即为无复流现象。研究证实无复流可导致梗死的延展,心功能恢复障碍,左心室重构等更多的合并症,也是心肌和微血管损伤的标志之一。与心肌充分复流的患者相比,无复流的患者在发生心肌梗死后更多的发生充血性心力衰竭,恶性心律失常和心脏性猝死,是影响PCI近期预后和远期心源性死亡及心脏事件的独立危险因素。     

经皮冠状动脉介入术中对无复流现象预防的临床研究

目的 探讨经皮冠状动脉介入治疗术中发生无复流现象的高发因素和强化抗血小板治疗对无复流现象的预防效果。方法 对618例冠心病患者行经皮冠状动脉介入治疗，根据介入术中发生无复流现象情况判别无复流现象高发的危险因素，并观察强化抗血小板治疗对急性冠状动脉综合征患者无复流现象的预防作用和不良反应。结果 患者年龄、性别，是否伴发高血压、糖尿病，血脂异常，目前吸烟，术前PT、APTI＇不影响无复流现象发生，但是，急性冠状动脉综合征、右冠状动脉病变、病变血管直径〉4mm、血管病变呈弥漫性病变、冠状动脉瘤样扩张伴狭窄、罪犯血管处有血栓征象患者无复流现象明显增加。术前应用替罗非班强化抗血小板治疗可以有效预防介入术中无复流现象的发生而不增加不良反应。结论 冠心病患者介入治疗前通过评价临床和冠状动脉造影情况可以发现预测无复流现象发生的危险因素，术前应用替罗非班强化抗血小板治疗可以有效预防无复流现象的发生。     

法舒地尔对急性ST段抬高型心肌梗死患者急诊PCI术中无复流现象及内皮细胞功能的影响

<正>急性ST段抬高型心肌梗死(STEMI)是目前致死的主要原因之一,目前,治疗STEMI的最有效措施为经皮冠状动脉介入治疗(PCI)[1]。开通罪犯血管后,再灌注治疗的效果与受损微血管的再灌注密切相关。开通罪犯血管后,缺血心肌缺乏充分的血液灌注又被称为无复流现象。在急诊PCI术中,无复流现象的发生直接影响手术成功率及患者预后,而目前尚缺乏能够逆转已发生的无复流现象的有效药物[2-4]。近期研究发现,内皮细胞功能障碍与无复     

冠脉无复流现象治疗的研究进展

急性心肌梗死(AMI)患者再通治疗时,无复流现象的发生严重影响了再通治疗的成功率。因此,改善心肌微循环再灌注,减少无复流现象的发生率成为当今治疗AMI的新热点。现对无复流现象的机制及各种改善心肌微循环治疗的研究进展及存在问题作一综述。     

急性心肌梗死患者无复流现象与降低血浆胆固醇的临床观察

目的 观察服用他汀类药物对患者血浆总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)及发生急性心肌梗死后急诊经皮冠状动脉成形术(PCI)后发生无复流现象的影响.方法 行急诊PCI的患者于冠状动脉抽血测TC定、LDL-C水平.将急诊开通梗死相关血管的161例患者依据PCI后有无复流分为,未使用他汀类药物复流(NSNN组,n=88)、未使用他汀类药物无复流(NSN组,n=19)、使用他汀类药物复流(SNN组,n=52)、使用他汀类药物无复流(SN组,n=2).对各组复流发生情况、血浆TC、LDL-C水平数据进行分析.结果 各组之间无复流现象发生率,NSNN组88例(54.7%); NSN组19例(11.8%); SNN组52例(32.3%); SN组2例(1.2%).使用他汀治疗后发生无复流现象比例显著低于未使用他汀治疗组(P<0.05).未发生复流现象组患者(NSNN、SNN)血浆TC及LDL-C水平显著低于发生无复流现象组患者(NSN、SN)(P<0.05或<0.01).结论 急性心肌梗死患者再灌注治疗后发生无复流现象可能和血脂水平有关.他汀类药物可以显著改善急性心肌梗死患者急诊再灌注治疗无复流现象的发生,其机制之一可能通过降低血浆胆固醇.同时血浆胆固醇及LDL-C低水平的患者发生无复流概率可能较小.     

冠状动脉介入术后心肌无复流的评估及处理

心肌无复流（no-reflow,NR）指的是经冠状动脉介入治疗（PCI）后,病变管腔狭窄已被解除,但心肌组织仍未获充分血流灌注的现象。NR现象在急性心肌梗死（AMI）、非ST段抬高型急性冠状动脉综合征（NSTE-ACS）、稳定性心绞痛（SA）、冠状动脉搭桥（CABG）术后桥血管再狭窄等接受急诊或择期PCI的患者中均可出现,其与心室重塑、心力衰竭和主要心血管事件密切相关,因而及时识别和处理心肌NR是改善患者预后的关键环节之一。     

法舒地尔对急性冠状动脉综合征患者心肌保护作用

<正>急性冠状动脉综合征(ACS)再灌注心肌治疗有效治疗方法为经皮冠状动脉介入治疗(PCI),患者术后易出现无复流现象[1],其发生率5%-50%,患者心外膜冠状动脉灌注良好,心肌灌注不良,存在早期梗死后并发症风险[2]。目前对微循环无复流防治缺乏有效治疗药物,法舒地尔为临床应用的Rho激酶抑制剂,研究证实对包括冠状动脉痉挛、冠脉再通手术后的再狭窄、PCI术中发生无复流均具有很好的治疗作用和安全性[3,4],本研究旨在对ACS患者     

冠状动脉无复流现象的临床研究进展

冠状动脉无复流(no-reflow,NR)是指急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(Percutaneous oronary interventions,PCI)或静脉溶栓治疗、其梗死的相关动脉(Infarction Relative Artery,IRA)再通后,冠状动脉造影排除病变部位因内膜撕裂、管壁夹层、血栓栓塞、急性支架内血栓形成、心外膜血管痉挛等急性PCI机械并发症因素,冠状动脉所支配的区域心肌组织无灌注或灌注不良的现象.短暂的动脉闭塞是无复流发生的前提条件.     

冠状动脉内注射替罗非班对急诊介入治疗中无复流的影响

随着操作技术的成熟及药物洗脱支架(DES)时代的来临,经皮冠状动脉介入治疗(PCI)已经成为急性心肌梗死(AMI)的首选治疗方法.AMI患者的病死率及心肌再梗死率已经明显降低,但仍有部分患者术中出现“无复流现象”(no flow phenomenon),导致微循环障碍,心肌组织不能有效灌注,目前认为是PCI近期预后和远期心源性猝死及心脏事件的独立危险因素.已有研究表明,血小板糖蛋白Ⅱb/Ⅲa受体拮抗剂替罗非班,能显著减轻血栓负荷,有效改善心肌组织水平再灌注,提高直接PCI术的成功率.替罗非班的常规应用方法为静脉注射,本研究采用冠状动脉内直接注射替罗非班治疗AMI患者PCI术中出现的无复流现象,并与常用的治疗无复流现象药物-维拉帕米进行治疗,探讨冠状动脉内注射替罗非班治疗无复流的疗效.     

New strategies for the management of no-reflow after primary percutaneous coronary intervention

The myocardial no-reflow phenomenon is characterized by a reduced antegrade myocardial blood flow despite an open infarct-related artery in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Importantly, no-reflow is known to be associated with unfavorable clinical outcome and prognosis. It is a complex phenomenon and is caused by the variable combination of four pathogenetic components: distal atherothrombotic embolization, ischemic injury, reperfusion injury and susceptibility of coronary microcirculation to injury. As a consequence, appropriate strategies to prevent or treat each of these components are expected to reduce the occurrence of no-reflow. Mechanical and pharmacological approaches performed before, during and after performing myocardial revascularization have been investigated in recent studies, in order to reduce the rate of no-reflow. In this article, we concentrate on the major preventive and therapeutic approaches currently available for the management of the no-reflow phenomenon.     

冠心病介入治疗中的无血流现象及处理

目的　评价血小板表面糖蛋白受体(GPⅡb/Ⅲa)拮抗剂ReoPro对硝酸甘油不能缓解的冠状动脉无血流现象(No-Reflow)的疗效以及对住院期间临床预后的影响。方法　回顾性研究了伴或不伴No-Reflow现象病人的临床特点、住院期间主要心血管事件(死亡、心肌梗死、血管再通术)发生率。结果　1093例病人中经皮球囊扩张术(PTCA)352例，支架术741例；共23例病人被描述有No-Reflow现象，其中6例病人对硝酸甘油冠状动脉内注射无反应，在给予ReoPro后TIMI血流明显改善(0.83±0.41vs2.50±0.54，P＜0.002)，与同期不伴有No-Reflow现象相比，住院期间死亡(0vs0.74%，P＞0.75)、靶血管再介入(0vs1.10%，P＞0.75)、搭桥术(0vs0.21%，P＞0.90)发生率无区别，但心肌梗死发生率较高(Q波心肌梗死16.7%vs0.37%，P＜0.005；无Q波心肌梗死50%vs1.05%，P＜0.005)。结论　ReoPro能明显改善对硝酸甘油无反应No-Reflow病人的TIMI血流及临床预后，也提示血小板介导的微血管血栓及栓塞是这类病人No-Reflow现象的重要形成因素。     

Assessment of no-reflow phenomenon after acute myocardial infarction with harmonic angiography and intravenous pump infusion with Levovist: comparison with intracoronary contrast injection.

Myocardial contrast echocardiography (intracoronary application) has emerged as an accurate method to detect the "no-reflow phenomenon." To investigate the diagnostic value of harmonic angiography after intravenous infusion of Levovist in assessing "no-reflow," both intracoronary and intravenous contrast injections were performed in a group of patients with acute myocardial infarction. Seventeen consecutive patients with a successfully reperfused acute myocardial infarction within 6 hours of symptom onset were selected for this study. All patients underwent contrast echocardiography with harmonic angiography with Levovist (400 mg/mL, intravenous pump infusion, trigger intervals 1:4 to 1:8) and sonicated albumin (0.5 to 1 mL, intracoronary bolus) on day 1 after the achievement of a sustained coronary reflow. Myocardial perfusion was qualitatively assessed with a 12-segment model. The endocardial length of the residual contrast defect after reflow was also calculated. Forty-four of 204 segments were not analyzed after intravenous contrast echocardiography and 37 after intracoronary contrast echocardiography because of artifacts. Intracoronary and intravenous injections showed a perfusion defect in 31 (19%) segments, with a concordance of 89% (kappa coefficient, 0.72). Concordance in anteroseptal, anterolateral, and inferolateral segments was 95% (kappa = 0.92), 88% (kappa = 0.66), and 83% (kappa = 0.57), respectively. With intracoronary injection used as the reference method, intravenous injection had a sensitivity of 74% and a specificity of 93% for diagnosing contrast defects. The endocardial extent of no-reflow was 18 +/- 19 after intravenous and 21 +/- 17 after intracoronary contrast echocardiography (P = not significant). Intravenous contrast echocardiography with Levovist reliably identifies the no-reflow phenomenon after successful reperfusion, especially in acute anteroseptal myocardial infarction.     

CMR of microvascular obstruction and hemorrhage in myocardial infarction

Microvascular obstruction (MO) or no-reflow phenomenon is an established complication of coronary reperfusion therapy for acute myocardial infarction. It is increasingly recognized as a poor prognostic indicator and marker of subsequent adverse LV remodeling. Although MO can be assessed using various imaging modalities including electrocardiography, myocardial contrast echocardiography, nuclear scintigraphy, and coronary angiography, evaluation by cardiovascular magnetic resonance (CMR) is particularly useful in enhancing its detection, diagnosis, and quantification, as well as following its subsequent effects on infarct evolution and healing. MO assessment has become a routine component of the CMR evaluation of acute myocardial infarction and will increasingly play a role in clinical trials of adjunctive reperfusion agents and strategies. This review will summarize the pathophysiology of MO, current CMR approaches to diagnosis, clinical implications, and future directions needed for improving our understanding of this common clinical problem.     

中性粒细胞计数与急诊PCI术中无复流现象的关系研究

目的探讨急性心肌梗死患者入院中性粒细胞水平与急诊经皮冠脉介入治疗术后无复流现象的关系。方法入选接受急诊PCI治疗的急性心肌梗死患者150例,检测入院时中性粒细胞水平。依据入院时中性粒细胞水平结果将患者分为中性粒细胞未升高组(≤6.4×109/L)和中性粒细胞升高组(>6.4×109/L),根据PCI后冠脉造影血流速度分级,将患者分为冠脉血流正常组(TIMI分级=3)和无复流组(TIMI分级≤2),进一步比较组间临床特征的差异。采用多因素logistic回归分析入院中性粒细胞水平与无复流发生关系,以ROC曲线评估中性粒细胞计数预测无复流发生的诊断价值。结果中性粒细胞升高组患者中无复流的发生率明显高于中性粒细胞未升高组(33.3%vs.17.2%,P<0.05)。无复流组患者入院中性粒细胞水平明显高于冠脉血流正常组[(7.9±4.3)×109/L vs.(6.2±3.0)×109/L,P=0.012]。多因素logistic回归发现入院中性粒细胞水平是急性心肌梗死急诊PCI术后冠脉造影无复流的独立危险因素(OR值=2.40,95%CI为1.18～5.15,P=0.023),但是ROC曲线分析表明入院中性粒细胞水平不能作为诊断无复流的单项检验指标。结论入院时中性粒细胞水平是急性心肌梗死急诊PCI术后冠脉造影无复流发生的独立危险因素,但是不能作为单一生物标记物用于预测无复流的发生。     

替罗非班与维拉帕米治疗急性冠脉综合征介入术后无复流的临床疗效对比研究

目的对比观察替罗非班与维拉帕米治疗急性冠脉综合征(ACS)介入术后无复流的临床疗效。方法选取经皮冠状动脉介入术后无复流ACS患者60例随机分为替罗非班治疗组和维拉帕米治疗组。经冠状动脉给药后48h,观察并记录两组患者TIMI血流分级及心电图变化;术后2周,观察并记录心源性猝死、再发心绞痛、新发心肌梗死等心脏不良事件的发生率。结果替罗非班组TIMI血流0级、1级发生率显著低于维拉帕米组,TIMI血流2级、3级发生率显著高于维拉帕米组,两组比较差异有显著性(P0.05);替罗非班组心电图改善明显,与维拉帕米组比较差异有显著性(P0.05);术后2周替罗非班组不良心脏事件发生率显著低于维拉帕米组(P0.01)。结论替罗非班治疗急性冠脉综合征介入术后无复流现象安全有效,值得临床推广使用。     

No-reflow phenomenon: maintaining vascular integrity

The no-reflow phenomenon relates to the inability to reperfuse regions of the myocardium after ischemia, despite removal of the large epicardial coronary artery occlusion. The mechanism involves microvascular obstruction. In experimental studies, using markers for flow (thioflavin S, carbon black, microspheres), perfusion defects associated with no-reflow demonstrated ultrastructural evidence of localized endothelial swelling and blebs that appeared to obstruct flow. In humans no-reflow is more complicated due to the microemboli of atherosclerotic debris and thrombi generated by percutaneous coronary intervention. The no-reflow zone expands during the first few hours of reperfusion suggesting an element of reperfusion injury. In animal models, extensive no-reflow was associated with worse infarct expansion. The phenomenon of no-reflow following reperfusion therapy for myocardial infarction in humans has been demonstrated by magnetic resonance imaging, echo contrast agents, thallium, technecium-99m-labeled albumin microspheres, Thrombolysis In Myocardial Infarction (TIMI) scores, and myocardial blush grade. Patients exhibiting no-reflow following reperfusion therapy for myocardial infarction have greater left ventricular dilation and remodeling, more congestive heart failure, shock, and reduced survival. Certain vasodilators (adenosine, nitroprusside, nicorandil, and calcium blockers) are used acutely in the catheterization laboratory and appear to improve no-reflow, but systematic studies on therapy for no-reflow are needed. There is now clinical evidence that no-reflow is a strong predictor of long-term mortality that is independent of and beyond that provided by infarct size. Identifying and treating no-reflow may have important benefits including enhancing delivery of nutrients and cells required for healing and reducing infarct expansion and ventricular remodeling, which ultimately may reduce congestive heart failure and mortality.