盐酸替罗非班对急性心肌梗死急诊经皮冠状动脉介入治疗中TIMI血流影响的临床研究

目的分析Ⅱb/Ⅲa受体拮抗剂盐酸替罗非班对ST段抬高急性心肌梗死(STEMI)患者急诊经皮冠状动脉介入治疗(PCI)治疗中TIMI血流的影响。方法选择急诊入院STEMI患者48名,分为试验组(盐酸替罗非班+PCI)27例和对照组(直接PCI)21例。收集所有病例的临床和冠状动脉造影资料,观察PCI术前、术后TIMI血流情况。结果试验组于术前应用盐酸替罗非班使PCI前梗死相关血管TIMI血流分级提高,试验组达1级血流者比例高于对照组(37%比9.5%,P<0.05);对照组完全闭塞者比例明显高于试验组(38.1%比7.4%,P<0.01);两组患者PCI术后TIMI3级血流比例差异无统计学意义,TIMI2级血流比例试验组低于对照组。结论Ⅱb/Ⅲa受体拮抗剂盐酸替罗非班可改善STEMI患者梗死相关血管的TIMI血流。     

GP Ⅱb/Ⅲa受体拮抗剂对STEMI患者急诊PCI治疗中TIMI血流的影响

目的 探讨ST段抬高型急性心肌梗死（STEMI）患者急诊经皮冠状动脉介入（PCI）治疗中运用血小板糖蛋白(GP)Ⅱb/Ⅲa受体拮抗剂盐酸替罗非班对患者梗死相关血管血流的影响作用。方法 按照就诊顺序将92例STEMI患者分为试药组和对照组各46例,试药组患者行PCI前1~3 h冠脉内应用替罗非班,对照组直接行PCI,比较两组患者PCI中梗死相关血管的急性心肌梗死溶栓试验(TIMI)血流情况、主要心血管不良事件及预后情况。结果 PCI术前,研究组的TIMI血流分级Ⅲ级（33%）、Ⅱ级（43%）高于对照组的Ⅲ级和Ⅱ级构成比,试药组的TIMI血流分布显著优于对照组（P<0.05）。PCI术后,试药组的TIMI血流分级Ⅲ级（91%）、Ⅱ级（9%）与对照组的Ⅲ级（85%）、Ⅱ级（15%）分布比较接近,两组PCI术后TIMI血流分级比较差异不显著。PCI术前与术后,试药组的TIMI心肌再灌注(TMP)血流分级分布均显著的优于对照组（P<0.05）。PCI术后住院期间,两组患者的主要心血管不良事件发生率、术后左室射血分数值,血小板计数减少情况比较差异均不显著。结论 急诊PCI术前常规应用替罗非班对改善术前梗死血管血流、心肌灌注、术后心肌灌注均有显著作用。     

冠脉内注射盐酸替罗非班在急性STEMI急诊PCI中应用的有效性及安全性

目的评价冠脉内注射血小板膜糖蛋白（GP）Ⅱb/Ⅲa受体拮抗剂盐酸替罗非班在急性ST段抬高型心肌梗死（STEMI）急诊经皮冠状动脉介入（PCI）治疗中的安全性及有效性。方法我院急性STEMI冠脉造影（CAG）显示梗死相关血管（IRA）有血栓征象的患者67例,分成试药组（PCI前冠脉内注射盐酸替罗非班+PCI,n=35）与对照组（直接PCI,n=32）,对比2组患者PCI术中IRA远端TIMI血流,术后左室射血分数（LVEF）,住院期间的主要不良心血管事件（MACE）及出血情况。结果试药组术中无再流及再灌注心律失常的发生率明显低于对照组（3%vs19%;3%vs16%,P<0.05）;试药组术后LVEF明显高于对照组[（57±5）%vs（51±10）%,P<0.05];住院期间MACE发生率试药组低于对照组（3%vs9%）,两组均未发生严重出血并发症。结论急诊PCI前冠脉内缓慢注射盐酸替罗非班对急性STEMI患者行急诊PCI安全有效。     

替罗非班对急性冠脉综合征经皮冠状动脉介入术后无复流现象的影响

目的观察盐酸替罗非班对急性冠脉综合征（ACS）患者经皮冠状动脉介入术（PCI）后无复流现象的影响。方法纳入ACS患者行PCI治疗术后无复流患者72例,随机分为替罗非班组36例和对照组36例。对照组经冠状动脉给予硝普钠0.9μg/kg,替罗非班组经冠状动脉给予盐酸替罗非班负荷剂量10μg/kg,3min内注完,随后以0.15μg/（kg·min）微量泵持续静脉泵入24h。观察两组患者冠脉给药前、给药后20min靶血管前向血流的TIMI血流分级、心电图改变及术后2周内主要不良心脏事件及药物的不良反应。结果冠状动脉内给药20min后造影显示,两组患者梗死相关动脉TIMI血流分级均较给药前有改善,替罗非班组IRA的TIMI血流0级、1级发生率显著低于对照组,TIMI血流3级发生率显著高于对照组,差异均有统计学意义（P〈0.01）;冠状动脉给药2h后与给药前比较,对照组心电图改善不明显,而替罗非班组患者心电图获得显著改善,两组冠脉给药2h后ST抬高及压低程度、缺血损伤导联数差异均有显著统计学意义（P〈0.01）;术后2周内替罗非班组主要不良心脏事件显著低于对照组（P〈0.01）;术后2周内两组不良反应的发生率差异无统计学意义（P〉0.05）。结论经冠状动脉给予盐酸替罗非班治疗可有效地改善ACS患者术后无复流现象,并减少术后2周内主要不良心脏事件。     

术前使用替罗非班及其时间对急性心肌梗死相关血管血流的影响

目的:探讨急性ST段抬高心肌梗死(ASTEMI)行急诊直接冠状动脉成形术(PCI)患者术前使用替罗非班及其时间对梗死相关血管(IRA)血流的影响。方法:2009年1月到2012年10月266例ASTEMI行直接PCI的患者被随机分为替罗非班组(134例,PCI前开始静脉使用替罗非班),常规治疗组(132例,PCI前未使用替罗非班),按急诊使用替罗非班时间(3h)分<3h组和≥3h两亚组,比较各组PCI前后IRA的TIMI血流。结果:PCI术前,与常规治疗组比较,替罗非班组TIMI3级血流者比例(10.6%比20.9%,P=0.028)明显提高;PCI术后,替罗非班组TIMI3级血流者比例升高更显著(78.8%比92.5%,P=0.001);术前替罗非班组<3h组(63例)较≥3h组(71例)血流明显改善(TIMI2级+3级,63.5%比29.6%,P<0.01)。结论:早期使用替罗非班可改善急性ST抬高型心肌梗死患者梗死相关血管的PCI术后TIMI血流,且越早使用作用越明显。     

冠脉内注射替罗非班治疗急性冠脉综合征 介入术后无复流的有效性和安全性

目的 评价冠脉内注射国产盐酸替罗非班对急性冠脉综合征（ACS）介入术后无复流患者TIMI血流的影响及安全性。方法 ACS患者行支架植入术后判定无复流者46例,随机分为替罗非班组(冠脉内注射盐酸替罗非班10 μg/kg)26例,硝酸甘油组(冠脉内注射硝酸甘油200 μg)20例。观察给药后30 min TIMI血流分级及校正的TIMI计帧数（CTFC）,2 d后安全性的终点及30 d主要不良心血管事件(MACE)发生率。结果 替罗非班组介入术后无复流患者TIMI Ⅲ级血流获得率显著高于硝酸甘油组(65% vs 30%,P<0.05);校正的TIMI计帧数显示替罗非班组血流快于硝酸甘油组［(72±19) vs (93±22),P<0.01］,两组患者30 d的MACE发生率替罗非班组低于硝酸甘油组(4% vs 20%),但差异未达到显著水平。替罗非班组出血不良反应较硝酸甘油组略高（12% vs 10%）,但差别无统计学意义,两组均未见血小板减少。结论 冠脉内注射国产盐酸替罗非班治疗ACS介入术后无复流患者是有效和安全的。     

经抽吸导管冠状动脉内注射替罗非班对急诊介入治疗无复流的影响

目的探讨经抽吸导管冠状动脉注射血小板糖蛋白Ⅱb/Ⅲa受体拮抗剂替罗非班对急性ST段抬高型心肌梗死患者急诊PCI术中无复流的影响。方法 60例急诊PCI术并全部使用抽吸导管的急性ST段抬高型心肌梗死的患者随机分为2组,常规组30例,在急诊冠状动脉造影抽吸治疗后,经指引导管应用替罗非班,常规剂量外周静脉持续泵入;实验组30例,常规组基础上,经抽吸导管冠状动脉内注射替罗非班,常规剂量外周静脉持续泵入。比较2组围术期出血、梗死相关血管恢复前向血流情况。结果实验组首次用药的罪犯血管TIMI 2~3级比例显著高于常规组(86.67%vs 63.33%,χ2=4.356,P=0.037);末次用药的罪犯血管TIMI 2~3级比例显著高于常规组(93.33%vs 70.00%,χ2=5.455,P=0.020);实验组TIMI 3级比例显著高于常规组(66.67%vs 30.00%,P<0.05),2组表面出血和内脏出血比较,差异无统计学意义(3.33%vs 3.33%,3.33%vs 6.67%,χ2=0.351,P=0.554)。2组围术期和术后近期均无心脏不良事件发生。结论急性ST段抬高型心肌梗死患者在急诊PCI术时,经过抽吸导管注射替罗非班,能有效地改善梗死相关血管前向血流。     

盐酸替罗非班对急性冠脉综合征hs-CRP和MMP-9的影响

目的观察盐酸替罗非班对急性冠脉综合征（ACS）患者治疗前后血清超敏C反应蛋白（hs-CRP）,基质金属蛋白酶-9（MMP-9）水平的影响,探讨盐酸替罗非班能否抑制斑块炎症反应,及稳定斑块的可能机制。方法55例初诊为ACS的患者随机分为对照组（n=31）和试验组（n=24）,试验组在对照组给予口服阿司匹林,氯吡格雷等常规治疗药物的基础上加用静脉滴注盐酸替罗非班,用超敏乳胶增强免疫比浊法测定ACS患者治疗前后hs-CRP水平,酶联免疫反应试剂盒测定MMP-9水平。结果两组治疗前血清hs-CRP,MMP-9水平未见明显差异;两组治疗后hs-CRP,MMP-9水平均显著下降（P<0.01）;治疗后,替罗非班组下降更显著（P<0.01）。结论盐酸替罗非班能够显著影响血清hs-CRP,MMP-9水平,从而说明盐酸替罗非班亦能通过抑制血管炎症达到稳定斑块的作用。     

急诊室使用替罗非班对IRA再通和TIMI血流的影响

目的探讨急诊室给予替罗非班对ST段抬高型急性心肌梗死(STEMI)患者梗死相关动脉(IRA)再通和经皮冠状动脉介入(PCI)术后即刻心肌灌注的影响。方法治疗组47例患者PCI术前在急诊室给予替罗非班,对照组50例患者在PCI术中给予替罗非班,观察两组急诊造影中IRA再通率、PCI术后即刻靶血管TIMI血流分级及不良反应发生率。结果急诊造影时IRA再通率(38.29%)显著高于对照组(20.00%),两组差异有统计学意义(P<0.05)。急诊造影时TIMI血流Ⅲ级患者治疗组(34.04%)显著高于对照组(10.00%),两组比较差异有统计学意义(P<0.05)。术后即刻靶血管TIMI血流Ⅲ级患者治疗组(93.62%)显著高于对照组(76.00%),两组比较差异有统计学意义(P<0.05)。结论 STEAMI患者PCI术前急诊室即予替罗非班治疗能提高急诊造影时IRA再通率,改善术后即刻心肌灌注,且安全性好。     

盐酸替罗非班对急诊经皮冠状动脉介入治疗无再流现象的影响

目的：观察盐酸替罗非班对ST段抬高急性心肌梗塞（STEMI）患者急诊经皮冠状动脉介入治疗（PCD中血流的影响。方法：一选择急诊入院STEMI患者43名，随机分为盐酸替罗非班组23例和对照组20例。替罗非班组PCI术前开始应用盐酸替罗非班，持续泵人至术后36-48h。对照组应用常规PCI。收集所有病例的临床及冠状动脉造影资料，观察PCI术前、术后血流情况。结果：替罗非班组急诊PCI术后TIMI血流3级的发生率（94％）较对照组（89％）显著增加（P〈0．05）。结论：替罗非班可改善STEMI患好梗塞相关血管的TIMI血流。     

Provisional T-stenting and kissing balloon in the treatment of coronary bifurcation lesions: results of the French multicenter "TULIPE" study.

BACKGROUND: In previous prospective studies, a strategy of (a) stenting of the main branch, (b) provisional T-stenting of the side branch, and (c) final kissing balloon inflation, was associated with high success and low target lesion revascularization (TLR) rates on the long-term. OBJECTIVES: To examine the performance of this strategy in a multicenter study. METHODS: Consecutive patients were treated at 14 French medical centers for de novo coronary bifurcation lesions with the same technique used. Immediate results and clinically-driven TLR at 7 months were examined. RESULTS: The mean reference diameters of the main and side branches were 3.2 +/- 0.6 mm and 2.4 +/- 0.5 mm, respectively. The side branch was stented in 34% of patients. A <30% residual stenosis in the main branch was achieved in 99%, <50% in the side branch in 90%, and both in 89% of procedures. The in-hospital major adverse cardiovascular event were a Q-wave and 5 non-Qwaves MI (0.54% and 2.7%). At 7 months of follow-up, 3 patients (1.76%) had died, 1 suffered a non-Q-wave MI (0.59%), and 28 (15.88%) underwent TLR. By multivariate analysis, a lower left ventricular ejection fraction (OR: 0.934), moderate calcifications (OR: 7.86), and non-use of the "jailed" wire technique (OR: 4.26) were associated with reinterventions during follow-up. CONCLUSIONS: A strategy of provisional T-stenting with a tubular stent and final kissing balloon angioplasty for the treatment of coronary bifurcation lesions was safe and associated with a low TLR rate at 7 months. This strategy should be applicable to the new era of drug eluting stents.     

Grading the angiographic extent of collateral filling

Angiography frequently demonstrates a collateral circulation in severe coronary artery disease. An easily applicable method to quantify collateral flow might be a useful adjunct for the assessment of the hemodynamic effects of coronary artery disease. The purpose of this study was to validate a visual scaling of the extent of angiographic collateral filling by comparison with flowmeter- and microsphere-derived measurements of collateral flow. In 12 open-chest dogs, collaterals from the circumflex artery were angiographically visualized (n = 80) by creating acute critical left anterior descending artery occlusion. The extent of collateral filling was graded in four levels from 0 = no visible filling to 3 = complete epicardial filling. Collateral filling correlated with the change in flow of the collateral supplying circumflex artery (Q; r = 0.84) which was + 5.3 ±4.6% with grade 1, + 9.1 ±3.5% with grade 2 and + 14.6 ±4.7% with grade 3 (p < 0.01). In parallel, coronary flow reserve decreased from 4.1 ±0.8 with grade 0 to 2.9 ±0.2 with grade 3 (p < 0.01). Colored microspheres were injected subselectively into the circumflex artery of 9 dogs (45 injections). The ratio of microspheres counted in the collateralized myocardium of the left anterior descending artery to the total number injected increased from 0.6 ±0.9% for grade 0 to 17.1 ±2.8% with grade 3 (p < 0.01). Absolute collateral flow derived from microsphere counts averaged 5.5 ±0.9 ml/min with grade 3 and closely correlated with collateral filling grade (r = 0.88). Semiquantitative grading of angiographic collateral filling in response to acute coronary occlusion in a canine model correlates with an increase in collateral source artery flow, absolute collateral flow and a decrease in source artery flow reserve. These data suggest that this scale might be a simple but useful adjunct tool to assess the hemodynamic significance of a collateral circulation.This work was supported by a grant from the NLHBI 1 R01 HL40865. Dr. Schuhlen is the recipient of a grant from the Deutsche Forschungsgemeinschaft (#Schu657/1-1 and 1–2).     

Embolization complicating coronary angioplasty in the presence of an intracoronary thrombus

Two cases of coronary occlusion and subsequent embolization during percutaneous coronary angioplasty (PTCA) are described. Prior to PTCA, angiographic evidence of intracoronary thrombus was present. Abrupt reclosure after dilation was treated by successful redilation. However, coronary embolization of thrombus debris occurred downstream in one patient and into an adjacent coronary branch in the second patient.     

非罪犯冠脉斑块研究的进展

加强冠心病的二级预防是目前防控急性冠脉综合征（ACS）的重要手段。本文对ACS与非罪犯冠脉斑块的关系作了综述。     

Is short-stay coronary angioplasty safe?

Percutaneous transluminal coronary angioplasty (PTCA) is usually performed as an inpatient procedure and the patients are monitored for several days afterward. Over a 13-month period, in 91 of 373 PTCA procedures, the clinical condition of the patient did not necessitate inpatient status before PTCA. PTCA was done the day of admission and discharge planned the following. Overall hospital stay was planned as less than 24 hours. PTCA was done in one vessel in 62 patients, two vessels in 24, three vessels in 3, and four vessels in 2 patients. PTCA was initially successful (less than 50% residual stenosis) in 85 patients (93%). In one of these, acute occlusion occurred the next morning and urgent bypass surgery was done. PTCA failed in 6 patients who left the catheterization laboratory with unchanged coronary anatomy. Bypass surgery was performed that day in 2 patients, on another admission in 1 patient, and medical therapy continued in the other 3 patients. Of the 88 patients not receiving same admission bypass surgery, 84 (95%) were discharged in less than 24 h. Hospitalization was prolonged (1-5 days) in 4 patients. This was because of nonobstructive dissection treated with heparin for approximately 24 h in 2 patients; a catheterization site hematoma in 1 patient, and post-PTCA noncardiac chest pain in another. No patient had inhospital myocardial infarction or death. The only late complication was in a patient treated with heparin and monitored for 2 days; 3 weeks later angina returned and he died suddenly. These data suggest PTCA can safely be done in selected patients with both single and multivessel disease in a short stay inhospital setting.(ABSTRACT TRUNCATED AT 250 WORDS)     

LAD-right ventricular fistula complicating PTCA: Another case

Coronary perforation caused by percutaneous transluminal coronary angioplasty (PTCA) occurs rarely and most often leads to communication to the pericardial space. We report a case where PTCA caused a coronary artery rupture and fistulization to the right ventricular outflow tract. Cathet. Cardiovasc. Diagn. 42:34–36, 1997. © 1997 Wiley-Liss, Inc.     

Treatment of ruptured coronary aneurysm with a novel covered stent

Coronary artery aneurysms are relatively rare but have been diagnosed with increasing frequency since the advent of coronary arteriography. Their reported incidence varies from 1.5% to 5% with male dominance and a predilection for the right coronary artery (RCA), accounting for over 40% of all cases. The most common etiology amongst adults remains atherosclerosis accounting for 50% of coronary aneurysms. We describe the first use of a novel flexible pericardium covered stent for successful treatment of a ruptured coronary aneurysm in 76 year old lady. © 2008 Wiley‐Liss, Inc.     

Techniques for palmaz-schatz stent deployment in lesions with a large side branch

Palmaz-Schatz coronary stent implantation in lesions with a large side branch are reported. The first case describes how to manage plaque shifting after stent implantation. The second and third cases demonstrate a kissing balloon predilatation and stent dilatation technique of a bifurcational lesion. The final case demonstrates a stent implantation technique through the stent struts of a previously deployed stent.     

Angiographic demonstration of coronary sinus thrombosis: A potential consequence of trauma to the coronary sinus

Abnormalities of the coronary sinus are rarely encountered. A case is presented demonstrating for the first time the angiographic appearance of coronary sinus thrombosis. This may have been the result of surgical trauma during mitral valve replacement or inadvertent cannulation of the coronary sinus during right heart catheterization or pacemaker insertion. Although the clinical significance of coronary sinus thrombosis is uncertain, obstruction of coronary sinus blood flow should not be deleterious because of multiple anastomoses between the coronary sinus system and the anterior cardiac veins. Difficulty in cannulating the coronary sinus for physiologic studies should suggest the possibility of coronary sinus thrombosis, especially in patients who have undergone mitral valve replacement. This may be confirmed by observing the venous phase of selective left coronary arteriography. Finally, coronary sinus thrombosis may be important as a source of pulmonary emboli. The prevalence of this serious complication requires further study.     

Coronary arteriovenous-arterial fistula

A case of multiple arteriovenous fistulae is described in an adult with coronary artery disease. One of these fistulae drained into the anterior interventricular vein, which in turn communicated with and perfused an obstructed left anterior descending coronary artery.