延迟支架置入术在高血栓负荷急性ST段抬高型心肌梗死患者急诊冠状动脉介入治疗中的应用

目的观察高血栓负荷急性ST段抬高型心肌梗死(STEMI)患者直接经皮冠状动脉介入治疗(PCI)后靶病变的变化及延迟支架置入情况。方法入选48例高血栓负荷STEMI患者,急诊予单纯球囊扩张和(或)冠状动脉血栓抽吸,梗死相关动脉前向血流心肌梗死溶栓试验(TIMI)血流分级3级,7 d后复查冠状动脉造影(CAG),根据靶病变血管狭窄情况必要时置入支架治疗。观察靶病变变化的相关数据,包括狭窄程度、长度、近端参考血管直径、远端参考血管直径,比较老年患者(≥60岁)和中青年患者(<60岁)支架置入比例。结果 7 d后复查CAG显示靶病变直径狭窄程度较直接PCI时减轻(35.5%±14.1%比48.8%±11.0%,P<0.01)、病变长度缩短[(15.69±5.36)mm比(18.94±5.37)mm,P<0.01],靶病变近端参考血管直径[(3.29±0.33)mm比(3.24±0.32)mm,P=0.02]和远端参考血管直径[(3.18±0.33)mm比(3.08±0.33)mm,P<0.01]增大;其中,39.6%(19/48)患者因靶病变狭窄>50%置入支架,老年患者和中青年患者置入支架比例分别是56%(9/16)、31%(10/32)(P=0.04)。结论对于中青年高血栓负荷不适宜直接支架置入术的STEMI患者急诊予单纯球囊扩张和(或)血栓抽吸即时开通梗死相关动脉,再延迟必要时支架置入治疗策略是安全、有效的。     

血管内超声在急性冠脉综合征中的运用价值

目的分析急性冠脉综合征患者冠状动脉造影(CAG)及血管内超声(IVUS)检查数据,探讨血管内超声在定量分析冠状动脉临界病变管腔狭窄率,斑块性质,评价经皮冠状动脉介入(PCI)治疗效果中的作用。研究血管内超声(IVUS)在急性冠脉综合征(ACS)临界病变中的应用价值。方法 2010年1月—2014年3月大同市三医院心内科32例根据临床表现诊断为ACS患者,行冠状动脉造影评估患者左主干(LM)、左前降支(LAD)、左回旋支(LCX)、右冠状动脉(RCA)的管腔狭窄情况;冠状动脉造影发现狭窄≥70%病变直接行PCI,临界病变血管段进行IVUS检测,观察血管壁的形态结构,分析动脉粥样硬化斑块的类型、性质及其狭窄程度,对符合PCI干预指征的病变行PCI术。PCI术后行IVUS检查即刻评价支架置入是否理想、是否合并手术并发症。结果 32例患者中CAG发现冠脉血管12支17处病变管腔直径狭窄率≥70%,予直接行支架植入术,共植入17枚支架;CAG测得38处管腔直径狭窄率为50%~70%(临界病变),经IVUS测得有33处病变管腔狭窄率≥70%,涉及28位患者,共置入33枚支架,单支架23例,双支架5例;3CAG与IVUS检测的38处临界病变处直径狭窄率及管腔面积狭窄率(斑块负荷)比较,IVUS测值显著高于CAG测值有统计学意义(P0.01)。术后行IVUS检查示均显示支架完全贴壁、扩张充分、展开均匀、完全覆盖病变,未发现冠脉内夹层形成、壁内血肿、支架断裂等PCI术后并发症。结论 CAG不同程度地低估了冠状动脉临界病变狭窄,IVUS与CAG相比发现的临界病变管腔狭窄率诊断更精确。IVUS对斑块定性较CAG更优。更能准确选择临界病变支架置入的适应证。IVUS能明确冠状动脉临界病变的性质和狭窄程度。     

急性STEMI患者急诊PCI术后亚急性期支架内狭窄(血栓)危险因素

目的采用循证医学方法,探求ST段抬高型心肌梗死(STEMI)行急诊经皮冠脉介入术(PCI)后30 d内发生支架内狭窄(血栓)的影响因素。方法回顾性收集STEMI首次发病行急诊PCI术后30 d内发生支架内狭窄(血栓)的24例患者围术期资料(病例组),按照同时段内性别1∶2配伍原则设计病例对照研究,收集两组围术期26项临床特征,通过单因素分析探求支架内狭窄的潜在影响因素,并通过非条件Logistic回归模型探求PCI术后发生支架内狭窄(血栓)的独立危险因素。结果 PCI术后1～30 d内支架内狭窄(血栓)发生率为6.92%。单因素分析显示:病例组与对照组在入院心衰Killip分级、冠脉狭窄支数、入院TIMI危险评分、支架植入数量、支架最小直径、术后即刻TIMI S3级血流、是否氯吡格雷抵抗、合并糖尿病等特征构成方面差异显著(P均0.05)。Logistic回归模型分析:入院TIMI高危险评分(OR=3.904)、术后即刻未获得TIMI 3级血流(OR=3.180)、植入2枚以上支架(OR=2.852)、氯吡格雷抵抗(OR=5.053)、合并糖尿病(OR=4.513)是PCI术后30 d发生支架内狭窄的独立危险因素(P均0.05)。结论对入院病情严重尤其是糖尿病合并复杂冠脉病变或术中无复流的STEMI患者要高度警惕PCI术后支架内狭窄或血栓的发生,术后要根据氯吡格雷抵抗情况合理选择双抗方案。     

血流储备分数指导下分期PCI干预非梗死相关动脉对STEMI患者短期预后的影响

目的:探讨血流储备分数(FFR)指导下分期行经皮冠状动脉(冠脉)介入术(PCI)干预非梗死相关动脉(non-IRA)对ST段抬高型心肌梗死(STEMI)患者预后的影响。方法:将100例拟分期PCI干预non-IRA的STEMI患者随机分为FFR指导下功能性血运重建组(FFR组)和单纯冠脉造影指导下血运重建组(CAG组),各50例。FFR组对狭窄70%～90%的non-IRA行FFR检查,FFR≤0.80为PCI干预的指证;CAG组对狭窄≥70%的non-IRA仅冠脉造影指导下行PCI。比较2组PCI资料和住院期间主要并发症,均术后随访12个月,比较2组术后1个月和12个月时主要不良心血管事件(MACE)的发生率。结果:FFR组和CAG组比较,人均支架植入量[(1.5±0.5)枚∶(2.6±1.0)枚,P≤0.01]和支架植入率[84.2%∶100%,P=0.003]显著降低;2组的PCI时间、造影剂剂量、住院时间、住院费用和住院期间主要并发症均无统计学差异;术后1个月FFR组未增加MACE事件发生率[1例(2%)∶3例(6%),P=0.617];术后12个月FFR组MACE事件[2例(4.08%)∶8例(16.70%),P=0.042]显著降低。结论:对STEMI多支血管病变患者在FFR指导下non-IRA分期功能性血运重建可减少不必要的PCI干预,降低术后12个月的MACE事件发生率。     

急性心肌梗死患者高敏C反应蛋白与梗死相关血管早期自发再通的相关性研究

目的探讨急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者入院时高敏C反应蛋白(high-sensitivity C-reactive protein,hs-CRP)水平与梗死相关血管早期自发再通的直接相关性。方法收集2014年1月~2015年12月北京安贞医院诊断为急性STEMI患者268例,按照冠状动脉造影梗死相关血管TIMI血流分级分为血管未通组181例(TIMI 0~Ⅰ级),血管再通组87例(TIMIⅡ~Ⅲ级)。入院后立即采集外周静脉血,由中心化验室检测hs-CRP,常规行超声心动图检查,所有患者在症状发生12h内行冠状动脉造影。结果血管未通组与血管再通组梗死相关血管(左前降支、左回旋支和右冠状动脉)、病变血管(单支病变、双支病变和3支病变)比较,差异无统计学意义(P0.05)。血管再通组hs-CRP水平明显低于血管未通组,差异有统计学意义[(18.69±21.23)mg/L vs(25.17±24.36)mg/L,P0.05]。结论入院hs-CRP水平在急性STEMI患者早期血管再通中明显降低。     

血流储备分数指导下功能性血运重建对STEMI多支血管病变患者预后的影响

目的观察血流储备分数(FFR)指导下经皮冠状动脉介入治疗(PCI)功能性血运重建对急性ST段抬高型心肌梗死(STEMI)多支血管病变患者短期预后的影响。方法回顾性分析陕西省第四人民医院心血管内科2016年1月～2017年1月住院治疗STEMI多支血管病变患者的病历资料,根据干预非梗死相关血管(Non-IRA)时是否行FFR检查将患者分为:FFR组68例(FFR指导下功能性血运重建组)和CAG组92例(冠状动脉造影指导下血运重建组)。比较两组支架置入数量、平均支架总长度和围手术期主要并发症,患者术后随访12个月,比较两组术后1个月和术后12个月主要不良心血管事件(MACE)发生率。结果 FFR组支架置入数量[(1.5±1.0)枚vs.(2.6±0.5)枚,P=0.02]和平均支架总长度[(51.4±30.0)mm vs.(67.2±20.5)mm,P=0.03]显著低于CAG组(P0.05);术后1个月两组MACE发生率(1.5%vs. 3.3%,P=0.64)无统计学差异(P0.05),继续随访至术后12个月,FFR组MACE发生率(5.9%vs. 16.3%,P=0.04)较CAG组显著降低。结论 STEMI多支血管病变患者,FFR指导下分期PCI功能性血运重建减少支架置入数量和患者术后12个月发生MACE的风险。     

血清Apelin水平与ST段抬高型心肌梗死患者梗死相关血管自然再通的相关性

目的:探讨血清Apelin水平与急性ST段抬高型心肌梗死(STEMI)患者梗死相关血管自然再通的相关性。方法:入选2016-01至2016-12就诊于中日友好医院心内科的280例拟行急诊经皮冠状动脉介入治疗(PCI)的STEMI患者,PCI前(入院即刻)检测血清生化指标及血清Apelin水平,根据入院冠状动脉造影罪犯血管心肌梗死溶栓治疗临床试验(TIMI)血流分为两组:自然再通组(TIMI血流2~3级,n=57)和非自然再通组(TIMI血流0~1级,n=223)。应用多变量Logistic回归分析明确自然再通的独立预测因素。结果:自然再通组血清Apelin水平明显高于非自然再通组[(0.82±0.34)ng/ml vs(0.35±0.22)ng/ml,P=0.04]。多变量Logistic回归分析显示,血清Apelin水平是自然再通的独立预测因素(OR=2.18, 95%CI:1.10~4.33,P=0.01)。受试者工作特征曲线显示,以0.75 ng/ml为临界值预测自然再通的预测价值敏感度为77%,特异度为81%。结论:血清Apelin水平升高是STEMI患者梗死相关血管自然再通的独立预测因子,测定血清Apelin水平对STEMI患者自然再通有较高的预测价值。     

血流储备分数指导下ST段抬高型心肌梗死多支血管病变患者非梗死相关血管分期完全血运重建的临床研究

目的评估血流储备分数(FFR)在急性ST段抬高型心肌梗死(STEMI)多支血管病变患者非梗死相关血管(non-IRA)分期经皮冠状动脉介入治疗(PCI)完全血运重建中的临床价值。方法选取陕西中医药大学第二附属医院心血管内科2015年6月至2016年5月已成功行PCI开通梗死相关血管(IRA),拟分期PCI治疗(间隔≥7 d)non-IRA的STEMI多支血管病变患者90例,按随机数字表法分为FFR指导下完全血运重建组(FFR组)45例和冠状动脉造影指导下完全血运重建组(CAG组)45例。FFR组狭窄>90%的non-IRA病变直接行PCI治疗,对狭窄70%~90%的病变行FFR检查,仅对FFR<0.80的non-IRA行PCI治疗;CAG组对狭窄≥70%的non-IRA依据术者经验行PCI治疗,处理的靶血管参照血管直径≥2.5 mm。比较两组PCI时间、支架置入数量、造影剂用量、住院时间、住院费用和围术期并发症,随访患者术后6个月主要不良心脑血管事件发生情况。结果 FFR组支架置入数量[(1.68±0.75)枚比(2.83±0.54)枚,t=7.662,P<0.001]和造影剂用量[(164.8±35.7)ml比(195.0±41.9)ml,t=4.271,P=0.04]均明显少于CAG组;术后随访6个月,FFR组再次血运重建率显著低于CAG组(4.7%比19.5%,P=0.04),两组主要不良心脑血管事件发生率差异无统计学意义(均为P>0.05)。结论 STEMI多支血管病变患者在FFR指导下对non-IRA行分期完全血运重建可减少支架置入数量、造影剂用量及术后6个月再次血运重建率。     

药物涂层球囊治疗对冠状动脉分叉病变患者的疗效

目的:研究药物涂层球囊(DCB)治疗对冠状动脉分叉病变患者的疗效。方法:于我院治疗的100例冠状动脉分叉病变患者被随机均分为支架植入组[经皮冠状动脉介入(PCI)治疗基础上加用裸金属单纯支架植入]与DCB组(PCI治疗基础上加用紫杉醇DCB)。比较两组术前、术后、术后9个月靶病变分支最小管腔内径(MLD)、直径狭窄率,术后9个月晚期管腔丢失(LLL)、再狭窄率、主要不良心血管事件(MACE)、靶病变再次血运重建(TLR)、靶病变失败[Target Lesion Failure (TLF)]、心源性休克、靶血管心肌梗死发生率。结果:与支架植入组比较,DCB组术后MLD[(1.66±0.29)mm比(2.04±0.32)mm]、术后9个月MLD [(1.40±0.46)mm比(1.75±0.53) mm]均显著扩大(P均=0.001)。术后9个月,DCB组再狭窄率(4.0%比18.0%)、MACE发生率(8.0%比24.0%)均显著低于支架植入组(P均<0.05);两组LLL、TLF、心源性休克、靶血管心肌梗死、TLR发生率无显著差异(P均>0.05)。结论:DCB可显著扩大冠...     

不同支架植入方式对小血管支架内再狭窄的影响

目的:观察不同支架植入方式对小血管（血管直径≤2.75 mm）支架内再狭窄的影响。方法: 对69（男51,女18）例患者共111处病变进行治疗,实验组（n=38）直接植入支架64枚（雷帕霉素药物洗脱支架53枚,紫杉醇药物洗脱支架11枚）,对照组（n=31）预扩张后植入支架47枚（雷帕霉素药物洗脱支架41枚,紫杉醇药物洗脱支架6枚）,两组患者术后即刻行冠脉血管内超声(IVUS)检测最小支架直径及横截面积。术后有胸闷胸痛症状患者即刻行冠脉造影术及IVUS,无症状患者6个月后复查。通过IVUS检测,对两组管腔丢失及支架内再狭窄率进行比较。结果: 两组支架植入术后即刻最小支架直径实验组为（2.38±0.26）mm,对照组为（2.34±0.24）mm（P＞0.05）;支架横截面积实验组为（4.5±1.0）mm2,对照组为（4.3±0.9）mm2（P＞0.05）;6个月随访后复查两组管腔丢失,实验组为（1.44±0.30）mm,对照组为（0.98±0.24）mm（P=0.01）;支架内再狭窄发生率实验组为15 %;对照组为30%（P＜0.05）。结论: 对冠状动脉小血管病变患者直接药物洗脱支架植入组支架内再狭窄发生率低于预扩张后支架植入组。     

Vasoconstrictor component of atherothrombotic culprit lesions in ST-segment elevation myocardial infarction

ObjectiveThe vasoconstrictor component of atherothrombotic culprit lesions in ST-elevation myocardial infarction (STEMI) patients has not been fully investigated. This study was aimed at assessing the vasoconstrictor component of atherothrombotic culprit lesions in patients with STEMI receiving primary percutaneous coronary intervention (PCI).MethodsA group of 100 patients with STEMI were enrolled prospectively. Baseline coronary angiography achieving normal antegrade flow was followed by 200 μg of intracoronary nitroglycerin (NTG) injection and repeat coronary angiography at the same projection view for culprit lesions was performed. End points were the changes in lesion length, reference vessel diameter, minimal lumen diameter, and diameter stenosis by quantitative coronary analysis before and after NTG injection.ResultsReference vessel diameter (2.7 ± 0.5 mm vs. 2.9 ± 0.5 mm, p < 0.001) and minimal lumen diameter (0.9 ± 0.4 mm vs. 1.2 ± 0.5 mm, p < 0.001) increased after NTG injection, whereas lesion length (24.1 ± 7.4 mm vs. 23.4 ± 7.6 mm, p = 0.001) and diameter stenosis (66.6 ± 14.8% vs. 58.3 ± 16.1%, p < 0.001) decreased. The median percentage change of diameter stenosis was ?4.0% (Interquartile range: ?13.8% to ?1.0%), which was used as the cut-off value to divide the cohort into NTG responder or nonresponder groups accordingly. Total stent length was significantly shorter in the responder group compared with the nonresponder group (27.4 ± 11.6 mm vs. 33.7 ± 16.8 mm, p = 0.042).ConclusionThis study showed the presence of a vasoconstrictor component in atherothrombotic culprit lesions in STEMI patients receiving primary PCI. Vasodilating effort by NTG may decrease stent length used for culprit lesions.     

Effectiveness and safety of the genous endothelial progenitor cell-capture stent in acute ST-elevation myocardial infarction

The endothelial progenitor cell (EPC)-capture stent promotes endothelialization and preliminary studies have suggested its safety and feasibility in ST-elevation myocardial infarction (STEMI). Detailed late clinical follow-up and angiographic analyses are, however, limited. We sought to determine late angiographic and clinical outcomes of the Genous EPC-capture stent in primary angioplasty. EPC-capture stents were implanted during primary angioplasty in 489 consecutive patients presenting with STEMI from 2004 through 2008. The first 100 consenting patients undergoing successful stent implantation scheduled to undergo relook coronary angiography at 6 to 12 months were enrolled. Ninety-five patients with 96 lesions were analyzed independently. Mean duration of follow-up coronary angiography was 245 days. In-stent late luminal loss measured 0.87 ± 0.67 mm. Binary restenosis (defined as >50% diameter stenosis) was 28%, with diffuse in-stent restenosis (Mehran class II) as the predominant pattern. Of 27 patients with binary restenosis, 14 (52%) were symptomatic, with 10 patients undergoing target lesion revascularization. Asymptomatic patients had significantly larger reference vessel and in-stent minimal luminal diameters (2.77 ± 0.39 vs 2.54 ± 0.44 mm, p = 0.040; 2.74 ± 0.34 vs 2.31 ± 0.72 mm, p = 0.004, respectively). Follow-up late loss and diameter stenoses were also in favor of the asymptomatic group. Major adverse cardiac event rate was 16% at a mean follow-up of 34 months. There were no cases of Academic Research Consortium-defined stent thrombosis. In conclusion, implantation of the EPC-capture stent during primary angioplasty is associated with a favorable late clinical outcome but with higher than anticipated angiographic late loss.     

Six-month results of a biodegradable polymer and rapamycin-coating stent for coronary artery disease

Objective To assess the safety and efficacy of a novel biodegradable polymer and rapamycin-coating stent, the EXCEL stent, in the treatment of coronary artery disease (CAD), as compared with the Cypher?stent. Methods In this prospective, non-randomized study, 60 consecutive patients with symptomatic CAD received either an EXCEL stent (n=32), or a CypherTM stent(n=28),according to their respective treatment intention. Follow-up angiography was performed at a mean of 180±40 days. The primary endpoint of the study was the occurrence of a major adverse cardiac event (MACE), including death, myocardial infarction, or target-vessel revascularization during the 6 months after stenting. The secondary end points included the in-stent late luminal loss (LLL), percentage of in-stent stenosis of the luminal diameter, and the rate of restenosis (luminal narrowing of 50 percent or more) at 6 months. Results There were no significant differences between the two groups in baseline characteristics, including the distribution of target vessel and lesion types. During the follow up period of 6 months, there were no occurrences of MACE in either group. Twenty-seven patients (84%) in the EXCEL group and 10 (36 %) in the Cypher?group underwent quantitative coronary angiography at 6 months. For these patients, no restenosis occurred, and there were no differences in the in-stent stenosis of the luminal diameter (5.98±5.52 % vs 5.21±6.3%, P>0.05) and the LLL (-0.02±0.09 mm vs -0.01±0.07 mm, P>0.05). Conclusions Compared with the CypherTM stent, the EXCEL Stent with biodegradable polymer and rapamycin-coating showed similar efficacy in the prevention of neointimal proliferation, restenosis, and associated clinical events in CAD patients.     

两种国产西罗莫司洗脱支架治疗ST段抬高型心肌梗死患者的疗效和安全性研究

目的 比较两种国产西罗莫司洗脱支架(Excel与Firebird)对急性ST段抬高型心肌梗死(STEMI)患者行直接经皮冠状动脉介入治疗(PCI)的有效性和安全性.方法 入选我院急性STEMI患者249例,根据植入支架类型,随机分为Excel支架组136例(54.6%)和Firebird支架组113例(45.4%).随访6～24个月,平均12个月行定量冠状动脉造影复查.比较两组患者手术即刻成功率,术后住院及随访过程中主要不良心脏事件(包括心原性死亡、再发心肌梗死和靶病变血运重建)发生率及晚期管腔丢失、支架再狭窄、支架内血栓发生率.结果 两组患者术前临床基线特征及冠状动脉病变情况、直接PCI术后即刻情况差异均无统计学意义(P＞0.05);术后平均12个月随访中,两组患者死亡分别为2例(1.47%)与1例(0.88%),无心原性死亡,非致死心肌梗死分别为1例(0.74% )与1例(0.88%),靶血管再次血运重建分别为2例(1.47%)与2例(1.77%),差异无统计学意义(均P＞0.05).定量冠状动脉造影随访两组支架内最小管腔内径、节段内最小管腔内径、支架内晚期管腔丢失、节段内晚期管腔丢失,差异无统计学意义(均P＞0.05);支架内再狭窄、节段内再狭窄、支架内血栓形成的发生率差异亦无统计学意义(均P＞0.05).结论 STEMI患者直接PCI应用两种国产西罗莫司洗脱支架均有效、安全.

Abstract：

Objective To compare the efficacy and safety of two kinds of homemade sirolimus-eluting stents (Firebird and Excel) for treatment of acute ST segment elevation myocardial infarction (STEMI) in patients who underwent percutaneous coronary intervention (PCI). Methods The 249 consecutive patients with STEMI who underwent PCI were randomly divided into two groups: Excel group (n=136) and Firebird group (n=113). They were followed up for 6-24 months, and coronary angiography was reviewed average 12 months later. The primary endpoints were major adverse cardiac events, including death, reinfarction and target vessel revascularization. The second endpoints included late luminal loss and restenosis 12 months after treatment. Results There were no significant differences in baseline data, coronary arterial lesion before operation, and immediateness condition after PCI between the two groups (all P＞0.05). Within follow-up, there were 2 (1.47%) death cases and 1 (0.88%) death case, 1 (0.74%) and 1 (0.88%) nonfatal myocardial infarction case, 2 (1.47%) and 2 (1.77%) target vessel revascularization cases in the two groups respectively (all P＞0.05). There were no significant differences in late luminal loss of in-stent and in-segment, the rates of in-stent restenosis, in-segment restenosis and stent thrombosis, the in-stent minimal lumen diameter and in-segment minimal lumen diameter between the two groups (all P＞0.05). Conclusions The two kinds of homemade sirolimus-eluting stents may have similar efficacy and safety in patients with STEMI treated with primary PCI.     

A contemporary re-evaluation of culprit lesion severity in patients presenting with STEMI

Background: Historical data report fatal myocardial infarction occurring when mildly-stenotic coronary plaques rupture; however, recent data suggest haemodynamically-significant coronary stenoses with fractional flow reserve (FFR) ≤ 0.8 and vessels with high plaque burden and minimum luminal area (MLA) < 4 mm² by intravascular ultrasound (IVUS) may be prognostically important. Therefore, we sought to re-evaluate culprit stenosis severity in patients presenting with ST-segment elevation myocardial infarction (STEMI).

Methods: Patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI with adjunctive thrombectomy between October 2008 and February 2010 (n = 336/572; 59%) underwent quantitative coronary angiography (QCA) after thrombus aspiration to determine vessel reference area (RA), MLA and percentage area stenosis (AS). To validate findings, QCA and FFR were measured in 50 patients with stable angina and an angiographically-intermediate lesion.

Results: STEMI patients had anatomically-severe underlying culprit disease similar to that of the stable cohort (AS: 91.6 ± 9.5% versus 90.1 ± 8.1%; P = 0.11). Additionally, anatomically-severe lesions defined by QCA were more likely to be functionally-significant by FFR and vice-versa (P = 0.02 and 0.002 respectively).

Conclusion: These contemporary data suggest that STEMI culprit lesions, defined by luminal stenosis after thrombus aspiration, are angiographically significant, with similar stenosis severity to stable, ischaemia-inducing lesions.     

增强型体外反搏对冠心病患者巨噬细胞移动抑制因子和P-选择素水平的影响

目的探讨增强型体外反搏（EECP）对冠心病患者巨噬细胞移动抑制因子（MIF）和P-选择素水平的影响。方法229例经冠脉造影术证实有药物洗脱支架置入指征的冠心病患者,依照其意愿分为支架组和非支架组;两组再分别随机分为EECP亚组和非EECP亚组。两个EECP亚组于术后1周开始进行EECP（每日治疗1h,每周5次,持续7周）。分别于术前,术后1h、1周和9周时测定血浆MIF和P-选择素水平。结果①支架组：MIF和P-选择素水平在支架术后1h较术前显著升高（P〈0．01）,术后1周时降至术前水平,而在术后9周时则降至最低（与术前比较P〈0．05）。术后9周时EECP亚组MIF和P-选择素的降低幅度明显大于非EECP亚组（P〈0．05）。②非支架组：术后1h、1周时MIF和P-选择素水平与术前比较均无变化。术后9周时,两个亚组的MIF和P-选择素水平均明显降低（与术前比较P〈0．05）,EECP亚组MIF和P-选择素的降低幅度明显大于非EECP亚组（P〈0．05）。③术后9周时,支架组的EECP亚组与非支架组的EECP亚组之间MIF和P-选择素水平比较差异均无统计学意义。结论EECP可显著降低冠心病患者MIF和P-选择素水平,对接受冠脉药物洗脱支架术的患者疗效等同。     

Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent in Acute Myocardial Infarction: The REVELATION Randomized Trial

ObjectivesThis study sought to assess the efficacy and safety of a drug-coated balloon (DCB) strategy versus drug-eluting stent (DES) in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI).BackgroundIn primary percutaneous coronary intervention for STEMI, stenting has proved to be beneficial with regard to repeat revascularization, but not recurrent myocardial infarction or death, compared with balloon angioplasty alone. A strategy of DCB angioplasty without stenting might abolish the potential disadvantages of stent implantation while reducing the probability of restenosis observed in plain old balloon angioplasty.MethodsIn the prospective, randomized, single-center REVELATION trial, we compared DCB with DES in patients presenting with STEMI. Patients with a new, nonseverely calcified culprit lesion in a native coronary artery and a residual stenosis of <50% after pre-dilatation were randomized to treatment with a DCB or DES. The primary endpoint was fractional flow reserve at 9 months, allowing for a functional measurement of the infarct-related lesion.ResultsA total of 120 patients were included. At 9 months after enrolment, the mean fractional flow reserve value was 0.92 ± 0.05 in the DCB group (n = 35) and 0.91 ± 0.06 in the DES group (n = 38) (p = 0.27). One abrupt vessel closure requiring treatment occurred after treatment with DCB. Up to 9-months follow-up, 2 patients required nonurgent target lesion revascularization (1 in each group).ConclusionsIn the setting of STEMI, the DCB strategy was noninferior to DES in terms of fractional flow reserve assessed at 9 months. Furthermore, it seemed to be a safe and feasible strategy. (Revascularization With Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stenting in Acute Myocardial Infarction [REVELATION]; NCT02219802)     

Coronary vessel diameters during and after primary percutaneous coronary artery intervention

Background

Primary percutaneous coronary intervention (P-PCI) is the gold standard treatment for acute coronary syndromes. Plasma levels of catecholamines and other vasopressors are elevated during acute myocardial infarction (AMI) and coronary vasoconstriction is frequent. We aimed to compare the reference vessel diameter (RVD) of the infarct-related artery (IRA) during primary PCI and after an average of 3 days.

Methods

Coronary angiography (CAG) was performed on 58 patients with acute ST-segment elevation myocardial infarction (STEMI) and TIMI 3 flow after P-PCI (43 men, 15 women; mean age, 55.5?±?10 years). TIMI 3 flow was achieved either by simple balloon dilatation and/or thrombus aspiration. Lesion length, RVD, minimal lumen diameter (MLD), mean vessel diameter (meanD), and area of stenosis were compared during P-PCI and follow-up CAG.

Results

RVD, MLD, and meanD values were significantly higher during the follow-up CAG than after P-PCI (RVD 2.7?±?0.7 mm vs. 2.9?±?0.7 mm, p?=?0.001; MLD 1.5?±?0.5 mm vs. 1.7?±?0.4 mm, p?=?0.002; meanD 2.2?±?0.5 mm vs. 2.4?±?0.5 mm, p?=?0.001). Area of stenosis values were significantly lower during the follow-up CAG than after primary PCI (69.5?±?16.5?% vs. 62.1?±?15?%, p?=?0.001). Lesion lengths were not statistically significant during the follow-up CAG and primary PCI (lesion length 24.0?±?10.8 mm vs. 22.1?±?8.8 mm, p?>?0.05).

Conclusion

This study showed that RVD was higher at the follow-up CAG a few days after AMI in patients who had TIMI 3 flow after P-PCI with simple balloon dilatation and/or thrombus aspiration. A delay of a few days for stent implantation in P-PCI allows for larger-diameter stent use and may help to reduce stent thrombosis and restenosis rates.     

急性ST段抬高型心肌梗死应用血栓抽吸和静脉溶栓开通冠脉的疗效比较

目的 比较急性ST段抬高型心肌梗死（STEMI）患者经导管血栓抽吸和静脉溶栓两种方法对择期PCI即刻及近期疗效的差异.方法 回顾分析2009年1月至2012年1月收治的60例急性STEMI且符合梗死相关动脉（IRA）高血栓负荷患者的临床资料.其中14例通过反复抽吸血栓使IRA血流恢复TIMI 3级,设为抽吸组;22例成功静脉溶栓患者,设为溶栓组.依其IRA的残余狭窄病变（RSL）及非IRA以外的罪犯相关病变（CRL）的冠脉造影,狭窄程度≥70％为冠脉支架置入标准,比较两组IRA的RSL病变与非IRA的CRL病变处理的差异、冠脉TIMI血流分级及心肌灌注呈色（BMG）显像分级的差异、即刻效果、1个月时心功能的差异及MACE差异.结果 IRA及CRL的病变分布及形态、支架置入无复流、支架特征（个数、直径、长度）、支架直接置入率、高压球囊使用率、最后扩张压力等指标,两组比较差异无统计学意义（P＞0.05）,但MBG达到3级者抽吸组明显优于溶栓组（93.0％比63.6％,P＜0.05）.1个月时左室直径、EF值、血浆BNP和hs-CRP,抽吸组均明显优于溶栓组（均P＜0.05）,两组均无MACE事件发生.结论 对高血栓负荷的STEMI患者进行单纯急诊血栓抽吸,择期PCI较静脉溶栓开通后择期PCI效果好,也是安全的.