冠状动脉介入治疗急性心肌梗死35例临床分析

目的 :了解 3 5例急性心肌梗死 (AMI)患者经皮腔内冠状动脉介入治疗 (PCI)的疗效、适应证及并发症。方法:对 3 5例 AMI患者行 PCI治疗 ,其中男性 3 4例 ,女性 1例 ,年龄 3 9～ 72 (5 4.8± 8.6)岁。其中 2 1例患者为急诊 PTCA,均在发病后平均 (7.4± 6.6) h内直接进行 PTCA;3例为溶栓失败后补救性 PTCA;11例为延迟PTCA。 结果 :PCI成功率为 10 0 % ,术前梗塞相关血管平均狭窄 (93 .2± 5 .9) % ,术后残余狭窄为 (10 .6± 6.3 ) %。结论:AMI时行急诊 PTCA成功率高 ,残余狭窄少 ,对溶栓失败或并发心源性休克者应积极行 PTCA,可获得较高的梗塞相关血管再通率和较低的心梗复发率和死亡率 ,同时可减少梗塞面积 ,保护心功能     

Long-term outcomes of drug-eluting versus bare-metal stent implantation in patients with chronic total coronary artery occlusions

Background There are limited data on the efficacy of drug-eluting stents （DES） for treatment of chronic total occlusions （CTO）. The aim of the study was to evaluate the long-term clinical outcomes of DES implantation for CTO compared with bare-metal stent （BMS） implantation.
Methods Between June 1995 and December 2006, a total of 1184 patients with successful recanalization of at least one de novo CTO lesion were consecutively registered, including 660 （55.7%） who underwent DES and 524 （44.3%） who underwent BMS implantation. All patients were followed up for up to 5 years for occurrence of major adverse cardiac events （MACE）. Long-term survival rates were estimated with the Kaplan-Meier method.
Results Baseline clinical and angiographic characteristics were comparable between the two groups except that patients in the DES group received longer dual antiplatelet therapy （（7.4±2.5） months vs （1.7±0.8） months, P 〈0.001）. Average follow-up periods were （4.7±0.89） and （3.2±1.3） years for the BMS and DES groups, respectively. There was no significant difference in 5-year survival rates between the two groups （90.3% for DES group vs 89.6% for BMS group, Log-rank P=0.38）, but the 5-year target vessel revascularization （TVR）-free survival rate in the DES group was significantly higher than that in the BMS group （81.6% vs 73.5%, Log-rank P 〈0.001）. The cumulative MACE-free survival in the DES group was also significantly higher than that in the BMS group （80.6% vs 71.5%, Log-rank P〈0.001）. The rates of readmission caused by cardiovascular disease （27.0% vs 37.8%, P 〈0.001） and the need for bypass surgery were significantly lower in the DES group （1.5% vs 3.4%, P 〈0.05）. By multivariable analysis, DES implantation could significantly lower the long-term MACE risk of PCI for CTO patients （HR： 0.492; 95% Cl 0.396-0.656, P 〈0.001）. Left ventricular ejection fraction 〈50% and elderly （〉65 years） were identified as independent predictors of long-term MACE during follow-up.
Conclusion This study demonstrates the long-term （up to 5 years） efficacy of DES for treatment of CTO, which is superior to BMS implantation in reducing the rates of TVR and MACE, as well as the need of re-admission and bypass surgery.     

Impact of admission creatinine level on clinical outcomes of patients with acute ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention with drug-eluting stent implantation

Background Prognosis of patients with acute ST-elevation myocardial infarction （STEMI） and renal dysfunction （RD） who received primary percutaneous coronary intervention （PCI） has not been fully investigated in the drug-eluting stent （DES） era. This study aimed to evaluate the impact of admission serum creatinine level on short-term outcomes in patients with acute STEMI undergoing DES-based primary PCI.
Methods Primary PCI with DES implantation was attempted in 619 consecutive STEMI patients within 12 hours of symptom onset. Among them, 86 patients had a serum creatinine level ≥115 μmol/L on admission （RD group）, and the remaining 533 patients had normal renal function （non-RD group）. The primary endpoint was 30-day major adverse cardiac events （MACE, including death, non-fatal reinfarction, and target vessel revascularization）, and the secondary endpoint was subacute stent thrombosis.
Results Patients in the RD group were older than those in the non-RD group. There are more female patients in the RD group and they had a history of hypertension, myocardial infarction and revascularization. The occurrence rates of Killip class ≥2 （29.1% vs 18.6%, P=0.02） and multi-vessel （62.8% vs 44.5%, P=0.001） and triple vessel disease （32.6% vs 18.2%, P=0.002）, in-hospital mortality （9.3% vs 3.8%, P=0.03）, and MACE rate during hospitalization （17.4% vs 7.7%, P=-0.006） were higher in the RD group than those in the non-RD group. At a 30-day clinical follow-up, the MACE-free survival rate was significantly reduced in the RD group （76.7% vs 89.9%, P=-0.0003）. Angiographic stent thrombosis occurred in 3 （3.5%） and 7 （1.3%） of patients in the RD group and non-RD group, respectively （P=0.15）. Multivariate analysis revealed that the serum creatinine level 〉115 μmol/L on admission was an independent predictor for MACE rate at a 30-day follow-up （Hazard ratio （HR） 3.31,95% CI 1.19-9.18, P 〈0.001）.
Conclusion Despite similar prevalence of stent thromb     

健康教育对减少PTCA+STENT术后并发症的观察

目的探讨不同的健康教育对经皮冠状动脉腔内成形术及支架术（PTCA及STENT术）术后并发症的影响。方法将140例经股动脉行冠状动脉腔内成彤术及支架术的患者，随机分为实验组（64例）和对照组（76例），实验组实行及时、全面、准确的健康教育，对照组实行传统的健康教育。结果实验组术后并发症明显少于对照组，P〈0.05，差异有显著性。结论及时、全面、准确的健康教育减少了术后并发症的发生。     

磁化支架防治犬PTCA术后冠状动脉再狭窄

目的　探讨磁化支架对 (PTCA,Percutaneoustranslum inal coronary angioplasty)术后冠状动脉再狭窄的防治作用 .方法　 2 0只健康杂种犬 ,超大球囊反复扩张损伤靶血管 (前降支或旋支中段 )制备 PTCA术后冠状动脉狭窄模型 (大于 5 0 % )后随机分成对照组和实验组各 10只 ,对照组靶血管置入普通 Palmaz支架 ,实验组靶血管置入磁化 Palmaz支架 .手术前、后不用抗血小板药和抗凝药 ,术后 6 mo冠状动脉造影并处死犬 ,切取靶血管 3cm进行组织病理学检查 .结果　冠状动脉造影示冠状动脉再狭窄率对照组 30 % ,实验组 0 ;组织病理学检查靶血管平均内膜厚度 [对照组 (2 .98±0 .5 6 ) m m,实验组 (1.13± 0 .4 1) mm ]有显著差异 ,P<0 .0 5 .结论　磁化支架对犬 PTCA术后冠状动脉再狭窄有显著的防治作用 .     

直接经皮冠脉内支架植入术治疗急性心肌梗死

目的：评价直接冠脉内支架植入术治疗急性心肌梗死的临床疗效。方法：１７例急性心肌梗死患者于症状发作后２～１４小时施行冠脉内支架术。结果：所有患者冠脉再通均获成功。ＴＩＭＩ血流均达到３级。无残余狭窄,血管再通距症状发作时间平均５．７小时,所有患者胸痛均在术后２小时内明显缓解;除２例ＳＴ段持续抬高外,其余病例均在术后２小时ＳＴ段下降〉５０％;心肌酶峰明显提前。１例左主干病变于术后１周发生严重泵衰竭死亡;     

经皮冠状动脉腔内成形术治疗复杂冠状动脉病变

目的探讨应用经皮冠状动脉腔内成形术（ＰＴＣＡ）治疗复杂冠状动脉病变的效果。方法５例冠心病患者经选择性冠状动脉造影证实为复杂冠状动脉病变即Ｂ型或Ｃ型病变者，采用Ｇｒｕｅｎｔｚｉｇ等建立的方法进行ＰＴＣＡ。结果１２处冠状动脉病变扩张成功１０处，成功率为８３．３％，其余两处病变一处因球囊未能通过狭窄部，另一处因术中患者发生严重的心律失常而未行扩张。术后患者的症状均得以缓解或消失。结论ＰＴＣＡ也适用于治疗复杂冠状动脉病变，且疗效较好，但危险性较大，并发症较多。     

缠绕型和管型冠状动脉内支架在冠心病治疗中的应用

目的　探讨应用缠绕型和管型冠状动脉内支架治疗冠心病的效果。方法　对 2 3例冠心病患者根据不同情况植入冠状动脉内支架 ,其中DeNovo支架 17个 ,Suboptimal支架 6个 ,Bail-out支架 2个。结果　 2 3例患者 2 5支血管植入 2 5个冠状动脉内支架。其中缠绕型支架 9个 ,包括Gianturco -Robin支架2个 ,XT支架 7个 ;管型支架植入 16个 ,均为NIR支架。植入前降支 15个 ,回旋支 2个 ,右冠状动脉 8个。所有支架植入均获得成功。 3例心绞痛复发的患者经造影证实为再狭窄 ,其中XT支架 1个 ,NIR支架 2个 ,总的再狭窄率为 12 % ,缠绕型和管型支架的再狭窄率分别为 11%和 12 .5 %。结论　冠状动脉内支架为治疗PTCA术后急性冠状动脉闭塞、降低再狭窄率的有效措施 ;根据不同的病变合理选择缠绕型和管型支架可提高支架植入的成功率 ,减少并发症。     

Treatment of fatal coronary artery spasm by stent implantation: A case report

Variantanginahasbeenconvincinglydemonstratedtobeduetocpicardialcoronaryarteryspasm,whichmayoccurnotonlyatthesiteofflow--limitingstenosesofvariableseventybutalsoinangiographicallynormalsegments.Ithasalsobeenrecognizedasthecauseofacutecardiacevents,includingmyocardialinfarctionandsuddencardiacdeath.Themanagementofvariantanginadependsonmainlypharmacologicaltherapy.Recently,wehavesuccessfullyimplantedanintracoronarystentinapatientwithlife-threateningarrhythmiasduetorightcoronaryarteryspasm.CASER…     

紫杉醇洗脱支架治疗冠状动脉硬化性心脏病近期效果

目的评价紫杉醇洗脱支架（PES,商品名TAXUS）治疗冠状动脉硬化性心脏病患者的近期效果及安全性.方法对2003年7月至2004年11月在我院接受PES植入治疗的300例患者的即刻疗效和随访结果进行总结与分析.结果300例患者共处理350处病变,植入支架355枚,其中B2型以上复杂病变248处（70.9%）,小管径支架（2.50～2.75 mm）94处（26.5%）、长支架（＞20 mm）130处（36.6%）;术中未发生严重并发症,手术成功率100%.随访250例（83.3%）,平均随访6个月（1～15个月）,8例（2.7%）患者有心绞痛样发作,其中2例冠状动脉造影复查无支架再狭窄病变,1例于术后5个月发生心肌梗死,2例因非心源性因素死亡.结论PES治疗冠状动脉硬化性心脏病近期效果明显,且较为安全.     

A high maintenance dose of clopidogrel improves short-term clinical outcomes in patients with acute coronary syndrome undergoing drug-eluting stent implantation

Background Recurrent ischemic events occurred even during routine use of 75 mg clopidogrel in addition to aspirin, that indicated a potentially insufficient maintenance dosage of clopidogrel. The aim of the present study was to evaluate the short-term efficacy and safety of a 150 mg maintenance dose of clopidogrel following a 600 mg loading dose in patients with an acute coronary syndrome （ACS） undergoing drug eluting stent （DES） implantation.
Methods Between November 2005 and November 2006, a total of 813 consecutive ACS patients undergoing DES implantation were enrolled. A 600 mg loading dose was administered before percutaneous coronary intervention （PCI） and patients were randomized to receive clopidogrel 75 mg or 150 mg for 30 days in addition to 300 mg aspirin daily. Primary end points were the composite of cardiac death, non-fatal myocardial infarction （MI） and urgent target vessel revascularization （UTVR）. Secondary end points included stent thrombosis （ST）, major and minor bleeding events at 30 days. Results At a follow-up period of 30 days, 4 （1.0%） patients in the 150 mg group and 9 （2.2%） patients in the 75 mg group （P 〉0.05） reached the primary end points. There was no significant difference in the incidences of MI （0.5% vs 1.2%, P〉0.05）, UTVR （0.7% vs 2.0%, P 〉0.05）, and cardiac death （0.2% vs 0.2%, P 〉0.05） between the two groups. The incidence of ST （0 vs 1.5%, P 〈0.05） was significantly lower in the 150 mg group than that in the 75 mg group. There were no significant differences between both groups regarding the risk of major （0.2% vs 0, P 〉0.05） or minor （0.5% vs 0.2%, P 〉0.05） bleedings.
Conclusion A high clopidogrel maintenance dose of 150 mg daily following a 600 mg loading dose for the first month after PCI procedure reduces the risk of ST and appears to be safe in patients with ACS undergoing DES implantation.     

紫杉醇洗脱支架治疗冠状动脉硬化性心脏病近期效果

目的 评价紫杉醇洗脱支架(PES,商品名TAXUS)治疗冠状动脉硬化性心脏病患者的近期效果及安全性。方法 对2003年7月至2004年11月在我院接受PES植入治疗的300例患者的即刻疗效和随访结果进行总结与分析。结果 300例患者共处理350处病变,植入支架355枚,其中B2型以上复杂病变248处(70.9%),小管径支架(2.50~2.75mm)94处(26.5%)、长支架(>20mm)130处(36.6%);术中未发生严重并发症,手术成功率100%。随访250例(83.3%),平均随访6个月(1~15个月),8例(2.7%)患者有心绞痛样发作,其中2例冠状动脉造影复查无支架再狭窄病变,1例于术后5个月发生心肌梗死,2例因非心源性因素死亡。结论 PES治疗冠状动脉硬化性心脏病近期效果明显,且较为安全。     

Predictive value of postprocedural leukocyte count on myocardial perfusion, left ventricular function and clinical outcomes in ST-elevated myocardial infarction after percutaneous coronary intervention

Background  Baseline white blood cell (WBC) count was correlated with ischemic events occurrence in patients with ST-elevated myocardial infarction (STEMI). However, circulating WBC count is altered after percutaneous coronary intervention (PCI). The aim of this study was to assess the relationship between postprocedural WBC count and clinical outcomes in STEMI patients who underwent PCI.

Methods  A total of 242 consecutive acute STEMI patients who underwent successful primary PCI were enrolled and followed up for two years. WBC counts were measured within 12 hours after PCI. ST-segment resolution (ST-R) and myocardial blush grades (MBG) were evaluated immediately after PCI. Left ventricular ejection fraction (LVEF) was obtained at baseline and 12–18 months after PCI.

Results  Postprocedural WBC count was an independent inverse predictor of ST-R (OR 0.80, P <0.0001) and MBG 3 (OR 0.82, P <0.0001). It was negatively correlated with LVEF (baseline r=–0.22, P=0.001; 12–18 months r=–0.29, P <0.0001). The best cutoff value of WBC for predicting death was determined to be 13.0×10⁹/L. The patients with a postprocedural WBC count above 13.0×10⁹/L showed a significantly lower cumulative survival rate (30 days, 82.4% vs. 99.0%, P <0.0001 and 2 years 75.0% vs. 96.4%, P <0.0001). Multivariate Cox regression analysis showed that a postprocedural WBC count was a strong independent predictor of 30-day mortality (HR 8.48, P=0.019) and 2-year mortality (HR 4.93, P=0.009).
Conclusions  Increased postprocedural WBC count is correlated with myocardial malperfusion and left ventricular dysfunction, and is an independent predictor of poor clinical outcomes in STEMI patients who underwent PCI.

     

Outcomes after primary coronary intervention with drug-eluting stent implantation in diabetic patients with acute ST elevation myocardial infarction

Background Drug-eluting stent (DES) has been used widely for the treatment of patients with acute coronary syndrome with or without diabetes mellitus during percutaneous coronary intervention (PCI), but its long-term safety and efficacy in diabetic patients with acute ST elevation myocardial infarction (STEMI) remain uncertain. This study aimed to investigate the clinical outcomes after primary coronary intervention with DES implantation for diabetic patients with acute STEMI, compared with non-diabetic counterparts. Methods From December 2004 to March 2006, 56 consecutive diabetic patients (diabetic group) and 170 non-diabetic patients (non-diabetic group) with acute STEMI who underwent primary PCI with DES implantation in 3 hospitals were enrolled. Baseline clinical, angiographic, and procedural characteristics, as well as occurrence of major adverse cardiac event (MACE) including cardiac death, non-fatal recurrent myocardial infarction (re-MI) and target vessel revascularization (TVR) during hospitalization and one-year clinical follow-up were compared between the two groups. Results Patients in diabetic group were more hyperlipidemic (69.6% and 51.8%, P=0.03) and had longer time delay from symptom onset to admission ((364±219) minutes and (309±223) minutes, P=0.02) than those in non-diabetic group. The culprit vessel distribution, reference vessel diameter, and baseline TIMI flow grade were similar between the two groups, but multi-vessel disease was more common in diabetic than in non-diabetic group (82.1% and 51.2%, P&lt;0.001). Despite similar TIMI flow grades between the two groups after stenting, the occurrence of TIMI myocardial perfusion grade (TMPG) ≥2 was lower in diabetic group (75.0% vs 88.8% in non-diabetic groups, P=0.02). The MACE rate was similar during hospitalization between the two groups (5.4% vs 3.5%, P=0.72), but it was significantly higher in diabetic group (16.1%) during one-year follow-up, as compared with non-diabetic group (6.5%, P=0.03). The cumulative one-year MACE-free survival rate was significantly lower in diabetic than in non-diabetic group (78.6% vs 90.0%, P=0.02). Angiographic stent thrombosis occurred in 5.4% and 1.2% of the patients in diabetic and non-diabetic group, respectively (P=0.19). All of these patients experienced non-fatal myocardial infarction.Conclusions Although the early clinical outcomes were similar in diabetic and non-diabetic patients with acute STEMI treated with DES implantation, the cumulative MACE-free survival at one-year follow-up was worse in diabetic than in non-diabetic patients. More effective diabetes-related managements may further improve the clinical outcomes of diabetic cohort suffering STEMI.     

泮托拉唑对急性心肌梗死行经皮冠状动脉支架植入术患者消化道出血的预防

目的观察泮托拉唑在急性心肌梗死经皮冠状动脉支架植入术(PCI)治疗中对消化道出血的预防效果。方法急性心肌梗死行PCI患者87例分为观察组45例和对照组42例,对照组给予常规治疗,观察组在常规治疗基础上加用泮托拉唑,观察2组患者住院期间PCI成功率、并发症、病死率及7 d内消化道出血发生情况。结果观察组和对照组消化道出血的发生率分别为4.4%和21.4%,观察组明显低于对照组(P<0.05)。结论急性心肌梗死PCI治疗中预防性使用泮托拉唑能有效防止消化道出血的发生。     

西罗莫司涂层支架与非涂层支架治疗急性心肌梗死的疗效及安全性比较

1 文献类型 治疗。 2 证据水平 1a。     

中国患者行颈动脉支架效果：一项单中心研究

目的：回顾性分析在中国人群中对颈内动脉狭窄患者行颈动脉支架的疗效分析 方法：收集并回顾宣武医院2001年1月-2012年8月行CAS的1700例患者,分析术后30天并发症,统计方法采用单变量分析方法和多因素logistic回归分析。 结果：术后30天内的主要不良事件共43例(2.53%),在单因素分析中,症状性患者、神经功能缺损和术前未服用他汀类药物的患者术后MI、卒中和死亡率显著增高。在多因素分析里,症状性和神经功能缺损是围手术期MI、卒中和死亡的独立性危险因素。     

PTCA及支架植入术治疗心肌梗死并重症泵功能衰竭近期效果观察

目的 探讨经皮冠状动脉血管成形术(PTCA)及支架植入术治疗心肌梗死合并重症泵功能衰竭对心功能的影响。方法 分析2000年5月~2002年1月在珠江医院成功接受PTCA及支架植入术治疗的73例心肌梗死合并重症泵功能衰竭患者的临床资料,按其是否有伴发症、血管病变程度及手术的复杂程度分组,比较术前和术后7 d的左室射血分数(LVEF)。结果 血管病变的程度和手术的复杂程度与是否有伴发症无相关(P>0.05)。除合并慢性肾功能不全的患者,其余各组患者术前和术后7 d心功能的改善均有统计学意义(P<0.05)。不同程度的血管病变和不同手术复杂程度的患者心功能术前和术后7 d的提高均有显著差异。结论 PTCA及支架植入术能明显改善心肌梗死合并重症泵功能衰竭患者近期的心功能。     

The role of coronary angioplasty and stenting in acute myocardial infarction

Despite the improvements in the pharmacological treatment of acute myocardial infarction, it is recognised that thrombolysis fails to reproduce reperfusion in a significant proportion of patients. Coronary interventional techniques have been shown to offer an alternative reperfusion strategy. There is increasing evidence that mechanical reperfusion may offer significant advantages over established thrombolytic therapy.