急性心肌梗死经皮冠状动脉介入术中心律失常及处理

目的比较分析因急性心肌梗死接受经皮冠状动脉介入术病人的心律失常特点以及处理策略。方法观察209例急性心肌梗死病人在直接经皮冠状动脉介入术中心律失常的类型以及在不同的干预血管：右冠状动脉、左前降支和左回旋支中的发生机会。结果209例急性心肌梗死患中共出现86例心律失常，其中右冠状动脉病变27例，左前降支病变44例，左回旋支病变18例，共出现窦性心动过缓14例，共出现室性心律失常51例。结论右冠状动脉病变的病人术中发生的窦性心动过缓比其他血管病变多；室性心律失常在接受直接经皮冠状动脉介入术治疗的急性心肌梗死病人中多见：应积极防治在急性心肌梗死直接经皮冠状动脉介入术中出现的各种严重心律失常。     

低血钾与急性心肌梗死的梗死部位冠状动脉病变及预后的关系

目的探讨低血钾与急性心肌梗死的梗死部位、冠状动脉病变及预后的关系。方法根据心肌梗死早期血钾水平把110例患者分为低血钾组、正常血钾组,对比两组的梗死部位、冠状动脉病变特征、并发症和预后情况。结果急性心肌梗死患者低血钾36例(占32.7%),其中广泛前壁心肌梗死(57.1%)与下壁(23.9%)相比更易合并低血钾(P<0.01)。低血钾组的梗死相关血管更多为前降支(55.6%)和近段病变(55.6%),与对照组差异有统计学意义(分别为P=0.01,P=0.03)。低血钾组心力衰竭、严重心律失常、梗死后心绞痛等并发症发生率显著高于正常血钾组(均为P<0.05)。结论急性心肌梗死合并低血钾的梗死相关血管多为近段病变,多为前降支,预后相对较差。     

92例急性下壁心肌梗死病变血管分析

目的分析引起急性下壁心肌梗死病变血管的特点。方法回顾性分析2010年1月—2010年6月92例急性下壁心肌梗死病人的心电图特征以及冠状动脉造影检查。结果单独右冠状动脉病变8例(9%),单独左前降支病变3例(3%),单独左回旋支病变1例(1%),右冠状动脉+左前降支病变13例(14%),右冠状动脉+左回旋支病变5例(5%),右冠状动脉+左前降支+左回旋支病变55例(60%),左前降支+左回旋支病变6例(7%),左主干+三支病变1例(1%)。结论引起急性下壁心肌梗死的病变血管以右冠状动脉为主,目前以多支病变为主。     

心电图检出心律失常与冠状动脉病变关系

目的分析心电图检出心律失常与冠状动脉病变关系,为急性心肌梗死诊治、预后提供参考。方法选取我院120例急性心肌梗死患者为研究对象,所有患者均行动态心电图检测和冠状动脉造影,记录心律失常发生率,造影结果依照冠状动脉病变支数、病变血管、和狭窄程度进行分组,分析各种心律失常与冠状动脉病变情况的相关性。结果 120例中室性心律失常46例(39.0%),房性心律失常72例(61.0%)。ST段抬高79例(65.8%),ST段压低32例(26.7%),ST段无偏移9例(7.5%)。Lown3级及以上室性早搏发生率,冠状动脉多支病变(62.1%)显著高于单支病变(15.5%)(p0.05);缓慢心率失常发生率,多支病变(55.6%)显著高于单支病变(22.2%)和双支病变(22.2%)(p0.05);房性心律失常发生率,多支病变显著高于单支病变和双支病变(p0.05)。频发室早发生率,左主干及前降支(71.4%)显著高于左回旋支(14.3%)和右冠状动脉(14.3%)(p0.05);Lown3级及以上室性早搏发生率,左主干及前降支显著高于左回旋支和右冠状动脉(p0.05)。而ST段抬高和ST段压低时,冠状动脉狭窄程度(大于90%)患者发生率最高。结论急性心肌梗死患者病程中多出现心律失常,且与冠状动脉病变情况密切相关,判断动态心电图检查下的心律失常有助于预判急性心肌梗死冠脉病变情况,为急性心肌梗死预后提供参考。     

心肌梗死患者不同冠状动脉病变的动态心电图研究

目的探讨心肌梗死不同冠状动脉病变患者动态心电图心律失常的发生情况,为临床抗心律失常方案的选择提供依据。方法回顾性分析自2013年1月~2016年1月于北京地坛医院接受动态心电图检查以及冠状动脉造影检查的81例心肌梗死患者的临床资料。统计上述患者发生心律失常的情况;对比冠状动脉单支病变、双支病变以及多支病变患者心律失常的发生情况;对比不同罪犯血管心律失常的发生情况。结果 81例心肌梗死患者中,心律失常发生率为98.77%,其中71例出现房性心律失常,54例出现室性心律失常。复杂或者恶性心律失常在双支病变患者中的发生率为66.67%,多支病变患者的发生率为52.00%,均显著高于单支病变患者的发生率(P均0.05);房性心律失常在多支病变患者中的发生率为78.00%,显著高于单支病变和双支病变患者的发生率(P均0.05)。左主干及前降支病变复杂或者恶性心律失常的发生率为68.89%,房性心律失常的发生率为80.00%,均显著高于左回旋支和右冠状动脉病变的发生率(P均0.05)。结论动态心电图可作为诊断心肌梗死后心律失常的重要依据,同时有助于评估心肌梗死的严重程度,对判断预后有一定的参考价值。     

介入后放射性皮肤损伤一例

患者,男性,56岁.主因发作性胸闷1年,加重伴胸痛1小时入院.心电图提示急性下壁心肌梗死.立即行急诊冠脉造影示三支病变,累及前降支、回旋支、右冠.其中前降支近段狭窄约90％,回旋支近段以远100％闭塞.右冠状动脉近段以远100％闭塞.考虑右冠状动脉为罪犯血管.经与家属商量后行右冠状动脉PCI术.成功开通右冠状动脉后,10天后择期行前降支及回旋支PCI术.其中回旋支为慢性完全闭塞病变(CTO)开通时间长达1.5h,照射剂量达1.96Gy.术后患者无不适.冠状动脉造影结果如图1.     

超声心动图联合心电图对急性心肌梗死及其并发症的诊断价值

目的探讨超声心动图联合心电图对急性心肌梗死及其并发症的诊断价值。方法回顾性分析92例心肌梗死患者的超声心动图、心电图及冠状动脉造影资料,进行对比分析。结果超声心动图对心肌梗死的正确诊断率显著高于心电图,但差异无统计学意义(χ2=2.28,P0.05),心电图联合超声心动图的诊断率显著高于心电图和超声心动图(χ2=15.23,P0.01;χ2=5.42,P0.05)。不同病变部位正确检出率由高到低依次为左前降支、左前降支+右冠状动脉、右冠状动脉、3支、左回旋支、左前降支+左回旋支和左回旋支+右冠状动脉,其中左前降支病变正确检出率最高为96.43%,左回旋支+右冠状动脉的正确检出率最低为40.00%,二者比较,差异具有统计学意义(χ2=7.94,P0.01)。结论超声心动图联合心电图可提高单一诊断方法对急性心肌梗死的诊断率,超声心动图对急性心肌梗死病变部位及并发症的诊断具有一定临床价值。     

高龄急性心肌梗死患者发生早期恶性室性心律失常的相关因素分析

目的分析影响高龄(≥75岁)急性心肌梗死患者发生早期恶性室性心律失常的相关因素。方法选取110例高龄急性心肌梗死患者,按照动态心电图结果分为无恶性室性心律失常组(无MVA组,n=69),恶性室性心律失常组(MVA组,n=41),比较两组性别、血糖、高血压、心肌梗死病史、心率变异性、左心室射血分数、总胆固醇、肌钙蛋白Ⅰ、血钾、血肌酐、超声心动图和有无行经皮冠状动脉介入术等参数行Logistic回归分析。结果 110例患者共41例(37.27%)出现早期恶性室性心律失常,其中死亡7例(17.07%)。Logistic回归分析结果表明低心率变异性、低左心室射血分数、低血钾、高肌钙蛋白Ⅰ、高肌酸激酶同工酶、心功能Killip分级Ⅱ级、罪犯血管支数及梗死面积是高龄急性心肌梗死患者发生早期恶性室性心律失常的危险因素;行经皮冠状动脉介入术是早期恶性室性心律失常者的保护因素。结论高龄急性心肌梗死患者发生早期恶性室性心律失常的可能性及死亡率较高,伴有低心率变异性、低左心室射血分数、低血钾、高肌钙蛋白Ⅰ、高肌酸激酶同工酶、较高的心功能Killip分级是早期恶性室性心律失常发生的危险因素。     

前壁AMI合并CRBBB的冠脉病变特点

目的探讨急性前壁心肌梗死合并完全性右束支阻滞的冠状动脉病变特点。方法回顾2018年1月至2019年12月的102例急性前壁心肌梗死患者的冠状动脉造影结果,分为完全性右束支阻滞组(38例)和不合并束支传导阻滞组(64例),对比两组之间的冠状动脉病变特点。结果观察组罪犯血管左冠状动脉前降支罪犯段位于第一间隔支以上病例数有32例(84.2%),对照组26例(40.6%);两组比较差异有统计学意义(p0.001)。观察组左冠状动脉前降支内血栓例数有22例(57.9%),对照组20例(31.3%),两组比较差异有统计学意义(p=0.002)。观察组有侧支循环3例(7.9%),均为Rentrop侧支等级Ⅰ级,来源于右冠状动脉;对照组:26例(40.6%),来源于右冠状动脉22例,左冠状动脉回旋支4例,Rentrop侧支等级Ⅱ级20例,Rentrop侧支等级Ⅰ级6例,两组比较差异有统计学意义(p0.001)。结论观察组对比对照组其左冠状动脉前降支病变部位多发生于第一间隔支近段,其血栓发生率高于对照组,侧支循环形成远低于对照组。     

93例急性心肌梗死患者的心电图及冠脉造影分析

目的探讨急性心肌梗死患者心电图sT改变的导联与冠状动脉罪犯血管的关系。方法对93例急性心肌梗死患者心电图ST段改变与选择性冠状动脉造影结果进行对比分析。结果心电图V1-V4sT抬高伴Ⅱ、Ⅲ、aVFST段下移的罪犯血管主要为左前降支（LAD）,少数前壁心肌梗死伴下壁sT段抬高;Ⅱ、Ⅲ、aVFST抬高伴V1-V4 ST段下移的主要罪犯血管为右冠状动脉（RCA）,少部分为左回旋支（LCX）,极少部分为LAD;胸前导联T高尖与ST抬高导联不一致可排除LAD;高侧壁Ⅰ、AVLST段抬高多数罪犯血管为LCX。结论心电图ST改变的导联对急性心肌梗死罪犯血管能进行初步预测。     

ST段抬高急性心肌梗死患者心电图对应导联ST段改变不同类型的临床预后

目的探讨ST段抬高急性心肌梗死（STEMI）患者心电图（ECG）对应导联ST段改变（R-ST-D）不同类型与罪犯冠状动脉病变及临床预后的关系。方法选择住院初发STEMI资料完整967例,根据R-ST-D振幅分4种类型,即R-ST-D振幅无下移（I组）143例;R-ST-D下移振幅小于或等于梗死区ST段抬高振幅（1I组）664例;R-ST-D下移振幅大于梗死区ST段抬高振幅（Ⅲ组）93例;R-ST-D和梗死区ST段均抬高（IV组）67例;分析其ECGR-ST-D4种类型与罪犯冠状动脉病变和临床高危预后的关系。结果R-ST-D4种类型中I组、Ⅱ组、Ⅲ组发生率分别为14．8％,68．7％,9．6％,并以前降支为主单支病变多见。Ⅳ组发生率6．9％,主要累及复合前壁,前降支,回旋支及右冠状动脉。泵衰竭、低血压、严重心律失常、AMI扩展、室壁运动失调、左室射血分数≤50％及住院病死率分别为71．6％,41．8％,61．2％,34．3％,100．0％,40．3％和16．4％（P〈0．05或P〈0．01）。结论STEMI患者ECGR．ST-D不同类型对罪犯冠状动脉病变和临床近期预后具有预测作用。     

以晕厥为首发症状的急性心肌梗塞相关血管分析

目的:探讨以晕厥为首发症状的急性心肌梗塞(AMI)与梗塞相关血管之间的关系。方法:对200例急性ST段抬高型心肌梗塞(STEMI)并进行急诊经皮冠状动脉介入治疗(PCI)患者中15例以晕厥为首发症状的梗塞相关血管进行分析。结果:以晕厥为首发症状的患者在26例梗塞相关血管为左回旋支者中有5例(占19.2%);65例梗塞相关血管为右冠状动脉者中有7例(10.8%);109例梗塞相关血管为左前降支者有3例(2.8%),梗塞相关血管为左前降支者的晕厥为首发症状的发生率显著低于梗塞相关血管为右冠状动脉,及左回旋支者(P0.05)。结论:梗塞相关血管为左回旋支或右冠状动脉的AMI患者,晕厥的发生率显著高于梗塞相关血管为左前降支的AMI患者。     

Spontaneous and electrically induced ventricular arrhythmias during acute ischemia superimposed on 2 week old canine myocardial infarction

The arrhythmogenic effect of acute reversible myocardial ischemia before and 2 weeks after experimental myocardial infarction was investigated in 37 dogs that underwent reversible 10 min occlusion of the first major marginal branch of the left circumflex coronary artery. Subsequently, 24 of the dogs underwent experimental myocardial infarction with permanent left anterior descending coronary ligation, and 13 dogs served as sham-operated controls. Two weeks later, an open chest programmed electrical stimulation was performed in the 13 sham-operated and 24 postinfarction dogs to determine its accuracy in predicting the ventricular arrhythmias that develop during a subsequent episode of acute reversible ischemia. After programmed electrical stimulation, the left circumflex marginal branch was reversibly occluded for 10 min at the same site. The incidence of spontaneous ventricular fibrillation during reversible left circumflex marginal coronary occlusion did not differ from the first to the second study in sham-operated dogs, whereas in the postinfarction dogs, it increased from 13% before infarction to 54% after infarction (p = 0.005). The outcome of programmed electrical stimulation predicted spontaneous ventricular arrhythmias during coronary occlusion in only 21% of the postinfarction dogs. The accuracy of programmed electrical stimulation was 42% and its predictive value was 47% in detecting the dogs with spontaneous ventricular fibrillation. Regional myocardial blood flow measurements by microsphere technique identified the severity of reversible ischemia in the infarct border and periinfarction zones as a correlate of spontaneous ventricular fibrillation during coronary occlusion. In contrast, total infarct size correlated with electrically induced but not with spontaneous ventricular arrhythmias.     

右冠状动脉与左回旋支病变致右室梗死32例临床对比分析

目的探讨右冠脉与左回旋支病变致右室梗死冠脉病变特点及临床特征。方法筛选我院2007年10月至2013年11月入院的32例右室心肌梗死患者,根据梗死相关动脉分为右冠组（25例）和左回旋支组（7例）。收集其临床资料及冠脉造影结果,进行分析总结。结果右冠组多为近段病变,左回旋支组多为中远段病变。右冠病变致右室梗死,其缓慢性心律失常发生率高于左回旋支病变（P〈0．05）。结论右室梗死多见于中青年患者,多为右冠脉近端病变所致。右冠脉病变恶性缓慢型心律失常发生率高于左回旋支病变,且预后差于左回旋支病变。     

急性下壁心肌梗死患者心电图胸前导联ST段改变的临床意义

目的探讨急性下壁心肌梗死患者心电图胸前导联ST段改变与冠状动脉造影(CAG)所见冠状动脉病变部位的关系及其临床意义。方法 187例急性下壁心肌梗死患者,按入院时18导心电图胸前导联ST段改变分为3组,ST段无变化组(47例),ST段抬高组(16例),ST段压低组(124例);所有患者均行CAG。结果急性下壁心肌梗死伴胸前导联ST段抬高时多为右冠状动脉(RCA)近段闭塞(14例,82.3%),尤其是伴圆锥支动脉闭塞,与RCA中远端闭塞(2例,5.9%)比较差异有统计学意义(P0.01),且14例(73.7%)伴有右心功能不全和血流动力学障碍。下壁心肌梗死胸前导联ST段压低者可见于RCA、回旋支(LCX)闭塞及RCA、LCX闭塞与前降支(LAD)、对角支(D)病变的不同组合,其中LCX闭塞伴RCA病变者多表现为朐前ST V_4～V_6的压低,RCA闭塞伴LAD近端病变多有胸前ST V_1～V_6的压低,RCA伴D病变胸前ST V_1～V_3压低,与对照组比较差异有统计学意义(P0.05)。结论急性下壁心肌梗死合并胸前导联ST段抬高表明为RCA近段或丌口闭塞且多伴右心室心肌梗死和心功能不全;下壁心肌梗死伴胸前导联ST段压低提示为多支病变,ST V_1～V_3压低多伴有对角支严重狭窄,STV_1～V_6压低多伴有前降支的严重狭窄。     

Noninvasive assessment of left and right ventricular filling in myocardial infarction with a two-dimensional Doppler echocardiographic method

Inflow characteristics of left and right ventricular filling were assessed in 40 patients with myocardial infarction and in 10 normal subjects by pulsed Doppler echocardiography. Patients with myocardial infarction were subdivided into four groups, focusing on the involvement of right ventricular and septal branches of the coronary arteries. Group I consisted of 11 patients with anterior infarction who showed an obstructive lesion of the proximal left anterior descending branch involving the first septal perforator with a patent right coronary artery. Group II consisted of 10 patients with inferior infarction who showed an obstructive lesion of the proximal right coronary artery involving the right ventricular branch. Group III consisted of 12 patients with both anterior and inferior infarction who showed obstructive lesions of both the proximal left anterior descending branch and the right coronary artery involving the right ventricular branch. Group IV consisted of seven patients with lateral infarction who showed an obstructive lesion of the diagonal branch or branches of the circumflex coronary artery with a patent left anterior descending branch and right coronary artery. Three measurements were performed from the transmitral and transtricuspidal inflow velocity patterns to assess the left and right ventricular diastolic behaviors. These measurements were: acceleration half-time, deceleration half-time of early diastolic rapid inflow, and the ratio of the peak velocity of early diastolic rapid inflow to that of the late diastolic inflow due to the atrial contraction. Impaired diastolic filling of the left ventricle compensated by enhanced left atrial contraction was observed in patients with myocardial infarction from groups I, II, III and IV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications of emergency coronary angioplasty for acute myocardial infarction]

To assess the incidence and consequences of complications occurring during emergency percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI), we studied 347 patients who underwent PTCA within 24 hours after the onset of AMI. Acute occlusion occurred in 29 patients (8.4%), of whom 16 patients underwent successful repeat PTCA. All of them survived until hospital discharge. The in-hospital reocclusion rates of these 16 patients were comparable to those of patients who had not experienced acute occlusion (18.8 vs 12.8%, ns). In the remaining 13 patients, reperfusion were not successful after acute occlusion, and 6 died. Side branch occlusion occurred in 21 patients (6.1%). Left circumflex artery occlusion occurring during PTCA for the proximal left anterior descending artery was fatal in 3 patients. Right ventricular branch occlusion during PTCA for the middle of the right coronary artery resulted in intractable right ventricular infarction in one patient, and he died. Among 14 patients who underwent repeat angiography, 13 had a patent side branch which had been occluded during PTCA. One patient had coronary rupture and died. During PTCA of the proximal left anterior descending artery, acute occlusion of the artery without reperfusion or occlusion of the left circumflex artery was often fatal. However, the prognosis of acute occlusion was relatively good, if repeat PTCA was successful and most of the occluded side branches remained patent in the chronic state.     

急性心肌梗死患者Ⅲ度房室传导阻滞与房室结动脉血供的关联性

目的 观察和分析急性心肌梗死(AMI)患者Ⅲ度房室传导阻滞(AVB)与房室结动脉血供的关系。方法 将入选的AMI患者,按是否并发Ⅲ度AVB分为两组:病例组为AMI并发Ⅲ度AVB的患者（n=35例）,对照组为AMI未并发Ⅲ度AVB的患者（n=215例）,通过观察梗死相关动脉并分析房室结动脉血供来源情况,分析AMI患者不同房室结动脉血供来源发生Ⅲ度AVB的几率,并观察AMI并发Ⅲ度AVB的患者,房室结动脉血运改善后Ⅲ度AVB恢复时间。结果 房室结动脉血供来源于右冠状动脉的右上降支动脉和回旋支的kugel’s动脉之一或二者双重血供。病例组患者,其房室结动脉血供仅来源于右冠状动脉的右上降支或回旋支的kugel’s动脉,无前降支来源,并且右冠状动脉较回旋支多见（P<0.01）。当梗死相关动脉得到再灌注,恢复血运后,AVB均恢复到窦性心律。结论 急性心肌梗死Ⅲ度AVB发生患者与其房室结动脉血供中断有关,恢复房室结动脉血供后AVB恢复窦性心律。     

实时三平面组织追踪成像定量评价心肌梗死患者左心室长轴位移

目的:应用实时三平面组织追踪成像(Triplane-TTI)技术定量评价心肌梗死(MI)患者二尖瓣瓣环及左心室各节段心肌收缩期位移特点。方法:单纯左前降支MI患者17例(B组),左旋支或(和)右冠支MI患者19例(C组),包含左前降支病变的双支或多支患者23例(D组),健康志愿者25例作为对照组(A组)。采集Triplane-TTI图像,分析获得各室壁房室平面收缩期最大位移(AVPD)及各节段心肌收缩期最大位移(Dmax)。结果:B、C、D3组平均AVPD与A组比较均减低,D组尤为显著(P0.05)。B组下侧壁、下壁及后间隔位点,C组前间隔及前壁位点AVPD虽然减低,但与A组比较差异不具有统计学意义。A组同一水平各节段心肌Dmax差异不明显,同一室壁从基底段、中间段至心尖段Dmax逐渐减低,呈梯度变化。B、C、D 3组Dmax不同程度减低,与A组比较及3组间比较大部分心肌节段差异均具有统计学意义(P0.05)。AVPD和Dmax减低室壁与梗死相关冠状动脉供血区域基本符合。结论:对于心肌梗死患者应多位点测量AVPD,避免高估或低估;Dmax能准确反映MI患者左心室局部心肌收缩功能的变化。     

急性心肌梗死伴新发右束支阻滞的临床意义

目的 探讨急性心肌梗死（AMI）合并新发右束支阻滞（RBBB）的临床特征及意义.方法 回顾性分析同期住院的AMI伴新发RBBB（观察组）与同期住院的无新发RBBB患者（对照组）,比较两组的基线资料、心电图、冠状动脉造影（CAG）、肌钙蛋白（cTNI）滴度、血清肌酸激酶同工酶（CK-MB）峰值、心功能及院内主要不良心脏事件（MACE）.结果 观察组新发RBBB多继发于急性前侧壁心肌梗死,梗死相关动脉（IRA）以左冠状动脉前降支（LAD）近端多见;观察组cTNI滴度、（CK-MB）峰值、Killip平均分级、住院期间MACE发生率均明显高于对照组,而左室射血分数（LVEF）则低于对照组.结论 AMI合并新发RBBB提示心梗面积大,病情凶险,预后不良,应尽早行再灌注治疗.