糖尿病对冠状动脉介入治疗后心肌灌注的影响

目的探讨糖尿病合并急性心肌梗死(AMI)患者,冠状动脉介入治疗(PCI)后心肌微循环灌注状态.方法PCI再灌注成功的AMI患者85例,根据有无合并糖尿病分为两组,以反映心肌微循环灌注状态的简易实用指标:心电图的ST段回落速度为标准,计算再灌注治疗90min后12导联心电图ST段的下移幅度,并进行比较.结果糖尿病组患者PCI后ST段的下移幅度＜70%的明显高于非糖尿病组(60%vs 39%,P＜0.05),TIMI血流3级少见(81%比96%,P＜0.05),左心室射血分数明显低于非糖尿病组(47%vs 56%,P＜0.05),左心功能不全、室性心律失常发生率均明显高于非糖尿病组(10%vs4.6%;32%vs15%,P＜0.05)).结论AMI再灌注治疗后,心肌组织水平灌注状态与临床预后有关,糖尿病患者合并急性心肌梗死预后差.     

顿抑心肌的微循环障碍机制研究

目的 :探讨顿抑心肌微循环改变及机制。方法 :制备左前降支冠脉(LAD)阻断不同时间 ( 15和 60min)后再灌注 2h犬心肌顿抑模型 ,在不同观察时间点行静脉心肌声学造影 (MCE) ,计算心肌视频密度峰值(PVI)、MCE曲线上升斜率 (α)和曲线早期下降斜率 ( β) ,分别代表心肌血流灌注量、灌注速度和排空速度。测定相应时间点冠状静脉窦血乳酸浓度。结果 :⑴心肌顿抑早期PVI显著增高 ,1h后恢复至结扎前水平 ;⑵再灌注期顿抑区与正常区PVI比值、α比值、β比值显著高于LAD结扎前 ,随着再灌注时间的延长比值逐渐回降 ;⑶再灌注期冠状静脉窦血乳酸浓度明显增高。结论 :心肌顿抑早期心肌微循环处于“高动力”状态 ,血流灌注增加与排空加快并存 ;顿抑心肌缺氧代谢加强 ;心肌内微循环短路可能是心肌顿抑微循环障碍的机制。     

NT-proBNP在急性心肌梗死中的应用

目的：分析不同部位急性心肌梗死(AMI)NT-proBNP的关系及急诊PCI术对前壁AMI NT-proBNP的影响。方法选取2012年3月~2014年7月入住中南大学湘雅二医院心内科的急性AMI患者共263例,按梗死部位分为：非ST段抬高型、下壁和前壁三组。选取无器质性心脏病患者为对照组,选取行急诊PCI术的急性前壁AMI患者为PCI组;各组均测定血清NT-proBNP。结果各AMI组的NT-proBNP均高于对照组(P<0.05)。前壁AMI组的NT-proBNP最高(P<0.05)。前壁AMI,行PCI术组的NT-proBNP低于未行PCI术组(P<0.05)。结论血清NT-proBNP可作为评价急性AMI梗死部位的指标。 PCI术可降低急性AMI患者的NT-proBNP。     

心肌声学造影的发展及在冠心病诊治中的运用

心肌声学造影(Myocardial Contrast Echocardiography，MCE)在评价心肌微循环血流灌注，评定冠脉储备及冠脉血运重建后的疗效等方面的运用已成为一项十分重要的研究课题。MCE是指将含有微气泡的造影剂直接经冠状动脉或外周静脉注入，当微气泡通过心肌微血管床时，应用二维或多普勒超声技术使含血心肌的微气泡显像，以观察心肌血流灌注、冠脉血流储备。目前，它被认为是无创性评定心肌微循环灌注的最有潜力的工具。本文就近年来心肌声学造     

冠心病患者心肌声学造影定量分析的初步研究

拟探讨MCE定量分析在缺血性心脏病上的诊断价值。对10例临床诊断冠心病的患者行MCE,从时间-强度曲线中获得造影剂再灌注强度峰值(SIpeak),再灌注时间(Rt),再灌注率(b)和心肌血流量(SI×b)。同一检查对象不同心肌节段的4个参数(SIpeak、Rt、b和SI×b)均有统计学上的差异(P<0.05),对照组和观察组SIpeak具有统计学上的差异,SIpeak预测缺血性心脏病的ROC曲线下面积(AUC)为0.782,最佳临界值为64.4,以SIpeak≤64.4来预测缺血性心脏病,敏感性83.3%,特异性69.0%。利用超声造影匹配成像技术能够较满意地显示心肌灌注状态,初步研究表明通过MCE及Qontrast多参数定量分析软件可以评价心肌梗死区和缺血区的血流灌注缺损。SIpeak是预测缺血性心脏病的敏感指标。     

冠状造影脉冲响应分析评价心肌微循环

目的探讨冠脉造影脉冲响应分析评价心肌微循环的价值。方法数字血管造影脉冲响应函数分析系统 ,分析视频时间密度曲线 ,测定造影剂平均通过微循环时间倒数(Tmicro -1),作为评价局部心肌微循环灌注指标。结合定量冠脉造影(QCA)、计算机测量冠脉血流速度并计算冠脉血流动力学参数来评价冠脉狭窄和介入治疗前、后心肌微循环和大小循环动力学之间的变化关系。结果随着近段冠脉狭窄MLD缩小 ,Tmicro-1 减少 ;PCI治疗后 ,随着MLD增加 ,Tmicro -1增加 ,两者之间呈良好相关(r=0.87,P<0.001)。示意Tmicro -1可作为评估冠脉狭窄程度的临床指标 ;急性冠脉综合征PCI治疗后 ,随着狭窄MLD增加 ,Tmicro-1 和CFV、Rcor均得到一致改善 ,但PCI前Tmicro-1 与CFV之间并非线性相关(r=0.18,P>0.05) ,可能与大、小循环之间存在不同的影响因素有关 ,但Tmicro -1更能反应局部心肌灌注。结论QCA结合Tmicro -1、CFV等定量指标 ,有利于提高常规冠脉造影解剖形态与生理功能相结合、大(体循环)、小(微循环)循环相关联的综合诊断水平     

急性心肌梗死直接PCI术后QT离散度变化的研究

目的观察直接冠状动脉介入术(PCI)对急性心肌梗死(AMI)患者QT离散度(QTd)的影响.方法 115例发生于12H以内的急性心肌梗死患者,均行直接PCI治疗,并达到TIMI血流3级,观察治疗前后QTd的变化.结果治疗前QTd较正常显著延长(P<0.01),PCI成功后2天QTd较术前明显缩短.结论成功的PCI术能显著缩短AMI的QTcd,改善预后.QTcd可以作为一种简单、可靠的判定AMI再通的临床指标.     

超负荷量氯吡格雷对急性心肌梗死急诊PCI后心肌微循环再灌注的影响

目的:观察急性心肌梗死(AMI)患者急诊经皮冠脉介入(PCI)前超负荷量应用硫酸氢氯吡格雷(简称氯吡格雷)对PCI术后患者心肌微循环再灌注和心功能的影响。方法:将52例成功急诊PCI的急性心梗患者随机平分为氯吡格雷超负荷剂量组(600mg组)及氯吡格雷负荷剂量组(300mg组),每组26例,术后第7天比较两组患者左室射血分数(LVEF)、术后24h的ST段抬高总和回落百分比(sumSTR%)、术后即刻的心肌呈色显像(Blush)3级获得率。结果:600mg组LVEF、sumSTR%和Blush 3级获得率均高于300mg组(P均0.05)。结论:急性心梗患者PCI术前应用超负荷量氯吡格雷可以改善术后心功能及心肌微循环再灌注。     

一种新的基于MCE的心肌微循环定量分析系统的研制

基于心肌声学造影(MCE)的心肌微循环定量分析系统,对实时MCE图像进行处理,通过非线性回归分析方法计算出心肌供血区内心肌血容量、血流速度、血流量以及三者的心内、外膜层跨壁梯度等冠脉微循环临床诊断指标,能有效满足临床需求,实现了实时MCE的定量分析.     

芪丹通脉片对缺血/再灌注犬心肌微血管功能的影响

目的评价中药复方芪丹通脉片对急性缺血再灌注致心肌微血管功能的影响。方法应用12只健康犬,随机分为对照组(control)和芪丹通脉片治疗组(QDTMT treatment group),对照组经十二指肠给予生理盐水(1.5ml/kg),给药后30min分离冠状动脉左前降支,放置电磁流量计探头测定血流量,在其下缘左前降支1/2处结扎90min,松开后再灌注180min观察,分别于灌胃前、缺血90min和再灌注180min静脉快速均匀推入微泡声学造影剂SONOVUE,FLASH模式进行静脉声学造影,实时连续记录心肌声学造影前后的图像采用,采用Echopac图象工作站软件包进行分析心肌声学造影的图像视频密度,根据时间-视频密度曲线计算曲线下面积(area under curve,AUC)以评价心肌微血管的血流灌注状态,根据图像分析缺血心肌范围的影响。芪丹通脉片组则经十二指肠给予芪丹通脉片浸膏混悬液(1g/ml,1.5ml/kg),其余实验过程同对照组。并在不同时间点从冠状静脉窦采血,检测血清中NO和血浆中ET-1的含量。结果在基础状态、缺血前和缺血90min,对照组和芪丹通脉片干预组的时间-视频密度曲线计算曲线下面积(AUC)以及缺血后出现的灌注缺损所占左心室的百分比没有显著差异。然而再灌注180min两组的AUC存在显著差异(14.09±2.31 vs 11.47±1.55,P<0.05),左心室心肌灌流均没有完全恢复,但芪丹通脉片能够显著促进再灌注后心肌微循环灌流的恢复(92.10±2.2)%,与对照组(87.49±4.12)%比较,存在显著差异(P<0.05)。在缺血90min和再灌注180min,芪丹通脉片处理组血清中NO和血浆中ET-1分别为(68.98±10.01)μmol/L、(67.55±9.81)μmol/L和(114.73±11.89)μg/L,(139.97±12.36)μg/L,与对照组存在显著差异(56.38±8.27)μmol/L,(53.55±6.03)μmol/L和(137.40±13.48)μg/L,(161.90±19.14)μg/L,(P<0.05)。结论芪丹通脉片能够促进心肌缺血/再灌注后微循环血流的恢复,调节循环血中的NO和ET含量,改善微循环功能,抑制缺血/再灌注所致的心肌损伤。     

无复流现象对急性心肌梗死患者经皮冠状动脉腔内介人治疗时机选择的影响

目的比较研究急性心肌梗死患者行经皮冠状动脉腔内介入治疗(PCI)的时机选择与慢血流/无复流(SNR)现象的关系。方法选择272例急性心肌梗死行PCI治疗的患者为研究对象。TIMI2级血流患者136例,其中60例24h内施行即刻PCI,28例在梗死后24h至一周施行PCI,48例一周后至一月内行PCI;TIMI3级血流患者136例,其中62例在急性心肌梗死发病24h内行PCI,31例发病24h至一周内行PCI,43例一周后至一月内行PCI。分别比较各组的一般情况,冠脉造影梗死相关血管(IRA)行PCI前后的血流情况。结果TIMI2级血流组和TIMI3级血流组中24h至一周内行PCI治疗的患者SNR发生率显著高于24h内即刻PCI组和一周后择期PCI组(8/60vs22/28,22/28vs16/48,P均<0.05)(14/31vs6/62,14/31vs4/43,P均<0.05),且在TIMI2级血流组中即刻PCI组的SNR发生率明显低于一周后择期PCI组(8/60vs16/48,P<0.05);TIMI3级血流组中即刻PCI组的SNR发生率与一周后择期PCI组无差异(6/62vs4/43,P<0.05);TIMI2级与TIMI3级血流组在24h至一周内行PCI的患者SNR的发生率差异显著(22/28vs14/31,P<0.05)。结论急性心肌梗死患者即刻PTCA的血流恢复优于择期PTCA,尤其TIMI血流≤2级的患者。     

AMI患者PCI前后sCD40L的水平及临床意义

目的:探讨急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(PCI)前后血清可溶性CD40L的水平变化及临床意义.方法:应用酶联免疫吸附法对40例AMI患者进行了PCI治疗前后血清sCD40L、cTnI及CK-MB的检测,并与40例对照组患者进行比较.结果:AMI组sCD40L水平在PCI术前及术后即刻及术后2h均高于对...     

经静脉心肌超声造影对心肌梗死患者自体骨髓单个核细胞移植后心肌微循环的评价

目的利用经静脉心肌超声造影（IMCE）观察心肌梗死患者自体骨髓单个核细胞移植术前后心肌微循环的变化。方法40例急性心肌梗死患者在病情稳定后7～10d,行延迟经皮冠状动脉成形术（PCI）。随机分成骨髓细胞移植组（20例）和对照组（20例）,观察术前、术后1月、术后6月左心室舒张末内径（LVDd）,左室射血分数（LVEF）和术前及术后1个月的IMCE,测量平台期的心肌显像增大强度A,曲线上升平均斜率β及A与β之积在手术前后的变化。结果移植组LVEF由术前的（37.26±4.21）1月后上升到（54.42±5.26）（P〈0.05）;而对照组差异不显著（38.86±4.63对40.28±4.56）（P〉0.05）。LVDd移植组术后6月与术前比较差异不显著（50.23±3.42对52.48±3.26）（P〉0.05）;而对照组（50.96±2.68对64.31±3.28）（P〈0.05）心脏有扩大趋势。IMCE示手术后相关心肌节段的A、β及A.β均较术前显著增加。其中A.β（dB/s）移植组由术前的2.37±0.16（dB/s）增加到术后的15.60±0.24（dB/s）;较对照组（2.06±0.12至7.98±0.23）增加更为明显（P〈0.05）,示急性心肌梗死延迟PCI术后梗死相关节段心肌血流灌注速度和灌注量均有增加,自体骨髓单个核细胞移植组增加更明显。结论自体骨髓单个核细胞移植可改善梗死区心肌微循环,明显增加心肌血流量。     

急性心肌梗死病人血浆巨噬细胞移动抑制因子水平变化的研究

目的 :研究急性心肌梗死 (AMI)病人血浆巨噬细胞移动抑制因子 (MIF)水平变化的特征。方法 :征集完全符合诊断标准的AMI病人 37例 ,不稳定型心绞痛 (UA)病人 2 6例 ,稳定型心绞痛 (SA)病人 39例 ,接受经皮腔内冠状动脉成形术(PTCA)病人 2 6例 ,有非典型胸痛而冠状动脉造影正常的对照组 31例。这几组病人分别在发病第 1,2 ,3天抽取血样 ,用酶联免疫吸附试验 (ELISA)检测MIF水平 ,用贝克曼生化仪检测心肌酶的水平。结果 :在发病第 1～ 3天 ,AMI病组与SA组、UA组、PTCA组、对照组等比较 ,AMI病组血浆MIF水平明显高于其它病组 ,差异具有显著性 (P <0 0 0 1)。在发病第 1,2天 ,其MIF水平变化量的差异也具有显著性 (P <0 0 5 )。结论 :血浆MIF升高不仅可反映AMI病人病情的严重性 ,而且在预测AMI早期的潜在危险性方面具有重要作用     

Real-time myocardial contrast echocardiography as a useful tool to select candidates for coronary revascularization among patients with end-stage renal disease - a 3-year follow-up study

PurposeTo evaluate a real-time myocardial contrast echocardiography (MCE) as a tool to select candidates for coronary revascularization among patients with ESRD and to assess the rate of revascularization and mortality.Material / Methods58 ESRD patients were screened for CAD using MCE. We analyzed the rate of coronary revascularization during 3-year follow-up. Patients with and without perfusion disturbances on MCE were compared.ResultsCAD was found in 46.2% patients out of 39 who underwent coronary angiography. 11 (39.3%) patients out of 28 from the group with perfusion defects on MCE underwent revascularization procedure (21.4% - PCI, 17.9% - CABG). No one from the group without perfusion defects had revascularization procedure. Perfusion defect (OR 1.37 CI 1.37–1.86, p=0.022) was related to revascularization in multivariant analysis (OR 12.87, CI 1.86-89.21, p=0.025). There was no difference in mortality between the group which underwent invasive procedures and treated conservatively (p=0.6643). In ROC analysis defects on MCE and CAD on angiography were equally good in anticipating combined end-point (AUC 0.716, CI 95% 0.544–0.851 and AUC 0.747, CI 95% 0.577–0.875, p=0.701) and death (AUC 0.752, CI 95% 0.582–0.878 and AUC 0.729, CI 95% 0.558–0.861, p=0.805).ConclusionsOur results indicate that MCE is a safe and uncomplicated method which may help along with other methods to select candidates for coronary revascularization among ESRD patients. In our study coronary revascularization procedures were successful but they did not improve patients’ survival on 3-year follow-up.     

Percutaneous Coronary Intervention for Acute Myocardial Infarction in Elderly Patients with Renal Dysfunction: Results from the Korea Acute Myocardial Infarction Registry

This study aimed to evaluate the effects of percutaneous coronary intervention (PCI) on short- and long-term major adverse cardiac events (MACE) in elderly (>75 yr old) acute myocardial infarction (AMI) patients with renal dysfunction. As part of Korea AMI Registry (KAMIR), elderly patients with AMI and renal dysfunction (GFR<60 mL/min) received either medical (n=439) or PCI (n=1,019) therapy. Primary end point was in-hospital death. Secondary end point was MACE during a 1 month and 1 yr follow-up. PCI group showed a significantly lower incidence of in-hospital death (20.0% vs 14.3%, P=0.006). Short-term and long-term MACE rates were higher in medical therapy group (31.9% vs 19.0%; 57.7% vs 31.3%, P<0.001), and this difference was mainly attributed to cardiac death (29.3% vs 17.6%; 51.9% vs 25.0%, P<0.001). MACE-free survival time after adjustment was also higher in PCI group on short-term (hazard ratio, 0.67; confidence interval, 0.45-0.98; P=0.037) and long-term follow-up (hazard ratio, 0.61, confidence interval, 0.45-0.83; P=0.002). In elderly AMI patients with renal dysfunction, PCI therapy yields favorable in-hospital and short-term and long-term MACE-free survival.     

甘糖酯、藻酸双酯钠对急性心肌梗塞患者红细胞变形能力的影响

对43例急性心肌梗塞(AMI)患者的研究表明:AMI患者红细胞变形能力明显低于正常人。将其红细胞体外孵育24h后,其变形能力明显低于孵育前;但加甘糖酯和藻酸双酯钠孵育的红细胞,其变形力明显改善,其中以甘糖酯的作用更显著。提示甘糖酯、藻酸双酯钠对改善AMI患者的微循环状态、增加缺血心肌的血流灌注、缩小梗塞面积可能有重要的意义。     

Acute coronary syndrome and cell technologies

The authors researched into the possibility of autologous bone marrow stem cell (MSC) application in patients with acute myocardial infarction (AMI). 10 patients with AMI received cell therapy after giving an informed consent. ECG and EchoCG revealed myocardial infarction (MI) in the basin of the anterior interventricular branch (AIB) of the left coronary artery (LCA) in 4 patients, in the basin of the circumflex branch (CB) of the LCA--in 3 patients, and in the basin of the right coronary artery (RCA)--in 3 patients. Patients older than 70, patients with acute heart failure and those who developed AMI more than 48 hours ago, were excluded from the study. All the patients were male, aged 56.3 +/- 5.2 years, mean time from pain onset to the performance of myocardial revascularization was 11.4 +/- 7.2 hours. Marrow mononuclear fraction was introduced into the infarction-related artery on the 5th-7th day after primary angioplasty and stenting. Marrow sampling and cell material introduction did not cause any complications. All the patients were re-studied 1 month after the MSC transplantation. All the patients' condition improved; no complications or side effects of the interventions were observed. Left ventricle ejection fraction increased from 42.9% to 51.4%; the average number of asynergic segments was 5.3 +/- 0.7 before the intervention and decreased to 2.6 +/- 0.7 (p < 0.01) afterwards. Systolic velocity before the intervention was 2.5 cm/sec, and after the procedure it increased to 4.6 cm/sec in the segments submitted to isolated revascularization and to 6.1 cm/sec--in segments where the intervention was accompanied by the introduction of MSC (p < 0.01). Contrast EchoCG demonstrated an increase of myocardial perfusion in the area of cell therapy. The chief results of the study are as follows: 1) autologous MSC transplantation in patients with acute coronary syndrome is a safe and well-tolerated procedure; 2) myocardial revascularization in combination with MSC introduction in AMI area improves total and local contractile myocardial function and normalizes diastolic filling process in the LV; 3) cell therapy improves the myocardial perfusion.