冠状动脉内注射腺苷对急性心肌梗死再灌注后无复流的影响

目的 评价冠状动脉内注射腺苷对急性心肌梗死(AMI)再灌注治疗后无复流的影响。方法 共62例行经皮冠状动脉介入治疗（PCI）的AMI患者,被随机分为对照组和腺苷组。以PCI后最终冠脉造影校正的心肌梗死溶栓试验血流帧数（corrected thrombolysis in myocardial infarction frame count,cTFC）为标准,当cTFC≥23时诊断为无复流。PCI前、后采集肘静脉血检测肌酸激酶同工酶(CK-MB)和超敏C反应蛋白(hsCRP)。比较两组无复流发生率及血浆心肌酶和炎症因子的变化。结果 腺苷组中无复流的发生率较对照组明显降低(P<0.05)。腺苷组CK-MB和hsCRP较对照组明显降低(P<0.05)。多元线性回归分析显示CK-MB、hsCRP与无复流显著相关(P<0.05)。结论 AMI患者冠脉内应用腺苷能有效降低无复流的发生,降低血浆心肌酶、炎症因子水平。     

直接冠状动脉内支架置入术对急性心肌梗死无复流的影响

目的评价直接冠状动脉(冠脉)内支架置入术对ST段抬高型急性心肌梗死无复流的影响。方法对157例ST段抬高型急性心肌梗死患者分别行直接冠脉内支架置入(直接支架组,85例)和球囊预扩张后支架置入(常规支架组,72例)。比较两组介入治疗时平均X线曝光时间、造影剂用量、术后TIMI血流分级和心电图ST段变化。结果直接支架组和常规支架组比较,前者节省球囊,平均X线曝光时间和造影剂用量均显著降低[(24.6±16.9)minvs(34.4±17.5)min,(115±37)mLvs(166±61)mL;P均<0.05];二者术后TIMI3级差异无统计学意义(91.8%vs83.3%,P=0.107);前者TIMI0~1级未见显著降低,但有明显的下降趋势(3.5%vs11.1%,P=0.064);前者心电图ST段无回落发生率显著降低(22.4%vs41.7%,P=0.009)。结论对于ST段抬高型急性心肌梗死中适当的冠脉病变,直接冠脉内支架置入术不仅可以节省球囊,减少X线曝光时间和造影剂用量,而且可能减少无复流发生。     

急性心肌梗死直接冠状动脉介入治疗中的无复流现象研究

目的探讨急性ST段抬高性心肌梗死(STEMI)直接冠状动脉介入治疗时对无复流现象的临床疗效.方法54个月期间对232例STEMI实施直接PCI,25例(10.8%)梗死相关动脉(IRA)出现无复流现象.冠状动脉内处理包括注射各种药物、生理盐水或动脉血冲洗和主动脉气囊反搏术.结果25例无复流患者中,男18例,女7例,平均年龄60.7岁(34-85岁).16例发生在右冠状动脉,其中14例IRA粗大.20例合并有高血压病(其中14例还合并2型糖尿病),18例合并高脂血症.经过处理,17例IRA为3级TIMI前向血流,以后临床经过良好.6例为TIMI 2级血流,4例术后临床经过良好,2例分别在术后4 h和70h死亡.2例TIMI 0-1级血流,术中死亡.结论直接PCI的无复流发生率为10.8%,死亡率达16%.无复流主要见于IRA为粗大右冠状动脉并且合并高血压病以及高脂血症的患者.无复流的处理应当是综合性的,但并非总是有效.     

预防性药物干预对糖尿病并急性心肌梗死急诊冠状动脉介入治疗中无复流的影响

目的:明确急性心肌梗死(AMI)并糖尿病冠状动脉介入治疗(PCI)前药物干预是否可以有效预防PCI过程中无复流现象.方法:首先将入选患者按照PCI是否出现无复流分为无复流组和正常血流组,然后对药物干预情况、生化、PCI情况等进行Logistic分析,明确药物干预与无复流的关系.结果:他汀类药物是AMI并糖尿病行PCI出现无复流的保护因子[χ2=9.360,P=0.002,Exp(B)=0.309), 服用时间≥3个月的无复流发生率明显降低(3.8%,10.9%,χ2=5.413,P=0.020). 而血管紧张素转化酶抑制剂类、β受体阻滞剂、阿司匹林对无复流的发生无明显影响(P>0.05).结论:长期服用他汀类药物可以减少AMI并糖尿病PCI中无复流的发生.     

急性ST段抬高型心肌梗死急诊冠状动脉支架置入后慢血流或无复流现象的影响因素

目的研究老年急性ST段抬高型心肌梗死(STEMI)患者急诊PCI后出现冠状动脉慢血流现象(CSFP)的潜在临床预测因素。方法选择接受急诊PCI术的老年STEMI患者419例,根据PCI后TIMI分级分为对照组(3级)347例和实验组(0~2级)72例,收集受试者一般临床资料及血管造影等资料。采用ROC曲线分析CSFP的预测因素。结果实验组术中再灌注损伤、支架总长度、造影剂剂量、支架后扩张、合并心源性休克、D-二聚体水平、住院期间病死率以及LVEF<50%比例明显高于对照组(P<0.05)。支架后扩张、D-二聚体水平、造影剂剂量及合并心源性休克均为CSFP的独立危险因素(P<0.05,P<0.01)。D-二聚体水平、支架后扩张及两者联合检测预测CSFP的ROC曲线下面积分别为0.618(95%CI:0.543~0.693)、0.585(95%CI:0.513~0.657)、0.670(95%CI:0.603~0.738)。高D-二聚体患者CSFP发生率和住院期间病死率明显高于低D-二聚体患者(P<0.01)。结论D-二聚体水平及行支架后扩张为CSFP的独立危险因素,且D-二聚体是CSFP不良预后的可靠标志物。     

急性心肌梗死直接介入治疗后无复流的血管因素

目的:探讨急性ST段抬高型心肌梗死(STEAMI)患者直接经皮冠状动脉内介入治疗(percutaneous coronary intervention,PCI)后与无复流有关的血管因素。方法:回顾性分析410例STEAMI患者直接PCI后的临床和造影资料,无复流患者51例,由其余359例直接PCI后TIMI3级血流者中随机抽取60例作为正常血流组。结果:无复流的发生率为12.44%。:两组在几乎完全闭塞、血栓、钙化、长病变等造影发现的罪犯血管形态学改变存在显著性差异。结论:STEAMI患者如果在造影时发现罪犯血管存在几乎完全闭塞、血栓、钙化、长病变等形态学改变,则直接PCI后无复流的发生率明显著增加。     

冠状动脉内直接支架术对无复流现象的影响

目的评价冠心病患者冠状动脉内直接支架术对术后无复流的影响。方法入选239例接受冠脉内直接支架术的患者（直接支架组）和239例球囊预扩张后行冠脉支架术的患者（常规支架组）,分析两组患者的术中无复流现象发生率,并观察住院期间主要不良心血管事件发生率。结果直接支架组术后无复流发生率（8.8%）低于常规支架组（19.2%,P<0.01）,直接支架术组主要心血管事件发生率也较低（6.7%vs13.4%,P<0.01）。结论冠脉内直接支架有助于降低冠心病患者无复流现象和不良心血管事件发生率。     

地塞米松对兔急性心肌梗死血运重建后心肌无复流影响的实验研究

目的观察地塞米松对兔实验性急性心肌梗死(AMI)血运重建后心肌无复流(NR)现象的影响。方法新西兰大白兔40只,随机分为4组。开胸结扎冠状动脉左降支60min,继之解除结扎,重建血运,Ⅰ组、Ⅱ组、Ⅲ组、对照组分别静脉注射地塞米松2.5mg,5.0mg,10.0mg和生理盐水5mL。观察左室心肌NR范围、心肌梗死范围,并检测血清肌酸激酶(CK)、肿瘤坏死因子(TNF-α)及白细胞介素-6(IL-6)水平。结果Ⅱ组与Ⅲ组的心肌NR范围、心肌梗死范围均显著低于Ⅰ组和对照组(P<0.01);Ⅱ组与Ⅲ组之间比较无统计学意义(P>0.05)。Ⅰ组、Ⅱ组和Ⅲ组CK,TNF-α和IL-6血清水平均显著低于对照组(P<0.05或P<0.01)。结论单次应用地塞米松可显著减轻实验性AMI血运重建后的心肌NR现象,缩小梗死范围,其作用效果与剂量相关。     

急性心肌梗死直接介入治疗后无复流现象形成因素分析

目的:探讨急性心肌梗死直接介入治疗后发生无复流现象的有关预测因素。方法:分析急性心肌梗死直接介入治疗后发生无复流患者67例。正常血流对照组70例,2组间临床资料及冠状动脉造影结果进行比较。结果:无复流组PCI前缺血时间较长[(5.9±3.6)vs(4.3±2.7),P<0.05],血栓负荷更重(83.5%vs67.1%,P<0.05),多支病变例数较多(76%vs54%,P<0.05),造影后心肌梗死溶栓试验(TIMI)血流常为0级或1级(90%vs64%,P<0.05),供应罪犯血管的侧支循环较少(10%vs20%,P<0.05)。结论:急性心肌梗死患者缺血时间长、多支血管病变、造影时TIMI血流0或1级、侧支循环较少者直接PCI后易发生无复流。     

欣怡胶囊对兔急性心肌梗死再灌注后心肌无复流程度的影响

目的：观察欣怡胶囊对兔急性心肌梗死（AMI）再灌注后心肌无复流的影响。方法将80只兔分为5组,模型组,阳性药组（替罗非班60μg/kg）,欣怡胶囊高、中、低剂量组（4.0 g生药/kg、2.0 g生药/kg、1.0 g生药/kg）,每组16只,另取14只作为假手术组,灌胃给药5 d后分别建立 AMI缺血再灌注模型,结扎兔冠状动脉左回旋支近段3 h,再灌注1 h,记录 AMI术前和 AMI再灌注后心电图,比较 J点抬高情况;AMI再灌注后左心室插管连接 POWERLAB生物信号采集处理系统,记录血流动力学相关指标;采用Evan’s蓝和硫磺素 S对心脏进行活体染色,记录心肌无复流程度。结果欣怡胶囊高、中和低剂量组心肌无复流程度均比模型组显著降低,分别降低了38.1%、24.5%和19.7%（P〈0.05或P〈0.01）,AMI再灌注后心电图中 J点比模型组明显降低,左心室内压（LVSP）、心率（HR）、左心室压力最大上升速率（＋dp/dtmax）、左心室内压最大下降速率（-dp/dtmax）明显升高,左心室舒张末期内压（LVEDP）明显降低,差异有统计学意义（P〈0.05或P〈0.01）。结论欣怡胶囊灌胃给药能一定程度预防和改善兔 AMI再灌注后导致的心肌无复流现象。     

Intracoronary verapamil for reversal of no-reflow during coronary angioplasty for acute myocardial infarction.

No-reflow is a frequent observation during direct PTCA for acute myocardial infarction (AMI) and associated with a poor clinical outcome. This study assesses the value of verapamil for reversal of no-reflow during PTCA for AMI. In a consecutive series of 212 direct or rescue PTCAs for AMI, a TIMI flow grade < 3 was observed in 23 patients (10.8%). Ten of these patients had received GP IIb/IIIa antagonists before PTCA. Seven patients with AMI and TIMI grade 3 flow served as controls. All lesions were treated by stents. In 18 patients with systolic blood pressure > 90 mm Hg, nitroglycerine (0.1 mg i.c.) was given. Verapamil (1 mg over 2 min) was given via an infusion catheter distal to the angioplasty site. Before and after nitroglycerine, after verapamil, and 15 min later coronary flow was assessed by the TIMI frame count method (TFC). Nitroglycerine had no effect on TFC. Verapamil reduced TFC from 56 +/- 9 frames to 24 +/- 4 (P < 0.001). In controls, TFC did not change significantly. The TIMI flow grade was restored to TIMI flow grade 3 in 65%. In two of seven right coronary and one of three circumflex arteries, intermittent AV block II occurred during verapamil injection, which disappeared after atropine. No-reflow after PTCA for AMI can be reversed by intracoronary verapamil. This supports the hypothesis that no-reflow is caused by acute microvascular dysfunction probably because of a disorder in calcium homeostasis or microvascular spasm.     

国产替罗非班对急性心肌梗死冠状动脉介入治疗术后心肌灌注的影响

目的评价替罗非班在急性心肌梗死（AMI）直接冠状动脉介入治疗（PCI）中的有效性和安全性。方法行直接PCI治疗的AMI患者,分为预先应用替罗非班组（40例）和对照组（32例）,比较两组患者的无复流发生率、心肌灌注分级（TMPG）和出血并发症。结果两组患者均成功完成PCI操作,试验组有4例（10%）出现无复流或慢复流现象,对照组共有8例（25%）出现无复流现象,试验组无复流发生率有低于对照组的趋势,但未达到显著水平,替罗非班组的TMPGⅢ级比例高于对照组,但未达到统计学显著水平,两组主要不良事件无显著性差异。两组患者总的出血并发症相似,均无严重出血并发症。结论国产替罗非班能降低AMI直接PCI时无复流现象,改善冠状动脉血流,且不增加严重出血并发症。     

Treatment of slow/no-reflow phenomenon with intracoronary nitroprusside injection in primary coronary intervention for acute myocardial infarction.

Slow/no-reflow phenomenon is a serious problem complicating primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) and is associated with a poor prognosis. From January 2002 to November 2002, 11 of the 70 consecutive patients with ST elevation AMI who were subjected to primary PCI using balloon angioplasty and/or stenting developed slow/no-reflow phenomenon (TIMI 1 flow in 2, TIMI 2 in 8, and TIMI 2.5 in 1). They were 10 men and 1 woman, aged 64 +/- 11 years (range, 46-81). The culprit vessels were six in the left anterior descending coronary artery, three in the right coronary artery, one in the left circumflex coronary artery, and one in saphenous vein graft. Multiple bolus doses (100 microg) of nitroprusside were injected into the index artery through the guiding catheter using a 3 ml syringe until the TIMI flow grade improved by at least one grade or the systolic pressure decline below 80 mm Hg (one patient). The total drug dose varied from 100 to 700 microg. Following the drug treatment, angiographic TIMI flow grade improved by at least one grade in 9 (82%) of the 11 patients (P = 0.007). The TIMI frame counts significantly decreased from 36 +/- 17 frame counts to 16 +/- 11 frame counts (P = 0.012). All patients were discharged without major adverse cardiovascular events. Intracoronary bolus injection of nitroprusside using a 3 ml syringe appears to be a feasible, safe, and effective technique for the management of slow/no-reflow phenomenon complicating primary PCI.     

急诊经皮冠状动脉介入治疗冠状动脉造影无复流的相关因素

目的　探讨急诊经皮冠状动脉介入治疗 (percutaneouscoronaryinterventions,PCI)冠状动脉(冠脉 )造影无复流现象的相关因素。方法　自 1999年 1月至 2 0 0 2年 10月 ,回顾性分析 4 97例急诊PCI病人的临床和冠脉造影资料 ,冠脉造影无复流病人 5 8例 ,由其余的 4 39例急诊PCI冠脉前向血流TIMI 3级的病人中随机抽取 6 0例 ,为正常血流组。运用Logistic回归分析无复流的相关因素。结果　无复流的发生率为 12 6 %。单因素分析表明 :糖尿病、症状开始到再灌注的时间、梗死前心绞痛、Kil lip心功能分级、Q波计数、室壁运动积分差异有显著性。而多因素Logistic回归分析表明 :症状开始到再灌注的时间、梗死前心绞痛、Killip心功能分级、Q波计数是无复流的相关因素。结论　大面积心肌坏死、严重的心肌损害、心功能不全和症状开始到再灌注的时间长 ,可能会促使无复流的形成 ;梗死前心绞痛可能减少无复流的发生。而冠心病的危险因素与无复流没有相关性。     

Clinical outcomes of dexamethasone-eluting stent implantation in ST-elevation acute myocardial infarction.

OBJECTIVES: The aim of our study was to evaluate the safety and midterm clinical results of dexamethasone-eluting stent (DexES) implantation in ST-segment elevation acute myocardial infarction (STEMI). BACKGROUND: Inflammation plays a pivotal role in both inestabilization of coronary atherosclerotic plaques and development of restenosis after stent placement. Antiinflammatory agents may attenuate those mechanisms and improve clinical outcomes. There is little information about clinical results of DexES and no data are available about their utilization during percutaneous coronary intervention (PCI) in STEMI. METHODS: Consecutive patients with STEMI that underwent primary or rescue PCI in our institution were treated with DexES. Clinical follow-up with routine realization of noninvasive test for detection of myocardial ischemia and coronariography if necessary, were performed. The objective of the study was to evaluate the rate of MACE (death, reinfarction, or target lesion revascularization) during midterm follow-up. RESULTS: The procedure was successful in 96.7% of cases. There were no in-hospital deaths or reinfarctions. One acute stent thrombosis occurred and no subacute thrombosis were observed. During a mean follow-up period of 384 days, cardiac-related death was 1.1%, there were no reinfarctions or late stent thrombosis and target lesion revascularization rate was 4.2%. CONCLUSION: We conclude that utilization of DexES for PCI in STEMI is safe and provides good midterm clinical outcomes.     

Relation of stent overexpansion to the angiographic no-reflow phenomenon in intravascular ultrasound-guided stent implantation for acute myocardial infarction

The angiographic no-reflow phenomenon is observed in some patients during stent implantation for acute myocardial infarction (AMI). We attempted to clarify the influence of stent overexpansion and plaque morphology on the angiographic no-reflow phenomenon in AMI patients who underwent intravascular ultrasound (IVUS)-guided stent implantation. We assessed the thrombolysis in myocardial infarction (TIMI) flow grade in the coronary angiographic findings, and quantitative and qualitative IVUS findings, in a total of 90 patients who underwent IVUS-guided stenting for AMI. The patients were divided into two groups according to the stent-to-artery ratio: overexpansion group (ratio 1.2) and non-overexpansion group (ratio <1.2). Angiographic no-reflow (defined as TIMI flow grade <3) in stent implantation was observed in 15 patients (17%). Angiographic no-reflow was more frequently observed in the overexpansion group than in the non-overexpansion group (32% vs 11%, P = 0.0312). Patients with no-reflow had more lipid pool-like images or fissure/dissection than those without. In the overexpansion group, a lipid pool-like image and fissure/dissection were more frequently observed in patients with no-reflow. The rate of target lesion revascularization (TLR) in the overexpansion group was significantly lower than that in the non-overexpansion group during the follow-up period (10% vs 18%, P = 0.0476), but the incidence of pump failure in the overexpansion group was higher than that in the non-overexpansion group during the hospital course (28% vs 14%, P = 0.0358). Stent overexpansion in AMI patients is related to a higher incidence of angiographic no-reflow, especially if the lesion has a lipid pool-like image or fissure/dissection, although there is a tendency for lower TLR.     

Successful stent implantation for acute myocardial infarction after failed thrombolytic therapy associated with massive hemorrhage

Stent implantation in the setting of failed rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction is considered a high-risk procedure, because of the possibility of stent thrombosis. Withholding anticoagulation in such a patient who also has a bleeding diathesis may further increase the risk of stent thrombosis. This case demonstrates the feasibility of stent implantation after failure of thrombolytic therapy and rescue angioplasty for acute myocardial infarction in the setting of massive intra-abdominal hemorrhage. © 1996 Wiley-Liss, Inc.     

Hospital outcome after bailout coronary stenting in patients with acute myocardial infarction

We evaluated the outcome of bailout coronary stenting in acute myocardial infarction. Fifty patients (35 men, mean age 60 plusmn; 12) with acute myocardial infarction consecutively underwent bailout stenting after primary and rescue coronary angioplasty (n=41 and 9, respectively). Cardiogenic shock was present in six patients, and 17 others had contraindications to thrombolysis. Stent implantation was successful in 49/50 patients. The antithrombotic regimen combined heparin, aspirin, and ticlopidine. One patient had symptomatic stent closure. Predischarge angiography in 41/44 survivors showed widely patent stents in 40/41 patients. Six patients (4 of whom had been admitted with cardiogenic shock) died in the hospital. During acute myocardial infarction, bailout stenting can achieve high TIMI grade 3 coronary patency (here, 92%), and low acute stent closure rates (here, 2%). However, in-hospital mortality remained high, at nearly 10%, mainly due to the severe risk profile in this patient subset. Cathet. Cardiovasc. Diagn. 44:371–377, 1998. © 1998 Wiley-Liss, Inc.     

药物洗脱支架在急性心肌梗死急诊冠脉介入治疗中的应用

目的探讨药物洗脱支架在急性心肌梗死(AMI)急诊冠脉介入治疗中应用的安全性和有效性。方法选择2002-11~2004-11在深圳市人民医院心内科收治的77例AMI患者,均在起病12h内给予急诊经皮冠状动脉介入治疗(PCI),按介入治疗时使用的支架不同分为两组:雷帕霉素药物洗脱支架组(38例)和普通支架组(39例)。结果所有77例病人PCI均获得成功。雷帕霉素药物洗脱支架组38支梗死相关血管的38处病变置入了38个支架;普通支架组39支梗死相关血管的39处病变置入了39个支架。两组病人的PCI后造影情况、临床情况差异无显著性。结论CypherTM雷帕霉素药物洗脱支架应用于急性心肌梗死血栓性病变是安全的和有效的。