急性心肌梗塞静脉溶栓后冠状动脉造影早期和晚期的改变

目的研究急性心肌梗塞（ALMI）静脉溶栓后冠状动脉的解剖特点及其演变。方法100例AMI病人应用尿激酶和链激酶溶栓后”分钟行早期的冠状动脉造影（CAG）。3～4周后再次行晚期的CAG。结果100例AMI溶栓成功60例，失败40例，再通率％％。CAG提示有残留血栓的84例（84％），其中有40例（48％）为冠状动脉完全阻塞。溶栓再通病人经3～4周后再次CAG发现，8例狭窄加重，10例狭窄减轻。结论AMI是由突然冠状动脉血栓性闭塞所致并可用溶栓剂或机械的方法使闭塞的冠状动脉再通。溶栓通常不能使血栓完全溶解，使用PTCA已被建议为改善严重残留狭窄病变的重要疗法。     

急性心肌梗死经皮冠状动脉成形术治疗的近期疗效

目的：观察急性心肌梗死（AMI）经皮冠状动脉成形术（PTCA）及原发性冠状动脉内支架植入术的近期疗效。方法：204例AMI患发病0．5－26h内行急诊冠状动脉造影（CAG），证实冠状动脉闭塞，仅对梗死相关血管直径行TPCA及原发性冠状动脉内支架植入，。结果：全组204例患再通197例，成功率96％，发病至血管再通的时间1－27h，平均5．6h，PTCA失败7例，其中心包填塞2例，钢丝不能通过2 ，术中死亡2例（均发生在伴有心源性休克的前壁心肌梗死患），率为0．9％，5周内死亡2例（经PTCA及支架植入术后心功能未明显改善，死亡心功能不全），2－6个月死亡6例（因再发心肌梗死而死亡，总死亡率4．9％。结论：AMI后早期（6h内）成功的再灌注可挽求涉死的心肌，缩小梗死面积和明显降低死亡率，即使 在较晚时间（＞12h)，病人仍有胸痛及ST段抬高，使梗死的血管再通仍可达到治疗的目的。早期充分的再灌注可明显改善患的预后，急诊TPCA治疗，可命名开通闭塞血管的届时时间提前，PTCA后残余狭窄甚微，再灌注血流充分，极少发生恢复期心肌缺务及心功能不全，在条件的大型A,TPTCA治疗AMI的最佳方法。     

直接经皮腔内冠状动脉成形术治疗急性心肌梗塞

1995年8月至1996年10月急性心肌梗塞（AMI）胸痛后1．0～6．0小时（平均3．6±1．2小时）入院患者28例行直接经皮腔内冠状动脉成形术（PTCA），结果：25例（89．3％）血管再通，再通血管残留狭窄平均为14．5％±10．3％（0％～40％），血管再通距胸痛发病时间平均为5．6±2．2小时（3～9小时），23例再通存活患者中1例（4．3％）发生梗塞后早期（起病后30天内）心绞痛，认为直接PTCA在AMI治疗中占有重要位置。     

急性心肌梗塞溶栓失败患者行补救性经皮腔内冠状动脉成形术临床研究

为评价溶栓失败急性心肌梗塞（AMI）行补救性经皮腔内冠状动脉成形术（PTCA）的疗效及安全性，对35例AMI患者溶栓后90min行冠状动脉造影。根据梗塞相关动脉开通情况，16例成功者（甲组）中12例7～21d后行延迟PTCA治疗；19例失败者（乙组）中13例（乙1组）即刻行补救性PTCA，其余6例（乙2组）溶栓失败而未行PTCA者给一般药物治疗。结果表明，甲级中12例行延迟PTCA，成功11例（91．6％），正例于PTCA中出现冠状动脉急性闭塞并致小灶下壁心肌梗塞；乙1组13例行补救PTCA，全部成功（100％）。甲组住院期总心脏事件发生率（19％）与乙1组（23％）相似，且出院前心功能无显著差异。而乙2组6例中住院期死亡率（33％）及总心脏事件发生率（50％）增高。提示AMI溶栓失败患者补救PTCA成功率高、并发症少，能减少住院期心脏事件并促进左心室功能改善。     

急诊冠脉介入治疗急性心肌梗塞的临床观察

目的：观察急诊冠脉介入治疗急性心肌梗塞（AMI）的安全性及有效性。方法：对42例AMI患者在发病0．5～12小时内行直接PTCA术，必要时联合临时心脏起搏技术及主动脉气囊反搏术，梗死相关血管（IRA）43支，TIMI血流0级：30例（71．4％），Ⅰ级：9例（21．4％），Ⅱ级：3例（7．2％）。结果：43支IRA中39支获得再通（90．9％），均达TIMI Ⅲ级血流，再通血管残余狭窄〈20％，5例合并左心功能不全（killip分级Ⅱ～Ⅲ级）及3例合并心源性休克患者，术后症状明显改善，1例死亡（2．5％）。术后6例（15％）直接PTCA成功患者心绞痛再发，再次PTCA后血管再通。结论：直接PTCA治疗AMI成功率高，病死率低，近期预后良好，是一种安全有效的治疗方法。     

冠脉再通后心肌梗死的发生部位

经皮穿刺冠脉腔内成形术(PTCA)已被公认为是治疗冠脉疾病的一种有效方法,但术后似有一定比例的急性心肌梗死(AMI)发生。本文旨在探讨PTCA后AMI的发生部位。 PTCA后冠脉>50％的狭窄均予解除为完全再通,尚有部分存在为不完全再通。AMI发生在与再通处≤2cm部位为再通处AMI;>2cm部位或其他冠脉为非再通处AMI。作者在2216例PTCA者中发现34例于PTCA 2周后发生35例次AMI。其中PTCA后     

经皮冠状动脉成形术(PTCA)引起急性冠脉闭塞的临床病理学研究

对象闭塞组24例,为PTCA后24小时内发生冠状动脉完全闭塞的病例,年龄44～78岁,男13例、女11例,其中急性心肌梗塞(AMI)15例,心绞痛9例,病变在左前降支17例,右冠状动脉6例,左旋支1例。对照组86例,为初次施行PTCA,狭窄程度20％以上得到改善且未发生急性冠脉闭塞的成功病例。尸体解剖3例,分别为施行PTCA后第5、14、17日死亡的病例。方法在PTCA前后行冠状动脉造影(CAG)病变形态由两名以上阅片者判定。临PTCA前用肝素10 000U静注,硝酸甘油0.3mg和心痛定10mg含子舌下。凡是AMI在施行PTCA前都加用尿激酶(UK)冠脉内注射。尸体解剖病例是在死后12小时内经CAG确诊为PTCA施行部位完全闭塞者,取冠状动脉行H.E.和elastica VanGieison染色。     

补救性冠状动脉成形术治疗老年人急性心肌梗死

目的 评价老年人急性心肌梗死（AMI）溶栓失败后补救性冠状动脉成形术（PCTA）的成功率。住院存活率及6个月随访结果。方法 28例老年人AMI,于发病（胸痛）开始6h内接受静脉溶栓治疗,溶栓开始90min时行冠状动脉造影,示TIMI（心肌梗死溶栓试验）血流0-1级或虽达2级但仍有胸痛,立即给予急诊补救性PTCA并记录其成功率、住院存活率,术后随访6个月。结果 全部患者中梗塞相关动脉（IRA）31支,其中前降支病变17支,右冠状动脉病变10支,回旋支病变4支,补救性PTCA使26例患者IRA完全再通,成功率92.9%,TIMI血流均达3级,其中10例补救性PTCA后因残余狭窄大于50%而植入支架。成功的补救性PTCA患者住院存活率96.3%,1例死亡,术后随访6个月,4例因胸痛复发经冠状动脉造影证实为再狭窄（15.4%）。未成功的补救性PTCA患者中1例死亡（死亡率50%）。结论 老年人AMI溶栓失败后补救性PTCA成功率及住院存活率高,远期预后良好。     

冠状动脉溶栓治疗后残留狭窄程度的预测

方法 133例急性心梗患者(AMI)发病后6小时内接受冠脉内尿激酶治疗,在40～60分钟内,给予960000～1440000U。随即所摄冠脉造影片用来评价残留狭窄。结果 114例溶栓成功,14例无效,5例在溶栓过程中未行血管成形术。冠脉溶栓成功的患者,根据梗塞区供血冠脉残留(内径)狭窄<75％和≥75％分成两组。以两组的年     

高龄急性心肌梗死合并泵功能衰竭患者主动脉内气囊反搏术辅助介入治疗的研究

目的探讨急性心肌梗死（AMI）合并泵功能衰竭的高龄患者行急诊冠脉介入治疗辅以主动脉内气囊反搏术（IABP）的安全性及有效性。方法62例高龄AMI并发泵功能衰竭患者分为IABP组（28例）及对照组（34例），IABP组在IABP支持下行急诊冠状动脉造影，对梗死相关血管（IRA）直接行PTCA及支架置入术，对照组单纯行PTCA及支架置入术，治疗前及3个月后行心脏超声检查及心功能测定。结果两组心功能较术前均明显改善，但IABP组较对照组改善更加明显。IABP组完成梗死相关血管再通，没有血管再闭塞事件发生。无术中死亡，院内死亡率28．6％；对照组患者院内死亡率64．7％，其中4例发生血管再闭塞事件，8例术中死亡。结论AMI合并泵功能衰竭高龄患者行急诊冠脉介入治疗时，联合应用主动脉内气囊反搏可增加冠脉介入治疗安全性。降低病死率，减少血管再闭塞率，提高手术成功率。     

Early and Late Coronary Angiographic Changes After Thrombolysis in Acute Myocardial Infarciton

Objective The coronaryanatomic feature and development after thrombolysis in acute myocardial infarction (AMI) were studied. Mehtods 100 patients with AMI received urokinase and strepokinase. Coronary angiography (CAG) was performed at 90 minuts and again at 3 to 4 weeks. Results Successful thrombolysis occurred in 60 cases, but failed in 40. The ratio of reperfusion was 60%. CAG showed there were residual thrombi in 84 patients (84% ) and complete coronary occlusion in 40(40% ). Angiography at 3 to 4 weeks after thrombolysis showed the stenosis worsened in 8 patients and improved in 10. Conclusion AMI is caused by sudden coronary thrombotic occlusion and can be reperfused by using thrombolytic agent or mechanical methods. Throm-bolytic agents usually can not resolve thrombi completely. So percutaneous transluminal coronary angiography (PTCA) is recommended as an important method to improve serious residual stenosis.     

Primary angioplasty in acute myocardial infarct with or without a stent implant: the experience and results at 6 months in the first 200 patients

BACKGROUND: Although it is superior to thrombolysis, primary PTCA does have some limitations, both in hospital (recurrent ischemia and reinfarction due to reocclusion of the infarct-related artery) and at the six-month follow-up (high rate of late restenosis). Coronary stenting is a promising way of solving some of these problems, even if its use in patients with acute myocardial infarction could prove to be controversial because of intracoronary thrombus. In this study, we propose two procedural strategies in the treatment of the infarct-related artery (IRA): the search for optimal angiographic results after PTCA ("stent-like result"--SLR--with residual stenosis < or = 20%--no dissection--TIMI III flow) or intracoronary stenting when SLR was not obtained after a second inflation. METHODS AND RESULTS: From December 1995 to May 1998, 200 patients with AMI underwent direct PTCA or rescue PTCA because of failed thrombolysis. There were 143 men and 57 women, mean age 65 (range 36-84). Nineteen patients were in cardiogenic shock and 25 were in Killip class > II. Recanalization of the IRA was achieved in 196 patients (98%). In four patients, it was not possible to cross total occlusion with the guide-wire. SLR post-PTCA was achieved in 40 patients (20%). Stents were placed in 147 patients (75%), with "elective" implantation in 73 lesions because of suboptimal results after PTCA in 41, and early loss or coronary dissection with threatening occlusion in 33. In nine patients without SLR, stenting was not performed because of diffuse disease of the IRA. In-hospital complications included ten deaths (8 of 19 patients with cardiogenic shock at admission and 2 with multivessel disease and severe left ventricular dysfunction). None of the patients required emergency coronary bypass for procedural complications. One patient had a subacute thrombosis on the third day after bail-out stent implantation (re-PTCA). Five patients required elective bypass surgery to complete revascularization for multivessel disease with ten days after the surgical procedure. At the six-month follow-up, one patient had died of cardiogenic shock. Eleven (5%) patients with bail-out procedures underwent coronary bypass surgery or PTCA. Thirty-one patients (31/168) had recurrence of ischemia: 15 patients in the stent group, 11 in SLR group and 5 in the non-SLR group. Re-PTCA was performed in 20 patients, CABG in five and medical therapy in six. Other patients were angina-free at follow-up. CONCLUSIONS: Based on our experience, seeking optimal angiographic results with or without (SLR) stent implantation is a safe and effective operative approach to achieve the best procedural and clinical outcome and reduce complications in patients undergoing PTCA for AMI.     

Reappraising the role of immediate intervention following thrombolytic recanalization in acute myocardial infarction

Early studies indicated that after successful thrombolytic recanalization, adjunctive percutaneous transluminal coronary angioplasty (PTCA) was not appropriate, even when a significant residual stenosis was present. The aim of this study was to assess in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) who underwent successful recanalization after thrombolytic therapy. The relation between repeat AMI/unstable angina and the severity of the stenosis, as well as other angiographic and clinical features was also examined. One hundred patients with AMI of <10 hours underwent coronary angiography 2 hours after receiving thrombolytic therapy. Salvage PTCA +/- stenting was performed if recanalization was unsuccessful (Thrombolysis In Myocardial Infarction [TIMI] trial grade 0 to 2), and no PTCA was undertaken if there was brisk anterograde flow (TIMI 3). Angiographic analysis was performed to assess the severity of the residual lesion, as well as the presence or absence of thrombus. Forty patients had unsuccessful recanalization, and of these, 36 underwent attempted PTCA. Of the 60 patients with TIMI 3 flow, 15 required repeat angiography and PTCA after repeat AMI (n = 13) or unstable angina (n = 2) within 5 days. Receiver-operating characteristic analysis indicated an optimum percent diameter stenosis predictor of 85% for repeat AMI/unstable angina. There was no additional relation to age, gender, time to thrombolysis, the infarct-related artery, or the presence of culprit lesion thrombus. After recanalization, a high-grade stenosis >85% is common (n = 25, 42.4%). This is associated with a 54% repeat AMI/unstable angina risk-a ninefold increase in the incidence of such events than in patients with lesions <85%. Thus, patients with narrowings >85% may benefit from early intervention rather than a conservative approach. Narrowings <85% have a 94% probability of no repeat AMI/unstable angina and do not require early intervention.     

Combined revascularization strategy for acute myocardial infarction in patients with intracoronary thrombus: preceding intracoronary thrombolysis and subsequent mechanical angioplasty

Thrombus in the infarct-related artery is one of the limitations for flow restoration in primary percutaneous transluminal coronary angioplasty (PTCA) treatment for acute myocardial infarction (AMI). The present study investigated the benefit of preceding intracoronary thrombolysis (ICT) by retrospectively analyzing acute phase flow restoration in 80 AMI patients with intracoronary thrombus: 40 undergoing primary PTCA alone (primary PTCA group) and 40 treated with preceding ICT plus PTCA (combined group). Acute phase Thrombolysis in Myocardial Infarction (TIMI) grade flow was as follows: TIMI 0/1: 35.0% vs 12.5% for the primary PTCA group and the combined group, p=0.06; TIMI 2: 7.5% vs 15.0%, p=NS; TIMI 3: 57.5% vs 72.5%, p=NS). In the subgroup analysis, it was also less in the combined group among 33 patients with a left anterior descending coronary artery (LAD) lesion (42.1 % vs 7.1%, p=0.08), but not among the remaining 47 with either a right coronary artery or left circumflex artery lesion. The combined therapy may potentially provide better acute phase flow restoration in AMI patients with an intracoronary thrombus in a LAD lesion.     

Presence of angina pectoris before acute myocardial infarction and degree of residual stenosis after coronary thrombolysis

This study tested the hypothesis that the degree of residual stenosis after coronary thrombolysis reflected that of original stenosis presented by symptom of angina before acute myocardial infarction (AMI). The relation between the presence of angina before AMI and the degree of residual stenosis after coronary thrombolysis was observed in 57 patients with successful coronary thrombolysis for AMI. Patients with significant coronary artery stenoses other than the artery responsible for AMI were excluded from this study. In 22 patients with chronic angina for 2 weeks or longer before AMI, 14 patients had a residual stenosis of 75% or more and 8 patients had a residual stenosis of less than 75%. In 35 patients with angina for less than 2 weeks or not at all before AMI, 9 patients had a residual stenosis of 75% or more, and 26 patients had a residual stenosis of less than 75% (p less than 0.01). In the course of progression of coronary artery disease, some patients had AMI without severe underlying stenosis and others with severe underlying stenosis. Patients with chronic angina before AMI might tend to have AMI with acute occlusion superimposed on the severe organic stenosis. Patients without chronic angina before AMI would be more at risk for AMI caused by acute occlusion without underlying severe stenosis.     

Mechanism of acute myocardial infarction in patients with prior coronary artery bypass grafting and therapeutic implications

Although acute myocardial infarction (AMI) is usually due to thrombotic occlusion when involving a native coronary artery, the mechanism responsible for AMI in patients with previous coronary artery bypass grafting (CABG) is not well understood. Since knowledge of pathophysiology of AMI may alter subsequent management, angiograms obtained between 1 hour and 7 days of AMI (median 1 day) were reviewed in 50 patients greater than 1 year after CABG. The culprit vessel was identified by the presence of residual stenosis and/or thrombus in the vessel supplying the infarct zone or by reviewing previous angiograms. The infarct vessel was identified as a vein graft in 38 (76%) patients, the native vessel in 8 patients (16%) and could not be accurately determined in 4 patients (8%). Among the 38 vein grafts suspected as the infarct vessel, unequivocal angiographic evidence of residual thrombus (filling defect/persistent staining) was present in 31 (82%) and was greater than 2 cm in length in 15 patients. Successful reperfusion occurred in only 2 of 8 (25%) grafts after intravenous thrombolytic therapy. Intragraft thrombolysis with or without additional angioplasty was successful at restoring flow in 8 of 10 (80%) grafts. Data indicate that in patients who have undergone previous CABG, AMI is usually caused by thrombotic occlusion of a saphenous vein graft and that conventional intravenous thrombolytic therapy may be inadequate to restore flow. The large mass of thrombus and absent flow in the graft may require subselective drug infusion, a higher thrombolytic dose or a mechanical means of recanalization.     

Evaluation of lesions suitable for percutaneous transluminal coronary angioplasty after thrombolytic therapy of acute myocardial infarction

Forty-two patients of acute myocardial infarction (AMI) and clinically successful thrombolysis underwent coronary angiography 7.6 +/- 3.6 days after the AMI. The infarct related artery was patent in 33 of 42 (78.5%) patients, and 27 of these 33 (82%) had residual diameter stenosis of 70 per cent or more. Arteries showing more than 70 per cent luminal diameter narrowing were considered suitable for percutaneous transluminal coronary angioplasty (PTCA) if the lesion was less than 1 cm in length and there was no significant left main or distal lesion. Based on the above criteria, 22 of the 33 patients (66%) with recanalised infarct-related artery were found to have lesions suitable for PTCA. Thus, after successful thrombolysis, significant proportion of patients of acute myocardial infarction have residual lesions that are suitable for PTCA.     

Percutaneous transluminal coronary angioplasty, alone or in combination with urokinase therapy, during acute myocardial infarction

To investigate the effect of pre-treatment of a thrombus with a low dose of urokinase on establishing patency in a persistent infarct-related artery (IRA) during direct percutaneous coronary angioplasty (PTCA), the frequency of acute restenosis during direct PTCA, alone, or in combination with the intracoronary administration of urokinase, was examined in a consecutive nonrandomized series of patients with acute myocardial infarction (AMI). Two hundred and seventy-two successful PTCA patients (residual stenosis <50%) were divided into 2 groups: 88 patients received pre-treatment with intracoronary urokinase following PTCA (combination group); 184 received only direct PTCA without thrombolytic therapy (PTCA group). In the present study, after achievement of a residual stenosis of less than 50%, IRA was visualized every 15 min to assess the frequency of acute restenosis, which was defined as an acute progression of IRA with more than 75% restenosis after initially successful PTCA. In the patients with a large coronary thrombus, the frequency (times) of acute restenosis was significantly lower in the combination group than in the PTCA group (0.98+/-0.19 vs 2.92+/-0.32, p<0.0001). On the other hand, in the patients with a small coronary thrombus, the frequency of acute restenosis showed no difference in either group. The present study indicates that in patients with AMI, PTCA combined with pre-treatment of a low dose of urokinase is much more effective than PTCA alone, especially for those patients who have a large coronary thrombus.     

Coronary angioplasty in acute coronary syndrome

PTCA is a widely used technique in patients post-acute myocardial infarction (AMI) as well as in unstable angina (UA). The precise timing of its application and some aspects of the indication nowadays remains a matter of controversy. Primary PTCA is not generally considered to be the initial treatment of AMI. In contrast, immediate PTCA after thrombolysis has been proposed attempting to decrease the incidence of early reocclusion, improve myocardial salvage, decrease the incidence of postinfarction angina and improve survival. Nevertheless, three recent controlled studies (TAMI, TIMI II and ECSG) have demonstrated that an "aggressive" strategy with obligatory, invasive intervention following thrombolysis does not provide any advantage in terms of survival, rate of reocclusion or improved ventricular function and is, in fact, likely to be harmful. Emergent coronary arteriography after AMI should be reserved for unstable patients with continued or recurrent ischemia in the CCU. In elective basis it should be indicated in all patients with spontaneous or provocable ischemia prior to hospital discharge. If high grade coronary stenoses are identified, the patient should be considered for PTCA or surgical revascularization. In our own experience with coronary arteriography 24 hours to 15 days after intravenous thrombolysis with SK, PTCA is anatomically feasible in 44% of all the patients and in 60% of those showing a patent vessel. However, when indicated because of postinfarction angina or a positive stress test, PTCA was performed only in 22%, some of them presenting with a totally occluded vessel. In case of stenosis lesser than 100% the dilation success rate is slightly lower than that of out entire series (84% vs 88%), but the incidence of acute occlusion is significantly higher (10% vs 6%), particularly in patients with angiographic evidence of intracoronary thrombi. The incidence of "non-significant" (less than 70%) stenosis spontaneously increases when the coronary arteriography is performed late during hospitalization (34% vs 17% when the patient is studied in the first 24-48 hours).(ABSTRACT TRUNCATED AT 250 WORDS)