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。     

经皮冠状动脉腔内成形术治疗急性心肌梗死（附5例报告）

目的：观察急性心肌梗死（AMI）患应用经皮冠状动脉腔内成形术（PTCA）的临床疗效。方法：对5例AMI患在发病12小时内行直接PTCA＋支架放置式。梗死相关血管：左前降支1例,右冠状动脉并左回旋支1例,右冠状动脉3例,结果：5例患均手术成功,随访2－11个月均无心脏事件发生。结论：冠状动脉内支架植入术为AMI的一种有效方法,有益于患的预后。     

不稳定型心绞痛的介入治疗体会

目的 观察不稳定型心绞痛经皮冠状动脉腔内成形术（PTCA）治疗的效果。方法 38例患者共50支血管进行了PTCA或PTCA＋支架治疗。结果 共植入支架48个，单纯PTCA2例均获成功。无一例发生严重并发症。结论 对内科保守治疗无效的不稳定型心绞痛患者，为避免AMI和猝死的发生，应及时采取介入治疗。本疗法安全，成功率高，并发症少。     

溶栓禁忌证的老年急性心肌梗死患者直接介入治疗的探讨

目的　探讨不能溶栓的老年急性心肌梗死 (AMI)患者直接介入治疗的安全性与有效性。方法　对 31例 70岁以上的患者 ,3例 6 0～ 6 9岁有溶栓禁忌证的老年心肌梗死的患者进行了直接经皮冠状动脉腔内成形术 (PTCA)与冠状动脉内支架术。结果　有 34例梗死相关动脉 (IRA)心肌梗死溶栓试验 (TIMI)血流 0级 2 7例 ,1级 7例。 31例直接行PTCA成功 ,其中 4例患者直接PTCA后其残余狭窄 <10 %且无明显的内膜撕裂和夹层。 2 7例IRA具有支架置入的适应证 ,即刻造影IRATIMI血流达 3级。 2例行冠状动脉旁路移植术 (CABG)。有 1例因IRA完全闭塞 ,PT CA未能成功。直接介入成功率 97%。 31例患者经过平均 (11.4± 3.7)个月随访 ,无再梗死及急诊再次血运重建 ,但 4例有心绞痛 ,造影证实为冠状动脉支架再狭窄再次行PTCA成功。结论　对溶栓有禁忌证的老年AMI患者行直接介入治疗 ,具有较高的成功率及安全性。     

本刊常用英文缩写词汇

急性心肌梗死（AMI） 经皮冠状动脉腔内成形术（PTCA） 经皮冠状动脉介入治疗（PCI）     

重组组织型纤溶酶原激活剂加补救性冠状动脉介入术与直接冠状动脉介入术对急性心肌梗死的疗效研究

目的：为比较急性心肌梗死（AMI）患应用重组组织型纤溶酶原激活剂（rt-PA)50mg治疗，加补救性经皮冠状动脉腔内成形术（PTCA）或冠状动脉内支架（Stent）置入术与直接PTCA／Stent置入术临床疗效。方法：135例首次AMI患随机给予以静脉rt-PA溶栓加补救性PTCA／Stent(A组）和直接PTCA／Stent(B组）。68例患用阿司匹林和肝素后，接受rt-PA50mg治疗，67例直接PTCA和支架。行急诊冠状动脉造影 （CAG），以TIMI血流分级法评估，必要时做PTCA／Stent。本研究终点包括分析两组患的梗死相关血管（IRA）开通率，并发症发生率、病死率及左心室功能。结果：A组IRA开通率为91．0％，B组IRA开通率95．5％。患于首次PTCA前及在3周后用超声心电图测定两组患左心室射血分数（LVEF）。两组患到达导管室时IRA血流已达TIMI3级（n=34其中A组24例，B组10例），最初和恢复期EF值分别为60．8％和62．5％，经介入治疗后变为TIMI3级（n=80），其中A组75％（33／44），B组为84．2％（47／57），最初EF57．0％和恢复期EF57．2％。从未获TIMI3级（n=21），其最初EF54．1％和恢复期EF53．2％为最低。结论：溶栓剂rt-PA50mg治疗加补救性PTCA／Stent与直接PTCA／Stent,在AMI中的疗效比较，可使IRA开通，有利于保护AMI患的左心室功能和不增加副作用。     

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。     

老年急性心肌梗死患者急诊PCI的疗效

目的：探讨直接经皮冠状动脉介入治疗（PCI）对老年急性心肌梗死（AMI）的疗效。方法：75例AMI患者在发病12小时内接受冠状动脉造影，并对73例的梗死相关动脉行急诊PCI，随访1～12个月主要心血管事件发生情况。结果：73例接受PCI的患者中7例行单纯PTCA，66例（88％）置入支架；2例行急诊冠状动脉旁路移植术（CABG）；1例术中发生室颤，复律无效死亡，共有3例于住院期间死亡。随访期间主要心血管事件发生率11．6％（8／69），其中2例猝死，4例出现再梗死，2例因支架内再狭窄行再次PCI。结论：急诊经皮冠状动脉介入术治疗老年急性心肌梗死可有效地使梗死相关动脉再通，成功率高，死亡率低，近期预后良好。     

血管内支架在冠状动脉复杂病变中的临床应用

因冠状动脉复杂病变或经皮冠状动脉腔内成形术（PTCA）并发内膜夹层12例，成功植入冠状动脉支架（CS）17支，取得显著临床效果，且并发症少。初步结果提示，冠心病介入治疗中选择性应用CS，有益于PTCA后急性并发症的防治，亦可减少冠状动脉再狭窄的形成。     

血管内窥镜在冠心病患者介入治疗中的应用

目的探讨冠心病介入治疗后冠状血管内腔的情况及其与介入治疗方法的关系.方法应用冠脉血管内窥镜观察31例冠心病(急性心肌梗死早期和恢复期)患者,经皮冠状动脉腔内再通术(PTCR)组14例,经皮冠状动脉腔内成形术(PTCA)组10例,支架置入组15例(其中8例行PTCA后置入支架)治疗后即刻及1个月后的冠状动脉内腔血栓的形态、颜色情况.结果在支架置入组中冠状动脉内腔均为附壁内栓,无一例是管腔内血栓;而在PTCR组和PTCA组中管腔内血栓分别占86%和90%,比支架置入组管腔内血栓多(P＜0.001).结论通过冠脉血管内窥镜的应用得知,在冠心病介入治疗中,支架置入术在降低急性冠状动脉闭塞及再狭窄等并发症的发生率方面优于PTCA和PTCR.     

A randomized trial comparing myocardial salvage achieved by coronary stenting versus balloon angioplasty in patients with acute myocardial infarction considered ineligible for reperfusion therapy

OBJECTIVES: We assessed myocardial salvage achieved by reperfusion with percutaneous coronary interventions (PCI) and compared stenting with balloon angioplasty (PTCA) in patients with acute myocardial infarction (AMI) ineligible for thrombolysis. BACKGROUND: A substantial proportion of patients with AMI are currently considered ineligible for thrombolysis, and reperfusion treatment is frequently not recommended for them. It is not known whether these patients benefit from PCI. METHODS: The Stent or PTCA for Occluded Coronary Arteries in Patients with Acute Myocardial Infarction Ineligible for Thrombolysis (STOPAMI-3) trial, a randomized, open-label study, included 611 patients with AMI who were ineligible for thrombolysis (lack of ST-segment elevation on the electrocardiogram, late presentation >12 h after symptom onset, and contraindications to thrombolysis). Patients were randomly assigned to receive either coronary artery stenting (n = 305) or PTCA (n = 306). Scintigraphic myocardial salvage index (proportion of the initial myocardial perfusion defect that was salvaged by reperfusion) was the primary end point of the study. RESULTS: A considerable myocardial salvage was achieved with both stenting and PTCA. In patients assigned to receive stenting, the median size of the salvage index was 0.54 (25th and 75th percentiles, 0.29 and 0.87), as compared with a median of 0.50 (25th and 75th percentiles, 0.26 and 0.82) in the group assigned to receive PTCA (p = 0.20). Mortality at six months was 8.2% in the group of patients assigned to receive stenting and 9.2% in the group of patients assigned to receive PTCA (p = 0.69). CONCLUSIONS: Patients with AMI who are currently considered ineligible for thrombolysis by conventional guidelines may greatly benefit from primary PCI. The benefit seems to be comparable when a strategy of stenting is compared with a strategy of PTCA in these patients.     

血栓抽吸联合经皮腔内冠状动脉成形术治疗急性心肌梗死的疗效研究

目的了解在血栓负荷重的STEMI患者中血栓抽吸联合经皮腔内冠状动脉成形术的疗效,比较延迟支架置入与即刻支架置入两种方法对患者住院期间临床疗效的影响。方法分析我院心内科2009年8月—2011年8月因STEMI就诊,接受急诊介入手术治疗的55例患者。根据冠状动脉内介入治疗方法的不同分为:急诊血栓抽吸联合经皮腔内冠状动脉成形术(PTCA)+延迟支架置入术组(A组),PTCA+延迟支架置入术组(B组),急诊直接支架置入术组(C组)。比较3组住院期间发生支架内血栓、死亡、恶性心律失常、急性左心力衰竭、心源性休克的情况。结果3组住院期间心脏事件发生率分别为3%、8%和15%,死亡分别为0、3和3例,术后急性期支架内血栓1例,发生在C组,各组间比较差异无统计学意义(P>0.05);A组和B组发病10～14d行冠状动脉造影发现罪犯血管再次闭塞2例,发生在B组;罪犯血管远端达到TIMI血流Ⅲ级共17例(68%),分别为A组11例(73.3%),B组6例(60%),组间比较差异无统计学意义(P>0.05)。结论在STEMI急诊介入手术中对血栓负荷较重而不宜予支架置入治疗的患者,选择急诊血栓抽吸+经皮腔内冠状动脉成形术恢复罪犯血管血流,并在发病10d左右进行延迟支架置入术安全可靠,效果优于单纯直接支架置入术治疗。     

急性心肌梗死患者经皮冠状动脉介入后心率震荡的变化

目的探讨经皮冠状动脉介入(PCI)治疗急性心肌梗死(AMI)后对窦性心率震荡(HRT)的影响。方法选120例急性心肌梗死患者分为直接PCI组、延迟PCI组和药物治疗组三组,各组均为40例,入选病例均有单发室性期前收缩(VPC)并且有完全的代偿间歇,AMI后1~3周对患者行24h动态心电图检测,获得震荡起始(TO)、震荡斜率(TS)、震荡斜率起始时间(TT)等指标,比较三种治疗方法对急性心肌梗死后窦性心率震荡现象的影响。结果直接PCI组TT、TO低于延迟PCI组和药物治疗组,而TS高于延迟PCI组和药物治疗组(P<0.01),同时延迟PCI组上述指标也优于药物治疗组(P<0.05)。结论AMI患者经直接或延迟PCI后HRT各参数得到不同程度改善,直接PCI更优,故对于AMI患者应尽早行直接PCI,对于无条件者行延迟PCI同样获益。     

经皮冠状动脉介入治疗对急性心肌梗死患者窦性心率震荡及心率变异性的影响

目的探讨经皮冠状动脉介入术（PCI）治疗急性心肌梗死（AMI）后对窦性心率震荡（HRT）和心率变异性（HRV）的影响。方法将150例急性心肌梗死患者分为直接PCI组、延迟PCI组和药物治疗组各50例,分别予直接PC、I延迟PC I和药物治疗。AMI后2~3周各组行动态心电图检查分析其HRT参数：震荡初始（TO）和震荡斜率（TS）,同时获取HRV指标：24 h时平均R-R间距的标准差（SDNN）,每5 min时间段R-R间距平均值的标准差（SDANN）。结果直接PCI组TO明显低于,TS、SDNN、SDANN明显高于延迟PC I组及药物治疗组（P均〈0.01）;延迟PCI组TO明显低于,TS、SDNN、SDANN明显高于药物治疗组（P均〈0.05）。结论直接或延迟PC I可有效地改善AMI心肌缺血,有利于防止恶性心律失常和心性猝死的发生;直接PC I效果更优。     

Long-term clinical outcome of rescue balloon angioplasty compared with rescue stenting after failed thrombolysis

Failed thrombolysis following acute myocardial infarction is associated with a poor prognosis. Balloon angioplasty with or without stenting is an established procedure in acute myocardial infarction and for failed thrombolysis (rescue percutaneous transluminal coronary angioplasty [PTCA]). Intracoronary stenting improves initial success rates, decreases incidence of abrupt closure, and reduces the rate of restenosis after angioplasty. The purpose of this study was to compare the effect of rescue PTCA with rescue stenting in the treatment of acute myocardial infarction after failed thrombolysis. Clinical data are from a retrospective review of 102 patients requiring rescue balloon angioplasty or stenting after failed thrombolysis for acute myocardial infarction. There was a greater incidence of recurrent angina in 11 patients (22%) in the rescue PTCA group versus 2 patients (4%) in the rescue stenting group. The in-hospital recurrent myocardial infarction rate was 14% in the rescue PTCA group versus 2% in the stented group. In the rescue PTCA cohort, 11 patients (22%) required in-hospital repeat revascularization versus 2 patients in the stented group. The in-hospital mortality rate was higher in the PTCA group (10%) versus that in the stent group (2%). There was no significant difference in the incidence of postdischarge deaths. Rescue stenting is superior to rescue angioplasty. The procedure is associated with lower in-hospital angina and recurrent myocardial infarction, and the need for fewer repeat revascularizations. Long-term patients treated with stents required fewer revascularization procedures. Overall, rescue stenting was associated with a significantly lower mortality.     

AMI静脉溶栓后即行PTCA与直接冠状动脉支架术的疗效比较

目的 比较rt-PA(50mg)静脉溶栓后即刻行经皮腔内冠状动脉成形术与直接冠状动脉支架术治疗急性心肌梗死(AMI)的临床疗效.方法119例AMI患者随机分为AB两组.A组65例行rt-PA半量(50mg)静脉溶栓后即刻行冠状动脉血管造影,及经皮冠状动脉腔内血管成行术,B组54例行直接冠状动脉支架术.术后观察20天.结果(1)首次冠状动脉造影显示:A组梗塞相关动脉(IRA)69支,开通为54%:B组IRA 57支,开通率为15%.两组开通率相比有非常显著性差异(P<0.01).(2)A,B两组行PTCA和支架置入术后对IRA恢复TIMI Ⅲ级血流效果相同,A组100%,B组98%,两者相比无显著性差异(P>0.05).(3)病人住院10～20天,二维超声心动图显示,左心室射血分数(LVEF)达到或超过60%者,A组为88%,而B组仅占69%.两者相比有显著性差异(P<0.05).(4)脑卒中或大出血并发症两组病例均未发生.(5)住院病死率,A组3%(2/65),B组3.7%(2/54),两者相比无显著性差异(P>0.05).结论小剂量rt-PA静脉溶栓后即刻行冠状动脉成形及支架置入术与直接冠状动脉支架置入术治疗AMI临床疗效相比,前者较后者具有更早地使IRA前向血流再灌注,减低冠状动脉支架置入术中并发症发生,从而具有较好的左心室功能保护,且不增加不良事件的发生.     

急性心肌梗塞经桡动脉冠状动脉介入治疗远期疗效

目的：探讨急性心肌梗塞（AMI）后延迟经桡动脉冠状动脉腔内成形术及支架术治疗的远期疗效。方法：133例AMI患者被分为经皮冠状动脉介入治疗组（PCI组）和非PCI组,PCI组于发病后平均13d行PCI术。随访两组患者的心脏事件发生率。结果：随访期间,与非PCI组相比,PCI组患者主要不良心血管事件发生率明显降低（80％比27．3％,P〈0．05）,左室射血分数明显提高[（42±6．9）％比（57．4±3．5）％,P〈0．05]。结论：急性心肌梗塞后延迟冠状动脉介入治疗可减少患者的心脏事件发生。     

Ten-year experience with early angioplasty in 759 patients with acute myocardial infarction

OBJECTIVES: How effective and safe is rescue percutaneous transluminal coronary angioplasty [PTCA] compared with primary PTCA, and is it cost effective? BACKGROUND: In acute myocardial infarction (AMI), primary PTCA has been shown to be beneficial in terms of clinical outcome. In contrast, the value of rescue PTCA has not been established. METHODS: In a retrospective analysis, we compared the angiographic and clinical outcomes of 317 consecutive patients who had rescue PTCA approximately 90 min after failed thrombolysis and 442 patients treated with primary PTCA. An estimation of interventional costs was compared with the strategies of primary and rescue PTCA or with the strategy of thrombolysis with rescue PTCA, when indicated. RESULTS: Baseline characteristics between primary and rescue PTCA were comparable for most variables. Treatment delay was longer for patients who had rescue PTCA: 240 min. versus 195 min. Coronary patency after PTCA was comparable: 90.2% for rescue PTCA and 91.4% for primary PTCA (p = 0.67, power 71.9%). In-hospital mortality rates were 4.7% and 6.6%, respectively (p = 0.37). Also, the other complications were fairly similar during the in-hospital phase and during one-year follow-up. Predictors of death were age, infarct size, localization of AMI, failed PTCA and left main stem occlusion. The estimated interventional costs during one-year follow-up were $7,377 for primary PTCA and $8,246 for rescue PTCA: difference $869 (11.7%). CONCLUSIONS: In this retrospective analysis of 759 patients with AMI, rescue angioplasty early after failed thrombolysis seems to be as effective and safe as primary PTCA. In the present evaluation, interventional costs of primary PTCA are less than those of rescue PTCA (p = 0.0001).     

血管内窥镜评价急性心肌梗塞患者的介入治疗

目的：探讨介入治疗后出现的血栓形态与介入治疗方法的关系。　　方法：应用血管内窥镜观察经介入治疗后３１ 例急性心肌梗塞（ＡＭＩ）患者经皮冠状动脉腔内再通术（ＰＴＣＲ）组１４例,经皮冠状动脉腔内成形术（ＰＴＣＡ）组１０ 例,支架置入组１５ 例（其中８例行ＰＴＣＡ后支架置入）冠状动脉血栓形态。　　结果：在支架置入组均为附壁血栓,无一例是管腔内血栓;而在ＰＴＣＲ组和ＰＴＣＡ组中管腔内血栓分别占８６％ 和９０％ ,比支架置入组管腔内血栓有意义地增多（Ｐ＜ ０．００１）。　　结论：３种ＡＭＩ介入治疗中,支架植入术在降低急性冠状动脉闭塞及再狭窄等并发症的发生率方面,优于ＰＴＣＲ和ＰＴＣＡ。     

急性心肌梗塞的急诊介入性治疗

目的:评价AMI急诊介入性治疗的安全性和有效性.方法:对35例发病在2～26小时之内的AMI病人行直接PTCA7例,补救性PTCA18例,立即PTCA10例,其中2例急诊支架置入.结果:PTCA处理的成功率94.3%,IRA直径狭窄程度由术前的98.11±3.20%降至术后的17.07±10.90%(P<0.001),TIMI-3级再灌注恢复率达100%.死亡3例,无其它并发症(包括再梗塞、缺血复发、急诊CABG和出血).结论:AMI的急诊介入性治疗是安全有效的,成功率高,并发症发生率低;与溶栓疗法相比较,PTCA可迅速恢复IRA的有效再灌注,即TIMI-3级血流恢复率高;对危重AMI病人急诊PTCA治疗可降低死亡率,并可改善病人的近远期预后.