急性右室心肌梗死扩容不充分患者直接经皮冠状动脉介入术中经股静脉鞘管扩容的体会

目的:探讨急性右室心肌梗死(ARVI)扩容不充分患者直接经皮冠状动脉介入术(PCI)中经股静脉鞘管快速扩容的可行性和安全性。方法:40例因ARVI行PCI的患者随机分为实验组(经股静脉鞘扩容)和对照组(常规经外周静脉扩容),每组各20例,对比2组术中血压的变化及血管活性药物的使用情况。结果:实验组术中血压下降幅度低于对照组(P0.05),血管活性药物的使用率也明显少于对照组(20%vs 50%,P0.05),实验组手术时间短于对照组(P0.05)。结论:ARVI患者PCI术中经股静脉鞘扩容快速、有效、安全可行。     

尿激酶原联合尼可地尔术前冠脉灌注对STEMI患者PCI术后心功能、炎性反应及MACE影响

[摘要]目的：探讨尿激酶原联合尼可地尔对ST段抬高型心肌梗死（STEMI）患者急诊直接经皮冠状动脉介入（PCI）术后心功能、炎性反应及心血管事件发生的影响。方法：入选2018年11月～2019年11月在我院心内科收治的126例行PCI的STEMI患者为研究对象,按照随机数表法分为观察组和对照组各63例,对照组给予尿激酶原（10mg）;观察组在对照组基础给予尼可地尔（12mg）治疗。比较两组患者术后心功能超声指标、炎症反应及不良心血管事件发生情况。 结果：两组术后6个月心功能、炎性反应较本组术后1、3个月均有所改善（P <0.05）;观察组术后1、3个月LEVDD、LVESVI较对照组均有所下降（P< 0.05),术后6个月LEVDD（43.29±3.18vs.47.43±3.58 ）mm、LVESVI（32.86 ±6.43vs.38.17±6.93）ml/m2显著低于对照组,（P<0.05);观察组术后1、3个月LEVF、PER较对照组有所提高（P<0.05),术后6个LEVF(59.48±4.19vs.56.89±4.49 )%、PER(1.91±0.19vs.1.82±0.24)EDV/s显著高于对照组,（P<0.05);两组术后炎性反应CRP（12h、7d）、IL-6（12h）时点出现升高,术后其他时点均有所下降（P<0.05）;观察组术后6个月MPO（171.62±21.11vs.198.25±20.11）mg/L、CRP（3.08±0.86vs.4.23±0.51）mg/L、IL-6（2.51±0.44vs.3.08±0.95）mg/L、BNP（139.94±17.36vs.168.95±19.64）pg/ml显著低于对照组（P<0.05）;观察组靶血管血运重建、心绞痛、心力衰竭、再发心肌梗死比例均低于对照组,但差异无统计学意义(P＞0.05),不良心血管事件（MACE）总发生率为（11.11%vs.28.57%）显著低于对照组（P<0.05）。结论：尿激酶原联合尼可地尔应用于行PCI术的STEMI患者,可进一步有效改善其心功能,抑制炎症反应,减少不良心血管事件的发生。     

血栓弹力图指导冠脉支架术后双重抗血小板治疗的研究

目的 通过对行经皮冠状动脉介入术（PCI）的患者进行血小板功能测定，了解不同方案双重抗血小板治疗的临床预后的差异。 方法 前瞻性地连续收入诊断为冠心病行择期PCI的患者800例，根据术后血栓弹力图（TEG）检测结果将患者分为对照组（NPR+常规抗血小板治疗）、标准治疗组（HPR+常规抗血小板治疗）和强化治疗组（HPR+强化抗血小板治疗），随访1年MACE事件和TIMI出血事件发生率。 结果 经TEG检测发现ADP抑制率<40%即高血小板反应性（HPR）有246名患者（30.75%），随机分为标准治疗组（n=123）和强化治疗组（n=123），其余为对照组（n=554）。2个HPR组与对照组（NPR组）相比女性的比例明显居多（43.1% vs 22.4%和38.2% vs 22.4%， P<0.001），血糖（FBG）水平明显增高（8.7±3.4 vs 6.9±2.9和8.8±3.1 vs 6.9±2.9，P<0.001），心肌酶水平明显增高（CK-Mb 2.7±0.7 vs 1.8±0.3和2.8±0.4 vs 1.8±0.3, P<0.01; TnI 0.8±0.3 vs 0.2±0.1和0.9±0.4 vs 0.2±0.1，P<0.001）；标准治疗组MACE事件总发生率明显高于另外2组（P<0.001），而强化治疗组与对照组相比MACE事件发生率差异无统计学意义（P>0.05）；3组间总出血事件差异无统计学意义（P>0.05）。 结论 TEG检测快速、简单和准确，采用TEG对PCI术后患者进行常规检测，对HPR患者及时予以强化双重抗血小板治疗，可以有效减少临床缺血不良事件的发生。     

早期口服尼可地尔在老年急性 ST 段抬高心肌梗死急诊 PCI 中的效果

目的 通过观察早期口服尼可地尔对老年急性ST段抬高心肌梗死（STEMI）患者急诊PCI术后的心肌受损程度、冠脉微循环灌注水平、心脏功能的影响及MACE,探讨尼可地尔对老年急性ST段抬高心肌梗死患者心肌保护作用。方法 2013.7—2015.1入院的115例行急诊PCI的老年STEMI患者（>60岁）,随机分为尼可地尔组57例和对照组58例,尼可地尔组入院确诊后即刻顿服尼可地尔15mg,对照组仅行再灌注治疗,尼可地尔组术后继续口服尼可地尔5mg TID,而对照组口服单硝酸异山梨酯片20mg TID。监测手术前后心肌损伤标志物肌钙蛋白。术中记录所有病人梗死相关动脉情况、PCI后校正TIMI帧数（CTFC）及心肌灌注分级（TMP)。PCI术后一周行超声心动图检查,记录左室射血分数（LVEF）及左室舒张末期内径（LVEDD）。记录PCI术后30d主要不良心脏事件（MACE）。结果 两组患者PCI术后12小时、24小时静脉血cTnI检测结果均较术前明显升高,但均明显低于对照组（P<0.05）。尼可地尔组术后校正的TIMI帧数（CTFC）小于对照组（29.64±3.18 vs 32.70±4.55, P<0.05）;心肌灌注分级TMP2级以上的比例尼可地尔组高于对照组（78.95% vs 62.07%, P<0.05）。尼可地尔组病人的射血分数高于对照组（54.36±5.03vs. 51.09±4.45,P<0.05）。PCI术后30d尼可地尔组MACE发生率低于对照组（7.02% vs 20.69%, P<0.05）。结论：早期口服尼可地尔可减轻老年急性ST段抬高心肌梗死患者急诊PCI术后的心肌受损程度,改善心肌微循环灌注,保护左心室功能,减少了MACE事件发生。     

不稳定型心绞痛患者应用曲美他嗪对PCI相关心肌损伤及左心室功能的影响

目的 探讨曲美他嗪对不稳定型心绞痛（UAP）患者经皮冠状动脉介入治疗（PCI）术相关心肌损伤及术后左心室功能的影响。方法 入选2011年1月至2014年1月在高州市人民医院心内科拟行择期PCI术的UAP患者106例,采用随机数字表法分为两组：曲美他嗪组（n＝51）和对照组（n＝55）。曲美他嗪组在常规药物治疗的基础上,于PCI术前0.5～1.0h口服60 mg曲美他嗪（负荷剂量）,PCI术后口服常规剂量曲美他嗪（20mg,3次/d）。分别测定PCI术前和术后16～18h患者血清肌钙蛋白I（cTnI）浓度,通过电话随访了两组患者PCI术后的相关情况。结果 PCI术后16～18h时,两组患者的cTnI水平均高于术前（P＜0.05）,且两组比较差异有统计学意义（P＜0.05）。与对照组相比,曲美他嗪组患者术后cTnI水平＞0.10μg/L的患者比例较少（P＜0.05）。截至随访结束,曲美他嗪组患者左心室收缩末内径（LVESd）显著低于对照组[（31.00±4.33） vs （33.29±2.11）mm;P＜0.05],左心室射血分数（LVEF）明显高于对照组[（65.65±3.94）% vs （62.29±3.06）%;P＜0.05],两组患者主要心血管事件（MACE）发生率差异无统计学意义（7.8% vs 9.1%）。结论 PCI术前口服负荷剂量曲美他嗪可减少手术相关心肌损伤,术后长期服用可改善患者左心室功能。     

老年冠心病患者血清RBP4水平与氧化应激、颈动脉粥样硬化的关系研究

目的：探讨冠心病患者血清视黄醇结合蛋白4（retinal binding protein 4, RBP4）水平的变化,及其与氧化应激、颈动脉粥样硬化的关系。方法：选取老年冠心病患者100例及健康体检者100例,采用酶联免疫吸附法测定血清RBP4水平,黄嘌吟氧化酶法及硫代巴比妥酸显色法分别测定血清超氧化物歧化酶活性和丙二醛水平,高分辨彩色血管多普勒超声仪测量颈动脉粥样斑块面积和内-中膜厚度（IMT）。结果：冠心病组血清RBP4（35.10±5.76 vs. 27.82±4.90 ng/mL）和丙二醛（14.21±1.22 vs. 9.89±1.64 ?mol/L）水平,以及颈动脉粥样斑块面积（15.27±1.16 vs. 10.13±2.53 mm2）、IMT（1.19±0.13 vs. 1.03±0.16 mm）均明显高于健康体检者组（P<0.01）,血清超氧化物歧化酶活性（76.49±13.82 vs. 93.29±12.11 kU/L,P<0.01）则明显低于健康体检者组。血清RBP4水平与丙二醛（R = 0.486）、颈动脉粥样斑块面积（R = 0.354）及IMT（R = 0.388）呈正相关（P<0.05）,与血清超氧化物歧化酶活性呈负相关（R = 0.343,P<0.05）。结论：老年冠心病患者血清RBP4水平明显升高,并且升高的RBP4水平与氧化应激损伤及颈动脉粥样硬化程度呈正相关。     

老年急性心肌梗死急诊PCI术后联合服用尼可地尔与曲美他嗪对改善心功能的短期随访研究

目的：观察急诊经皮冠状动脉介入术(PCI)后联合服用尼可地尔、曲美他嗪对对老年多支病变ST段抬高型心肌梗死(STEMI)心功能的改善效果。方法：将2014年6月-2016年12月期间105例急诊PCI有效病例据随机数字分为观察组(52例)、对照组(53例),对照组出院后服用盐酸曲美他嗪片,每次20mg,每日3次,连服6个月,观察组在对照组基础上加服尼可地尔片,每次5mg,每日3次,术后随访6个月,比较两组血清学心肌损伤标志物、顿抑心肌血流灌注、心功能及不良心血管事件。结果：两组术后6个月BNP、Hs-CRP、MMP-9均显著低于本组术后3个月水平(P<0.05);术后3个月,观察组BNP(202.7±42.6 vs. 225.7±48.3) pg/ml显著低于对照组(P<0.05),术后6个月观察组BNP(137.9±36.5 vs. 165.9±41.1) pg/ml、Hs-CRP(4.19±1.23 vs. 5.01±1.55) mg/L、MMP-9(82.8±13.6 vs. 95.7±17.4) μg/L均显著低于对照组(P<0.05)。心肌核素显像显示两组术后6个月SRS、TPD%均显著低于术后3个月水平(P<0.05);术后3个月观察组SRS(15.6±3.8 vs. 17.9±4.3)显著低于对照组,术后6个月观察组SRS(8.9±2.3 vs. 13.5±2.8)、TPD%(18.2±4.9 vs. 22.4±5.7)%均显著低于对照组(P<0.05)。超声心动图检查显示两组术后LVEF、PER均较出院前显著提高(P<0.05),LVESVI、LVEDVI均显著降低(P<0.05);术后3个月观察组LVEF(56.1±4.5 vs. 53.9±4.6)%显著高于对照组,术后6个月观察组LVEF(58.8±4.7 vs. 56.5±4.7)%、PER(1.82±0.13 vs. 1.77±0.11) EDV/s均显著高于对照组(P<0.05),而LVESVI(38.5±6.3 vs. 42.1±7.8) ml/m₂、LVEDVI(85.6±12.5 vs. 92.4±14.4)ml/m₂均显著低于对照组水平(P<0.05)。观察组随访期内心绞痛发生率(7.7% vs.17.0%)、靶血管血运重建比例(1.9% vs.5.7%)、再入院比例(5.8% vs.9.4%)低于对照组,差异均无统计学意义(P＞0.05)。结论：尼可地尔、曲美他嗪对改善心肌灌注作用协同,急诊PCI术后口服曲美他嗪基础上加服尼可地尔有助于减轻心肌损伤,提高心功能,联合用药长期效果更为显著。     

曲美他嗪对心肌缺血再灌注损伤患者血清生化水平及心功能影响

目的：探究曲美他嗪对心肌缺血再灌注损伤患者的血清生化水平和心功能的影响。方法：选取我院在2013年5月-2015年5月期间进行PCI治疗的心绞痛患者110例作为研究对象，按照随机数表法将其随机分为观察组55例和对照组55例，两组患者均进行PCI治疗，并予以常规药物治疗。观察组患者在上述治疗基础上，服用曲美他嗪，观察两组患者血清生化水平及心功能的变化。结果：观察组患者在术后6h、术后24h的血清中cTnI和CK-MB含量都明显低于相应时间段内的对照组患者，差异显著（P<0.05）。术后1个月，观察组患者的左室射血分数为（64.3±7.5）%，明高于对照组（50.2±7.6）%，差异显著（t=9.79,P=0.00）。术后3个月，观察组患者的左室射血分数为（65.8±7.8）%，明高于对照组（57.1±7.4）%，差异显著（t=6.00,P=0.00）。观察组患者心血管不良事件发生率为10.91%（6/55），明显高于对照组41.82%（23/55），差异显著（2 =11.00,P=0.00）。结论：PCI 配合曲美他嗪能显著改善手术带来的心肌缺血再灌注带来的损伤，进一步改善治疗后患者的心功能     

单纯药物球囊扩张对冠状动脉主支中远段病变治疗的临床应用

目的 观察单纯药物球囊处理冠状动脉主支中远段病变的有效性及安全性。方法 选择2014年5月至2018年3月在我院行冠脉造影证实冠心病,于冠状动脉主支中远段行单纯药物球囊处理41例患者,对照组选择同期78例患者行传统球囊扩张+支架植入术,术后即刻复查造影,术后9个月临床临床随访,观察组即刻手术效果、统计患者主要心脑血管不良事件。结果 2组手术患者均无冠脉穿孔、心包填塞等事件发生,观察组41例患者行药物球囊扩张术,成功率95.1%。对照组78例患者行传统球囊扩张+支架植入术,成功率93.6%。观察组与对照组成功率比较无统计学差异（P<0.05）,观察组即刻血管最小管腔直径由术前（1.06±0.42mm）增加至术后（3.14±0.51mm）(p<0.05),复查冠脉造影血管最小管腔（3.16±0.54）（P>0.05）,对照组即刻血管最小管腔直径由术前（1.14±0.48mm）增加至术后（3.22±0.56mm）p<0.05),复查冠脉造影血管最小管腔（3.12±0.61）（（P>0.05））,随访期间,两组均无心源性死亡、致死性心肌梗死、靶病变血管再重建。结论 单纯药物球囊扩张对冠状动脉主支中远段病变治疗安全有效,可在临床中应用。     

电针联合目标温度管理对心肺复苏患者神经功能的影响

目的： 探讨电针联合目标温度管理对心肺复苏患者神经功能的保护作用。方法： 选择心跳骤停（CA）复苏成功自主循环恢复后的昏迷患者72例,随机分为对照组（36例）和电针组（36例）,对照组在常规治疗的基础上给予目标温度管理,电针组在对照组治疗的基础上联合电针疗法。2周后,比较2组患者的大脑功能评分（CPC）、血清神经元特异性烯醇化酶(NSE)和脑电双频指数(BIS)。结果：ROSC1周及2周后,电针组BIS值较对照组明显升高[(62.8±12.6) vs (55.8±12.0);[(79.6±8.9) vs (67.4±11.8),均P<0.05）],电针组NSE值较对照组明显降低[(18.9±5.3) vs (22.7±8.8);(15.3±5.5) vs (19.4±9.6),均P<0.05）]。6个月后电针组CPC1~2分构成比较对照组高,CPC3~5分构成比较对照组降低(均P<0.05)。两两比较差异有统计学意义（均P<0.05）。结论：电针联合目标温度管理可减轻CA后患者的脑损伤,改善患者神经功能预后,具有一定的临床应用价值。     

Randomized, controlled study of long-acting local anesthetic (levobupivacaine) in femoral artery sheath management during and after percutaneous coronary intervention

OBJECTIVE: To assess the effect of long-acting local anesthetic (levobupivacaine) in addition to lidocaine for the management of femoral artery sheaths during and after percutaneous coronary intervention (PCI). BACKGROUND: Femoral artery sheaths are commonly used during PCI. Sheath removal is often delayed after the procedure by which time short-acting local anesthetic agents may no longer be effective. METHODS: Sixty patients were randomized to either usual care or the administration of local levobupivacaine after PCI. Patients were asked to report their pain experienced on a visual analogue score. RESULTS: Thirty patients received additional levobupivacaine (0.5%) and 30 received standard care. There were no procedural differences between the groups, except that more patients in the control group received intravenous (IV) morphine at the time of sheath removal. There was no difference between the control group and levobupivacaine group in pain scores at the time of sheath insertion. (2.0 +/- 0.4 versus 1.8 +/- 0.3; p = 0.80). Both groups recorded low pain scores while waiting for sheath removal, and the score was slightly (but not significantly) lower in the levobupivacaine group (1.3 +/- 0.2 versus 0.8 +/- 0.2; p = 0.09). Pain scores were lower in the levobupivacaine group during sheath removal 2.2 +/- 0.4 versus 1.1 +/- 0.2; p = 0.02). There were no differences in terms of blood pressure between the groups at any time point. CONCLUSIONS: Levobupivacaine reduced the need for IV opiate and provided better analgesia than lidocaine alone in patients undergoing PCI.     

颈动脉狭窄患者血管内支架成形术中麻醉药物的应用

目的探讨颈动脉狭窄患者血管内支架成形术(PTAS)中神经安定镇痛麻醉药物的应用和术中管理。方法颈动脉狭窄患者行PTAS 174例,获得知情同意后分为神经安定镇痛麻醉组(观察组,106例)和单纯局部麻醉组(对照组,68例)。观察两组患者入手术室、股动脉穿刺、球囊扩张、支架置入和术毕时血压、心率、脉搏氧饱和度(SPO2)的变化;对患者意识进行Ramsay镇静分级;记录两组血管活性药物的使用情况。结果支架置入成功率为99.4%;观察组Ramsay镇静分级多在Ⅱ~Ⅳ级(90.6%),对照组多在Ⅰ级(91.2%);两组患者SPO2均高于90%;观察组股动脉穿刺时收缩压与入手术室时比较明显降低(P<0.05);观察组行股动脉穿刺时收缩压与对照组比较明显降低(P<0.05);观察组血管活性药物的使用(51.1%)低于对照组(69.5%,P<0.05)。结论在PTAS中维持患者适宜的镇静程度,有利于维持循环稳定,并减少血管活性药物的使用,是保障手术成功和减少手术并发症发生的关键因素之一。     

一种穿刺置管新方法在ECMO联合IABP介入治疗复杂高危冠心病中的应用

目的 评估应用同侧股动脉置入主动脉内球囊反搏（IABP）和大直径经皮冠状动脉介入（PCI）治疗指引导管,联合对侧股动脉与股静脉用于置入体外膜肺氧合（ECMO）的穿刺策略,观察该置管方式对于复杂高危冠心病患者（CHIP）完成PCI手术的安全性和可行性。 方法 共纳入7例患者,左侧股动脉与股静脉置入ECMO鞘管（动脉置管直径15F,静脉置管直径17F）,右侧股浅动脉置入IABP（均为7F动脉鞘管）,右侧股总动脉置入PCI股动脉鞘管（均为7F动脉鞘管）,ECMO动脉及静脉穿刺处采用预置ProGlide血管缝合器止血,PCI和IABP股动脉穿刺处应用Angioseal血管封堵器止血。术后针对股动脉、股静脉穿刺部位进行临床症状与体征评估,并全部进行血管超声检查,观察该穿刺置管的成功率以及完成PCI手术的可行性,观察住院期间穿刺部位相关的并发症发生率。 结果 7例患者中,男性6例,女性1例,年龄（57±12）岁,合并高血压5例（71%）、糖尿病3例（43%）、慢性肾病1例（14%）、高脂血症4例（57%）、卒中1例（14%）、外周血管疾病4例（57%）。双侧股动脉,左侧股静脉穿刺成功率100%,PCI手术完成率100%。仅一例患者术后超声检查发现股浅动脉穿刺部位发生皮下小血肿,所有患者住院期间均未观察到严重血管并发症。 结论 在CHIP患者中,当需要ECMO联合IABP维持血流动力学稳定,并需要穿刺股动脉置入大直径指引导管完成复杂PCI手术的情况下,可采用同侧股浅动脉置入IABP,股总动脉置入大直径（7F）PCI动脉鞘管,对侧股动脉、股静脉置入ECMO的手术穿刺策略,该方法安全可行。     

保护性临时起搏对急性下壁心肌梗死急诊介入治疗再灌注低血压恢复时间及药物使用的影响

目的：探讨保护性临时起搏对急性下壁心梗（AIMI）患者急诊经皮冠状动脉介入治疗（PCI）再灌注低血压恢复时间和药物使用情况的影响。方法：在符合入选标准的AIMI，且成功完成急诊PCI的住院患者中，选择保护性起搏和非保护性起搏患者各52例，以收缩压〈90mmHg和／或舒张压〈60mmHg为低血压标准，两组分别有保护性起搏再灌注低血压组（23例），非起搏再灌注低血压组（16例）。观察两组再灌注低血压患者的药物使用情况以及低血压的缓解时间。结果：保护性起搏与非起搏再灌注低血压两组患者需要使用药物治疗比例无明显差别（78．3％比81．3％，P=0．820）。两组用药后低血压恢复时间亦无明显差别（〈5min恢复依次分别为92．3％，88．9％，P〉0．05）。结论：保护性临时起搏无减少再灌注低血压恢复时间及药物使用的作用。     

Determinants of rebound thrombin activity after cessation of heparin in patients undergoing coronary interventions

This study was designed to characterize hemostatic activation (using fibrinopeptide A (FPA), a marker of thrombin activity, and β-thromboglobulin (BTG), a marker of platelet activation) sequentially in the coronary and peripheral circulation in patients during percutaneous coronary intervention (PCI) and several hours after PCI and discontinuation of heparin therapy. Heparin administered during PCI is known to nonuniformly suppress thrombin activity in the coronary. Persistent elevations of FPA in coronary sinus (CS) blood during PCI have been associated with subsequent ischemic events. As a related consideration, rebound thrombin activity has been demonstrated in peripheral blood samples several hours after cessation of heparin therapy in patients with acute coronary syndromes. Accordingly, we hypothesized that increased thrombin activity occurs in the coronary circulation after PCI and is induced by cessation of intravenous heparin to facilitate vascular sheath removal. Such a rebound prothrombotic effect, may contribute to suboptimal outcomes after PCI. In 21 patients undergoing PCI, heparin-bonded catheters were employed to obtain sequential CS and femoral vein (FV) blood samples for measurement in the coronary and peripheral circulation of plasma FPA, a marker of thrombin activity in vivo, and BTG released by platelets during degranulation. Following heparin administration samples were obtained immediately prior to (base) and during (start and end) PCI. Late samples were obtained several hours after PCI (284 ± 46 min, mean ± SD) following the cessation of heparin and prior to planned vascular sheath removal. Mean FPA concentration in CS blood was low at baseline (3.82 ± 2.09 ng/ml) and did not increase during PCI. Mean FPA concentration in CS blood increased significantly several hours after cessation of heparin (3.42 ± 2.36 vs. 7.82 ± 9.98, end vs. late, P < 0.001). In contrast, mean FPA concentration in FV blood was highest at baseline following vascular sheath insertion, decreased during PCI (69%, P < 0.05, base vs. end), and trended upward after PCI and cessation of heparin. Mean FPA values were higher at all times in FV compared with CS blood samples and were not concordant after PCI. Elevation of coronary circulation FPA after PCI was maximal in patients with myocardial infarction within 7 days (13.7 ± 12.4 vs. 5.6 ± 7.9 ng/ml, P = 0.08), but was not influenced by heparin treatment prior to PCI, a history of unstable angina, or coronary stent placement during PCI (9 of 21 patients). BTG values showed less variation than did FPA values, and cessation of heparin after PCI was not associated with an increase in BTG in CS or FV blood samples. An increase in thrombin activity occurs in the coronary circulation after PCI following discontinuation of heparin. The extent of increased thrombin activity was greatest in patients with recent myocardial infarction and was not exacerbated by coronary stent placement during PCI. This phenomenon may contribute to the important minority of ischemic complications early after PCI. Cathet. Cardiovasc. Diagn. 44:257–264, 1998. © 1998 Wiley-Liss, Inc.     

心导管术后人工压迫止血无包扎对患者舒适度的影响

目的评价经皮股动脉冠状动脉介入诊疗术、人工压迫止血后无包扎对患者舒适度的影响。方法204例经皮股动脉冠状动脉造影或介入治疗的患者,按止血方法分为无包扎组即观察组123例（造影94例,介入治疗29例）和传统压迫组即对照组81例（造影38例,介入治疗43例）。观察组止血后4h床上活动,6h下地。对照组止血后12h下地活动。对比两组患者的舒适度。结果观察组患者舒适度明显优于对照组（P〈0．001）。结论心导管术后人工压迫止血无包扎4h床上活动,6h下地能提高患者舒适度,减轻腰背酸痛、排尿困难等不适,减少患者卧床痛苦。     

Comparison of Arterial and Venous Blood Flow Between Patients with Pressure Dressing or a New Hemostatic Puncture Closure Device After Cardiac Catheterization

The aim of the study was to compare arterial and venous flow volume in the punctured leg in patients given a conventional pressure dressing and those given a new hemostatic puncture closure device (Angio-Seal) after cardiac catheterization. We prospectively measured blood flow in 25 patients with pressure dressing (group A) and 25 patients with Angio-Seal (group B) after cardiac catheterization. Duplex sonographic measurements were performed at the superficial femoral artery and vein of the punctured leg. In group A measurements were performed before catheterization, during pressure dressing, and after removal of pressure dressing. In group B we performed the measurements before catheterization and after closure of the puncture site with Angio-Seal. Mean arterial and venous blood flow of the superficial femoral artery and vein were calculated. Statistical evaluation was performed using the one-sample Wilcoxon test. In group A there was a significant reduction of blood flow volume in both the femoral artery, from a mean of 119 mL/min before puncture to 78 mL/min with pressure dressing, and the femoral vein, from 114 mL/min before puncture to 82 mL/min with pressure dressing (P < 0.0001). After removal of pressure dressing the blood flow rose to 119 mL/min in the femoral artery and 116 mL/min in the femoral vein. In group B there was no change in flow volume before and after catheterization (femoral artery: 117 vs 118 mL/min, femoral vein 119 vs 120 mL/min, P = ns). We conclude that the use of pressure dressing after cardiac catheterization caused a significant reduction in arterial and venous blood flow (about 30%) during immobilization. The new Angio-Seal closure device did not affect arterial or venous flow.     

替罗非班对急性冠脉综合征经皮冠状动脉介入术后无复流现象的影响

目的观察盐酸替罗非班对急性冠脉综合征（ACS）患者经皮冠状动脉介入术（PCI）后无复流现象的影响。方法纳入ACS患者行PCI治疗术后无复流患者72例,随机分为替罗非班组36例和对照组36例。对照组经冠状动脉给予硝普钠0.9μg/kg,替罗非班组经冠状动脉给予盐酸替罗非班负荷剂量10μg/kg,3min内注完,随后以0.15μg/（kg·min）微量泵持续静脉泵入24h。观察两组患者冠脉给药前、给药后20min靶血管前向血流的TIMI血流分级、心电图改变及术后2周内主要不良心脏事件及药物的不良反应。结果冠状动脉内给药20min后造影显示,两组患者梗死相关动脉TIMI血流分级均较给药前有改善,替罗非班组IRA的TIMI血流0级、1级发生率显著低于对照组,TIMI血流3级发生率显著高于对照组,差异均有统计学意义（P〈0.01）;冠状动脉给药2h后与给药前比较,对照组心电图改善不明显,而替罗非班组患者心电图获得显著改善,两组冠脉给药2h后ST抬高及压低程度、缺血损伤导联数差异均有显著统计学意义（P〈0.01）;术后2周内替罗非班组主要不良心脏事件显著低于对照组（P〈0.01）;术后2周内两组不良反应的发生率差异无统计学意义（P〉0.05）。结论经冠状动脉给予盐酸替罗非班治疗可有效地改善ACS患者术后无复流现象,并减少术后2周内主要不良心脏事件。     

左旋卡尼汀对急性心肌梗死经皮冠状动脉介入治疗患者的心肌保护作用

目的在急性心肌梗死(AMI)接受直接经皮冠状动脉介入(PCI)治疗的患者中,评价国产左旋卡尼汀(L-carnitine,L-CN)对缺血-再灌注损伤心肌的保护作用。方法连续入选发病12h内ST段抬高AMI接受PCI的患者42例,随机分L-CN治疗组22例和对照组20例。观察肌酸磷酸激酶同工酶(CK-MB)、心肌TMP分级、术中再灌注心律失常、低血压、心电图ST段回落>50%、左心室舒张末期内径(LVEDD)和射血分数(LVEF)的改变。结果与对照组比较,L-CN治疗组CK-MB峰值明显减低,达峰时间提前;术中出现再灌注心律失常、低血压的比例明显减少;术后1h ST段回落>50%的患者比例明显增多;术后3个月时LVEDD仅轻度增大,LVEF显著升高。结论左旋卡尼汀对AMI直接PCI治疗患者的心肌具有抑制再灌注损伤、缩小梗死面积、改善心室重构等多重保护作用。     

Increased circulating endothelin-1 in rheumatic mitral stenosis: irrelevance to left atrial and pulmonary artery pressures

BACKGROUND: Increased plasma endothelin (ET)-1 concentrations have been observed in patients with rheumatic mitral stenosis (MS). However, the mechanisms of increased circulating ET-1 in patients with MS remain unclear. METHODS: We measured plasma concentrations of ET-1 in blood samples from the femoral vein and artery, and right and left atria obtained from 20 patients with moderate-to-severe rheumatic MS before and after percutaneous transluminal mitral valvuloplasty (PTMV) [group 1; 16 patients in chronic atrial fibrillation and 4 patients in sinus rhythm]. In addition, we measured plasma concentrations of ET-1 in the peripheral venous blood samples obtained from 22 control patients (including 14 healthy volunteers in sinus rhythm [group 2] and 8 patients in chronic lone atrial fibrillation [group 3]). Plasma ET-1 concentrations were measured by solid-phase, sandwich enzyme-linked immunosorbent assay. RESULTS: The peripheral venous plasma concentrations of ET-1 were significantly higher in group 1 patients (2.46 +/- 0.90 pg/mL) than in group 2 and group 3 patients (0.74 +/- 0.42 pg/mL and 0.99 +/- 0.41 pg/mL, respectively [mean +/- SD]; p < 0.0001). However, there was no significant difference in the peripheral venous concentrations of ET-1 between group 2 and group 3 patients. In group 1 patients, the plasma ET-1 concentration in the femoral vein (2.46 +/- 0.90 pg/mL) was significantly higher than that in the right atrium (2.02 +/- 0.69 pg/mL), left atrium (2.11 +/- 0.99 pg/mL), and femoral artery (2.05 +/- 0.75 pg/mL) [p = 0.0001]. The plasma ET-1 concentration in the femoral vein was not correlated with the mean left atrial pressure (r = 0.05; p = 0.838) and mean pulmonary artery pressure (r = 0.07; p = 0.757). The plasma ET-1 concentration in the left atrium was also not correlated with the mean left atrial pressure (r = 0.11; p = 0.656), mean pulmonary artery pressure (r = 0.06; p = 0.788), or mitral valve area (r = 0.02; p = 0.936). Although the area of mitral valve increased significantly (1.06 +/- 0.17 cm(2) vs 1.48 +/- 0.32 cm(2); p < 0.0001), and the mean left atrial pressure (23.0 +/- 5.1 mm Hg vs 17.6 +/- 5.9 mm Hg; p < 0.0001) and mean pulmonary arterial pressure (31.0 +/- 7.9 mm Hg vs 25.5 +/- 7.0 mm Hg; p < 0.001) fell significantly and immediately after PTMV, there were no significant changes in the plasma ET-1 concentrations in the femoral vein, right atrium, left atrium, and femoral artery immediately after PTMV. CONCLUSION: Increased production of ET-1 in the pulmonary circulation in response to increased pulmonary artery pressure was not the mechanism of increased circulating ET-1 concentration in patients with MS. We proposed that one of the mechanisms of increased ET-1 concentration in the femoral vein was increased peripheral ET-1 release due to increased systemic venous pressure and mechanical damage of the endothelium.