急性心肌梗死急诊介入治疗的临床观察

目的：观察急诊冠脉介入治疗(PCI)的疗效及安全性。方法：选择我科急诊收治的急性心肌梗死(心梗)患者116例进行急诊PCI，其中急性前壁、前间壁心梗68例，急性下壁心梗46例，急性前壁并下壁心梗2例；合并严重低血压或心源性休克12例，依Grenuzig’s法行PCI，必要时置入冠脉内支架。结果：本组急诊冠脉造影显示多支病变者66例，单支病变50例。73支前降支、44支右冠及8支回旋支靶血管行PCI；38例二处以上同时行PCI。成功109例，失败7例；94例患者同时植入支架117枚。1例未能通过病变。术后院内死亡4人，其中3例死于心衰、休克，1例死于室颤。随访2-93月大多数临床症状改善。结论：急性心肌梗死急诊介入治疗是一项恢复冠脉血流最直接、最有效的手段。对高危的心梗患者尤应加强围手术期的观察、处理，可降低急性心肌梗死的死亡率。     

急性心肌梗死直接冠状动脉介入治疗

 目的探讨急性心肌梗死急诊介入治疗在临床应用的策略.方法76例ST段抬高和(或)新发生左束支传导阻滞的急性心肌梗死患者,男52例,女24例;年龄43～82(61.5±13.6)岁.采用经股动脉或经桡动脉途径常规方法,行急诊冠脉造影和急诊PCI.结果76例患者PCI术后梗死相关血管血流达TIMI3级73例(96.1%),TIMI血流2级1例,失败2例.74支IRA共植入支架97枚,胸痛发作至IRA再通时间≤12 h和＞12h两组在年龄和性别方面有显著差异,胸痛发作至IRA再通时间＞12 h组的冠脉多支病变和心功能不全发生率高.结论急诊PCI不仅及时开通梗死相关血管,而且能消除狭窄,减低心脏事件发生率.故有条件的医院应首选PCI为急性心梗患者的治疗措施,尤其对高龄患者、有溶栓禁忌征者及有心原性休克的患者.     

新一代药物洗脱支架术后DAPT持续时间临床研究进展

<正>无论是非ST段抬高性急性冠脉综合征(acute coronary syndrome,ACS)高危患者,还是急性ST段抬高性心肌梗死患者,尽早接受经皮冠脉介入治疗是降低患者死亡风险、改善长期预后的有效方法之一。与金属裸支架相比,第一代药物洗脱支架(drug-eluting stent,DES)虽显著减少了支架内再狭窄及因此导致的靶血管再次血运重建,但支架内血栓的发生率却明显升高,特别是晚期、极晚期血栓~[1-2]。相关研究已证实,这与抗增殖药物抑制新     

改良T型药物洗脱支架置入术治疗冠状动脉分叉病变

目的评估改良T型支架置入术结合雷帕霉素洗脱支架CypherTM在冠状动脉(冠脉)分叉病变介入治疗中的应用。方法30例冠脉造影显示真性分叉病变患者,应用改良T型支架置入法在冠脉主支和分支内分别置入CypherTM支架,并行对吻球囊扩张术。观察术后即刻成功率和住院期、随访期不良事件发生率。结果30例中,即刻手术成功28例(93%),19例(63%)行对吻球囊扩张术。1例左前降支和第一对角支分叉病变发生急性血栓形成,导致对角支血流TIMI0～1级和急性前间壁心肌梗死;另1例对吻球囊扩张术后对角支开口残余狭窄40%,但无任何临床症状。30例平均临床随访(11±5)个月,无不良事件发生,9例(30%)于术后(10±3)个月行冠脉造影复查,无支架内和节段内再狭窄。结论改良T型支架置入术结合药物洗脱支架在冠脉分叉病变介入治疗中安全可行。     

冠状动脉支架内血栓形成患者的危险因素及预后

目的 分析冠状动脉药物涂层支架术后支架内血栓形成患者的危险因素及预后.方法 回顾性分析2006年7月到2012年3月冠脉支架内血栓形成的患者39例,并按1∶2配对抽取同期复查冠脉造影术未见支架内再狭窄患者78例,作为对照组从中分析术后支架内血栓形成的危险因素.结果 首发为急性心肌梗死、罪犯血管的支架直径及长度、术前左室射血分数(LVEF)低(＜50％)与支架内血栓形成相关.选择再次行急症经皮冠脉介入术(PCI)者33例,1例术后在院内死亡,余32例好转出院.结论 首发为急性心肌梗死、植入罪犯血管支架的直径较小及长度较长、术前LVEF低(＜50％)是支架血栓形成的独立危险因素.支架长度≥29.5 mm或支架直径≤2.94 mm与较高的支架内血栓的发生率相关.药物涂层支架术后发生支架内血栓的患者多表现为急性心肌梗死,发生支架内血栓后死亡率高,但早期行急症PCI是安全、有效的治疗.     

金属裸支架与药物洗脱支架在治疗症状性椎-基底动脉狭窄与急性闭塞中的应用

目的评价金属裸支架(bare metal stent,BMS)与药物洗脱支架(drug eluting stent,DES)治疗症状性椎-基底动脉狭窄与急性闭塞的安全性、有效性和中短期疗效并作初步比较。方法对2005年3月至2008年1月收治的25例症状性椎-基底动脉狭窄与急性闭塞患者行血管内球囊支架成形治疗。结果25例患者成功植入28枚球囊支架,其中BMS15枚,DES13枚。植入椎动脉支架25枚,基底动脉支架3枚(其中2枚为基底动脉急性闭塞经溶栓后植入)。血管平均狭窄程度从治疗前的平均81.4%(50%～95%)降低到6.3%(0%～15%)。22例经2～36个月临床随访,平均随访23个月,3例失访。1例患者植入1枚BMS后9个月症状复发,DSA复查发现支架再狭窄达50%,患者拒绝继续治疗;1例患者植入1枚DES后35d出现急性血栓闭塞,经急诊再植入1枚DES后血管开通良好。余20例超声复查支架通畅,未见明确狭窄,未见卒中及脑缺血发作。随访22例中19例(86.4%)症状明显缓解或消失,3例(13.6%)部分缓解。结论BMS与DES治疗症状性椎-基底动脉狭窄安全、有效,中短期效果令人满意。DES降低手术后支架内再狭窄发生率具有一定的预防作用,优于BMS金属裸支架。     

经桡动脉冠脉介入治疗急性冠脉综合征32例临床观察

目的：探讨桡动脉途径急诊经皮冠状动脉介入（PCI）治疗急性冠脉综合征（ACS）的效果。方法：回顾性分析经桡动脉急诊PCI治疗32例ACS患者的临床资料。结果：本组病例第一次球囊扩张时间均在90 min以内,平均（65 min）,并成功置入药物支架38枚。术中6例发生低血压,2例发生急性血栓形成。均抢救成功无1例死亡。随访6～12个月无主要不良心脏事件发生。结论：ACS患者经桡动脉行急诊PCI安全可行,效果肯定。因此,经桡动脉入径可作为ACS可选择的血管途径之一。     

冠心病介入治疗现况

自 1977年Ｇｒｕｎｔｚｉｇ首次开展经皮冠状动脉 (冠脉 )腔内成形术 (ＰＴＣＡ )以来 ,经过多年的实践 ,冠心病介入治疗发展迅猛。随着操作经验的积累和相关器材的改进 (尤其是冠脉内支架 ) ,冠心病介入治疗的适应证正在不断扩大 ,在急性冠脉综合征和急性心肌梗死治疗中介入治疗具有重要的地位。同时 ,已可对复杂或高危病变和多支血管病变行介入治疗。预防介入治疗后再狭窄的研究正在不断深入。一、冠心病介入治疗的临床适应证目前冠心病介入治疗的临床适应证 ,包括严重的可逆性心肌缺血、稳定或不稳定型心胶痛、急性心肌梗死、冠脉旁路术…     

急性心肌梗死80岁以上高龄患者急诊介入的临床效果

探讨80岁以上的高龄的急性心肌梗死（AMI）患者急诊介入治疗（PCI）的疗效及安全性。方法：对24例平均年龄（84．0±3．7）岁的急性心梗患者进行PCI,观察手术即刻效果及近远期疗效。结果：22例取得即刻成功（成功率91．7％）,共对32支靶病变血管行PCI,共植入支架41（平均1．7±0．8）枚。15支IRA为完全闭塞病变,即刻开通14支,院内死亡4例。平均随访（18．5±14．8）月,14例未再出现心绞痛,1例术后8月死：亍二肺癌。结论：急诊PCI对80岁以上的高龄AMI患者来说,仍是一种安全、有效的治疗手段。     

64排CT对冠状动脉临界病变治疗决策的指导意义

目的探讨64排CT测定冠状动脉斑块CT值,对于指导冠状动脉临界病变介入治疗的意义。方法选择经64排CT检查提示冠脉狭窄在50%～70%的临界病变,且斑块CT值为(14±26)HU,脂核体积>40%的冠心病患者120例,随机分为介入组及药物组,于治疗开始后10～12个月复查64排CT,随访并记录两组心脏不良事件。结果介入组46例及药物组45例在术后10～12个月进行了64排CT复查,介入组全部患者均未发现局部支架内血栓征象,但2例支架内再狭窄>50%,5例支架内轻度狭窄;药物组6例管腔狭窄加重至85%,与治疗前有明显差异,25例斑块CT值增加至(70±12)HU,2例变为钙化斑块,10例治疗期间因心绞痛加重行冠脉支架术,3例因急性心肌梗死急诊行冠脉支架术。结论 64排CT测定斑块CT值有助于判明冠状动脉临界病变是否需介入干预。     

冠状动脉介入治疗老年冠心病的临床研究

目的　评价冠状动脉介入 (PCI)治疗老年冠心病患者的临床疗效及安全性。方法　老年冠心病患者 5 2例 ,男性 3 8例 ,女性 14例 ,平均年龄为 68.1± 4.5岁 ( 65～ 81)岁 ,其中不稳定性心绞痛 15例 ,急性心肌梗死 7例 ,陈旧性心肌梗死 13例 ,稳定性心绞痛 17例。结果　 5 2例老年冠心病患者中单支病变 9例、双支病变 19例、三支病变 2 4例。 5 8支血管接受介入治疗 ,共置入支架 75枚。其中置入前降支 43枚 ,回旋支 11枚 ,右冠状动脉 2 1枚 ,手术成功率 95 .9%。A型病变成功率 10 0 %,B型病变成功率 10 0 %,C型病变成功率 92 .6%。 2例失败患者均为C型病变 ,导丝或球囊不能通过病变处。对这些患者进行跟踪随访 ,其中 1例术后 1月猝死 ,其余患者均存活。结论　冠状动脉介入治疗老年冠心病患者是安全而有效的治疗方法     

双源CT双能量冠脉成像对冠脉支架术后的临床价值

目的 探讨双源CT双能量冠脉成像对冠脉支架术后的临床价值.方法 对32例冠心病支架术后患者行双能量扫描,对比分析冠脉支架CT血管成像和选择性冠脉造影检查,将14例临床确诊陈旧性心梗患者进行心肌灌注分析.结果 32例患者置入46枚支架均成功显示,1例患者2枚支架因钙化评价受限.14例确诊为陈旧性心梗的患者均显示不同程度的心肌灌注缺损.结论 双源CT双能量扫描不但能较好的评价冠脉支架植入术后支架情况,还能对心肌灌注改变做出判断.     

男女急性心肌梗死患者临床特点及经皮冠状动脉介入治疗的对比研究

目的：探讨男女急性心肌梗死患者临床特点及经皮冠状动脉介入治疗的对比研究。方法：选择本院2005-09～2011-06因急性心肌梗死进行经皮冠状动脉介入治疗患者417例,男234例,女183例,统计临床表现、冠状动脉病变累及支数、急诊PCI成功率,住院病死率。结果：急性心肌梗死的2种临床类型分布在男性与女性差异无统计学意义,以ST段抬高心肌梗死为主。冠状动脉造影男性与女性均以3支病变为主（63．0％7 vs 0．6％,P=0．160）,单支病变差异无统计学意义。男性双支病变明显多于女性（24．3％ vs 13．7％,P=0．016）,差异有统计学意义。累及部位、手术成功率和院内病死率差异无统计学意义（P〉0．05）。结论：急性心肌梗死发生率高,通过探讨男女急性心肌梗死患者临床特点及经皮冠状动脉介入治疗的异同,有助于男女急性心肌梗死的发现、诊断及治疗,有助于其心血管并发症的预防。     

Acute myocardial infarction: safety of cardiac MR imaging after percutaneous revascularization with stents

PURPOSE: To retrospectively determine the safety of cardiac magnetic resonance (MR) imaging performed early (<14 days) after coronary stent implantation in patients with acute myocardial infarction (AMI). MATERIALS AND METHODS: This HIPPA-compliant study was approved by the institutional review board; the informed consent requirement was waived. Consecutive patients with AMI who underwent cardiac MR imaging (study group) shortly after stent implantation (median, 3 days) were compared with control subjects who did not undergo MR imaging and were matched for clinical factors and angiographic extent of coronary disease. A 1.5-T MR imager was used to evaluate cine function, perfusion, and viability. Rates of death, nonfatal myocardial infarction, or revascularization 30 days and 6 months after stent implantation were compared with chi(2) analysis. RESULTS: The study group consisted of 66 patients (median age, 56 years; 17 women) with 97 stents, 38 (39%) of which were drug eluting. The control group included 124 patients (median age, 58 years; 23% women) with 197 stents, 21 (10.7%) of which were drug eluting. There was no significant (P = .13) difference in the combined end point of death, nonfatal myocardial infarction, or revascularization between the study (2.0% [95% confidence interval: 0.0%, 4.5%]) and control (6.5% [95% confidence interval: 1.6%, 11.3%]) groups at 30-day follow-up. The event-free survival rate at 6-month follow-up was 91% in the study group and 83.7% in the control group (P = .18). Considering the end points separately, there was no difference in the event rate at 30-day or 6-month follow-up between groups. No adverse cardiovascular events occurred in patients with drug-eluting stents who underwent MR imaging. CONCLUSION: Cardiac MR imaging performed shortly after AMI and percutaneous revascularization with bare metal or drug-eluting stents appears safe. The risk of adverse cardiovascular events is low and similar to that in patients who do not undergo MR imaging.     

急性下壁心肌梗塞并右心室梗塞的冠脉病变特点

目的　了解下壁急性心肌梗塞 (AMI)并右心室梗塞 (RVMI)的冠脉病变特点。方法　对 43例 (其中 16例下壁AMI并RVMI患者的冠脉造影资料进行分析。结果　心电图提示下壁AMI并RVMI改变 16例 ,梗塞相关动脉 (IRA)为右冠脉 15例 (93 7% ) ,阻塞右冠脉近段 13例 (81 2 % ) ,中段 2例 (12 5 % ) ,均为右冠脉优势型。回旋支阻塞 1例(6 2 % ) ,且呈左冠脉优势型。结论　下壁AMI并RVMI的血管病变部位多见于优势型右冠脉的近段和中段。     

The site of acute myocardial infarction is related to the coronary territory of transient defects on prior myocardial perfusion imaging

Background

Prior studies have established the prognostic value of myocardial perfusion imaging. In particular, the presence and extent of transient defects have been shown to predict future cardiac events including acute myocardial infarction. However, the relationship between the location of the perfusion defect and the site of subsequent myocardial infarction remains unclear.

Methods and Results

Review of prior records of consecutive patients admitted with acute myocardial infarction identified 34 patients whose prior myocardial perfusion imaging studies had demonstrated transient defects and no interval revascularization. The coronary artery territory of the transient defects was identified and related to the site of subsequent acute myocardial infarction. To reduce the potentially confounding effect of progression of coronary artery disease between the time of the myocardial perfusion imaging study and subsequent infarction, patients were divided into those less than 2 years and those 2 years or greater between imaging and infarction. Among patients with a transient defect and less than 2 years between infarction and imaging, 11 (79%) of 14 had a myocardial infarction in the same coronary territory as their prior transient defect (p<0.0005). This association decreased to only five (25%) of 20 when the interval was 2 years or greater (difference not significant). Among 22 patients who had undergone prior coronary angiography, myocardial infarction occurred in the same coronary territory as the most severe angiographic stenosis in 12 (54%). The association was not related to the time interval between angiography and infarction.

Conclusions

There is a strong association between the coronary territory of transient defects on myocardial perfusion imaging and the site of subsequent myocardial infarction when the duration is less than 2 years. These observations support the concept that the hemodynamic significance of a coronary lesion is an important factor in the pathophysiology of acute myocardial infarction.     

外周支架在经皮冠状动脉介入治疗中的应用

目的评价PALMAZ BLUE.014外周支架(简称BLUE支架)在经皮冠状动脉介入治疗(PCI)中的疗效和安全性。方法经冠状动脉造影确诊5例冠心病患者,其参照血管直径≥5.0 mm(简称大冠状动脉),术中采用BLUE支架,共置入5枚,其中前降支3枚,右冠状动脉2枚。结果 5枚支架均顺利置入冠状动脉狭窄段,支架置入术后,残余狭窄≤10%。住院期间及术后随访6~12个月,所有患者均未出现胸痛或胸闷症状,未发生支架内血栓、心肌梗死及再次血管重建。术后6~12个月均复查冠状动脉造影,5枚支架内未见明显再狭窄。结论 BLUE支架用于PCI术,安全性好,疗效满意,可作为大冠状动脉冠心病患者PCI治疗的策略之一。     

Use of invasive and nuclear stress testing in patients with acute ischemic coronary syndromes in a large, urban, university-affiliated hospital

BACKGROUND: Several recent studies have suggested a high use of invasive procedures after acute myocardial infarction, without a corresponding improvement in survival. We assessed the relative use of invasive procedures and nuclear cardiac testing during acute coronary syndromes. METHODS AND RESULTS: We examined the in-hospital utilization rates of invasive and nuclear stress tests and their association with in-hospital mortality in all patients hospitalized with an acute coronary syndrome in a single, university-affiliated hospital for 3 years. The study cohort consisted of 1704 consecutive patients with acute myocardial infarction and 2414 patients with unstable angina pectoris. The utilization rate of nuclear stress testing was much lower than that of coronary angiography in patients with either acute myocardial infarction (11.9% vs. 73.9%, P<.001) or unstable angina (8.5% vs. 79.3%, P<.001). Patients examined with nuclear stress testing, as compared with patients examined solely by means of coronary angiography, had lower revascularization and in-hospital mortality rates, both after acute myocardial infarction (29.2% vs. 70%, P<.001, and 1.5% vs. 9.6%, P<.001, respectively) and unstable angina (14.6% vs. 80.6%, P<.001, and 1% vs. 5.1%, P<.001, respectively). Revascularization guided by means of nuclear stress testing had a lower mortality rate than that performed without the benefit of a nuclear test, both in patients with acute myocardial infarction (0% vs. 10.5%) and in patients with unstable angina (0% vs. 5.9%). CONCLUSION: Noninvasive stress imaging was used much less often than coronary angiography in patients with acute coronary syndromes. The lower mortality rate of patients examined with nuclear stress testing, compared with patients examined solely by means of coronary angiography, deserves further study, especially in patients undergoing revascularization.     

磁共振灌注成像在急性心肌梗死诊断中的价值

目的研究磁共振灌注成像在急性心肌梗死诊断中的价值。方法使用1.5T超导型磁共振扫描仪,对29例经临床诊断的急性心肌梗死病人行灌注成像,其中17例进行冠状动脉造影术,全部病例通过AW4.0工作站处理,计算出首过时间及首过最大上升斜率,同时测定正常心肌与心室腔的首过时间及最大上升斜率。对比剂总量20ml,注射流率首过3ml/s,共9ml,以后以1ml/s注射。结果29例心肌梗死病例显示延迟病灶明显强化及首过最大上升斜率降低,28例首过时间延迟,17例行冠状动脉造影,14例发现冠状动脉狭窄,未发现冠状动脉狭窄的3例,均为心内膜下或心外膜下梗死。结论急性心肌梗死MR灌注成像具有特征性表现。