冠状动脉内注射维拉帕米在PCI中无复流患者中的应用

目的 观察冠状动脉内注射维拉帕米治疗经皮冠状动脉介入术（PCI）中无复流现象的临床疗效.方法 将同期于我院行PCI且术中出现无复流的123例冠心病患者随机分为观察组58例和对照组65例,两组手术方法相同,出现无复流现象后分别经冠状动脉内注入维拉帕米和硝酸甘油.观察两组注射药物后首次和PCI中末次造影图像,评估心肌梗死溶栓试验（TIMI）血流分级、TIMI心肌组织灌注分级（TMPG）;同时观察术后1周左室射血分数（LVEF）及住院期间、术后60 d内主要心血管事件（MACE）发生情况.结果 观察组两次冠状动脉造影TIMI 3级血流获得率、TMPG 3级获得率均明显高于对照组,术后1周LVEF显著高于对照组,住院期间及PCI术后60 d内MACE发生率显著低于对照组,P均〈0.01.结论 PCI中冠状动脉内注射维拉帕米可明显改善患者血流、心功能,减少MACE发生.     

急性ST段抬高心肌梗死直接经皮冠状动脉介入术冠状动脉无复流现象对预后的影响

目的研究急诊经皮冠状动脉介入(PCI)治疗冠状动脉(冠脉)中无复流现象的临床意义.方法自2000年1月至2004年1月,回顾性分析我院336例急性ST段抬高心肌梗死(STEMI)直接PCI患者的临床和影像资料.急诊PCI支架置入即刻,在无影响血流的血栓、栓塞、夹层、痉挛情况下,冠脉造影前向血流≤TIMI2级为无复流,TIMI 3级为正常血流.冠脉无复流患者42例,利用Excel随机函数表,由其余294例急诊PCI冠脉前向血流恢复正常的患者中随机抽取45例,为正常血流组.随访6个月,观察有无心脏性猝死和非致命性心脏事件.结果无复流组发生充血性心衰、恶性心律失常、再发心绞痛、心脏性猝死高于冠脉血流正常组,无复流组6个月后左室射血分数显著低于冠脉血流正常组.结论无复流患者的心肌损害严重,梗死或濒临坏死的心肌范围广泛,强烈提示AMI预后不良.     

替罗非班联合替格瑞洛对STEMI患者行急诊PCI术后TIMI分级、心肌灌注、主要心脏不良事件发生的影响

目的探讨替罗非班联合替格瑞洛对ST段抬高型心肌梗死(STEMI)行急诊经皮冠状动脉介入术(PCI)患者术后TIMI分级、心肌灌注、主要心脏不良事件发生的影响。方法选取本院100例行PCI治疗的STEMI患者,随机分为对照组给予替格瑞洛治疗,观察组给予替罗非班联合替格瑞洛治疗,两组各50例。比较两组术后TIMI血流分级、心肌灌注、主要心脏不良事件发生的情况。结果观察组TIMI血流分级3级比例与术后ST段回落高于75%比例均明显高于对照组(均P0.05),且无复流发生率低于对照组(P0.05);观察组术后主要心脏不良事件发生率明显低于对照组(P0.05),且左心室射血分数明显高于对照组(P0.05),左心室舒张末期内径低于对照组(P0.05)。结论替罗非班联合替格瑞洛可有效改善行PCI治疗的STEMI患者心肌灌注,有助于保护患者心脏功能,降低无复流发生率,能够明显减轻主要心脏不良事件的发生率。     

主动脉内球囊反搏术联合血栓抽吸治疗大面积ST段抬高型急性心肌梗死患者的疗效

目的评价主动脉内气囊反搏术(IABP)联合血栓抽吸对急诊经皮冠状动脉介入(PCI)治疗的急性大面积ST段抬高型心肌梗死(STEMI)患者临床预后的影响。方法发病12 h内的急性大面积STEMI患者120例随机分为试验组和对照组各60例,均给予规范的药物治疗并急诊冠脉造影,试验组应用IABP联合冠脉内血栓抽吸,对照组单纯血栓抽吸后行PCI术。评价梗死相关血管PCI术后冠脉血流(TIMI)分级,心肌组织灌注(TMP)分级、无复流或慢血流发生率、IABP并发症及术后4 w心功能、主要不良心脏事件的发生情况。结果试验组PCI术后TIMI 3级血流发生率、TMP明显高于对照组;慢血流、无复流发生率明显低于对照组;术后4 w左心室射血分数(LVEF)明显高于对照组,左心室舒张末期内径、主要不良心脏事件的发生率小于对照组(均<0.05)。结论急性大面积STEMI患者急诊PCI前应用IABP联合血栓抽吸能改善梗死相关血管的急性心肌梗死溶栓(TIMI)血流,增加冠脉灌注,改善心功能,减少主要不良心脏事件的发生率,临床应用安全有效。     

急性心肌梗死患者白介素17水平与心肌无复流的相关性研究

目的探讨急性心肌梗死患者白介素17(IL-17)与经皮冠状动脉介入(PCI)术后心肌无复流的相关性。方法本研究为前瞻性队列研究。选取2014年1月至2016年1月在海口市人民医院行PCI治疗的106例急性心肌梗死患者,根据PCI术后心肌复流情况分为无复流组(TIMI血流分级≤2级)31例和复流组(TIMI血流分级3级)75例。分别测定患者PCI术前和术后肌钙蛋白I(cTnI)和IL-17的表达水平,超声心动图评估心功能,比较主要不良心血管事件(MACE)发生情况。结果 PCI术后16～18 h时,无复流组IL-17水平显著高于复流组[(58.49±1.52)μg/L比(41.24±3.12)μg/L,P<0.05]。无复流组术后cTnI水平明显高于复流组[(1.34±0.42)μg/L比(0.42±0.13)μg/L,P<0.05]。随访12个月后,无复流组的左心室射血分数明显低于复流组,而左心室收缩末期内径和左心室舒张末期内径均显著大于复流组(均为P<0.05),复流组的MACE事件发生率明显低于无复流组(5.3%比19.3%,P=0.013)。结论 IL-17对急性心肌梗死患者经皮冠状动脉介入术后无复流有一定的预测价值,可作为评估无复流的一个辅助指标。     

替罗非班对急性心肌梗死急诊冠状动脉介入治疗冠状动脉血流和微循环的影响

目的分析应用替罗非班对ST段抬高性心肌梗死患者急诊行冠状动脉介入治疗冠状动脉血流和微循环的影响。方法ST段抬高性心肌梗死行直接冠状动脉介入治疗患者58例,随机分为替罗非班组(n=30)和对照组(n=28)。比较两组患者临床基础情况、冠状动脉介入治疗前梗死相关血管开通率、手术前后心肌梗死溶栓治疗血流情况、心电图ST段回落、术后内皮细胞凋亡数及凝血状态、住院期间出血事件、主要心脏不良事件发生率和出院前左心室射血分数等。结果替罗非班组使术前TIMI血流分级达到1级血流比例明显高于对照组(P<0.05),2级及3级血流两组之间差异无显著性(P>0.05),同时在对照组血流完全闭塞率高于替罗非班组(P<0.01),术中无复流现象、再灌注心律失常、内皮细胞凋亡数及凝血因子在替罗非班组均显著低于对照组(P<0.05),再通后90min心电图相关导联ST段回落值替罗非班组明显大于对照组(P<0.05),出院前左心室射血分数、两组患者主要心脏不良事件发生率和住院期间主要出血事件发生率差异无统计学意义(P>0.05)。结论替罗非班对急性ST段抬高性心肌梗死急诊行介入治疗可改善术前梗死相关血管TIMI血流情况,使介入手术顺利更好进行,争取更多时间避免较多的心肌细胞永久性坏死,改善心肌微循环障碍,减少无复流现象。     

内皮细胞损伤对于经皮冠状动脉介入术后血流的意义

目的:研究经溶栓或经皮冠脉介入术(PCI)治疗后冠脉恢复正常血流患者和冠脉无复流患者内皮细胞的损伤情况,并探讨其临床意义。方法:选择90例PCI患者,根据术后血流分级(TIMI分级)分为两组,冠状动脉血流≤TIMI2级40例,为无复流组,TIMI3级50例,为对照组。检测两组患者冠脉血中内源性一氧化氮(NO)、内皮素(ET)、血小板表面活化标志蛋白(CD63)水平,以此判断内皮细胞受损情况。结果:PCI术后无复流组较对照组冠脉中NO明显减少[(41.52±6.1):(61.94±10.7)μmol/L],而ET[(117.42±11.1):(59.08±9.8)mg/L]、CD63[(7.43±8.2)%:(2.05±2.8)%]显著增加(P均0.05)。提示在PCI后患者出现无复流现象者较血流恢复正常者冠状动脉内皮损伤更严重。结论:内皮细胞损伤是冠状动脉PCI术后无复流的重要原因。     

冠状动脉内注射尼可地尔对急性ST段抬高型心肌梗死患者急诊经皮冠状动脉介入术中无复流的疗效及安全性

目的探讨尼可地尔对急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入(PCI)术中无复流的疗效及安全性。方法将2013年12月至2015年9月在内蒙古医科大学附属医院行急诊PCI治疗中发生无复流现象的87例STEMI患者随机分为观察组(44例)和对照组(43例),观察组患者经冠状动脉注射尼可地尔治疗,对照组患者经冠状动脉注射硝酸甘油治疗。观察比较两组患者注射5 min后的TIMI血流分级与校正的TIMI帧数,以及术后左心室射血分数、ST段回落率、出血、低血压和不良心血管事件发生率。结果经冠状动脉注射后5 min,观察组患者的TIMI 3级血流比例明显高于对照组(77.27%比51.16%,P=0.000),靶血管的校正的TIMI帧数明显低于对照组(28.3±5.2比40.6±7.3,P=0.003),术后1周的左心室射血分数明显高于对照组(50.78%±4.23%比43.84%±3.62%,P=0.027),术后ST段回落率明显大于对照组(84.09%比69.77%,P=0.016),不良心血管事件发生率明显小于对照组(36.36%比65.12%,P0.05)。结论经冠状动脉注射尼可地尔可有效改善急性STEMI患者急诊PCI中的无复流现象,且安全性较好。     

血清总胆红素水平与ST段抬高型心肌梗死患者经皮冠状动脉介入治疗术后冠状动脉血流的相关性

目的探讨血清总胆红素(STB)水平与ST段抬高型心肌梗死患者(STEMI)经皮冠状动脉介入治疗(PCI)术后冠状动脉血流的相关性。方法选取成功实施PCI的STEMI患者264例,根据TIMI血流等级将患者分成两组,TIMI 0~2组和TIMI 3组。根据STB水平分成高STB组(>0.9 mg/dl)和低STB组(≤0.9 mg/dl),应用单因素分析和多因素Logistic回归分析探讨PCI术后冠状动脉血流的相关因素。结果 TIMI 0~2组96例患者平均年龄(61.5±9.7)岁,其中男68例,TIMI 3组患者168例,平均年龄(59.3±10.4)岁,其中男132例;TIMI 0~2组STB水平明显高于TIMI 3组(P=0.013);院内心脏不良事件发生率明显高于TIMI 3组(P=0.000 1)。与低STB组相比,高STB水平组无复流现象明显增加(46.0%vs27.5%,P=0.000 9),主要心脏不良事件更加频繁(19.8%vs 8.7%,P=0.005);多因素Logistic回归分析,STB水平(OR=2.15,95%CI 1.87~2.52;P=0.002)仍然是影响PCI术后STEMI患者无复流现象发生的独立危险因素。结论 STB水平可作为STEMI患者PCI术后冠状动脉血流恢复不良的一个可靠而独立的生化标记物。     

冠状动脉内注射替罗非班对老年ST段抬高型急性心肌梗死患者直接PCI中无复流的疗效

目的观察冠状动脉内注射替罗非班对老年急性ST段抬高型急性心肌梗死(STEMI)患者直接经皮冠状动脉介入治疗(PCI)术中无复流的疗效。方法收集该院2008年1月至2011年1月老年急性STEMI行直接PCI术中出现无复流患者87例,其中替罗非班组42例,对照组45例。评估心肌梗死溶栓试验(TIMI)血流分级、TIMI心肌组织灌注分级(TMPG)、PCI术后90 min ST段完全回落率、肌酸激酶工功酶(CK-MB)和肌钙蛋白T(cTnT)峰值、PCI术后7 d左心室射血分数(LVEF)、住院期间和PCI术后180 d内主要心脏不良事件(MACE)、住院期间出血发生率。结果替罗非班组TIMI 3级及TMPG 3级血流比例均高于对照组(分别为81.0%vs 51.1%,76.2%vs 46.7%,均P<0.01),替罗非班组ST段完全回落率大于对照组(76.2%vs 48.9%,P<0.01),CK-MB及cTnT峰值均低于对照组〔(177.1±36.2)U/L vs(221.6±44.6)U/L,(4.90±1.85)ng/L vs(6.55±2.04)ng/L,均P<0.01)〕,PCI术后7 d LVEF高于对照组(49.3%±6.3%vs 44.9%±5.2%,P<0.01);住院期间MACE少于对照组,但差异无统计学意义(33.3%vs 60.0%,P>0.05);PCI术后180 d内MACE少于对照组(40.5%vs 71.7%,P<0.01);替罗非班组与对照组均增加了患者住院期间出血发生率,分别为23.8%和11.1%,但差异无统计学意义(P>0.05)。结论冠状动脉内注射替罗非班可以增加老年急性STEMI患者直接PCI术中发生无复流现象后冠状动脉血流和心肌组织灌注,减少心肌坏死,改善心功能和预后,不增加严重出血的风险,是老年STEMI患者直接PCI术中出现无复流现象后的一种安全、有效的治疗方法。     

Provisional T-stenting and kissing balloon in the treatment of coronary bifurcation lesions: results of the French multicenter "TULIPE" study.

BACKGROUND: In previous prospective studies, a strategy of (a) stenting of the main branch, (b) provisional T-stenting of the side branch, and (c) final kissing balloon inflation, was associated with high success and low target lesion revascularization (TLR) rates on the long-term. OBJECTIVES: To examine the performance of this strategy in a multicenter study. METHODS: Consecutive patients were treated at 14 French medical centers for de novo coronary bifurcation lesions with the same technique used. Immediate results and clinically-driven TLR at 7 months were examined. RESULTS: The mean reference diameters of the main and side branches were 3.2 +/- 0.6 mm and 2.4 +/- 0.5 mm, respectively. The side branch was stented in 34% of patients. A <30% residual stenosis in the main branch was achieved in 99%, <50% in the side branch in 90%, and both in 89% of procedures. The in-hospital major adverse cardiovascular event were a Q-wave and 5 non-Qwaves MI (0.54% and 2.7%). At 7 months of follow-up, 3 patients (1.76%) had died, 1 suffered a non-Q-wave MI (0.59%), and 28 (15.88%) underwent TLR. By multivariate analysis, a lower left ventricular ejection fraction (OR: 0.934), moderate calcifications (OR: 7.86), and non-use of the "jailed" wire technique (OR: 4.26) were associated with reinterventions during follow-up. CONCLUSIONS: A strategy of provisional T-stenting with a tubular stent and final kissing balloon angioplasty for the treatment of coronary bifurcation lesions was safe and associated with a low TLR rate at 7 months. This strategy should be applicable to the new era of drug eluting stents.     

Grading the angiographic extent of collateral filling

Angiography frequently demonstrates a collateral circulation in severe coronary artery disease. An easily applicable method to quantify collateral flow might be a useful adjunct for the assessment of the hemodynamic effects of coronary artery disease. The purpose of this study was to validate a visual scaling of the extent of angiographic collateral filling by comparison with flowmeter- and microsphere-derived measurements of collateral flow. In 12 open-chest dogs, collaterals from the circumflex artery were angiographically visualized (n = 80) by creating acute critical left anterior descending artery occlusion. The extent of collateral filling was graded in four levels from 0 = no visible filling to 3 = complete epicardial filling. Collateral filling correlated with the change in flow of the collateral supplying circumflex artery (Q; r = 0.84) which was + 5.3 ±4.6% with grade 1, + 9.1 ±3.5% with grade 2 and + 14.6 ±4.7% with grade 3 (p < 0.01). In parallel, coronary flow reserve decreased from 4.1 ±0.8 with grade 0 to 2.9 ±0.2 with grade 3 (p < 0.01). Colored microspheres were injected subselectively into the circumflex artery of 9 dogs (45 injections). The ratio of microspheres counted in the collateralized myocardium of the left anterior descending artery to the total number injected increased from 0.6 ±0.9% for grade 0 to 17.1 ±2.8% with grade 3 (p < 0.01). Absolute collateral flow derived from microsphere counts averaged 5.5 ±0.9 ml/min with grade 3 and closely correlated with collateral filling grade (r = 0.88). Semiquantitative grading of angiographic collateral filling in response to acute coronary occlusion in a canine model correlates with an increase in collateral source artery flow, absolute collateral flow and a decrease in source artery flow reserve. These data suggest that this scale might be a simple but useful adjunct tool to assess the hemodynamic significance of a collateral circulation.This work was supported by a grant from the NLHBI 1 R01 HL40865. Dr. Schuhlen is the recipient of a grant from the Deutsche Forschungsgemeinschaft (#Schu657/1-1 and 1–2).     

Embolization complicating coronary angioplasty in the presence of an intracoronary thrombus

Two cases of coronary occlusion and subsequent embolization during percutaneous coronary angioplasty (PTCA) are described. Prior to PTCA, angiographic evidence of intracoronary thrombus was present. Abrupt reclosure after dilation was treated by successful redilation. However, coronary embolization of thrombus debris occurred downstream in one patient and into an adjacent coronary branch in the second patient.     

非罪犯冠脉斑块研究的进展

加强冠心病的二级预防是目前防控急性冠脉综合征（ACS）的重要手段。本文对ACS与非罪犯冠脉斑块的关系作了综述。     

LAD-right ventricular fistula complicating PTCA: Another case

Coronary perforation caused by percutaneous transluminal coronary angioplasty (PTCA) occurs rarely and most often leads to communication to the pericardial space. We report a case where PTCA caused a coronary artery rupture and fistulization to the right ventricular outflow tract. Cathet. Cardiovasc. Diagn. 42:34–36, 1997. © 1997 Wiley-Liss, Inc.     

Treatment of ruptured coronary aneurysm with a novel covered stent

Coronary artery aneurysms are relatively rare but have been diagnosed with increasing frequency since the advent of coronary arteriography. Their reported incidence varies from 1.5% to 5% with male dominance and a predilection for the right coronary artery (RCA), accounting for over 40% of all cases. The most common etiology amongst adults remains atherosclerosis accounting for 50% of coronary aneurysms. We describe the first use of a novel flexible pericardium covered stent for successful treatment of a ruptured coronary aneurysm in 76 year old lady. © 2008 Wiley‐Liss, Inc.     

Techniques for palmaz-schatz stent deployment in lesions with a large side branch

Palmaz-Schatz coronary stent implantation in lesions with a large side branch are reported. The first case describes how to manage plaque shifting after stent implantation. The second and third cases demonstrate a kissing balloon predilatation and stent dilatation technique of a bifurcational lesion. The final case demonstrates a stent implantation technique through the stent struts of a previously deployed stent.     

Is short-stay coronary angioplasty safe?

Percutaneous transluminal coronary angioplasty (PTCA) is usually performed as an inpatient procedure and the patients are monitored for several days afterward. Over a 13-month period, in 91 of 373 PTCA procedures, the clinical condition of the patient did not necessitate inpatient status before PTCA. PTCA was done the day of admission and discharge planned the following. Overall hospital stay was planned as less than 24 hours. PTCA was done in one vessel in 62 patients, two vessels in 24, three vessels in 3, and four vessels in 2 patients. PTCA was initially successful (less than 50% residual stenosis) in 85 patients (93%). In one of these, acute occlusion occurred the next morning and urgent bypass surgery was done. PTCA failed in 6 patients who left the catheterization laboratory with unchanged coronary anatomy. Bypass surgery was performed that day in 2 patients, on another admission in 1 patient, and medical therapy continued in the other 3 patients. Of the 88 patients not receiving same admission bypass surgery, 84 (95%) were discharged in less than 24 h. Hospitalization was prolonged (1-5 days) in 4 patients. This was because of nonobstructive dissection treated with heparin for approximately 24 h in 2 patients; a catheterization site hematoma in 1 patient, and post-PTCA noncardiac chest pain in another. No patient had inhospital myocardial infarction or death. The only late complication was in a patient treated with heparin and monitored for 2 days; 3 weeks later angina returned and he died suddenly. These data suggest PTCA can safely be done in selected patients with both single and multivessel disease in a short stay inhospital setting.(ABSTRACT TRUNCATED AT 250 WORDS)     

Angiographic demonstration of coronary sinus thrombosis: A potential consequence of trauma to the coronary sinus

Abnormalities of the coronary sinus are rarely encountered. A case is presented demonstrating for the first time the angiographic appearance of coronary sinus thrombosis. This may have been the result of surgical trauma during mitral valve replacement or inadvertent cannulation of the coronary sinus during right heart catheterization or pacemaker insertion. Although the clinical significance of coronary sinus thrombosis is uncertain, obstruction of coronary sinus blood flow should not be deleterious because of multiple anastomoses between the coronary sinus system and the anterior cardiac veins. Difficulty in cannulating the coronary sinus for physiologic studies should suggest the possibility of coronary sinus thrombosis, especially in patients who have undergone mitral valve replacement. This may be confirmed by observing the venous phase of selective left coronary arteriography. Finally, coronary sinus thrombosis may be important as a source of pulmonary emboli. The prevalence of this serious complication requires further study.     

Coronary arteriovenous-arterial fistula

A case of multiple arteriovenous fistulae is described in an adult with coronary artery disease. One of these fistulae drained into the anterior interventricular vein, which in turn communicated with and perfused an obstructed left anterior descending coronary artery.