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| 应用自制带侧孔灌注球囊处理经皮冠状动脉介入术中无复流的方法 |
| 谭洪文△,张志钢△,白元,李长永,许旭东,张必利,朱嘉琦,赵仙先,吴弘*,秦永文* |
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(第二军医大学长海医院心血管内科, 上海 200433
△共同第一作者
*通信作者) |
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| 摘要: |
| 目的 探讨应用自制带侧孔球囊处理经皮冠状动脉介入术（percutaneous coronary intervention，PCI）过程中无复流（no-reflow，NR）的安全性及有效性。方法 2011年1月至2012年1月在我院行PCI术中发生NR的患者，排除冠状动脉狭窄、夹层、痉挛或血栓。共23例，平均年龄（62.0±13.8）岁，其中急诊ST抬高急性心肌梗死（ST segment elevation myocardial infraction，STEMI）患者14例，择期PCI患者9例；NR发生于前降支11例，右冠状动脉8例，回旋支4例。应用自制带侧孔球囊在发生NR的冠脉内推注硝酸甘油及盐酸替罗非班，观察治疗前后靶血管心肌梗死溶栓试验（thrombolysis in myocardial infarction，TIMI）血流分级情况，STEMI患者术后心电图ST段回落（ST segment resolution，STR）情况，术后3 d心电图ST-T变化情况，住院期间冠状动脉穿孔、夹层、血栓等并发症。术后1个月随访心电图，心脏超声射血分数（left ventricular ejection fraction，LÜEF）及短轴缩短率，术后6个月随访心功能及主要心血管不良事件（major adverse cardiovascular event，MACE）发生率。结果 应用带侧孔球囊冠脉内注射药物后血流TIMI 1级3例，TIMI 2级5例，TIMI 3级15例。14例急诊STEMI患者术后ST段完全回落（≥70%）8例，部分回落（30%～69%）4例，2例无回落（<30%）；2例ST段无回落患者中1例术后出现心室电风暴，经治疗后好转出院，1例术后因心包填塞经心胸外科急诊手术发现左室游离壁破裂，抢救无效死亡。9例择期PCI患者术后心电图ST段一过性抬高3例，经保守治疗1周心电图ST段回落，住院期间无冠状动脉穿孔、夹层、血栓发生。22例患者出院后1个月查心脏超声，平均LÜEF为（50.6±14.3）%，短轴缩短率0.36±0.04，心电图提示6例有非特异性ST-T改变。4例STEMI患者因非罪犯血管行PCI治疗时复查造影提示发生NR血管血流TIMI 3级。术后6个月时随访无MACE事件，心功能（NYHA）Ⅰ级18例，Ⅱ级4例。结论 初步研究表明应用自制带侧孔灌注球囊推注药物方法治疗PCI术中NR安全、经济、便捷、有效，但仍需大样本临床研究进行评价。 |
| 关键词: 经皮冠状动脉介入治疗 无复流 治疗 |
| DOI：10.3724/SP.J.1008.2014.00317 |
| 投稿时间：2013-11-17修订日期：2014-01-03 |
| 基金项目:中国医师协会阳光心血管研究基金（SCRFCMDA201225）. |
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| Self-made side hole balloon for treating no-reflow following percutaneous coronary intervention |
| TAN Hong-wen△,ZHANG Zhi-gang△,BAI Yuan,LI Chang-yong,XU Xu-dong,ZHANG Bi-li,ZHU Jia-qi,ZHAO Xian-xian,WU Hong*,QIN Yong-wen* |
(Department of Cardiovasology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
△Co-first authors.
*Corresponding author.) |
| Abstract: |
| Objective To assess the safety and effectiveness of self-made side hole balloon for treating no-reflow following percutaneous coronary intervention(PCI). Methods Twenty-three patients diagnosed with no-reflow during PCI from Jan. 2012 to Jan. 2013 were enrolled. Residual stenosis, thrombosis,dissection, and spasm of coronary artery were excluded. The mean age of the 23 patients was (62.0±13.8) years old. Of the 23 patients 14 had ST segment elevation myocardial infarction (STEMI), and 9 underwent elective PCI. There were 11 cases with no-reflow in the left anterior descending branch, 8 in the right coronary artery and 4 in the circumflex branch. The drugs (nitroglycerin and tirofiban) were selectively injected into the vessel using self-made side hole balloons. The thrombolysis in myocardial infarction (TIMI) grade before and after procedure,ST segment resolution (STR),ST-T changes for 24 and 72 hours and complications (perforation, dissection,and thrombosis of coronary artery) were observed postoperatively. Patients were followed up by ECG and echocardiogram at 1 month after PCI. Incidence of major adverse cardiovascular events (MACEs) and cardiac function were observed 6 months after PCI. Results After intracoronary administration of drug therapy, TIMI grade-1 flow was found in 3 patients, TIMI grade-2 flow in 5 patients and TIMI grade-3 flow in 15 patients. In patients with STEMI, complete resolution (≥70%) was found in 8 patients,partial resolution (30%-69%) in 4, and no resolution (<30%) in 2. One of the 2 patients with ventricular electrical storm was treated with temporary cardiac pacing and drug therapy and recovered within 1 week; the other one with pericardial tamponade who was treated with emergency surgery repair died. In 9 patients undergoing selected PCI,transient ST segment changes were noted in 3 patients which recovered within 1 week after conservative treatment; with no perforation, dissection,or thrombosis of coronary artery. One month after discharge, echocardiogram of the 22 patients showed a mean left ventricular ejection fraction (LÜEF) of (50.6±14.3)% and a fractional shortening in the short axis view of 0.36±0.04, and ECG showed non-specific changes of ST-T in 6 patients. In 4 patients with STEMI, culprit artery showed TIMI grade-3 by angiography performed during PCI for non-culprit vessel 1 month after primary PCI. At 6 months after primary PCI, there was no MACE; 18 patients were in New York Heart Association Class Ⅰ and 4 in Class Ⅱ. Conclusion Self-made side hole balloon is a safe, economical, effective and convenient method for intracoronary administration of nitroglycerin and tirofiban in treating no-flow during PCI, but the result still needs further verification. |
| Key words: percutaneous coronary intervention no-reflow treatment |
