急诊经皮冠状动脉腔内成形术治疗急性心肌梗塞并发心原性休克

Emergent percutaneous transluminai coronary angioplasty in acute myocardial infarction complicated by cardiogenic shock

12例急性心肌梗塞(AMI)并发心原性休克患者,应用急诊经皮冠状动脉腔内成形术(PT-CA)治疗.11例(91.7%)梗塞相关动脉再通,再通者7例(63.6%)休克被纠正,6例(54.5%)出院时存活.随访13～55(平均30.3±21.1)个月,4例(36.4%)长期存活.表明,国人AMI并发心原性休克患者行PTCA可明显降低病死率至50%以下,在主动脉内球囊反搏支持下,患者耐受操作良好,未发生与操作有关的并发症.左主干闭塞、3支冠状动脉病变特别是非梗塞相关动脉亦有慢性完全闭塞病变存在时病死率高,提示对这些患者可能需要更完全的血运重建.

In order to reduce the mortality of cardiogenic shock, emergent percutaneous transluminal coronary angiopiasty (PTCA) was performed in 12 acute my-ocardial infarction (AMI) patients complicating with cardiogenic shock in this institution from January 1990 to May 1994. There were anterolateral MI in 4 cases, inferoposterior MI in 7, anterior and inferior MI in 1, including 4 triple vessel disease, 6 double vessel disease. 1 single vessel disease and 1 left main coronary artery (LM) disease. The infarct -related coronary arteries (IRCA) were of LAD in 4 cases, RCA in 7, LCX in 1, and LM in 1 (both RCA and LAD were of IRCA in 1 case). The systolic biood pressure was less than 80 mmHg LVEDP was higher than 20mmHg and the evidences of decreased tissue perfusion were present in all the patients. Before PTCA, recurrent ventricular fibrillation was occurred in 2 cases, papillary muscular dysfunction and pulmonary edema in 1 and accompanied post-infarction angina pectoris in 1. PTCA was performed under assistance of IABP in 7 cases and of centrifugal pump in 1. Usually only IRCA was dilated during acute phase. Direct PTCA was undergone in 7 cases and rescue PTCA after failure of thrombolytic therapy in 5.The results revealed that procedures of PTCA were successful in 11 (91. 7%) of the 12 cases. One case failed with PTCA was reperfused by intracoro-nary thrombolytic therapy in the IRCA. Cardiogenic shock was reverted in 7 (63. 6/lj) of the 11 cases reperfused by PTCA, among whom 6 cases (54. 5%) survived. Four cases died from irreversible shock after 3 hours-9 days and 1 case with reversed shock died of cardiac rupture after 4 days. During a period of 13-55 months follow-up, long-term surviving were obtained in 4 cases. In conclusion, emergent PTCA can achieve high success rate and significantly decrease the mortality to less than 50% in patients with cardiogenic shock complicating AMI. The patients tolerate the PTCA procedure very well under the assistance of IABP even in very severe condition. The prognosis of patients with triple vessel disease and with total occlusion in one non-IRCA was very poor even after successful reperfusion of the IRCA, which suggested that complete revascularization might be necessary for these patients.