左主干急性闭塞或狭窄所致急性心肌梗死的急诊介入治疗

Primary percutaneous coronary intervention in patients with acute myocardial infarction induced by left main artery occlusion or severe stenosis

目的总结左主干急性闭塞或狭窄所致急性心肌梗死（AMI）患者急诊经皮冠状动脉介入治疗（PCI）的经验，探讨急诊PCI在此类患者中的安全性和有效性。方法从1995年1月至2004年12月，在1343例急诊PCI中，共有11例梗死相关血管为左主干。11例患者均为男性，年龄43～70岁，平均（56．4±9．2）岁，其中6例（54．5％）入院时即存在严重心原性休克。所有患者均在主动脉内球囊反搏支持下接受急诊PCI治疗。结果8例急诊置入支架，余3例仅行球囊扩张，后者有2例术后接受急诊冠状动脉旁路移植术。住院期间死亡5例（45．5％），存活的6例患者均完成3个月随访，其中4例随访超过2年，1例于术后4年猝死，1例患者术后5年重复造影检查结果良好。对比分析提示术前存在良好的侧支循环可能是影响此类患者急诊PCI术后疗效的因素。结论左主干急性闭塞或严重狭窄所致的AMI患者病情凶险，急性期死亡率高。侧支循环形成与否，治疗策略和预后不同，主动脉内球囊反搏支持下急诊PCI治疗可以挽救部分患者的生命和改善预后，对于侧支循环不良的患者，部分再灌注策略可能为一种有效手段之一，值得进一步研究。

Objective The effects of primary percutaneous coronary intervention （PCI） in patients with acute myocardial infarction （AMI） induced by left main （LM） artery occlusion were analyzed retrospectively in this study. Methods A total of 1343 consecutive AMI patients who underwent primary PCI between January 1995 and December 2004 were retrospectively studied. Results LM occlusion or severe stenosis were found in 11 patients [ all male, mean age （ 56. 4 ± 9.2 ） years （ range 43-70 years） ], cardiogenic shock was overt in 6 patients. Primary PCI were performed under the assistance of intra-aortic balloon pump （IABP） in these patients [ 8 stent implantation, 3 balloon dilation and 2 necessitating emergency CABG after balloon dilation ]. In-hospital mortality was 45. 5% （5/11）. Three-month follow-up were made in all survivals （6/11 ）. Analysis showed good collateral circulation flow from right coronary artery to left coronary artery was existed in all survival cases before PCI. Conclusion Prognosis of AMI patients with LM artery obstruction or severe stenosis was poor. Patients with pre-existed collateral circulation before primary PCI and IABP had a better clinical outcomes.