急性心肌梗死急诊介入治疗后患者心肌灌注的动态演变

Development of Myocardial Perfusion in Acute Myocardial Infarction Patients After Emergency Percutaneous Coronary Intervention

目的:观察急性心肌梗死(AMI)患者梗死相关血管再通达心肌梗死溶栓治疗临床试验(TIMI)3级血流后心肌组织灌注的动态演变,以探讨心肌无复流现象的临床特点及意义。方法:43例AMI患者,急诊冠状动脉介入治疗后梗死相关血管血流达TIMI 3级。分别于冠状动脉介入治疗后即刻、24 h内、2周和3个月时行单光子发射型计算机断层扫描(SPECT)。根据心肌灌注缺损积分,将患者分为无复流组(17例)和复流组(26例)。分析两组心肌灌注缺损积分、左心室射血分数、左心室舒张末期容积(LVEDV)和左心室收缩末期容积(LVESV)的变化规律,并进行组间比较。结果:(1)无复流组在冠状动脉介入治疗后即刻、24 h内、2周和3个月时的心肌灌注缺损积分分别为8．5±1．9, 6．4±2．3、4．6±2．1和4．2±1．7,复流组为4．1±1．0、1．7±1．2、0．5±1．1和0．4±1．0;无复流组和复流组冠状动脉介入治疗后积分在2周内均呈逐渐减低趋势,至2周时趋与稳定,2周和3个月之间比较均无显著差异(P>0．05);两组间同时相点比较,无复流组心肌灌注缺损积分在各点均显著高于复流组(P<0．01)。(2)两组左心室射血分数均呈逐渐增加趋势,但无复流组左心室射血分数较复流组恢复延迟,且在各时点均显著低于复流组。复流组冠状动脉介入治疗后左心室舒张末容积逐渐减小,无复流组则继续增加,2周时达高峰,而后开始减小,3个月时虽低于2周时,但仍显著大于冠状动脉介入治疗后24 h内(P<0．01);无复流组的左心室舒张末容积在各时相点均显著大于复流组。(3)无复流组冠状动脉介入治疗后即刻的灌注缺损积分与同时相点和3个月时的左心室射血分数均呈显著负相关(分别为r=-0．512,P< 0．05和r=-0．498,P<0．05)。结论:AMI血运重建后梗死相关血管血流达TIMI 3级的患者仍存在心肌无复流现象,但心肌无复流现象有随时间改善的趋势,至2周左右趋于稳定;早期的心肌灌注状况与后期的心功能恢复及左心室重构的发生密切相关。

Objective： To investigate the development of myocardial microvascular perfusion and the clinical significance of no reflow phenomenon in patients with acute myocardial infarction （AMI） after recanalization of infarction-related arteries. Methods： In 48 patients with first acute myocardial infarction underwent successful emergency percutaneous coronary intervention （PCI）, Single-photon emission computed tomography （SPECT） was used immediately ＇after PCI and repeated at 24 hours, 2 weeks and 3 months after PCI. All patients were assigned to no-reflow group （ n = 22） and reflow group （ n = 26） by SPECT score. To analyze the development of myocardial perfusion defect score, left ventricular ejection fraction （LVEF） , left ventricular end-diastolic volume （LVEDV） and left ventricular end-systolic volume （LVESV） in all patients. Results ： （ 1 ） Immediately, 24 hours, 2 weeks and 3 months after PCI, the mean values of SPECT myocardial perfusion defect score were 8.7 ±2. 4,6. 8 ± 2. 4,4. 8± 2.6 and 4.3 ± 1.9 respectively in no-reflow patients, Compared with 4. 1 ± 1.0, 1.7 ± 1.2,0. 5 ± 1.1 and 0. 4 ± 1.0 in patients with reflow. The differences were remarkable within the first 24 hours between groups （P 〈 0. 05 ）. The patients in no-reflow group had a higher myocardial perfusion defect score than those in reflow group （P 〈0. 01 ）. （2） LVEF was significantly improved at 3 months and significantly reduced immediately after PCI （P 〈 0. 05, respectively）. The patients in reflow group had a higher LVEF than those in no-reflow group immediately after PCI. （3） LVEDV was significantly greater at 2 weeks and 3 months than immediately after PCI （P 〈0.01 ）. LVESV was significantly greater at 2 weeks than immediately after PCI （ P 〈 0. 01 ） and significantly less at 3 months than immediately after PCI （ P 〈 0.05）. The patients in no-reflow group had a higher LVEDV and LVESV than those in reflow group at every time point. （4） The myocardial perfusion defect score immediately after PCI was negatively correlated with LVEF at 3 months after PCI （r = -0. 546, P 〈 0.01 and r = -0. 536,P 〈 0. 05, respectively）. Conclusion： Myocardial no-reflow phenomenon has an amelioration tendency with time going, and the tendency may be stable after 2 weeks ; Early myocardial perfusion has a close correlation with late myocardial function and left ventricle reconstitution.