经皮激光心肌血管重建术对心脏去神经和心肌缺血作用的临床研究

Chronic effects of percutaneous transmvocardial laser revascularization in patients with refractory angina

目的目前国内外对经皮激光心肌血管重建术(PMR)的疗效和作用机制有很大争议。本研究目的在于评价 PMR 是否能改善顽固性心绞痛患者的临床症状和心肌缺血的客观指标,以及PMR 对心脏的去神经作用,探讨 PMR 的临床疗效和可能的作用机制。方法30例顽固性心绞痛进行冠状动脉造影后不适合冠状动脉介入和外科冠状动脉旁路移植术治疗的患者,被随机分为两组:经皮激光心肌血管重建组17例和药物治疗组13例,随访(11.6±4.9)个月。经皮激光心肌血管重建术前、术后60 min 和术后1年冠状窦采全血,ELISA 测定去甲肾上腺素和肾上腺素浓度,Holter 分析心率变异性(HRV)、心肌缺血总负荷(TIB)和缺血性 ST 段事件(STI),心肌核素显像检查心肌灌注情况。结果 PMR 组17例患者中1例出现非持续性室性心动过速;2例打孔后出现心包压塞;1例于术后24 h 出现心力衰竭。药物治疗组无严重并发症发生。PMR组术后1年心绞痛级别下降1.7±0.3,与药物治疗组相比,差异有统计学意义(P<0.05)。运动耐量比药物治疗组有增加趋势,但未达到统计学意义。心肌缺血总负荷、缺血性 ST 段事件、心肌灌注情况术后24 h 和术后1年两组间差异均无统计学意义。PMR 组术后60 min 冠状窦去甲肾上腺素和肾上腺素含量明显低于药物治疗组(P<0.05),但术后1年两组间差异无统计学意义;PMR 组术后24 h 心率变异性显著高于药物治疗组(P<0.05),但是术后1年两组间差异无统计学意义。结论 PMR 虽然能改善顽固性心绞痛患者的临床症状,但是不能改善心肌缺血;PMR 早期有心脏去神经作用,但是远期作用不显著。

Objective Conflicting results exist on the therapeutic effects of percutaneous myocardial laser revascularization （PMR） in patients with refractory angina pectoris. This study assessed the effects of PMR on myocardial innervation and perfusion in patients with refractory angina pectoris. Methods Patients with refractory angina unsuitable for standard revascularization treatment （ PTI and CABG） were randomly divided into medication plus PMR （PMR, n = 17 ） and medication group （M, n = 13 ）. Coronary sinus noradrenaline （NE） and epinephrine （E） levels, heart rate variability （HRV）, total ischemic burden （TIB）, and ischemic ST segmental events （STI）, myocardial perfusion were evaluated at pre-, immediately post and 12 months post treatment （ mean followed up time = 11.6 ± 4. 9 months）. Results In PMR group, one patient developed non-persistent ventricular tachycardia, 2 developed pericardial tampenade and another one patient developed heart failure at 24 h after operation. Coronary sinus NE and E were significantly lower 60 rain post PMR compared to pre-PMR and HRV was significantly increased 24 h post PMR. One year post treatments, angina grade was significantly decreased in PMR （ 1.7 ±0. 3） than that in M group （0. 4 ±0. 2, P 〈 0. 05） while other parameters were similar between the groups. Conclusions PMR induced an early transient denervation and decreased angina grade one year post treatment in patients with refractory angina.