经皮激光心肌血运重建术的临床应用(附4例报告)

Clinical use of percutaneous laser myocardial laser revascularization:a report of 4 cases.

目的 评价钬激光经皮心肌血运重建术（ＰＭＲ） 的方法学。方法 病例选择：①顽固性Ⅲ～Ⅳ级心绞痛，②冠脉病变不适合搭桥，③６ 个月内无心肌梗死（ 心梗） ，④心电图和ＥＣＴ 示心肌缺血，⑤左室最大舒张厚度≥８ｍｍ 。操作方法：双平面左室造影，取最大舒张期作定位参照；激光器同步在Ｔ 波易损期前３０ｍｓ；经大腔管送入激光导管对缺血左室壁打孔，深度６ｍ ｍ ；在屏幕上标示打孔部位和序号。结果 ４ 例病人男性（６２ ±７） 岁。心绞痛（２１±９） 年，加拿大分级Ⅳ级３ 例，Ⅲ级１ 例。心电图和ＥＣＴ 示前壁、下壁或间隔缺血；左室壁最大舒张厚度（１１ ±３）ｍ ｍ ，射血分数（６２ ±５）％ ；冠脉造影３ 支和２ 支弥漫性病变各２ 例。共打孔（１４ ±３） 个，操作中病人无不适，无并发症，手术时间（６８±７）ｍｉｎ。术后心肌酶和心电监测正常，第３ 天心绞痛降为Ⅱ级１ 例、Ⅲ级２ 例，１ 周降为Ⅱ级３例，维持Ⅲ级１ 例，随访５ 个月均降为Ⅱ级。结论 采用钬激光系统行ＰＭＲ 安全可行，对Ⅲ～Ⅳ级心绞痛者能在短时间内控制症状。使用的操作方法简单实用，能有效防止心脏穿孔和心律失常。

Objective To evaluate the methodology of percutaneous laser myocardial revascularization(PMR)with holmium:YAG system.Methods Patients were selected by:①class Ⅲ to Ⅳ of angina pectoris;②the angina was refractory to more than three drugs;③not suitable for CABG;④without myocardial infarction within 6 months;⑤myocardial ischemia confirmed by ECT or ECG;⑥maximum diastolic wall thickness of left ventricle(LV)was ≥8mm.PMR steps include:①double plane LV angiogram;②the laser system calibration;③a laser catheter insertion into LV-via a guide tube;④endomyocardial channels in deepth of 6mm were made in the target LV walls.Results Four patients were male at the age of 62±7 years and with angina history of 21±9 years.They were refractory to 4±2 antiangina drugs.ECG or ECT showed inferior,anterior,or septal ischemia.The maximum LV diastolic wall thickness was 11±3mm.CAG showed bivessel or trivessel diffuse lesions.A total of 14±3 myocardial channels were made.Total procedure time was 68±7 min without major or minor complications.Angina class was decreased from Ⅲ or Ⅳ to Ⅱ in 5 month follow-up.Conclusion It is feasible and safe to conduct PMR by holmium:YAG laser system.The procedure used is simple,effective and has few complications.Refractory Ⅲ to Ⅳ class angina could be controlled by PMR conjuncted with regular antiangina drugs.