左主干病变导致急性ST段抬高型心肌梗死的诊治体会

Diagnosis and treatment of acute myocardial infarction with elevated ST-segment induced by left main coronary disease

目的:总结左主干狭窄或闭塞导致急性ST段抬高型心肌梗死(AMI)患者的临床特点,并提出其早期诊断和治疗体会。方法:复习我院2年内246例AMI急诊经皮冠状动脉介入治疗(PCI)的临床资料,其中7例梗死相关血管为左主干,均为男性,年龄36～83岁,所有患者无论是否存在心源性休克,均立即行主动脉内球囊反搏术,并在其支持下尽早接受急诊造影检查。结果:7例患者心电图均存在aVR导联ST段抬高(≥0.05mV),5例患者同时存在V1-V6导联ST段抬高及新出现完全右束支传导阻滞,其中4例入院时即存在严重心源性休克,6例急诊置入支架,另1例仅行球囊扩张,并接受急诊冠状动脉旁路移植术,住院期间死亡3例(42.9%),存活患者4例均完成1年随访。其中2例于1月随访时对其LAD进行PCI,1例于3月随访时进行了LAD和LCX的冠状动脉旁路移植术。结论:左主干急性闭塞或严重狭窄所致的AMI患者急性期病死率高;根据心电图和临床特点早期识别梗死部位,早期评估,并且无论是否出现低血压或心源性休克早期行主动脉内球囊反搏术,并在其支持下尽早再灌注治疗,加强术后监护,提高随访质量,可以挽救部分患者的生命和改善预后。

Objective： To summarize the clinical features of acute ST-segment elevation myocardial infarction due to stenosis or occlusion of left main coronary artery, and provide the experiences of early diagnosis and treatments. Methods：Clinical data of 246 cases with acute myocardial infarction （AMI） undergone emergency percutaneous coronary intervention （PCI） were reviewed, among those 7 cases were with left main infarct-related artery, all 7 patients with or without cardiogenic shock underwent intra-aortic balloon pump （IABP） counterpulsation immediately, and then received emergency angiography as soon as possible. Results： aVR ST-segment elevated in all 7 cases （≥0. 05 mV）, 5 cases existed V1 -V6 ST-segment elevation and developed complete right bundle branch block, 4 cases with serious cardiogenie shock on admission, 6 cases received emergency stenting, one case underwent balloon expansion followed by emergency coronary artery bypass grafting,3 cases died during hospitalization （42. 9%）, 4 survived cases achieved one year follow- up, among them 2 cases underwent LAD PCI at 1 month＇s follow-up, one case underwent LAD and LCX coronary artery bypass grafting in the follow-up at 3 months. Conclusions：The mortality is high in pa tients with AMI caused by stenosis or occlusion of left main coronary artery. Early identification and assessment of the infarction site are necessary at the base of electrocardiogram and clinical characteristics. Patients should undergo IABP and achieve reperfusion under its support as soon as possible whether with hypotension or cardiogenic shock or not. Strengthen the postoperative care, improve the quality of follow-up might improve the prognosis and save parts of patients lives.