单纯导管血栓抽吸快速恢复ST段抬高型心肌梗死心肌“再灌注”的临床观察

The clinical observation of rapid recover myocardium reperfusion by using only catheter thrombus aspieration in patients with STEMI

目的探讨单纯使用导管抽吸血栓方法开通急性sT段抬高型心肌梗死（STEMI）患者冠脉并恢复“再灌注”治疗的即刻及近期疗效。方法选择2009年1月至2012年1月收治的急性STEMI行急诊冠脉介入治疗病例中，符合纳入条件的梗死相关动脉（IRA）高血栓负荷患者共60例，其中18例为导管抽吸组，患者单纯通过反复抽吸血栓IRA血流已达到TIMI3级，待10~14d后再做冠脉造影以确定是否进行PCI治疗；另42例为强化介入组，除使用血栓导管抽吸外，一次性完成IRA的支架置人手术。观察两组术后即刻的TIMI分级，以及两组术前、术后2h肌酸激酶同工酶（CK—MB）、高敏c反应蛋白（hs—CRP）、B型脑利钠肽（BNP）水平；记录两组从穿刺进针至手术结束的时间；化验术前及术后1周的外周血白细胞计数；比较术后1周的心脏超声指标如左心室射血分数（LVEF）和左心室舒张末期内径（LVEDD）的变化；观察术中及术后消化道出血及住院期间MACE事件。结果单纯导管抽吸组经反复抽吸后，17例（94％）达TIMI3级血流程度，而强化介入组最终30例（71％）达TIMI3级血流程度，两组差异有统计学意义（P〈0．05）；导管抽吸组发生“无再流（no—flow）”相对较少，但差异无统计学意义（P〉0．05）。单纯导管抽吸组从进针至手术结束时间均较强化介入组缩短，差异有统计学意义（P〈0．01）。两组术后即刻胸痛缓解率、STR、术中心肌酶及其他生化指标、术后白细胞计数、心脏超声LVEF及LVEDD等指标，单纯抽吸组均优于强化介入组（P〈0．05）。单纯导管抽吸组术中1例呕出混有血性呕吐物，术后1例出现心绞痛发作；强化介入组术中有2例、术后1例呕出混有血性呕吐物，术后3例出现心绞痛发作，但两组比较差异无统计学意义（P均〉0．05）。结论单纯使用导管反复抽吸血栓可使部分高血栓负荷的急性STEMI患者恢复正常冠脉血流，在强化抗栓治疗保护下，即刻和近期疗效安全可靠。

Objective To evaluate the immediately and short term effect after opening infarction relation artery （IRA） and recovering ＂myocardium reperfusion＂ by using only thrombus aspiration catheter in patients with acute ST elevation myocardial infarction （STEMI）. Methods Of the patients with acute STEMI hospitalized from January 2009 to January 2012, which were underwent conventional procedures of emergency percutaneous coronary intervention （PCI）, total 60 patients were found in IRA with high thrombus burden. 18 cases of them were taken for thrombus aspiration group, because their IRA was achieved TIMI 3 grade in coronary flow only using catheter thrombus aspiration repeatedly, 10-14 days after then eoronaryarteriongraphy （CAG） was once again proceeded todecide whether implanting stent. The other 42 cases were taken for intensify intervention group, which were imme- diately implanted stent if necessary after using catheter thrombus aspiration. In 2 groups, immediate TIMI grade, time from needle to the procedure finished were recorded respectively, creatine kinase isoenzyme （CK-MB）, high sensitivity C-reactive protein（hs-CRP） and B type brain natriuretic peptide（BNP） were measured before and 2 hours after the procedure, leukocytes count was detected before and 1 week after the procedure, heart ultrasound indexes left ventricular ejection fraction（LVEF） and left ventricular end diastolic dimension （LVEDD） were mea- sured at 1 week after the procedure, alimentary tract hemorrhage was observed peropeative period and major ad- verse cardiovascular events （MACE） duration of hospital stay. Results Thrombus aspiration group, there were 17 cases （94%） whose coronary flow achieved TIMI 3 grade. Intensify intervention group, 30 cases （71%） achieved TIMI 3 grade. There was significant difference in 2 groups （P〈0.05）. The cases of happening ＂no reflow＂ were slightly fewer than intensify intervention group, but there were not significant difference （P〉0.05）. The time from needle to the procedure finished was significantly shorter in thrombus aspiration group than intensify intervention group （P〈0.01）. Chest pain immediate remission rate, S-T segment recover rate 1 hour after the procedure, CK- MB, hs-CRP and BNP 2 hours after the procedure, leukocytes count and LVEF, LVEDD 1 week after the proce- dure, all there were better in thrombus aspiration groupthan intensify intervention group （P〈0.05）. There was ! case with vomitus cruentus intra-operation, 2 cases with angina pectoris attacks after-operation in thrombus aspira- tion group, there were together 3 cases with vomitus cruentus during and after-operation, 3 cases with angina pec- toris attacks after-operation in intensify intervention group, but they were not significant difference （P〉0.05）. Conclusion Themethod by using only catheter thrombus aspiration is able to recover normal coronary flow of pa- tients suffering from acute STEMI with IRA high thrombus burden. Accompanying intensify anti-thrombus treat- ment, it is effective and safe immediately after-operation and in the near future.