应用自制带侧孔灌注球囊处理经皮冠状动脉介入术中无复流的方法

Self-made side hole balloon for treating no-reflow following percutaneous coronary intervention

目的 探讨应用自制带侧孔球囊处理经皮冠状动脉介入术（percutaneous coronary intervention,PCI）过程中无复流（no reflow,NR）的安全性及有效性.方法 2011年1月至2012年1月在我院行PCI术中发生NR的患者,排除冠状动脉狭窄、夹层、痉挛或血栓.共23例,平均年龄（62.0±13.8）岁,其中急诊ST抬高急性心肌梗死（ST segment elevation myocardial infraction,STEMI）患者14例,择期PCI患者9例;NR发生于前降支11例,右冠状动脉8例,回旋支4例.应用自制带侧孔球囊在发生NR的冠脉内推注硝酸甘油及盐酸替罗非班,观察治疗前后靶血管心肌梗死溶栓试验（thrombolysis in myocardial infarction,TIMI）血流分级情况,STEMI患者术后心电图ST段回落（ST segment resolution,STR）情况,术后3d心电图ST-T变化情况,住院期间冠状动脉穿孔、夹层、血栓等并发症.术后1个月随访心电图,心脏超声射血分数（left ventricular ejection fraction,LVEF）及短轴缩短率,术后6个月随访心功能及主要心血管不良事件（major adverse cardiovascular event,MACE）发生率.结果 应用带侧孔球囊冠脉内注射药物后血流TIMI 1级3例,TIMI 2级5例,TIMI 3级15例.14例急诊STEMI患者术后ST段完全回落（≥70％）8例,部分回落（30％～69％）4例,2例无回落（＜30％）;2例ST段无回落患者中1例术后出现心室电风暴,经治疗后好转出院,1例术后因心包填塞经心胸外科急诊手术发现左室游离壁破裂,抢救无效死亡.9例择期PCI患者术后心电图ST段一过性抬高3例,经保守治疗1周心电图ST段回落,住院期间无冠状动脉穿孔、夹层、血栓发生.22例患者出院后1个月查心脏超声,平均LVEF为（50.6±14.3）％,短轴缩短率0.36±0.04,心电图提示6例有非特异性ST-T改变.4例STEMI患者因非罪犯血管行PCI治疗时复查造影提示发生NR血管血流TIMI3级.术后6个月时随访无MACE事件,心功能（NYHA）Ⅰ级18例,Ⅱ级4例.结论 初步研究表明应用自制带侧孔灌注球囊推注药物方法治疗PCI术中NR安全、经济、便捷、有效,但仍需大样本临床研究进行评价.

Objective To assess the safety and effectiveness of self-made side hole balloon for treating no-reflow following percutaneous coronary intervention(PCI).Methods Twenty-three patients diagnosed with no-reflow during PCI from Jan.2012to Jan.2013 were enrolled.Residual stenosis,thrombosis,dissection,and spasm of coronary artery were excluded.The mean age of the 23patients was(62.0±13.8)years old.Of the 23patients 14had ST segment elevation myocardial infarction(STEMI),and 9underwent elective PCI.There were 11cases with no-reflow in the left anterior descending branch,8in the right coronary artery and 4in the circumflex branch.The drugs(nitroglycerin and tirofiban)were selectively injected into the vessel using self-made side hole balloons.The thrombolysis in myocardial infarction(TIMI)grade before and after procedure,ST segment resolution(STR),ST-T changes for 24and 72hours and complications(perforation, dissection,and thrombosis of coronary artery)were observed postoperatively.Patients were followed up by ECG and echocardiogram at 1month after PCI.Incidence of major adverse cardiovascular events(MACEs)and cardiac function wereobserved 6months after PCI.Results After intracoronary administration of drug therapy,TIMI grade-1flow was found in 3 patients,TIMI grade-2flow in 5patients and TIMI grade-3flow in 15patients.In patients with STEMI,complete resolution(≥70%)was found in 8patients,partial resolution(30%-69%)in 4,and no resolution(<30%)in 2.One of the 2patients with ventricular electrical storm was treated with temporary cardiac pacing and drug therapy and recovered within 1week;the other one with pericardial tamponade who was treated with emergency surgery repair died.In 9patients undergoing selected PCI,transient ST segment changes were noted in 3patients which recovered within 1week after conservative treatment;with no perforation,dissection,or thrombosis of coronary artery.One month after discharge,echocardiogram of the 22patients showed a mean left ventricular ejection fraction(LVEF)of(50.6±14.3)%and a fractional shortening in the short axis view of 0.36±0.04,and ECG showed non-specific changes of ST-T in 6patients.In 4patients with STEMI,culprit artery showed TIMI grade-3by angiography performed during PCI for non-culprit vessel 1 month after primary PCI.At 6 months after primary PCI,there was no MACE;18patients were in New York Heart Association ClassⅠand 4in ClassⅡ.ConclusionSelf-made side hole balloon is a safe,economical,effective and convenient method for intracoronary administration of nitroglycerin and tirofiban in treating no-flow during PCI,but the result still needs further verification.