双血管急性闭塞的急性ST抬高型心肌梗死的冠状动脉间血流灌注影响

A retrospentive analysis of blood flow perfusion among coronary arteries during double vessel acute simultaneous occlusion in acute ST-elevation myocardial infarction patients

目的 探讨双支冠状动脉急性闭塞致急性ST段抬高型心肌梗死（STEMI）的冠状动脉间的血流灌注影响及形成原因.方法 回顾性分析2013年2月至2014年2月在北京中日友好医院心内科连续行急诊直接经皮冠状动脉介入治疗的双支冠状动脉闭塞导致STEM1的15例患者,分析其临床资料、急诊冠脉造影、手术情况及复查的冠脉造影情况.对比TIMI前向血流比较各冠脉血管血流灌注情况.结果 15例STEMI患者,急性前壁下壁心肌梗死8例,急性下壁后壁心肌梗死5例,急性前壁侧壁心肌梗死2例,伴心源性休克早期表现者达14例;急诊手术采取一次性或分阶段治疗两种治疗策略.术后经冠心病监护病房继续治疗,患者全部存活.术后入选患者进行冠状动脉造影复查发现,所有入选患者在急诊手术中未开通的6支闭塞血管,自行再通其前向血流都在TIMI 2级以上.结论 双支冠脉急性闭塞的STEMI是临床罕见病例,可能存在冠状动脉先发罪犯血管闭塞同时诱发另一支冠状动脉急性病变而出现双支血管急性闭塞的形式,心源性休克可能参与该病理生理过程;并且STEMI合并心源性休克进行一次性治疗策有临床实践价值.

Objective To explore the impact on intervascular blood flow perfusion among coronary arteries in order to illuminate the mechanism of acute simultaneous occlusion of double vessels in patients with ST-elevation myocardial infarction （STEMI）.Methods A cohort of 15 consecutive STEMI patients with acute simultaneous occlusion of double vessels admitted from February 2013 to February 2014 were enrolled in this study.Those patients were treated with emergency primary percutaneous coronary intervention （p-PCI） after admission.The clinical data,the procedure of emergency p-PCI and the findings of coronary artery angiography （CAG） were retrospectively analyzed.Results Of 15 patients with STEMI,there were 8 with acute anterior and inferior wall MI,5 with acute inferior and posterior wall MI and 2 with acute anterior and lateral wall MI.Of them,14 patients manifested abruptly in the clinical feature of cardiagenic shock,and treatment strategy was one-step revascularization with p-PCI or muhiple-step revascularization procedures.All patients were survived after emergency p-PCI and then cared continuously in the Coronary Care Unit.They were checked with CAG,and CAG showed that 6 totally occluded coronary arteries resumed blood perfusion of more than TIMI 2 grade of the blood flow after p-PCI.Conclusions The double vessel occlusion STEMI is rare occurred in clinical medicine.The perfusion of non-culprit artery may be impaired and blocked as soon as the culprit artery was obstructed by thrombus to produce an acute double vessel occlusion of STEMI.And cardiogenic shock might be involved in the pathogenesis process.One-step treatment strategies for STEMI with cardiogenic shock could have clinical practice value.