渐进缺血后适应对经皮冠状动脉介入术患者心脏的保护作用

Cardioprotective effects of gradual ischemic postconditioning in percutanous coronary intervention

目的探讨直接经皮冠状动脉（冠脉）介入术（PPCI）中渐进缺血后适应（IP）再灌注对ST段抬高型急性心肌梗死（STEAMI）再灌注损伤的保护作用。方法选择2011年2月至2014年8月在江苏昆山市第一人民医院、江苏大学附属昆山医院心内科住院行PPCI的STEAMI患者102例，将患者按随机数字表法分为IP组32例、渐进IP组30例、常规再灌注组40例。IP组开通梗死相关血管后，通过预扩张球囊充盈／撤压时间为1min／1min，循环3次，然后予以持续再灌注；渐进IP组实施IP的时间呈渐进变化，即在3次球囊充盈／撤压时间分别为1min／1min、30s／30s、15s／15s；常规再灌注组闭塞血管开通后持续恢复冠脉供血。比较3组相关导联再灌注心律失常发生率、ST段回落率、校正心肌梗死溶栓治疗（TIMI）帧数（CTFC）、肌酸激酶同工酶（CK—MB）峰值、左室射血分数（LVEF）的变化，并随访不良事件的发生情况。结果3组基线资料均衡，有可比性。渐进IP组频发室性期前收缩（室早）发生率明显低于常规再灌注组[30．0％（9／30）比55．0％（22／40），P〈0．05]，IP组[34．4％（11／32）]室早发生率虽低于常规再灌注组，但差异无统计学意义（P〉0．05）。IP组和渐进IP组室性心动过速（室速）发生率明显低于常规再灌注组[15．6％（5／32）、13．3％（4／30）比40．0％（16／40），均P〈0．05]。IP组、渐进IP组心室纤颤、心动过缓、窦性停搏的发生率均低于常规再灌注组，但差异均无统计学意义（均P〉0．05）。IP组、渐进IP组ST段回落率、CTFC、CK—MB峰值均明显低于的常规再灌注组[ST段回落：（56．7±18．3）％、（57．3±21．5）％比（44．6±21．6）％；CTFC（帧）：25．47±5．37、24．46±6．41比31．62±7．56；CK—MB峰值（U／L）：126．3±78．5、121．6±82．5比147．4±72．5；均P〈0．05]，且以渐进IP组作用更优。IP组、渐进IP组LVEF水平均高于常规再灌注组（0．507±0．042、0．511±0．062比0．497±0．062），但差异无统计学意义（均P〉0．05）。常规再灌注组因反复室颤不能纠正死亡1例，无复流死亡1例。3组均各有1例患者术后4周内死亡，其中常规再灌注组1例为难治性心衰，IP组的2例均考虑为亚急性支架内血栓形成。各组均无严重出血事件的发生。结论渐进IP能更显著减轻STEAMI患者PPCI术中的心肌再灌注损伤。

Objective To observe the protective effect of gradual ischemic postconditioning （IP） capable of improving reperfusion on reperfusion injury in patients with ST-segment elevation acute myocardial infarction （STEAM1） undergoing primary percutaneous coronary intervention （PPCI）. Methods 102 in-patients with STEAMI undergoing PPCI in the Department of Cardiology in the First People＇s Hospital of Kunshan City Affiliated to Jiangsu University from February 2011 to August 2014 were enrolled in this study. They were divided into three groups by a random number table： IP group （32 cases）, gradual IP group （30 cases） and routine reperfusion group （40 cases）. In IP group, after the opening of the infarction related blood vessel, ischemic postconditioning within the first minute of arterial reperfusion was made through three episodes of 1 minute inflation and 1 minute pressure withdrawn of an angioplasty balloon, and then persistent reperfusion was carried out. In the gradual IP group, the patients received three times of gradual angioplasty balloon inflation and denation, 1 minute/lminute, 30 seconds/30 seconds and 15 seconds/15 seconds respectively, presenting the gradual change of IP time. In the routine reperfusion group, after the opening of blocked blood vessel, the patients underwent routine PCI to persistently recover the coronary artery blood supply. The changes of related lead ST segment regression （Sum-STR）, incidence of reperfusion arrhythmia, corrected thrombolysis in myocardial infarction （TIMI） franle count （CTFC）, peaks of MB isoenzyme of creatine kinase （CK-MB）, left ventricular ejection fraction （LVEF） and frequency of adverse events in follow-up period were compared among the three groups. Results The baseline characteristics were comparable in three groups. The incidence of ventricular premature beats was significantly lower in gradual IP group than that in routine reperfusion group [30.0% （9/30） vs. 55.0% （22/40）, P 〈 0.05], and although the incidence of ventricular premature beats was lower in IP group than that in routine reperfusion group [34.4% （11/32） vs. 55.0% （22/40）], no statistically significant difference was found （P 〉 0.05）. The incidence of ventricular tachycardia was significantly lower in IP and gradual IP groups than that in routine reperfusion group [15.6% （5/32）, 13.3% （4/30） vs. 40.0% （16/40）, both P 〈 0.05]. The incidences of ventricular fibrillation, bradyarrhythmia and sinus arrest were lower in IP group and gradual IP group than those in routine reperfusion group, but no statistically significant differences were found （all P 〉 0.05）. In IP group and gradual IP group, the Sum-STR incidence, CTFC, CK-MB peaks were lower than those of routine reperfusion group [Sum-STR： （56.7 ± 18.3）%, （57.3 ± 21.5）% vs. （44.6 _± 21.6）%; CTFC： 25.47 ± 5.37, 24.46 ± 6.41 vs. 31.62 ± 7.56; CK-MB peaks （U/L）： 126.3 ± 78.5, 121.6 ± 82.5 vs. 147.4 ± 72.5; all P 〈 0.05], the effect of gradual IP group being the best among the three groups. The levels of LVEF were slightly higher in IP and gradual IP groups than the level in routine reperfusion group （0.507 ± 0.042, 0.511 ± 0.062 vs. 0.497 ± 0.062）, but no statistically significant difference was found （both P 〉 0.05）. In routine reperfusion group, one patient died because the ventricular fibrillation could not be corrected and another one died of no-reflow during operation. Each group had 1 patient died during the 4 weeks of follow-up after operation, in the routine reperfusion group, one died of refractory heart failure, and the cause of death of other two patients, one in IP group and another in gradual IP group, was considered due to subacute thrombosis in stent. Major bleeding events were not found in each group. Conclusion Gradual IP can ameliorate myocardial reperfusion injury more significantly in patients with STEAMI undergoing PPCI.