超选择冠状动脉内注射替罗非班联合血栓抽吸对急性ST段抬高心肌梗死患者预后的影响

Effect of intracoronary tirofiban injection through thrombus aspiration catheter combined thrombus aspiration during primary percutaneous coronary intervention on acute ST-segment elevation myocardial infarction

目的比较经抽吸导管超选择至罪犯血管病变闭塞处前注射替罗非班后行血栓抽吸治疗与经指引导管于罪犯血管开口处注射替罗非班后行血栓抽吸治疗对急性ST段抬高心肌梗死(STEMI)患者预后的影响。方法连续入选靶血管肉眼可见(两位手术医师同时判断)血栓负荷的STEMI患者112例,随机分为两组:A组56例,经指引导管于罪犯冠状动脉开口注射替罗非班再行血栓抽吸术;B组56例,经抽吸导管于罪犯冠状动脉闭塞处前注射替罗非班再行血栓抽吸术。A组又分A1组26例、A2组30例,B组又分B1组31例、B2组25例,A1、B1指罪犯血管为左前降支或回旋支,A2、B2指罪犯血管为右冠状动脉且为分叉前闭塞。比较各组患者血栓抽吸后TIMI血流分级、住院期间出血情况及术后12个月主要不良心血管事件(MACE)的发生情况。结果 A1组和B1组、A2组和B2组的病变血管支数和罪犯血管分布情况分别比较,差异均无统计学意义(均P>0.05)。B1组行血栓抽吸1 min后[19例(73.1%)比27例(87.1%),P=0.04]和支架释放后即刻[22例(84.6%)比30例(96.8%),P<0.01]罪犯血管TIMI血流分级Ⅲ级占比高于A1组。A2组和B2组给药前、血栓抽吸1 min后、支架释放后即刻TIMI血流分级比较,差异均无统计学意义(均P>0.05)。A组和B组患者住院期间均未发生严重出血事件,中度出血和轻微出血的发生率分别比较,差异均无统计学意义(均P>0.05)。A1组住院期间[4例(15.4%)比2例(6.5%),P=0.03]及术后3个月[3例(11.5%)比1例(3.2%),P<0.01]的MACE发生率高于B1组,而术后12个月MACE发生率的差异无统计学意义。A2组和B2组住院期间、术后3个月及术后12个月的MACE发生率比较,差异均无统计学意义。结论对于病变血管为左冠状动脉的患者,经血栓抽吸导管超选择至病变闭塞处前给药对预防慢血流/无复流及减少患者短期(3个月内)MACE发生率效果可能会更好,而对于病变血管为右冠状动脉且为分叉前闭塞的患者,经血栓抽吸导管或经指引导管给药,效果可能无明显差异。

Objective To compare the effects of two approaches of intracoronary tirofiban（ through thrombus aspiration catheter verses guiding catheter） combined thrombus aspiration during primary percutaneous coronary intervention on ST-segment elevation acute myocardial infarction. Methods 112 consecutive acute myocardial infarction（ AMI） patients with thrombosis burden（ judge by two operators at the same time） were randomly divided into Group A [intracoronary tirofiban injection through guiding catheter combined thrombus aspiration（ control group） ] and Group B [intracoronary tirofiban injection through thrombus aspiration catheter combined thrombus aspiration（ research group） ]. Group A was further divided into A1 [infarction related artery（ IRA） was LAD or LXC] and A2 [IRA was RCA,and the blocking was before the bifurcation of RCA]. The same logistics applied to subgroup of B1 and B2 for Group B. The level of TIMI,in-hospital bleeding rate and the short-term major adverse cardiac events（ MACE） after PCI were compared between Group A and Group B after thrombus aspiration. The same comparison were done between A1 vensus B1 and A2 vsersus B2. Results Baseline features were comparable between all groups [Group A（ n = 56） vs. Group B（ n = 56）,A1（ n = 26） vs. B1（ n = 31）,A2（ n = 30） vs. B2（ n = 25）,all P〉 0. 05]. In-hospital bleeding events were similar across all groups（ Group A vs. Group B,A1 vs. B1,A2 vs. B2,all P〉0. 05）. The TIMI level of Group A was similar to Group B no matter 1 min later after thrombus aspiration or immediately after release the Cardiac Coronary Stent（ P〉 0. 05）. The MACE events of Group A in 3 months or 1 year after PCI or during hospital were similar to Group B（ all P〉0. 05）. The TIMI level of B1 was better than A1 no matter 1min later after thrombus aspiration（ P = 0. 04） or immediately after release the Cardiac Coronary Stent（ P〈0. 01） for the patients which IRA was LAD or LCX. The MACE events of B1 in 3months after PCI（ P〈 0. 01） or inhospital（ P = 0. 03） were less than A1 except 1 year after PCI（ P = 0. 37）. There were no differences between B2 and A2 in TIMI level of 1min later after thrombus aspiration（ P = 0. 68） and TIMI level of immediately after release the Cardiac Coronary Stent（ P = 0. 73）. Compared B2 to A2,the MACE events during in-hospital,3 months after PCI and 1 year after PCI were similar（ all P〉0. 05）. Conclusions For patients which IRA was LAD or LCX,intracoronary tirofiban injection through thrombus aspiration catheter combined thrombus aspiration during primary percutaneous coronary intervention can reduce the rate of slow flow / no reflow phenomenon and the rate of MACE in 3 months. For patients which IRA was RCA（ and the blocking was before the bifurcation）,there was no difference between intracoronary tirofiban injection through thrombus aspiration catheter or through guiding catheter.