经皮冠状动脉介入治疗冠状动脉左主干急性闭塞致心肌梗死的临床分析

Clinical analysis of percutaneous coronary intervention for treating the patients with acute myocardial infarction caused by sudden total occlusion of left main coronary artery

目的探讨冠状动脉左主干(left main coronary artery,LMCA)急性闭塞导致急性心肌梗死(acute myocardial infarction,AMI)的临床特点以及经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的疗效。方法回顾2000年至2016年因胸痛在大庆油田总院行急诊冠状动脉造影证实LMCA急性闭塞患者的住院资料,分析患者临床特点及随访情况。结果 LMCA急性闭塞AMI患者15例,13例行PCI术,接受PCI术的患者住院期间6例死亡,死亡率为46.2%。与存活组相比,死亡组患者右冠状动脉优势型的比率更低(100%比16.7%,P=0.005),差异有统计学意义。接受PCI术的13例患者中存活7例,存活率为53.8%;未行PCI术的2例患者中存活1例,存活率为50%,差异无统计学意义(P=1.000)。9例行直接PCI术,其中4例存活,存活率为44.4%;4例患者置入主动脉内球囊反搏(IABP)后被送回CCU进行双联抗血小板治疗,待病情稳定后行择期PCI术,其中3例存活,存活率为75.0%,差异无统计学意义(P=1.000)。在13例行PCI术的患者中,有9例患者PCI术后TIMI血流Ⅰ~Ⅱ级,其中存活6例,存活率为66.7%(6/9);有4例患者PCI术后TIMI血流Ⅲ级,存活1例,存活率为25%(1/4),差异无统计学意义(P=0.260)。8例术后服用氯吡格雷+阿司匹林双联抗血小板治疗,其中存活4例,存活率为50.0%(4/8);5例术后服用替格瑞洛+阿司匹林双联抗血小板治疗,其中存活3例,存活率为60.0%(3/5),差异没有统计学意义(P=1.000)。对8例存活者随访1个月~13年,平均(66.8±66.0)个月。1例患者(12.5%)死亡,为入院时发生心源性休克的患者。2例患者因心绞痛发作再次入院行保守治疗。1例患者行择期右冠状动脉PCI术。存活者无事件生存率为50%(4/8)。院内与长期随访的总体死亡率达到53.3%(8/15),其中合并心源性休克的患者死亡率100%(5/5),住院期间死亡率80.0%(4/5),随访期间死亡率20%(1/5),非心源性休克的患者死亡率30.0%(3/10)。结论 LMCA闭塞患者的死亡率很高,成功的PCI可以挽救部分患者的生命,存活者长期随访的严重不良事件发生率仍较高。

Objective To explore the clinical features of acute myocardial infarction（AMI）caused by lef t main coronary artery（LMCA） sudden total occlusion and to investigate the clinical efficacy of percutaneous coronary intervention（PCI）. Methods A retrospective analysis was carried out and patients with AMI due to LMCA sudden occlusion proved by emergency coronary angiography in General Hospital of Da Qing Oil Field between 2000 and 2016 were included. The patients were divided into the survival group and the deceased group. The clinical condition during hospitalization were compared. All in survived cases were followed up by telephone or at out-patient clinic. Results Among 1281 emergency coronary angiography cases, 15 patients were proved to have LMCA sudden occlusion and 13 of them received PCI. 6 patients died during hospitalization and the in-hospital mortality rate was 46.2%（6/13）. Among the 9 patients who received direct PCI,5 of them died（55.6%）;while 4 patients had elective PCI, 1 patient of them died（25%）. Three out of the 4 patients who presented TIMI grade 3 flow died. Among the 9 patients who had TIMI grade 1-2 flow, 3 patients died. Eight patients received deal anti-platelet therapy with clopidogrel and aspirin af ter PCI, and among them, 4 patients died. Among the 5 given ticagrelor, 2 patients died. During the follow-up period. 1 patient died of cardiogenic shock, 2 patients had recurrent angina and 1 patient required elective PCI to the RCA. Conclusions The morality of LMCA sudden total occlusion was significantly high. Successf ul PCI may be feasible to these patients, while the major adverse cardiovascular events（MACE） occurrence during long-term follow-up period remained high.