经导管靶向溶栓对ST段抬高型心肌梗死患者微循环的保护价值

Protective Effect of Transcatheter Thrombolysis on Microcirculation in Patients with ST-Segment Elevation Myocardial Infarction

目的通过微导管对急性ST段抬高型心肌梗死(STEMI)患者行冠状动脉内靶向溶栓,观察其对冠状动脉微循环灌注、心肌梗死面积及预后的影响。方法2018年6~12月,50例冠状动脉造影显示血栓积分≥3分高血栓负荷的急性STEMI患者应用随机数表法分为经微导管冠状动脉内靶向溶栓组(IT组)及常规血栓抽吸组(TA组),各25例。IT组通过微导管冠状动脉内给予低剂量重组尿激酶原10 mg,TA组常规血栓抽吸,支架植入术后即刻通过压力-温度导丝测定冠状动脉微循环阻力指数(IMR),心肌梗死溶栓试验(TIMI)血流分级、校正的TIMI血流帧数计数(CTFC)及TIMI心肌灌注分级(TMPG),测量肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、心肌肌钙蛋白I(cTnI)峰值水平及心电图ST回落(STR)情况,术后7 d行单光子发射计算机断层显像检查评价灌注缺损面积(PDA),心肌梗死术后24 h及3个月后行心脏超声评价心脏功能及结构,随访3个月内主要心脏不良事件发生及出血的发生。结果两组基线资料及冠状动脉造影资料、介入数据资料、TIMI分级、CTFC及STR比较,差异均无统计学意义(P>0.05)。IT组CK、CK-MB、cTNI峰值低于TA组,IT组TMPG 3级比例高于TA组,IT组IMR值低于TA组,差异均有统计学意义(P<0.05)。术后24 h,两组左室射血分数(LVEF)、左室舒张末径、室壁运动积分指数(WMSI)比较,差异均无统计学意义(P>0.05);术后3个月,IT组LVEF高于TA组,左室舒张末径、WMSI低于TA组,差异均有统计学意义(P<0.05);术后7 d,IT组PDA低于TA组,差异有统计学意义(P<0.05)。两组患者在出血事件及3个月内主要心脏不良事件发生情况比较,差异无统计学意义(P>0.05)。结论冠状动脉内靶向溶栓可有效降低高血栓负荷的STEMI患者的血栓负荷,恢复前向血流,提高冠状动脉微循环灌注水平,更好地发挥心肌保护作用;对于STEMI患者急诊介入治疗中,与单纯血栓抽吸相比,冠状动脉内靶向溶栓治疗能够明显缩小心肌梗死面积,改善心脏功能。

Objective To observe the effects of targeted intracoronary thrombolysis via a microcatheter on coronary microcirculation perfusion, myocardial infarction area and prognosis in patients with acute ST-segment elevation myocardial infarction(STEMI).Methods From June 2018 to December 2018,50 patients with acute STEMI presenting with large thrombus burden and thrombosis score≥3 on coronary angiography were enrolled.The patients were divided into the transcatheter intracoronary thrombolysis group(IT group, 25 cases) and the conventional thrombus aspiration group(TA group, 25 cases) by random number table.IT group was given 10 mg recombinant prourokinase into the coronary artery via a microcatheter, and TA group was given routine thrombus aspiration.After stent implantation, index of microcirculatory resistance(IMR), thombolysis in myocardial infarction(TIMI) flow classification, corrected TIMI frame count(CTFC) and TIMI myocardial perfusion grade(TMPG) were evaluated.The peak levels of CK,CK-MB,cTnI and ECG ST-segment resolution(STR) were examined. Perfusion defect area(PDA) was evaluated on day 7 after operation.Cardiac function and structure were examined at 24 hours and 3 months after operation.The occurrence of major adverse cardiac events(MACE) and bleeding within 3 months of follow-up were recorded.Results There were no significant differences between the two groups in baseline data, angiographic data, intervention data, TIMI classification, CTFC and STR(P>0.05).In IT group, the peak levels of CK,CK-MB and cTnI were lower than those in TA group, the proportion of TMPG3 was higher than that in TA group, and IMR was lower than that in TA group, there were significant differences between the two groups(P<0.05).At 24 hours after operation, there were no significant differences between the two groups in left ventricular ejection fraction(LVEF),left ventricular end diastolic diameter(LVED),and ventricular wall motion score index(WMSI)(P>0.05).At 3 months after operation in IT group, LVEF was higher than that in TA group, LVED and WMSI were lower than those in TA group, there were significant differences between the two groups(P<0.05).On day 7 after operation, PDA in IT group was lower than that in TA group(P<0.05).There were no significant differences between the two groups in bleeding events and MACE within 3 months(P>0.05).Conclusion Targeted intracoronary thrombolysis might play a myocardial protective role by reducing the thrombus load of STEMI patients with large thrombus load, restoring the forward blood flow and improving the coronary microcirculation perfusion.Compared with simple thrombus aspiration, intracoronary thrombolysis might significantly reduce the area of myocardial infarction and improve cardiac function for STEMI patients undergoing emergency intervention.