血栓抽吸治疗在急诊冠脉介入治疗中的应用

血栓抽吸治疗在急诊冠脉介入治疗中的应用国际心血管病杂志2011年3月第38卷第2期1I1tJCardiovascDis,March2011,Vo1.38,No.2血栓抽吸治疗在急诊冠脉介入治疗中的应用王忠凯赵仙先陈少萍秦永文【摘要】目的:评价急性心肌梗死急诊经皮冠脉介入治疗(PCI)中应用ZEEK血栓抽吸导管对改善心肌组织再灌注及对患者临床预后的作用.方法:选择2009年7月至2010年4月符合急诊PCI介入指征的急性心肌梗死患者58例,其中使用ZEEK血栓抽吸导管18例作为血栓抽吸组,未使用ZEEK血栓抽吸导管40例作为对照组,比较两组的基线资料,造影结果和临床预后.结果:血栓抽吸组TIMI3级血流比例,ST段回落率,无复流或慢血流现象发生率及出院前EF平均值均明显优于对照组(P<().05).结论:在急性心肌梗死急诊PCI中应用ZEEK血栓抽吸导管安全可行,有效地清除冠脉内血栓,改善心肌组织灌注,有可能改善术后心脏功能,并且不增加血管不良事件的发生率.【关键词】急性心肌梗死;经皮冠状动脉介入治疗;血栓抽吸;心肌再灌注DoI:10.3969/i.issn.16736583.2011.02.016UseofthrombusextractionduringprimarypercutaneouscoronaryinterventionWNGZhongkai,ZHAOXian一ian,CHENShaoping,QINYongzuen.DepartmentofCardiology,ChanghaiHospital,SecondMiliraryMedicalUniversity,Shanghai200433,ChinaAbstractObjective:ToassesstheeffectofZEEKaspirationthrombectomycatheterinimprovingmyocardialreperfusionandclinicalprognosisinpatientswithacutemyocardialinfarction(AMI)whounderwentprimarypercutaneouscoronaryintervention(PCI).Methods:FromJu1.2009tOApr.2010,atotalof58patientswithSTEMIundergoingprimaryPC1wereenrolledinthisstudy,andZEEKaspirationthrombectomycatheterswereusedin18casesofthem.Baselinecharacteristics,angiographicresultsandclinicalprognoseswerecomparedbetweenthetwogroups.Results:STsegmentresolution,TIMI3flow,rateofdistalembolization,andaverageleftventrieularejectionfractionbeforehospitaldischargeweresignificantlyimprovedinZEEKgroupcomparedtOthoseinthecontrolgroup.Conclusion:InAMIpatientstreatedwithprimaryPCI,theapplicationofZEEKaspirationthrombectomycatheterissafeandeffective,whichcan1owerthrombosisburden,improvedistalmyocardiumperfUSionandcardiacfunctionaftertheprocedure,anddosenotincreasetheincidenceofbloodvesselevent.KeywordsAcutemyocardialinfarction;Percutaneouscoronaryintervention;Thrombusaspirating;Myocardialreperfusion经皮冠状动脉介入治疗(PCI)是目前治疗急性心肌梗死(AMI)最有效的方法_1;.然而,对ST段抬高的AMI患者进行直接PCI时,可能导致大量的血栓或粥样硬化斑块脱落造成远端血管栓塞,出现无复流或慢血流现象,发生率可达710.由于存在无复流现象,即使梗死相关动脉(IRA)血运完全重建,梗死区仍存在微循环缺血,严重影响患者左室功能恢复及临床预后l3,成为制约急诊PCI效果的突出问题.随着介入器械的发展,新作者单位:200433上海,第二军医大学附属长海医院心内科?115?的血栓去除装置不断被引入临床应用,ZEEK血栓抽吸导管就是其中一种.该装置可直接抽吸悬浮血栓,操作简易,费用相对低廉,故临床应用较多.本研究的目的旨在探讨急性心肌梗死直接PCI术前应用ZEEK血栓抽吸导管对改善心肌组织再灌注及对患者临床预后的作用.l资料与方法1.1研究对象选择2009年7月至2010年4月在我科接受PCI治疗的AMI患者58例,其中男性49例,女性9例,年龄2978岁,平均(58.2410.99)岁.PCI?116?垦!笪苤查生月第38卷第2期IntJCardiovascDis,March2011,Vo1.38,No.2治疗过程中应用ZEEK血栓抽吸导管的18例患者为血栓抽吸组,只接受PCI治疗的40例患者为直接PCI组.入选标准:(1)具有典型的缺血性胸痛且症状持续30min以上,含服硝酸甘油不缓解;(2)标准l8导联心电图ST段相邻2个或2个以上导联抬高0.1mV并有心肌梗死变化;(3)血清心肌酶及心肌坏死标记物符合AMI变化;(4)发病时问<12h;(5)无严重肝肾功能障碍,感染,血液系统疾病患者;(6)梗死相关动脉(IRA)近端无迂曲,无明显钙化,直径3mm,冠状动脉造影提示存在大量血栓者.1.2血栓抽吸及PCI方法患者术前口服阿司匹林和氯吡格雷各300mg,经股动脉路径采用JudkinS法完成冠状动脉造影.血栓抽吸组在PCI术前应用吸栓导管(ZEEK血栓抽吸导管,ZEONMedical公司产品)抽吸血栓.沿6F指引导管送入0.014英寸指引导丝至病变远端,沿该指引导丝送吸栓导管至血栓处,用50ml注射器反复抽吸至血栓影消失或明显减少,抽吸后直接置人支架.直接PCI组即按常规手术步骤完成PCI手术.术中静脉注射肝素800010000IU,术后口服阿司匹林300mg/d(12周后改为100mg/d)和氯吡格雷75mg/d(>12个月),皮下注射低分子肝素37d.1.3观察指标(1)心肌梗死溶栓疗法血流分级(TIMI):3级为3个心动周期内血流到达冠状动脉远端;2级为超过3个心动周期血流到达冠状动脉远端;1级为血流不能使远端动脉血管床充分显影,少量显影剂穿过狭窄病变部位;0级为造影剂不能通过病变部位;(2)冠脉无复流:血管造影显示靶血管开通后远端前向血流明显减慢(TIMId3级)且已排除靶血管明显残余狭窄,冠脉夹层,栓塞,血栓或冠脉痉挛等;(3)ST段回落率:由2位专科医师独立分析心电图,判读结果不一致时由第3位核实确定,术前即刻和术后90min完成标准12导联心电图,所有患者都根据J点后20ms计算ST段抬高的总和以及ST回落程度,ST段回落>70定义为完全回落,3070为部分回落,%30为无回落;(4)肌钙蛋白(TnI)峰值:对症状发作时间明确的患者,发病12h取血测定结果为TnI峰值;对发作时间不明确的患者每4h取血1次,筛查TnI峰值;(5)出院前左室射血分数(二维法):由2位专科医师进行2次核查;(6)主要心脏不良事件(MACE):包括心源性死亡,急性心肌梗死或急诊血运重建等.1.4统计学处理计量资料以均数加减标准差表示,计数资料采用率或构成比表示.计量资料组间变量比较采用独立样本t检验,前后比较采用配对t检验,计数资料比较采用卡方检验.所有数据用统计学软件SPSS17.0处理,以P%0.05为有统计学差异.2结果2.1一般临床特征两组患者在年龄,性别,血压,血脂,血红蛋白,肾功能,伴随疾病及人院时心功能分级等指标差异均无统计学意义(P>0.05).所有患者在血栓抽吸和PCI之前TIMI血流均为O1级.2.2造影资料两组患者在病变血管支数,病变血管部位及血管直径,TIMI血流,手术操作时间等指标差异均无统计学差异;血栓抽吸组对比剂用量高于直接PCI组(见表1).表1两组患者临床指标比较2.3住院期间临床指标比较血栓抽吸组术后ST段回落率,TIMI3级血流,出院前EF值高于直接PCI组,无复流或慢血流发生率低于直接PCI组(P<0.05);再灌注时间,TnI峰值以及MACE等指标差异均无统计学意义(P>0.05,见表2).国际心血管病杂志2011年3月第38卷第2IntJCardiovascDis,March2011,Vo1.38,No.2表2两组患者住院期间临床指标比较3讨论在对血栓负荷较重的冠状动脉行直接PCI治疗时,有可能因操作人为地使碎裂的血栓及粥样斑块残片冲刷至远端形成栓塞,导致冠状动脉血流或组织水平灌注不能恢复,造成无复流或慢复流现象.无复流现象的发生会严重影响AMI患者的预后,与心肌充分复流的患者相比,无复流患者恶性心律失常,左室功能不全的发生率和病死率增加51O倍l_.血栓抽吸装置能抽吸出血栓或粥样斑块碎片,有效地预防冠脉远端栓塞而改善心肌灌注.TAPAS研究结果显示:与单纯PCI组相比,血栓抽吸联合PCI组术后心肌呈色分级(blush分级)3级率和完全ST段回落率明显增加.DEARMI研究结果也显示:直接PCI联合应用血栓抽吸装置可改善AMI患者心肌再灌注,降低CKMB水平,减少远端栓塞及无复流发生1.目前应用于临床的血栓抽吸装置较多,包括DiverCE,XSizer,Rescue等,由于缺乏大规模的随机试验结果,且目前用于临床的血栓抽吸导管型号外径多样,使用方法也不完全相同,其有效性各家报道不一1.使用大管径的导管和较高的负压多次反复抽吸有可能无益处,甚至造成严重并发症.ZEEK血栓抽吸导管在整个抽吸过程持续抽吸冠脉内的血栓,无需阻断冠脉血流,并且因其使用手工方式可根据不同病变部位和情况灵活采用不同的负压抽吸,避免抽吸负压过大导致不良作用.本研究结果显示,血栓抽吸组ST段回落率,TIMI3级血流及出院前平均EF值均高于直接PCI组,表明ZEEK血栓抽吸导管能明显改善心肌微循环再灌注,从而改善AMI患者近期心功能.研究还发现血栓抽吸组的无复流或慢血流发生率明显低于直接PCI组,这主要由于血栓抽吸能将部分血栓吸出体外,减轻了IRA内的血栓负荷.另外,血栓抽吸组中有2例患者在介入操作过程中反复发作恶性心律失常,因此在冠脉前向血流达到?117?TIMI2级即停止操作转入CCU病房继续治疗,术后2周患者均顺利出院,提示这部分患者仍然可以通过血栓抽吸获益,但尚需大样本临床试验证实.尽管研究结果显示血栓抽吸能改善微循环指标,减少无复流现象的发生,但两组的MACE发生率无统计学差异,原因可能是观察时间较短,如果能观察出院后半年,甚至1年后的指标,有可能出现差异.本研究结果提示,PCI术中应用ZEEK血栓抽吸导管操作简便,并不增加血管并发症风险,可有效地降低无复流或慢血流的发生率及血栓负荷,提高PCI成功率.但本研究样本数量有限,尚需要更大样本及更长时间的临床随访,以进一步证实和评价ZEEK血栓抽吸导管的I临床应用价值.参考文献1UiS,ChinoM,IsshikiRatesofprimarypereutaneouscoronaryinterventionworldwideJ.CircJ,2005,69(1):95100.2PrasadA,StoneGW,AymongE,eta1.ImpactofSTsegmentresolutionafterprima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