冠狀動脈無復(fù)流現(xiàn)象的防治和典型病例分析

1、冠狀動脈無復(fù)流現(xiàn)象的防治和典型病例分析 病人資料毛某，男性，78歲，糖尿病8年，高血壓病，高脂血癥，吸煙20余年，1年前戒除主因發(fā)作性劍突下疼痛4天，于2007年09月18日由門診以“冠心病 急性心肌梗死”收入科。ECG：V1-V5導(dǎo)聯(lián)ST段抬高。肌鈣蛋白升高。CAGCAG球囊擴(kuò)張前冠脈內(nèi)給予硝酸甘油200ug，欣維寧10ml 2.5*15mm球囊擴(kuò)張球囊擴(kuò)張后植入支架3.0*24mm植入后造影no-reflow先后冠脈給予欣維寧再10ml、硝酸甘油400ug，異搏定400ug后 近端植入支架3.5*14mm植入后造影no-reflow再先后冠脈給予欣維寧10ml、硝酸甘油500ug，異搏定6

2、00ug后 一、無復(fù)流概述 無復(fù)流現(xiàn)象(no-reflow)是指閉塞的心外膜冠狀動脈再通后，心肌組織無灌注的現(xiàn)象。冠狀動脈造影表現(xiàn)為血流明顯減慢(血流=50%)或ST段抬高指數(shù)增加(=30%)，對判斷微血管灌注或無復(fù)流均有較高準(zhǔn)確性(81%)。3、心電圖經(jīng)皮冠狀動脈介入治療后原病變部位無夾層、痙攣或阻塞而冠狀動脈血流小于心肌梗死溶栓治療臨床試驗(TIMI)II級或心肌灌注(TMP) 血流分級0-2級，可以判定無復(fù)流。對于冠狀動脈血流TIMI III級的病例，一部分表現(xiàn)為緩慢血流，另一部分為快血流，緩慢血流患者經(jīng)超聲、核素檢查后仍可檢出無復(fù)流病例，提示TIMI血流分級在判定無復(fù)流方面存在局限性。

3、4、冠狀動脈造影血流分級在傳統(tǒng)的TIMI血流分級法基礎(chǔ)上用校正的TIMI幀數(shù)來評估微循環(huán)血流。這是一種較精確的識別技術(shù)，較傳統(tǒng)的TIMI分級客觀、定量、可重復(fù)、敏感。造影劑到達(dá)指定的冠狀動脈遠(yuǎn)端所需的血管造影幀數(shù)越多，血流速度越慢，無復(fù)流存在的可能越大。5、校正的心肌梗死溶栓治療臨床試驗幀數(shù)(CTFC)采用多普勒血流導(dǎo)絲，進(jìn)行血管內(nèi)超聲檢查，測定時相性和平均冠狀動脈血流速度；測定絕對冠狀動脈血流儲備(CFR)指數(shù)，若顯示冠狀動脈血流儲備指數(shù)下降，收縮期順向血流速度下降，異常收縮早期逆向血流，舒張期血流速度迅速下降均提示無復(fù)流現(xiàn)象。收縮早期逆向血流是具有敏感性和特異性的評估無復(fù)流的指標(biāo)。6、冠狀

4、動脈內(nèi)多普勒血流 7、超聲心肌聲學(xué)造影(MCE) 將聲處理的造影物質(zhì)(如氟丙烷白蛋白)，其中含高能微泡，從冠狀動脈或靜脈途徑注入，然后做心肌超聲檢查，受累區(qū)無復(fù)流灌注反應(yīng)或心肌內(nèi)氣泡反常持續(xù)存在提示無復(fù)流現(xiàn)象。目前由于聲學(xué)造影劑的改進(jìn)，二次諧波成像技術(shù)的應(yīng)用和心肌聲學(xué)造影分析方法的進(jìn)步，心肌聲學(xué)造影被認(rèn)為是目前評估活體冠狀動脈微循環(huán)異常的最有效方法之一。8、冠狀動脈內(nèi)壓力測定應(yīng)用壓力導(dǎo)絲測量靶動脈的壓力階差，并計算心肌血流儲備分?jǐn)?shù)(FFRmyo)。當(dāng)有微循環(huán)病變存在時，血流儲備分?jǐn)?shù)值會升高，此時還應(yīng)當(dāng)結(jié)合冠狀動脈內(nèi)血流儲備分?jǐn)?shù)進(jìn)行判斷。如果血流儲備分?jǐn)?shù)值較高而冠狀動脈血流儲備值低，說明有微血管

5、功能障礙存在。9、其他方法放射性核素運動心肌灌注顯像、正電子發(fā)射斷層和對比增強磁共振顯像法，都可用于診斷無復(fù)流。四、無復(fù)流的危險因素PCI術(shù)后是否發(fā)生無復(fù)流可根據(jù)臨床特點、冠狀動脈造影及冠狀動脈內(nèi)超聲結(jié)果進(jìn)行初步判斷。研究發(fā)現(xiàn)，SVG PCI時，血栓形成、ACS、退化的靜脈移植物、潰瘍是發(fā)生低或無復(fù)流的4個獨立危險因素，發(fā)生SNR的危險分別為：低危(1%-10%) =3個危險因素。AMI PCI時，CAG見高負(fù)荷的血栓形成是發(fā)生無復(fù)流現(xiàn)象的獨立預(yù)測因素，表現(xiàn)為：IRA完全閉塞處呈切面殘端、阻塞近端血栓5mm、浮動血栓存在、阻塞遠(yuǎn)端造影劑持續(xù)淤滯、參考管腔直徑(RLD)=4mm、II型病變(IR

6、A不完全阻塞性血栓長度超過RLD3倍)。IVUS見到的有脂質(zhì)池樣圖象的大血管也處于發(fā)生無復(fù)流的高危險。相反，早期再灌注=2級、錐形阻塞，為不發(fā)生無復(fù)流的獨立預(yù)測因素。五、無復(fù)流的防治預(yù)防藥物遠(yuǎn)端保護(hù)/血栓抽吸裝置（主要用于橋血管PCI和AMI直接PCI）直接支架植入準(zhǔn)分子激光消栓藥物PCI術(shù)前或術(shù)中冠狀動脈內(nèi)或外周靜脈給藥 硝酸甘油（Nitroglycerin） 腺苷（Adenosine） 尼可地爾(KATP通道開放劑)（Nicorandil） 維拉帕米（Verapamil） 地爾硫卓（Diltiazem） GP IIb/IIIa受體拮抗劑（GP IIb/IIIa receptor antag

7、onist）等均可減少無復(fù)流現(xiàn)象的發(fā)生。維拉帕米Early Administration of Intracoronary Verapamil Improves Myocardial Perfusion During Percutaneous Coronary Interventions for Acute Myocardial InfarctionAMI 直接PCI前冠脈內(nèi)給予維拉帕米改善心肌灌注(CHEST 2005; 128:25932598)目的：To evaluate the effects of the administration of intracoronary verapam

8、il before the occurrence of no reflow during direct PCI.50 patients ready to undergo direct PCI within 12 h from the onset of AMIIntracoronary verapamil was administered immediately prior to balloon inflationHad not received intracoronary calcium-channel blockers were enrolled as control subjects.(C

9、HEST 2005; 128:25932598)(CHEST 2005; 128:25932598)TMPG ：TIMI myocardial perfusion grade尼可地爾Effects of Intravenous Nicorandil Before Reperfusion for Acute Myocardial Infarction in Patients With Stress HyperglycemiaAMI并應(yīng)激性高血糖病人再灌注治療前靜脈注射尼可地爾的療效Diabetes Care 29:202206, 2006METHODS：This study consisted

10、of 158 consecutive first AMI patients with stress hyperglycemia who underwent PCI within 24 h from the onset. They were randomly assigned to receive 12 mg of nicorandil (n=81) or a placebo (n =77) intravenously just before reperfusion. Stress hyperglycemia was defined as a blood glucose level 10 mmo

11、l/l (180 mg/dl).Diabetes Care 29:202206, 2006（）（）（）Diabetes Care 29:202206, 2006尼可地爾不同給藥途徑的療效Impact of Nicorandil to Prevent Reperfusion Injury in Patients With Acute Myocardial InfarctionSigmart Multicenter Angioplasty Revascularization Trial (SMART)Circ J 2006; 70: 1099 1104)90 個AMI起病6小時內(nèi)的住院病人，PCI

12、前TIMI血流0-1級。隨機分為A、B、C 3組 ，A組：尼可地爾 0.5 mg/次，PCI前和后1-2次冠脈注射 (總量原則上1-2 mg)。B組：將尼可地爾配成1 mg/ml. 先靜脈推注4 mg，然后6ml/h靜脈輸注，加上A組方案冠脈內(nèi)給藥。C組：無藥組Circ J 2006; 70: 1099 1104)Circ J 2006; 70: 1099 1104)Fig 1. Primary endpoint. *p50%并為心絞痛罪犯血管的患者，隨機分為PCI術(shù)中使用 Guardwire Plus 的遠(yuǎn)端球囊阻塞/血栓抽吸裝置組（N=406 ）和傳統(tǒng)0.014 inch導(dǎo)絲組 （N=39

13、5 ） 主要終點：30天內(nèi)死亡、心肌梗死、急診搭橋或靶病變再血管成形術(shù)的聯(lián)合終點。Circulation. 2002;105:1285-1290.)Circulation. 2002;105:1285-1290.)( P=0.004)（P=0.008)（P=0.02)The Distal Protection During Primary Percutaneous Coronary Intervention Alleviates the Adverse Effects of Large Thrombus Burden on Myocardial Reperfusion遠(yuǎn)端保護(hù)對大血栓負(fù)荷直接P

14、CI心肌再灌注的影響Circ J 2006; 70: 232 23888 consecutive patients undergoing DP during primary PCI within 24 h from the onset of AMI were enrolled in the study (DP group).81 consecutive patients undergoing primary PCI without using the DP device for AMI during the preceding 1 year (control group).Circ J 200

15、6; 70: 232 238The GuardWire Plus (Medtronic ) consists of a 0.014-inch guidewire incorporating a central inflation lumen to which an elastomeric balloon (3.06.0 mm in diameter)Circ J 2006; 70: 232 238Circ J 2006; 70: 232 238P0.05Circ J 2006; 70: 232 238Circ J 2006; 70: 232 238P0.05Limitations of usi

16、ng a GuardWire temporary occlusion and aspiration system in patients with acute myocardial infarction: multicenter investigation of coronary artery protection with a distal occlusion device in acute myocardial infarction (MICADO).J-Invasive-Cardiol. 2007 Mar; 19(3): 132-8 MICADOThe study was conduct

17、ed as a prospective， randomized，multicenter trial. This study evaluated the efficacy of distal protection with the GuardWire distal protection device in PCI at the time of AMI revascularization.Patients with AMI within 24 hours from onset were randomized into either PCI combined with a GuardWire，or

18、PCI without distal protection.The primary endpoints were TIMI perfusion grade (TMP) and no incidence of reflow. Secondary endpoints were major cardiac events (MACE) during 6-month follow up. J-Invasive-Cardiol. 2007 Mar; 19(3): 132-8 J-Invasive-Cardiol. 2007 Mar; 19(3): 132-8 （） MACE was observed in

19、 similar incidences between the two groups after 6-month follow upX-Sizer機械血栓抽吸裝置Incidence, predictors, and outcomes of device failure of X-sizer thrombectomy: Real-world experience of 200 cases in 5 yearsAm Heart J 2007;153:14.e13-14.e19.Am Heart J 2007;153:14.e13-14.e19.Am Heart J 2007;153:14.e13-

20、14.e19.Am Heart J 2007;153:14.e13-14.e19.直接支架植入A Randomized Comparison of Direct Stenting With Conventional Stent Implantation in Selected Patients With Acute Myocardial InfarctionAMI直接支架植入和傳統(tǒng)支架植入的隨機對照研究J Am Coll Cardiol 2002;39:1521randomized, single-center trial206 were allocated to direct stent i

21、mplantation (n=102) or stent implantation after balloon pre-dilation (n=104)J Am Coll Cardiol 2002;39:1521J Am Coll Cardiol 2002;39:1521J Am Coll Cardiol 2002;39:1521兩組住院期間的臨床結(jié)果準(zhǔn)分子激光消栓Excimer laser thrombus elimination for prevention of distal embolization and no-reflow in patients with acute ST ele

22、vation myocardial infarction Results from the randomized Laser AMI study27 consecutive patients with ST-segment elevation AMI (aged 57.89.2 years) were randomized either to balloon angioplasty and stent implantation alone (n=13) or adjunct ELCA (n=14).International Journal of Cardiology 116 (2007) 2

23、026ELCA was feasible and safe in all cases. No procedure-associated complications were observed.International Journal of Cardiology 116 (2007) 2026International Journal of Cardiology 116 (2007) 2026International Journal of Cardiology 116 (2007) 2026治療硝酸甘油（Nitroglycerin）腺苷（Adenosine）尼可地爾(KATP通道開放劑)（Nicorandil）維拉帕米（Verapamil）地爾硫卓（Diltiazem）硝普鈉（Sodium Nitroprusside）烏拉地爾（Urapidil）GP IIb/IIIa受體拮抗劑（GP IIb/IIIa receptor antagonist）Intr