急性心肌梗死桥血管病变急诊介入治疗的临床研究——年龄组对比分析
王禹 A.H.Katus K.K.Hasse 盖鲁粤 杨庭树 沈洪 计达 陈练 刘宏斌 孙志军 任艺红 金琴花王有 杜洛山 李志坚 邵如宏 李天德【摘要】 目的 评价包括ST段抬高性和非抬高性急性心肌梗死(AMI)患者在急诊冠状动脉(冠脉)造影明确其梗塞相关血管为静脉搭桥血管(SVBG)后，进行急诊直接经皮血管成型术(PCI)的临床有效性及安全性；比较≥70岁与<70岁两组患者SVBG病变再通的临床效果和不良事件。方法 分析2003年1月—2004年11月在解放军总医院和德国海德堡大学附属海德堡医院行急诊介入治疗的连续AMI患者309例,其梗塞相关血管为SVBG患者。全部患者行急诊冠脉造影，根据造影显示梗塞相关SVBG血流为心肌梗死溶栓治疗临床试验(TIMI)Ⅲ级以下，或同时伴有较明显胸痛，梗塞对应心电图导联ST段仍抬高或压低，并均在确认无介入治疗禁忌证后行急诊PCI治疗(包括球囊成型术或支架术)。比较两组患者即刻SVBG再通效果、血管有效再通成功率、住院期间病死率及短期临床效果。结果 急诊PCI治疗SVBG罪犯血管共309例支，≥70岁组213例，<70岁组96例。两组患者中应用各种血管远端保护器者47例，其比例两组间差异无显著性。两组患者行球囊扩张术和支架植入术的技术成功率、急性再闭塞率差异均无显著性。≥70岁组SVBG直接PCI后发生慢血流或无血流现象明显增多，住院期间绝对死亡数多(20/24例)，均较<70岁组明显升高。多次心肌梗死，SVBG连通大和优势冠脉血管，以及连通惟一仅存的SVBG时，发生慢血流或无血流后的死亡危险性较高。亚组分析显示：相对于慢血流或无血流患者，正常血流组行直接支架术率较高，但两组间差异无显著性(73.5%比67.3%,P>0.05)。结论 AMI梗塞相关SVBG病变、及≥70岁AMI患者组的急诊介入治疗围手术期总病死率较高。尽管两组PCI治疗手术技术成功率和各种血管远端保护器应用率差异无显著性，≥70岁组SVBG直接PCI后慢血流或无血流发生率较高，同时住院期间绝对死亡数较高。
【关键词】 心肌梗死，急性； 桥血管病变； 直接经皮血管成型术； 年龄； 有效性； 安全性
OBJIECTIVE: To evaluate the efficacy and the safety of emergent primary percutaneous coronary intervention (PCI) in the saphenous vein bypass graft (SVBG) of acute myocardial infarction (AMI), and compare the results between aged -patients with non-aged patients. METHODS: Three hundred and nine consecutive AMI patients with culprit SVBG vessels, were analysed, including aged patients 213 cases(>70 years old), nonaged patients 96 cases (<70 years old), underwent the emergent primary PCI after confirmed below TIMI III perfusion(TIMI 0-TIMI II) in coronary angiographies. The immediate results and in-hospital outcomes were compared between two groups. RESULTS: Procedural successful rate, re-occlusion rate, and emergency re-CABG had no significant differences between two groups. The rate of slow-flow/no-reflow and in-hospital mortality rate were significantly higher in elderly group (19.7% vs 10.4%, 9.4% vs 4.2%, both P<0.05), with no difference in the rate of the using of distal protection devices between two groups. The comparison of the rate of direct stenting in slow-flow/no-reflow subgroup with normal-flow subgroup, had not showed statistic difference (73.5% vs 67.3%, P>0.05). There was no statistic difference of heavy hemorrhage between two different age groups. CONCLUSION: The primary PCI for the elderly AMI patients with infarction-related SVBG vessels, has higher risks in slow-flow/no-reflow and the mortality, even with using the distal protection devises and direct stents implantation. ......
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