冠状动脉无复流现象的防治.ppt

冠状动脉无复流现象的防治,湘潭市中心医院孙智山,一、无复流概述,无复流现象(no-reflow)是指闭塞的心外膜冠状动脉再通后，心肌组织无灌注的现象。冠状动脉造影表现为血流明显减慢(血流=50%)或ST段抬高指数增加(=30%)，对判断微血管灌注或无复流均有较高准确性(81%)。,3、心电图,经皮冠状动脉介入治疗后原病变部位无夹层、痉挛或阻塞而冠状动脉血流小于心肌梗死溶栓治疗临床试验(TIMI)II级或心肌灌注(TMP)血流分级0-2级，可以判定无复流。对于冠状动脉血流TIMIIII级的病例，一部分表现为缓慢血流，另一部分为快血流，缓慢血流患者经超声、核素检查后仍可检出无复流病例，提示TIMI血流分级在判定无复流方面存在局限性。,4、冠状动脉造影血流分级,在传统的TIMI血流分级法基础上用校正的TIMI帧数来评估微循环血流。这是一种较精确的识别技术，较传统的TIMI分级客观、定量、可重复、敏感。造影剂到达指定的冠状动脉远端所需的血管造影帧数越多，血流速度越慢，无复流存在的可能越大。,5、校正的心肌梗死溶栓治疗临床试验帧数(CTFC),采用多普勒血流导丝，进行血管内超声检查，测定时相性和平均冠状动脉血流速度；测定绝对冠状动脉血流储备(CFR)指数，若显示冠状动脉血流储备指数下降，收缩期顺向血流速度下降，异常收缩早期逆向血流，舒张期血流速度迅速下降均提示无复流现象。收缩早期逆向血流是具有敏感性和特异性的评估无复流的指标。,6、冠状动脉内多普勒血流,7、超声心肌声学造影(MCE),将声处理的造影物质(如氟丙烷白蛋白)，其中含高能微泡，从冠状动脉或静脉途径注入，然后做心肌超声检查，受累区无复流灌注反应或心肌内气泡反常持续存在提示无复流现象。目前由于声学造影剂的改进，二次谐波成像技术的应用和心肌声学造影分析方法的进步，心肌声学造影被认为是目前评估活体冠状动脉微循环异常的最有效方法之一。,8、冠状动脉内压力测定,应用压力导丝测量靶动脉的压力阶差，并计算心肌血流储备分数(FFRmyo)。当有微循环病变存在时，血流储备分数值会升高，此时还应当结合冠状动脉内血流储备分数进行判断。如果血流储备分数值较高而冠状动脉血流储备值低，说明有微血管功能障碍存在。,9、其他方法,放射性核素运动心肌灌注显像、正电子发射断层和对比增强磁共振显像法，都可用于诊断无复流。,四、无复流的危险因素,PCI术后是否发生无复流可根据临床特点、冠状动脉造影及冠状动脉内超声结果进行初步判断。研究发现，SVGPCI时，血栓形成、ACS、退化的静脉移植物、溃疡是发生低或无复流的4个独立危险因素，发生SNR的危险分别为：低危(1%-10%)=3个危险因素。,AMIPCI时，CAG见高负荷的血栓形成是发生无复流现象的独立预测因素，表现为：IRA完全闭塞处呈切面残端、阻塞近端血栓5mm、浮动血栓存在、阻塞远端造影剂持续淤滞、参考管腔直径(RLD)=4mm、II型病变(IRA不完全阻塞性血栓长度超过RLD3倍)。,IVUS见到的有脂质池样图象的大血管也处于发生无复流的高危险。,相反，早期再灌注=2级、锥形阻塞，为不发生无复流的独立预测因素。,五、无复流的防治,预防,药物远端保护/血栓抽吸装置（主要用于桥血管PCI和AMI直接PCI）直接支架植入准分子激光消栓,药物,PCI术前或术中冠状动脉内或外周静脉给药硝酸甘油（Nitroglycerin）腺苷（Adenosine）尼可地尔(KATP通道开放剂)（Nicorandil）维拉帕米（Verapamil）地尔硫卓（Diltiazem）GPIIb/IIIa受体拮抗剂（GPIIb/IIIareceptorantagonist）等均可减少无复流现象的发生。,维拉帕米,EarlyAdministrationofIntracoronaryVerapamilImprovesMyocardialPerfusionDuringPercutaneousCoronaryInterventionsforAcuteMyocardialInfarctionAMI直接PCI前冠脉内给予维拉帕米改善心肌灌注,(CHEST2005;128:25932598),目的：ToevaluatetheeffectsoftheadministrationofintracoronaryverapamilbeforetheoccurrenceofnoreflowduringdirectPCI.50patientsreadytoundergodirectPCIwithin12hfromtheonsetofAMIIntracoronaryverapamilwasadministeredimmediatelypriortoballooninflationHadnotreceivedintracoronarycalcium-channelblockerswereenrolledascontrolsubjects.,(CHEST2005;128:25932598),(CHEST2005;128:25932598),TMPG：TIMImyocardialperfusiongrade,尼可地尔,EffectsofIntravenousNicorandilBeforeReperfusionforAcuteMyocardialInfarctioninPatientsWithStressHyperglycemiaAMI并应激性高血糖病人再灌注治疗前静脉注射尼可地尔的疗效,DiabetesCare29:202206,2006,METHODS：Thisstudyconsistedof158consecutivefirstAMIpatientswithstresshyperglycemiawhounderwentPCIwithin24hfromtheonset.Theywererandomlyassignedtoreceive12mgofnicorandil(n=81)oraplacebo(n=77)intravenouslyjustbeforereperfusion.Stresshyperglycemiawasdefinedasabloodglucoselevel10mmol/l(180mg/dl).,DiabetesCare29:202206,2006,（P=0.032）,（P=0.027）,（P=0.032）,DiabetesCare29:202206,2006,尼可地尔不同给药途径的疗效,ImpactofNicorandiltoPreventReperfusionInjuryinPatientsWithAcuteMyocardialInfarctionSigmartMulticenterAngioplastyRevascularizationTrial(SMART),CircJ2006;70:10991104),90个AMI起病6小时内的住院病人，PCI前TIMI血流0-1级。随机分为A、B、C3组，A组：尼可地尔0.5mg/次，PCI前和后1-2次冠脉注射(总量原则上1-2mg)。B组：将尼可地尔配成1mg/ml.先静脉推注4mg，然后6ml/h静脉输注，加上A组方案冠脉内给药。C组：无药组,CircJ2006;70:10991104),CircJ2006;70:10991104),Fig1.Primaryendpoint.*p50%并为心绞痛罪犯血管的患者，随机分为PCI术中使用GuardwirePlus的远端球囊阻塞/血栓抽吸装置组（N=406）和传统0.014inch导丝组（N=395）主要终点：30天内死亡、心肌梗死、急诊搭桥或靶病变再血管成形术的联合终点。,Circulation.2002;105:1285-1290.),Circulation.2002;105:1285-1290.),(P=0.004),（P=0.008),（P=0.02),TheDistalProtectionDuringPrimaryPercutaneousCoronaryInterventionAlleviatestheAdverseEffectsofLargeThrombusBurdenonMyocardialReperfusion远端保护对大血栓负荷直接PCI心肌再灌注的影响,CircJ2006;70:232238,88consecutivepatientsundergoingDPduringprimaryPCIwithin24hfromtheonsetofAMIwereenrolledinthestudy(DPgroup).81consecutivepatientsundergoingprimaryPCIwithoutusingtheDPdeviceforAMIduringthepreceding1year(controlgroup).,CircJ2006;70:232238,TheGuardWirePlus(Medtronic)consistsofa0.014-inchguidewireincorporatingacentralinflationlumentowhichanelastomericballoon(3.06.0mmindiameter),CircJ2006;70:232238,CircJ2006;70:232238,CircJ2006;70:232238,CircJ2006;70:232238,LimitationsofusingaGuardWiretemporaryocclusionandaspirationsysteminpatientswithacutemyocardialinfarction:multicenterinvestigationofcoronaryarteryprotectionwithadistalocclusiondeviceinacutemyocardialinfarction(MICADO).,J-Invasive-Cardiol.2007Mar;19(3):132-8,MICADO,Thestudywasconductedasaprospective，randomized，multicentertrial.ThisstudyevaluatedtheefficacyofdistalprotectionwiththeGuardWiredistalprotectiondeviceinPCIatthetimeofAMIrevascularization.PatientswithAMIwithin24hoursfromonsetwererandomizedintoeitherPCIcombinedwithaGuardWire，orPCIwithoutdistalprotection.TheprimaryendpointswereTIMIperfusiongrade(TMP)andnoincidenceofreflow.Secondaryendpointsweremajorcardiacevents(MACE)during6-monthfollowup.,J-Invasive-Cardiol.2007Mar;19(3):132-8,J-Invasive-Cardiol.2007Mar;19(3):132-8,（p=0.054）,MACEwasobservedinsimilarincidencesbetweenthetwogroupsafter6-monthfollowup,X-Sizer机械血栓抽吸装置,Incidence,predictors,andoutcomesofdevicefailureofX-sizerthrombectomy:Real-worldexperienceof200casesin5years,AmHeartJ2007;153:14.e13-14.e19.,AmHeartJ2007;153:14.e13-14.e19.,AmHeartJ2007;153:14.e13-14.e19.,AmHeartJ2007;153:14.e13-14.e19.,直接支架植入,ARandomizedComparisonofDirectStentingWithConventionalStentImplantationinSelectedPatientsWithAcuteMyocardialInfarctionAMI直接支架植入和传统支架植入的随机对照研究,JAmCollCardiol2002;39:1521,randomized,single-centertrial206wereallocatedtodirectstentimplantation(n=102)orstentimplantationafterballoonpre-dilation(n=104),JAmCollCardiol2002;39:1521,JAmCollCardiol2002;39:1521,JAmCollCardiol2002;39:1521,两组住院期间的临床结果,准分子激光消栓,Excimerlaserthrombuseliminationforpreventionofdistalembolizationandno-reflowinpatientswithacuteSTelevationmyocardialinfarctionResultsfromtherandomizedLaserAMIstudy27consecutivepatientswithST-segmentelevationAMI(aged57.89.2years)wererandomizedeithertoballoonangioplastyandstentimplantationalone(n=13)oradjunctELCA(n=14).,InternationalJournalofCardiology116(2007)2026,ELCAwasfeasibleandsafeinallcases.Noprocedure-associatedcomplicationswereobserved.,InternationalJournalofCardiology116(2007)2026,P0.05,InternationalJournalofCardiology116(2007)2026,InternationalJournalofCardiology116(2007)2026,治疗,硝酸甘油（Nitroglycerin）腺苷（Adenosine）尼可地尔(KATP通道开放剂)（Nicorandil）维拉帕米（Verapamil）地尔硫卓（Diltiazem）硝普钠（SodiumNitroprusside）乌拉地尔（Urapidil）GPIIb/IIIa受体拮抗剂（GPIIb/IIIareceptorantagonist）,IntracoronaryVerapamilforReversalofNo-ReflowDuringCoronaryAngioplastyforAcuteMyocardialInfarction冠脉内给予维拉帕米逆转AM