1、精品PPT課件 瀏覽免費 下載后可以編輯修改。 :/精品課件本文檔下載后可以修改編輯，歡迎下載收藏。冠狀動脈無復流現象的防治武警部隊心臟研究所武警部隊心血管介入中心武警總醫院心血管內科病人資料毛某，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導聯ST段抬高。肌鈣蛋白升高。CAGCAG球囊擴張前冠脈內給予硝酸甘油200ug，欣維寧10ml 2.5*15mm球囊擴張球囊擴張后植入支架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40

2、0ug，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600ug后 一、無復流概述 無復流現象(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象。冠狀動脈造影表現為血流明顯減慢(血流=50%)或ST段抬高指數增加(=30%)，對判斷微血管灌注或無復流均有較高準確性(81%)。3、心電圖經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，可以判定無復流。對于冠狀動脈血流TIMI III級的病

3、例，一部分表現為緩慢血流，另一部分為快血流，緩慢血流患者經超聲、核素檢查后仍可檢出無復流病例，提示TIMI血流分級在判定無復流方面存在局限性。4、冠狀動脈造影血流分級在傳統的TIMI血流分級法基礎上用校正的TIMI幀數來評估微循環血流。這是一種較精確的識別技術，較傳統的TIMI分級客觀、定量、可重復、敏感。造影劑到達指定的冠狀動脈遠端所需的血管造影幀數越多，血流速度越慢，無復流存在的可能越大。5、校正的心肌梗死溶栓治療臨床試驗幀數(CTFC)采用多普勒血流導絲，進行血管內超聲檢查，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，假設顯示冠狀動脈血流儲備指數下降，收縮期

4、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流現象。收縮早期逆向血流是具有敏感性和特異性的評估無復流的指標。6、冠狀動脈內多普勒血流 7、超聲心肌聲學造影(MCE) 將聲處理的造影物質(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，受累區無復流灌注反應或心肌內氣泡反常持續存在提示無復流現象。目前由于聲學造影劑的改進，二次諧波成像技術的應用和心肌聲學造影分析方法的進步，心肌聲學造影被認為是目前評估活體冠狀動脈微循環異常的最有效方法之一。8、冠狀動脈內壓力測定應用壓力導絲測量靶動脈的壓力階差，并計算心肌血流儲備分數(FFRmyo)。當有

5、微循環病變存在時，血流儲備分數值會升高，此時還應當結合冠狀動脈內血流儲備分數進行判斷。如果血流儲備分數值較高而冠狀動脈血流儲備值低，說明有微血管功能障礙存在。9、其他方法放射性核素運動心肌灌注顯像、正電子發射斷層和對比增強磁共振顯像法，都可用于診斷無復流。四、無復流的危險因素PCI術后是否發生無復流可根據臨床特點、冠狀動脈造影及冠狀動脈內超聲結果進行初步判斷。研究發現，SVG PCI時，血栓形成、ACS、退化的靜脈移植物、潰瘍是發生低或無復流的4個獨立危險因素，發生SNR的危險分別為：低危(1%-10%) =3個危險因素。AMI PCI時，CAG見高負荷的血栓形成是發生無復流現象的獨立預測因素

6、，表現為：IRA完全閉塞處呈切面殘端、阻塞近端血栓5mm、浮動血栓存在、阻塞遠端造影劑持續淤滯、參考管腔直徑(RLD)=4mm、II型病變(IRA不完全阻塞性血栓長度超過RLD3倍)。IVUS見到的有脂質池樣圖象的大血管也處于發生無復流的高危險。相反，早期再灌注=2級、錐形阻塞，為不發生無復流的獨立預測因素。五、無復流的防治嚴重患者發生急性糜爛性胃炎的病理機制可能為胃粘膜屏障功能減弱。胃粘膜的血流減少和可能伴有的酸分泌增加(如燒傷，中樞神經系統創傷和敗血癥)可促進粘膜炎癥和潰瘍的形成。 癥狀、體征和診斷：通常，患者可能因為病情太重而說不清胃部癥狀，即使癥狀存在，常是輕度的和非特異性的。首發的明

7、顯體征常為在鼻胃吸引時出現血液，一般發生在嚴重應激反應的最初25天內。 內鏡檢查可明確診斷，某些患者(如燒傷，休克和敗血癥)在急性損傷12小時內可發生急性糜爛。病灶多從胃底部開始，呈瘀點或瘀斑，逐漸融合成220mm不規那么的小潰瘍，出血極為少見，組織學病變局限于粘膜，經處理或除去應激后可迅速愈合。病灶可繼續發展，累及粘膜下層，甚至穿透漿膜，更為常見的是胃底部發生多處出血，胃竇部也可被累及。頭部損傷與其他情況不同，此時胃酸分泌不是減少，而是增加，病灶(Cushing潰瘍)可為孤立，也可累及十二指腸。 預防和治療：據報道，患者一旦發生嚴重出血(約見重癥監護病房患者的2%)，死亡率可達60%以上。大

8、量輸血會進一步削弱止血。雖然各種手術和非手術方法如抗分泌的潰瘍藥物，血管收縮劑，血管造影技術(如動脈栓塞)，內鏡下凝固療法已被采用，但效果并不理想。除全胃切除外，其他手術后的繼續出血是常見的，且死亡率與內科治療相同。 主體部分要一一列出準備開展的工作(學習)、任務，并提出步驟、方法、措施、要求。這 是計劃最重要的內容，也是篇幅最大的一部分。通常主體部分由于內容繁多，需要分層、分 條撰寫。常見的結構形式為：用“一、二、三的序碼分層次，用“(一)、(二)、 (三)加“123的序碼分條款。具體如何分層遞進，依內容的多少及其 內在的邏輯性而定，可參考后附例文。 3結尾 結尾可以用來提出希望、發出號召、

9、展望前景、明確執行要求等，也可以在條款之后就結束 全文，不寫專門的結尾部分。 所以讓人看明白為什么要這么去做這件事情，就是策劃要做的事情。 精品課件文檔本文檔下載后可以修改編輯，歡迎下載收藏。預防藥物遠端保護/血栓抽吸裝置主要用于橋血管PCI和AMI直接PCI直接支架植入準分子激光消栓藥物PCI術前或術中冠狀動脈內或外周靜脈給藥 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 antagonist等均可

10、減少無復流現象的發生。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 verapamil before

11、 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.(CHEST 2005

12、; 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 of 158 co

13、nsecutive 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 mmol/l (180

14、mg/dl).Diabetes Care 29:202206, 2006Diabetes 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小時內的住院病人，PCI前TIMI血流0-1級。隨機分

15、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 (總量原那么上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術中使用 Guardwire Plus 的遠端球囊阻塞/血栓抽吸裝置組N=406 和傳統0.014 inch導絲組 N=395 主要終點：30天內死亡、心肌梗

16、死、急診搭橋或靶病變再血管成形術的聯合終點。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遠端保護對大血栓負荷直接PCI心肌再灌注的影響Circ J 2006

17、; 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 2006; 70: 232 238The Gua

18、rdWire 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 using a GuardWire tempor

19、ary 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 conducted as a prospective，

20、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 PCI without distal pr

21、otection.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 similar incidences betw

22、een 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.e13-14.e19.Am Heart J 2007;1

23、53:14.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 implantation (n=102) or s

24、tent 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果準分子激光消栓Excimer laser thrombus elimination for prevention of distal embolization and no-reflow in patients with acute ST elevation myocardial infarc

25、tion 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) 2026ELCA was feasible and

26、 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Dil

27、tiazem硝普鈉Sodium Nitroprusside烏拉地爾UrapidilGP IIb/IIIa受體拮抗劑GP IIb/IIIa receptor antagonistIntracoronary Verapamil for Reversal of No-Reflow During Coronary Angioplasty for Acute Myocardial Infarction冠脈內給予維拉帕米逆轉AMI冠狀動脈成形術中無復流Cathet Cardiovasc Intervent 002;57:444451.a consecutive series of 212 direct o

28、r rescue PTCAs for AMI，a TIMI flow grade 3 was observed in 23 patients (10.8%)Ten of the 23 patients had received GP IIb/IIIa antagonists before PTCACathet Cardiovasc Intervent 002;57:444451.A：LAD閉塞，B：球囊擴張后TIMI2級血流，C：支架植入后無血流，D：沿導絲送入灌注導管至支架遠端，注入維拉帕米1mg，E：保留灌注導管造影TIMI3級，F：15MIN后造影Cathet Cardiovasc Intervent 002;57:444451.Individual changes of TFC in 23 patients with no-reflow after intracoronary verapamil. The significant change of group mean standard deviation is also shown (P 0.001).Cathet Cardiovasc Intervent 002;57:444451.Cathet Cardiovasc Int