CAJ | 학술논문

目的初步评价采用钬：YAG激光器及其导管系统对冠心病患者行经皮激光心肌血运重建治疗(PMR)的方法学和临床疗效。方法 14例病人均为男性，平均年龄(63.3±7.5)岁，心绞痛史(7.3±7.0)年。病例选择标准：①药物治疗无效的Ⅲ、Ⅳ级心绞痛；②冠状动脉病变不宜作经皮冠状动脉腔内成形术(PTCA)或冠状动脉旁路移植术；③左室射血分数(LVEF)≥45%；④6个月内无心肌梗死病史；⑤心电图、平板试验或ECT检查有心肌缺血证据；⑥超声检查左室壁最大舒张期厚度≥8 mm。操作方法：先作RAO 30°和LAO 60°左室造影，冻结在最大舒张期作为定位参照；将激光系统心电同步调整在T波易损期前30 ms，校正实际激光能量；经大腔引导管送入激光导管，对缺血左心室壁进行激光打孔，深度控制在6mm以内；在屏幕上标示出打孔部位和序号以保护打孔均匀。随访观察心绞痛级别、心电图、心脏超声、ECT、心肌酶等。结果每例平均打孔(17.5±4.1)个，发放脉冲(68.1±9.3)个，能量(135.8±18.2)J.PMR操作中病人无不适，操作时间(87.5±24.3)min,X线透视时间(23.5±7.6)min。未发生心包填塞等并发症。随访(4.9±1.4)个月，心绞痛平均下降2.4级，药物减少2.1种，缺血心壁减少0.9个，运动耐量提高(P<0.05)。结论 PMR是治疗顽固性心绞痛和改善心肌缺血的有效方法之一。其操作方法简单实用，可防止心脏穿孔和恶性心律失常发生。远期疗效尚有待进一步观察。
목적초보평개채용화：YAG격광기급기도관계통대관심병환자행경피격광심기혈운중건치료(PMR)적방법학화림상료효。방법 14례병인균위남성，평균년령(63.3±7.5)세，심교통사(7.3±7.0)년。병례선택표준：①약물치료무효적Ⅲ、Ⅳ급심교통；②관상동맥병변불의작경피관상동맥강내성형술(PTCA)혹관상동맥방로이식술；③좌실사혈분수(LVEF)≥45%；④6개월내무심기경사병사；⑤심전도、평판시험혹ECT검사유심기결혈증거；⑥초성검사좌실벽최대서장기후도≥8 mm。조작방법：선작RAO 30°화LAO 60°좌실조영，동결재최대서장기작위정위삼조；장격광계통심전동보조정재T파역손기전30 ms，교정실제격광능량；경대강인도관송입격광도관，대결혈좌심실벽진행격광타공，심도공제재6mm이내；재병막상표시출타공부위화서호이보호타공균균。수방관찰심교통급별、심전도、심장초성、ECT、심기매등。결과매례평균타공(17.5±4.1)개，발방맥충(68.1±9.3)개，능량(135.8±18.2)J.PMR조작중병인무불괄，조작시간(87.5±24.3)min,X선투시시간(23.5±7.6)min。미발생심포전새등병발증。수방(4.9±1.4)개월，심교통평균하강2.4급，약물감소2.1충，결혈심벽감소0.9개，운동내량제고(P<0.05)。결론 PMR시치료완고성심교통화개선심기결혈적유효방법지일。기조작방법간단실용，가방지심장천공화악성심률실상발생。원기료효상유대진일보관찰。
Objective　Evaluate the feasibility, safety and effect of the percutaneous laser myocardial revascularization (PMR) with Holmium: YAG laser generator and its affiliated catheter system in the treatment of Chinese patients (pts) with refractory Ⅲ～Ⅳ class of angina pectoris (Canadian criteria). Methods　Fourteen pts were all male, 63.3±7.5 years old, with the history of angina 7.3±7.0 years, refractory to 4.4±1.5 antiangina drugs. The angina of nine pts was CAC class Ⅳ and another five was class Ⅲ. Myocardial ischemia was confirmed by Treadmill ECG or SPECT. All pts had a normal LV size and the maxmum diastolic wall thickness was 10.8±1.6 mm. LVEF was 48.7±5.6%. Eleven pts had trivessel coronary diffuse lesions and three had bivessel diffuse lesion. Pts were selected by the criteria of: ①more than Ⅲ class of angina pectoris; ②the angina was refractory to more than three antiangina drugs; ③not suitable for CABG/PTCA; ④LVEF was greater or equal than 45%; ⑤without myocardial infarction within 6 months; ⑥myocardial ischemia confirmed by ECT or exercise test ECG; ⑦maxmum diastolic wall thickness of left ventricle (LV) was greater than 8 mm measured by echocardiography (ECHO). MLA1 Holmium: YAG generator and PMRL1 catheter system (Cardio Genesis Corp.) were used. PMR procedure steps include: ①double plane LV angiogram was conducted and the maximum diastolic imagines were freezen; ②laser system was calibrated; ③laser catheter was inserted into LV via guide tube; ④endomyocardial channels with deepth of 6 mm were made in the target LV walls and marked on the biplane screens; ⑤LV angiogram was repeated. Angina class, ECG, ECT, Holter and LV late potential were followed-up after PMR procedures. Results　Mean 17.5±4.1 myocardial channels were made in 3±0.7 LV wall. The numbers of laser pulses and enjergy were 68.1±9.3 and 135.8±18.2 J respectively. Total procedure time was 87.5±24.3 min and X radiation time was 23.5±7.6 min. There were no major or minor complications. During the follow-up of 4.9±1.4 month after the procedure, angina class was decreased from 3.6±0.5 to 2.1±0.6 (P<0.05). Myocaidial ischemia in ECG, SPECT was improved obviously. Conclusion　Our preliminary work suggests: ①PMR is a feasible and safe therapy to refractory Ⅲ to Ⅳ CAC class of angina. ②The procedure weused is simple, effective, easy to learn and with little complication. he long-term effect of PMR on AMI and sudden death needs further research.