中华心血管病杂志
中華心血管病雜誌
중화심혈관병잡지
Chinese Journal of Cardiology
2009年
9期
785-789
,共5页
赵汉军%颜红兵%李狄%刘臣%李文铮%马芹%王伟%王健%李庆祥%李世英%迟云鹏%吴铮%陈东
趙漢軍%顏紅兵%李狄%劉臣%李文錚%馬芹%王偉%王健%李慶祥%李世英%遲雲鵬%吳錚%陳東
조한군%안홍병%리적%류신%리문쟁%마근%왕위%왕건%리경상%리세영%지운붕%오쟁%진동
心肌梗死%冠状动脉血栓形成%血栓清除术%心肌再灌注
心肌梗死%冠狀動脈血栓形成%血栓清除術%心肌再灌註
심기경사%관상동맥혈전형성%혈전청제술%심기재관주
Myocardial infarction%Coronary thrombosis%Thrombectomy%Myocardial reperfusion
目的 对急性ST段抬高心肌梗死(STEMI)急诊经皮冠状动脉介入治疗术(PCI)中血栓抽吸获得的样本进行病理分析并探讨其临床意义.方法 搜集STEMI患者急诊PCI中的可见抽吸物,根据光镜下病理所见将其分为红细胞为主血栓(红血栓)、血小板/纤维素为主血栓(白血栓)、混合血栓(红细胞与血小板/纤维素含量近似)、斑块和血浆析出物成分.根据血栓时相将其分为新鲜血栓(<1 d)、裂解血栓(1～5 d)、新鲜+裂解血栓和机化血栓(>5 d).根据光镜下有无斑块物质分为无斑块组和斑块组,探讨清除斑块物质对心肌再灌注指标如心肌呈色分级(MBG)、心肌标志物估测的梗死面积[肌酸激酶(CK)、CK同工酶(CK-MB)峰值]、术后16 h内左心室舒张末内径(LVEDD)和左心室射血分数(LVEF)的影响.结果 共搜集49例单纯抽吸导管血栓清除术的可见抽吸物,光镜下确认46例有血栓成分,3例仅有斑块成分.红血栓、白血栓和混合血栓比例分别为41.3%(19/46)、30.4%(14/46)和28.2%(13/46).新鲜血栓、裂解血栓、新鲜+裂解血栓和机化血栓比例分别为47.8%(22/46)、32.6%(15/46)、10.9%(5/46)和8.7%(4/46).占57.1%(28/49)的样本中可见粥样斑块成分,还可见破裂斑块伴血栓形成、纤维斑块和正常内膜,比例分别为8.2%(4/49)、6.1%(3/49)和2.0%(1/49).无斑块组(n=21)和斑块组(n=28)之间基线资料差异无统计学意义(均P>0.05),MBG 3级比例[52.4%(11/21)比82.1%(23/28)]、CK峰值[(2629±2013)U/L比(1705±1647)U/L]、CK-MB峰值[(258±215)μg/L比(146±136)μg/L]和术后16 h内LVEF(0.52±0.08比0.59±0.10)差异均有统计学意义(均P<0.05).结论 STEMI患者急诊PCI中采用单纯抽吸导管可有效清除血栓和部分斑块物质,改善心肌再灌注和心功能,并限制梗死面积.急诊PCI中采用抽吸导管清除斑块物质即斑块减容可能是血栓抽吸改善心肌再灌注、限制梗死面积和预后的重要机制之一.
目的 對急性ST段抬高心肌梗死(STEMI)急診經皮冠狀動脈介入治療術(PCI)中血栓抽吸穫得的樣本進行病理分析併探討其臨床意義.方法 搜集STEMI患者急診PCI中的可見抽吸物,根據光鏡下病理所見將其分為紅細胞為主血栓(紅血栓)、血小闆/纖維素為主血栓(白血栓)、混閤血栓(紅細胞與血小闆/纖維素含量近似)、斑塊和血漿析齣物成分.根據血栓時相將其分為新鮮血栓(<1 d)、裂解血栓(1～5 d)、新鮮+裂解血栓和機化血栓(>5 d).根據光鏡下有無斑塊物質分為無斑塊組和斑塊組,探討清除斑塊物質對心肌再灌註指標如心肌呈色分級(MBG)、心肌標誌物估測的梗死麵積[肌痠激酶(CK)、CK同工酶(CK-MB)峰值]、術後16 h內左心室舒張末內徑(LVEDD)和左心室射血分數(LVEF)的影響.結果 共搜集49例單純抽吸導管血栓清除術的可見抽吸物,光鏡下確認46例有血栓成分,3例僅有斑塊成分.紅血栓、白血栓和混閤血栓比例分彆為41.3%(19/46)、30.4%(14/46)和28.2%(13/46).新鮮血栓、裂解血栓、新鮮+裂解血栓和機化血栓比例分彆為47.8%(22/46)、32.6%(15/46)、10.9%(5/46)和8.7%(4/46).佔57.1%(28/49)的樣本中可見粥樣斑塊成分,還可見破裂斑塊伴血栓形成、纖維斑塊和正常內膜,比例分彆為8.2%(4/49)、6.1%(3/49)和2.0%(1/49).無斑塊組(n=21)和斑塊組(n=28)之間基線資料差異無統計學意義(均P>0.05),MBG 3級比例[52.4%(11/21)比82.1%(23/28)]、CK峰值[(2629±2013)U/L比(1705±1647)U/L]、CK-MB峰值[(258±215)μg/L比(146±136)μg/L]和術後16 h內LVEF(0.52±0.08比0.59±0.10)差異均有統計學意義(均P<0.05).結論 STEMI患者急診PCI中採用單純抽吸導管可有效清除血栓和部分斑塊物質,改善心肌再灌註和心功能,併限製梗死麵積.急診PCI中採用抽吸導管清除斑塊物質即斑塊減容可能是血栓抽吸改善心肌再灌註、限製梗死麵積和預後的重要機製之一.
목적 대급성ST단태고심기경사(STEMI)급진경피관상동맥개입치료술(PCI)중혈전추흡획득적양본진행병리분석병탐토기림상의의.방법 수집STEMI환자급진PCI중적가견추흡물,근거광경하병리소견장기분위홍세포위주혈전(홍혈전)、혈소판/섬유소위주혈전(백혈전)、혼합혈전(홍세포여혈소판/섬유소함량근사)、반괴화혈장석출물성분.근거혈전시상장기분위신선혈전(<1 d)、렬해혈전(1～5 d)、신선+렬해혈전화궤화혈전(>5 d).근거광경하유무반괴물질분위무반괴조화반괴조,탐토청제반괴물질대심기재관주지표여심기정색분급(MBG)、심기표지물고측적경사면적[기산격매(CK)、CK동공매(CK-MB)봉치]、술후16 h내좌심실서장말내경(LVEDD)화좌심실사혈분수(LVEF)적영향.결과 공수집49례단순추흡도관혈전청제술적가견추흡물,광경하학인46례유혈전성분,3례부유반괴성분.홍혈전、백혈전화혼합혈전비례분별위41.3%(19/46)、30.4%(14/46)화28.2%(13/46).신선혈전、렬해혈전、신선+렬해혈전화궤화혈전비례분별위47.8%(22/46)、32.6%(15/46)、10.9%(5/46)화8.7%(4/46).점57.1%(28/49)적양본중가견죽양반괴성분,환가견파렬반괴반혈전형성、섬유반괴화정상내막,비례분별위8.2%(4/49)、6.1%(3/49)화2.0%(1/49).무반괴조(n=21)화반괴조(n=28)지간기선자료차이무통계학의의(균P>0.05),MBG 3급비례[52.4%(11/21)비82.1%(23/28)]、CK봉치[(2629±2013)U/L비(1705±1647)U/L]、CK-MB봉치[(258±215)μg/L비(146±136)μg/L]화술후16 h내LVEF(0.52±0.08비0.59±0.10)차이균유통계학의의(균P<0.05).결론 STEMI환자급진PCI중채용단순추흡도관가유효청제혈전화부분반괴물질,개선심기재관주화심공능,병한제경사면적.급진PCI중채용추흡도관청제반괴물질즉반괴감용가능시혈전추흡개선심기재관주、한제경사면적화예후적중요궤제지일.
Objective To analyze the components of retrieved materials from the culprit lesion in ST-segment elevation myocardial infarction (STEMI) patients by manual aspiration during primary percutaneous coronary intervention (PCI). Methods Visible retrieved materials were collected, fixed in formalin and processed for paraffin embedding, sectioned and stained with hematoxylin and eosin (HE). The retrieved materials were microscopically divided into erythrocyte-rich thrombi, platelet/fibrin-rich thrombi, combined thrombi (similar proportions of erythrocytes and platelet/fibrin components), atherosclerotic plaque materials and edematous components. Based on pathological findings, thrombus materials were classified into fresh (< 1 d), lytic (1-5 d), frash/lytic and organized thrombi(>5 d) after formation. All patients were further classified into plaque positive and plaque negative groups. Clinical and angiographic data were also obtained for analyzing possible association between pathological findings and surrogates of myocardial reperfusion, including myocardial blush grade (MBG), enzymatic estimated infarction size (peak CK and CK-MB levels), left ventricular end diastolic diameter (LVEDD) and left ventricular ejection fraction (LVEF) which were assessed 16 h after procedure. Results Visible samples were collected from 49 patients by manual catheter aspiration (thrombus components in 46 patients, atherosclerotic plaque only in 3 patients). Frequency of erythrocyte-rich thrombi, platelet/fibrin-rich thrombi and combined thrombi were 41.3% (19/46), 30.4% (14/46) and 28.2% (13/46), respectively. The incidence of fresh, lyric, fresh/lytic and organized thrombi were 47. 8% (22/46), 32. 6% (15/46), 10.9% (5/46) and 8.7% (4/46), respectively. Plaque materials were found in 57.1% (28/49) patients, including ruptured plaque accompanied by thrombus formation [8.2% (4/49)], fibrous plaque [6.1% (3/ 49)] and thickened intima [2.0% (1/49)]. Baseline characteristics did not differ between plaque positive (n=28) and plaque negative (n=21) groups. Ratios of MBG 3 were higher in plaque positive group than in plaque negative group [82.1% (23/28) vs. 52. 4% ( 11/21 ), P=0.025]. Peak CK and CK-MB levels were lower in the former than in the later [(1705±1647)U/L vs. (2629±2013)U/L, P=0. 042; (146± 136) μg/L vs. (258±215) μg/L, P=0.016; respectively]. Furthermore, LVEF were higher in plaque positive group than in plaque negative group (0.59±0. 10 vs. 0.52±0.08, P=0.012). Conclusion Manual catheter aspiration during primary PCI in STEMI patients is an effective way for removing thrombus and plaque materials, and plaque debulking before stenting or pre-dilation and this procedure might probably improve myocardial reperfusion, limit infarction size and improve cardiac function.
