PCI对急性心肌梗死室壁瘤的逆转效应及其心肌坏死炎症标记物水平变化的临床研究
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摘要
急性心肌梗死（acute myocardial infarction， AMI）发生后心室壁瘤（ventricular aneurysm，VA）的形成是失去收缩张力的梗死区坏死、损伤和缺血心肌与正常收缩心肌之间产生的收缩牵拉效应导致的心肌结构（包括心肌细胞及其胞外基质）和心室几何构型变化的病理生理过程，为AMI后心室重构的重度表现形式，其加重梗死后患者的心脏血流动力学异常，并且是决定梗死后心脏事件发生率和远期预后的主要因素。
在AMI早期阶段得到有效的心肌再灌注，充分持久的开通梗死相关动脉（infarct related artery, IRA）是保护心室功能、逆转VA的形成、改善临床预后的关键措施。静脉内溶栓治疗简单、方便、经济，且可在发病后短时间内进行，但其IRA开通率仅50-75%，且其中近半数仅能达到TIMI-II级血流，同时溶栓后复发心肌缺血和IRA再闭塞率可达15-30%以上。直接经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）虽可使IRA完全、持久开通，但与溶栓治疗相比存在着40-60min再灌注时间延迟问题。而将这两种方法结合起来的易化PCI（facilitated PCI）是否能达到IRA尽早、充分、持久开通，并挽救更多心肌、有效逆转VA形成尚不明了。通过99m锝-甲氧基-异丁基-异腈（99mTc-MIBI）心肌灌注显像结合导管法左心室造影（left ventriculography， LVG）和平衡法核素心室造影（equilibrium radionuclide angiography，ERNA）的方法，对比评价溶栓、直接PCI和易化PCI三种治疗方式对AMI后VA形成的逆转效应及其对心功能的影响，将从形态与功能的角度对三种治疗方法做出效果评价，从而为临床防治AMI后VA形成、保护心室功能的治疗方式提供选择依据。
有关急性心肌梗死经皮冠状动脉介入治疗（AMI-PCI）后的研究显示开通达到TIMI3级血流的血管仍可能存在心肌组织水平的再灌注不良。同时已有一些研究证实心肌呈色分级（MBG）是一种简便、直接、有效的评价AMI-PCI后心肌再灌注的临床可行方法，以MBG 0-1级界定为无复流的方法正在为冠脉介入临床所接受。但迄今为止，以MBG判断的无复流现象对近期和远期心室壁瘤形成和心室局部、整体功能及同步性的影响尚鲜有报道。采用MBG的方法界定出
AMI-PCI后存在无复流现象的患者为研究对象，应用导管法心室造影结合计算机平衡法心血池显像（ERNA）及相位分析技术，探讨MBG分级上AMI-PCI后有/无复流现象在AMI后心室壁瘤形成中的作用以及其对局部/整体心室收缩功能、收缩同步性功能变化的影响，对临床深刻认识PCI后无复流现象在心室重构及室壁瘤形成中的意义和提高PCI后无复流现象的防治水平均有重要的临床价值。
AMI后心肌缺血坏死、损伤、心室壁张力增加及压力负荷过重等均可直接或间接导致循环中心肌坏死和炎症标记物增加，在AMI后VA的形成和发展过程中脑钠素(brain natriuretic peptide，BNP)、白介素-8（interleukin-8，IL-8）和肌钙蛋白I(cardiac troponin I， cTnI)三种心肌坏死和炎症标记物的水平变化分别反映了AMI后急性心室重构过程中心室机械张力变化的影响、AMI面积深度与广度以及AMI后VA形成过程中心肌与血管的免疫炎症状态，联合检测上述三项主要心肌坏死和炎症标记物在AMI后VA形成中的水平变化有助于预测和评价AMI后VA的形态与功能。但是目前有关上述心肌坏死和炎症标记物在AMI后VA形成过程中的水平变化及其与VA发生发展的关系尚不清楚，动态测定血浆BNP、IL-8和cTnI三种心肌坏死和炎症反应标记物水平的变化不但反映了AMI后心肌坏死损伤程度、AMI后血管和心肌免疫炎症状态也反映了梗死心脏形态功能重构进程，是联合评价和预测AMI后VA形成患者心室功能状态和心脏事件发生率的可靠指标。
研究内容及结果如下：
第一部分 直接PCI和易化PCI对急性心肌梗死后室壁瘤形成的逆转效应及其对心室收缩同步性功能影响的对比研究
目的: 通过99mTc-MIBI心肌灌注显像（SPECT）结合左心室造影（LVG）和平衡法核素心室造影（ERNA）的方法，对比评价了溶栓、直接经皮冠状动脉介入治疗（PCI）和易化PCI三种治疗方式对急性心肌梗死（AMI）后左室室壁瘤（LVA）形成的逆转效应及其对心室收缩同步性功能的影响。
方法: 选择2001年9月-2003年9月我院收治的首次急性前壁心肌梗死患者，随机分为溶栓组、直接PCI组和易化PCI组。根据三组相应治疗后即刻行LVG确定为急性前壁心肌梗死合并LVA形成的97例患者入选为本研究对象，其中溶栓组（LVAT）28例、直接PCI组（LVAP）33例、易化PCI组（LVATP）36例。三组患者在年龄、性别、危险因素（包括高血压、糖尿病、高脂血症、吸烟史）、
Killip心功能分级以及持续胸痛发作至得到再灌注治疗的时间、入院至PCI时球囊扩张时间等方面均无显著性差异。溶栓与PCI均采用标准剂量与操作程序。三组患者于溶栓后或PCI前行急诊冠状动脉造影（CAG）及LVG，入院后6个月复查CAG及LVG，测定左心室舒张末期容积指数（LVEDVI）、左心室收缩末期容积指数（LVESVI）、左室射血分数（LVEF）、室壁运动记分（WMS）、左室舒张末期压（LVEDP）。三组患者于入院后1周行静息及硝酸甘油介入99mTc-MIBI SPECT，行自身和组间量化测定心肌缺血面积（IE）以判定存活?
The formation of ventricular aneurysm (VA) after acute myocardial infarction (AMI) is a pathophysiologic process of myocardial structure and ventricular geometry volume remodeling caused by contractive stretching effect between normal tension muscle and loss tension muscle involved in necrotic, injurious and ischemic myocardium around the myocardial infarction area. VA is a extreme manifestation of ventricular remodeling that deteriorated the hemodynamic abnormality, and is a main determinative factor for the cardiac accident and long term prognosis after AMI.
To gain the effective myocardial reperfusion in the early stage of AMI, the complete and persistent repatency of infarcted related artery (IRA) is the key management to protect ventricular function and reverse VA formation. The intravenous thrombolytic therapy is a simple, convenient and economic, and can practice in clinic within a short time after AMI onset, but it merely gains 50-70% repatency rate of IRA, and arrives at TIMI-II grade flow in half of them. Simultaneously the ischemic recurrence and IRA reocclusion rate may arrive above 15-30%. Although the primary percutaneous coronary intervention (PCI) can completely and persistently reopen the IRA, the reperfusion time is delayed of 40-60 min as compared to that of thrombolytic treatment. It is unclear whether the facilitated PCI which the thrombolysis and combined with primary PCI therapy is prior to the any one of them in the much early, complete and persistent repatency of IRA with salvage of much more myocardium. To compare and evaluate reversed effect on VA formation and influence on the cardiac systolic function and synchronization with thrombolysis, primary PCI and facilitated PCI by 99mTc-MIBI myocardial perfusion imaging combined catheterized left ventriculography (LVG) and equilibrium radionuclide angiography (ERNA) will conduct a efficient evaluation from the ventricular function and morphologic alteration and provide a excellent choice to
prevent from formation of VA and protect ventricular performance.
Recently, some experimental researches have shown that the TIMI-III grade flow of repatenced IRA can not reflect the effective reperfusion in myocardium tissue level, if it was recognized by myocardial blush grades (MBG) criterion. MBG is a simple, direct and effective method for myocardial reperfusion after PCI in AMI patients that has be proved by recent investigations. The 0 or I grade identified by MBG classification has been accepted as the clinic diagnosis criterion of no reflow phenomenon post PCI procedure. Until now, there is no clinic report of the short and long term influence on the VA formation, reginal and globle cardiac function as well the synchronization for no reflow phenomenon of IRA identified by MBG. To probe these influences by LVG and ERNA with phase analysis technique will contribute to the recognition of no reflow phenomenon in VA formation and raise the level of the prevention and management for no reflow phenomenon post PCI in clinic.
The myocardial necrotic and inflammatory markers are significantly increased, directly or indirectly due to the acute ischemia, injury and necrosis of myocardium and the increased impact on the ventricular wall tension and intraventricular pressure-volume load. The level of brain natriuretic peptide (BNP), cardiac troponin I (cTnI) and interleukin-8 (IL-8) respectively reflect the influence on ventricular wall mechanical tension alteration, the immune inflammation reaction of myocardium and vessels and the extent and depth degree of AMI during the process of VA formation and acute ventricular remodeling after AMI. Integral measurements of these three myocardial necrotic and inflammatory markers are beneficial to the prediction and evaluation of VA formation and cardiac performance after AMI. However, the change of myocardial necrosis and inflammation marker’s level and their relationship with the formation and development of VA after AMI have still been unclear in present. To dynamically measure the level alteration of the th
在AMI早期阶段得到有效的心肌再灌注，充分持久的开通梗死相关动脉（infarct related artery, IRA）是保护心室功能、逆转VA的形成、改善临床预后的关键措施。静脉内溶栓治疗简单、方便、经济，且可在发病后短时间内进行，但其IRA开通率仅50-75%，且其中近半数仅能达到TIMI-II级血流，同时溶栓后复发心肌缺血和IRA再闭塞率可达15-30%以上。直接经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）虽可使IRA完全、持久开通，但与溶栓治疗相比存在着40-60min再灌注时间延迟问题。而将这两种方法结合起来的易化PCI（facilitated PCI）是否能达到IRA尽早、充分、持久开通，并挽救更多心肌、有效逆转VA形成尚不明了。通过99m锝-甲氧基-异丁基-异腈（99mTc-MIBI）心肌灌注显像结合导管法左心室造影（left ventriculography， LVG）和平衡法核素心室造影（equilibrium radionuclide angiography，ERNA）的方法，对比评价溶栓、直接PCI和易化PCI三种治疗方式对AMI后VA形成的逆转效应及其对心功能的影响，将从形态与功能的角度对三种治疗方法做出效果评价，从而为临床防治AMI后VA形成、保护心室功能的治疗方式提供选择依据。
有关急性心肌梗死经皮冠状动脉介入治疗（AMI-PCI）后的研究显示开通达到TIMI3级血流的血管仍可能存在心肌组织水平的再灌注不良。同时已有一些研究证实心肌呈色分级（MBG）是一种简便、直接、有效的评价AMI-PCI后心肌再灌注的临床可行方法，以MBG 0-1级界定为无复流的方法正在为冠脉介入临床所接受。但迄今为止，以MBG判断的无复流现象对近期和远期心室壁瘤形成和心室局部、整体功能及同步性的影响尚鲜有报道。采用MBG的方法界定出
AMI-PCI后存在无复流现象的患者为研究对象，应用导管法心室造影结合计算机平衡法心血池显像（ERNA）及相位分析技术，探讨MBG分级上AMI-PCI后有/无复流现象在AMI后心室壁瘤形成中的作用以及其对局部/整体心室收缩功能、收缩同步性功能变化的影响，对临床深刻认识PCI后无复流现象在心室重构及室壁瘤形成中的意义和提高PCI后无复流现象的防治水平均有重要的临床价值。
AMI后心肌缺血坏死、损伤、心室壁张力增加及压力负荷过重等均可直接或间接导致循环中心肌坏死和炎症标记物增加，在AMI后VA的形成和发展过程中脑钠素(brain natriuretic peptide，BNP)、白介素-8（interleukin-8，IL-8）和肌钙蛋白I(cardiac troponin I， cTnI)三种心肌坏死和炎症标记物的水平变化分别反映了AMI后急性心室重构过程中心室机械张力变化的影响、AMI面积深度与广度以及AMI后VA形成过程中心肌与血管的免疫炎症状态，联合检测上述三项主要心肌坏死和炎症标记物在AMI后VA形成中的水平变化有助于预测和评价AMI后VA的形态与功能。但是目前有关上述心肌坏死和炎症标记物在AMI后VA形成过程中的水平变化及其与VA发生发展的关系尚不清楚，动态测定血浆BNP、IL-8和cTnI三种心肌坏死和炎症反应标记物水平的变化不但反映了AMI后心肌坏死损伤程度、AMI后血管和心肌免疫炎症状态也反映了梗死心脏形态功能重构进程，是联合评价和预测AMI后VA形成患者心室功能状态和心脏事件发生率的可靠指标。
研究内容及结果如下：
第一部分 直接PCI和易化PCI对急性心肌梗死后室壁瘤形成的逆转效应及其对心室收缩同步性功能影响的对比研究
目的: 通过99mTc-MIBI心肌灌注显像（SPECT）结合左心室造影（LVG）和平衡法核素心室造影（ERNA）的方法，对比评价了溶栓、直接经皮冠状动脉介入治疗（PCI）和易化PCI三种治疗方式对急性心肌梗死（AMI）后左室室壁瘤（LVA）形成的逆转效应及其对心室收缩同步性功能的影响。
方法: 选择2001年9月-2003年9月我院收治的首次急性前壁心肌梗死患者，随机分为溶栓组、直接PCI组和易化PCI组。根据三组相应治疗后即刻行LVG确定为急性前壁心肌梗死合并LVA形成的97例患者入选为本研究对象，其中溶栓组（LVAT）28例、直接PCI组（LVAP）33例、易化PCI组（LVATP）36例。三组患者在年龄、性别、危险因素（包括高血压、糖尿病、高脂血症、吸烟史）、
Killip心功能分级以及持续胸痛发作至得到再灌注治疗的时间、入院至PCI时球囊扩张时间等方面均无显著性差异。溶栓与PCI均采用标准剂量与操作程序。三组患者于溶栓后或PCI前行急诊冠状动脉造影（CAG）及LVG，入院后6个月复查CAG及LVG，测定左心室舒张末期容积指数（LVEDVI）、左心室收缩末期容积指数（LVESVI）、左室射血分数（LVEF）、室壁运动记分（WMS）、左室舒张末期压（LVEDP）。三组患者于入院后1周行静息及硝酸甘油介入99mTc-MIBI SPECT，行自身和组间量化测定心肌缺血面积（IE）以判定存活?
The formation of ventricular aneurysm (VA) after acute myocardial infarction (AMI) is a pathophysiologic process of myocardial structure and ventricular geometry volume remodeling caused by contractive stretching effect between normal tension muscle and loss tension muscle involved in necrotic, injurious and ischemic myocardium around the myocardial infarction area. VA is a extreme manifestation of ventricular remodeling that deteriorated the hemodynamic abnormality, and is a main determinative factor for the cardiac accident and long term prognosis after AMI.
To gain the effective myocardial reperfusion in the early stage of AMI, the complete and persistent repatency of infarcted related artery (IRA) is the key management to protect ventricular function and reverse VA formation. The intravenous thrombolytic therapy is a simple, convenient and economic, and can practice in clinic within a short time after AMI onset, but it merely gains 50-70% repatency rate of IRA, and arrives at TIMI-II grade flow in half of them. Simultaneously the ischemic recurrence and IRA reocclusion rate may arrive above 15-30%. Although the primary percutaneous coronary intervention (PCI) can completely and persistently reopen the IRA, the reperfusion time is delayed of 40-60 min as compared to that of thrombolytic treatment. It is unclear whether the facilitated PCI which the thrombolysis and combined with primary PCI therapy is prior to the any one of them in the much early, complete and persistent repatency of IRA with salvage of much more myocardium. To compare and evaluate reversed effect on VA formation and influence on the cardiac systolic function and synchronization with thrombolysis, primary PCI and facilitated PCI by 99mTc-MIBI myocardial perfusion imaging combined catheterized left ventriculography (LVG) and equilibrium radionuclide angiography (ERNA) will conduct a efficient evaluation from the ventricular function and morphologic alteration and provide a excellent choice to
prevent from formation of VA and protect ventricular performance.
Recently, some experimental researches have shown that the TIMI-III grade flow of repatenced IRA can not reflect the effective reperfusion in myocardium tissue level, if it was recognized by myocardial blush grades (MBG) criterion. MBG is a simple, direct and effective method for myocardial reperfusion after PCI in AMI patients that has be proved by recent investigations. The 0 or I grade identified by MBG classification has been accepted as the clinic diagnosis criterion of no reflow phenomenon post PCI procedure. Until now, there is no clinic report of the short and long term influence on the VA formation, reginal and globle cardiac function as well the synchronization for no reflow phenomenon of IRA identified by MBG. To probe these influences by LVG and ERNA with phase analysis technique will contribute to the recognition of no reflow phenomenon in VA formation and raise the level of the prevention and management for no reflow phenomenon post PCI in clinic.
The myocardial necrotic and inflammatory markers are significantly increased, directly or indirectly due to the acute ischemia, injury and necrosis of myocardium and the increased impact on the ventricular wall tension and intraventricular pressure-volume load. The level of brain natriuretic peptide (BNP), cardiac troponin I (cTnI) and interleukin-8 (IL-8) respectively reflect the influence on ventricular wall mechanical tension alteration, the immune inflammation reaction of myocardium and vessels and the extent and depth degree of AMI during the process of VA formation and acute ventricular remodeling after AMI. Integral measurements of these three myocardial necrotic and inflammatory markers are beneficial to the prediction and evaluation of VA formation and cardiac performance after AMI. However, the change of myocardial necrosis and inflammation marker’s level and their relationship with the formation and development of VA after AMI have still been unclear in present. To dynamically measure the level alteration of the th
引文
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