无再流治疗研究现状_尤士杰.ppt

The system is CE marked for central and peripheral vascular applications 无再流治疗研究现状 中国医学科学院 阜外心血管病医院 冠心病诊疗中心 尤士杰 AMI冠脉再通和心肌再灌注治疗 AMI冠脉再通治疗：溶栓或冠脉介入（PCI） 开通闭塞血管 恢复冠脉供血 心肌再灌注：指恢复心肌组织供血 是治疗AMI的最终目标 冠脉再通 ≠ 心肌再灌注“无再流”导致心肌不能“有效再灌注”已经成为后再灌注治疗时代的主要障碍！ 无再流现象（no-reflow phenomenon） 冠脉已开通，无明显机械堵塞 在心肌水平无有效的再灌注 发生率可高达37-43% 严重影响AMI患者的预后 Gersh BJ. Am Heart J. 1999; 138(2pt2): 188-202. Ito H, Maruyama A, Iwakura K, et al. Circulation. 1996; 93: 223-228. Ito H, Tomooka T, Sakai N, et al. Circulation. 1992; 85: 1699-1705. Abbo KM,Dooris M, Glaziar S. Am J Cardiol. 1995; 75: 778-82. Morshima J. Circulation. 1999; 100(Supple1): 451-456. 心肌无再流发生机制 微血管：痉挛 栓塞或血栓形成 结构完整性的破坏 缺血再灌注损伤 炎症和免疫反应 机械措施 （远端保护装置） Protected Acute MI InterventionsZurich Single Center Experience CTFC 32.9 Blush 3 18.8% CTFC 23.4 Blush 3 54.5% THROMBECTOMY IN AMI In case of large amount of thrombus (10% of acute MI has a 10 mm long visible thrombus) Angiojet (Possis*) has been used by Nakagawa et al. (AJC 1999) with a 93% rate of TIMI III flow X-szer (Endicor*) has recently studied by Reimers et al. With a 92% TIMI III rate 药 物 保 护 血小板GP IIb/IIIa 受体拮抗剂 阿昔单抗 (ReoPro, Abciximab) 腺苷 (Adenosine) 血管扩张剂： 钙离子拮抗剂、硝酸甘油、 KATP通道开放剂 中药：通心络? ADENOSINE EFFECT ON REPERFUSION INJURY Virmani et al. (Circulation 1987) 3,75 mg/min Adenosine versus placebo after LAD ligation Reduction of MI size from 18+-3% to 4.6+-3% p0.01 Increase of local flow in border zone Endothelium protection and decrease of neutrophils stagnation at the capillary level ADENOSINE TO TREAT NO-REFLOW Efficient in no-reflow refractory to verapamil (Fischell, Tiede,…) 6 mg in 500 ml saline, bolus injection of 10 ml (left) 5 ml (right), rythm survey; if well tolerated repeat injection to a total of 0.5 to 1.0 mg ADENOSINE IN LYTIC THERAPY : AMISTAD 236 pts (19 centres) suitable for lytic therapy 70 gammas/kg/min IV in 3 hrs vs nothing, beg