直接经皮冠状动脉介入治疗应用血栓抽吸对STEMI患者心肌灌注及临床预后的影响

doi:10.3969/j.issn.1007-3205.2021.07.006

摘要/Abstract

摘要： 目的探讨直接经皮冠状动脉介入治疗（primary percutaneous coronary intervention,PPCI）应用血栓抽吸对ST段抬高型心肌梗死（ST-segment elevation myocardial infarction,STEMI) 患者心肌灌注及临床预后的影响。
方法采用回顾性研究方法，纳入于河北省人民医院行PPCI的STEMI患者446例。依据术中是否应用血栓抽吸分为非血栓抽吸组（230例）和血栓抽吸组（216例）。收集临床资料和术后慢血流/无复流发生情况，记录术后12个月内主要不良心血管事件（包括心原性死亡、再发心肌梗死、靶血管血运重建）和缺血性脑卒中发生情况。
结果与非血栓抽吸组相比，血栓抽吸组造影显示心肌梗死溶栓治疗（thrombolysis in myocardial infraction,TIMI）血栓负荷≥4级、术前TIMI血流＜3级及术中替罗非班、尿激酶原的使用率更高，术中造影剂用量更多，而多支病变的比率较低，差异有统计学意义（P＜0.05）。二元Logistic回归分析显示造影TIMI血栓负荷≥4级、术前TIMI血流＜3级是PPCI术中使用血栓抽吸的影响因素（P＜0.05）。年龄（OR=1.03,95%CI：1.004~1.056，P=0.023）、造影剂用量（OR=1.004,95%CI：1~1.008，P=0.047）是发生无复流的独立危险因素；发生慢血流/无复流组患者较正常血流组患者中术中行血栓抽吸的比率低，多因素分析显示在全体人群中血栓抽吸与慢血流/无复流无关。Killip≥2级和左主干病变是主要不良心血管事件（major adverse cardiovascular events,MACE）的独立危险因素，而他汀类药物是MACE的保护性因素；Killip≥2级是心原性死亡的独立危险因素，而他汀类药物和射血分数是心原性死亡的保护性因素。血栓抽吸是高血栓负荷人群术后发生无复流的保护性因素；年龄、造影剂用量是高血栓负荷人群发生无复流的危险因素。高血栓负荷人群两组术后12个月的MACE、心原性死亡、再发心肌梗死、靶血管重建及缺血性脑卒中发生率差异无统计学意义（P＞0.05）。高血栓负荷人群两组间MACE及心原性死亡的Kaplan-Meier生存分析差异无统计学意义。Cox回归分析显示，血栓抽吸不是高血栓负荷人群MACE及心原性死亡的影响因素。
结论血栓抽吸可降低高血栓负荷STEMI患者术后无复流和慢血流的发生率，但不能改善术后12个月的临床预后。

关键词: 心肌梗死, 经皮冠状动脉介入治疗, 血栓切除术

Abstract: Objective To investigate the effect of thrombus aspiration during primary percutaneous coronary intervention(PPCI) in patients with ST-segment elevation myocardial infarction(STEMI) on myocardial reperfusion and clinical prognosis.
Methods We retrospectively analyzed the clinical data of STEMI patients who underwent PPCI in Hebei General Hospital. Patients were divided into non-thrombus aspiration group(n=230) and thrombus aspiration group(n=216). Clinical data and incidence of postoperative slow blood flow/no-reflow were collected, and major adverse cardiovascular events(MACE), including cardiac death, re-myocardial infraction, target vessal revascularization, and stroke were recorded during 12-month follow-up.
Results Compared with non-thrombus aspiration group, thrombus aspiration group showed higher use rate of thrombolysis in myocardial infarction(TIMI) thrombus load≥grade 4, preoperative TIMI blood flow <grade 3, intraoperative tirofiban and prourokinase, more intraoperative contrast agent, and lower rate of multivessel lesions(P＜05). Binary Logistic regression analysis showed that TIMI thrombus load ≥grade 4 and TIMI blood flow <grade 3 were the influencing factors of thrombus aspiration during PPCI(P＜0.05). Age(OR= 1.03,95%CI: 1.004-1.056, P=0.023) and contrast agent dosage(OR=1.004,95%CI: 1-1.008, P=0.047) were independent risk factors for no-reflow. The rate of thrombus aspiration in patients with slow flow/no-reflow was lower than that in patients with normal blood flow. Multivariate analysis showed that thrombus aspiration was not associated with slow flow/no-reflow in the whole population. Killip ≥ 2 and left main coronary artery disease were independent risk factors for MACE, while statins were protective factors for MACE; Killip ≥ 2 was an independent risk factor for cardiac death, while statins and ejection fraction were protective factors for cardiac death. Thrombus aspiration was a protective factor for no-reflow in patients with high thrombus load; Age and dosage of contrast agent were the risk factors of no-reflow in the population with high thrombus load. There was no-significant difference in MACE, cardiac death, recurrent myocardial infarction, target vessel reconstruction and ischemic stroke between the two groups at 12 months after operation(P＞0.05). There was no-significant difference in MACE and cardiac death by Kaplan Meier survival analysis between two groups. Cox regression analysis showed that thrombus aspiration was not the influencing factor of MACE and cardiac death in the population with high thrombus load.
Conclusion Thrombus aspiration could reduce the incidence of slow flow/no-reflow in patients with high thrombus load, but could not improve clinical prognosis at 12 months after operation.

Key words: myocardial infraction, percutaneous coronary intervention, thrombectomy

张飞飞, 宋学莲, 谢悦陶, 刘立天, 党懿, 齐晓勇. 直接经皮冠状动脉介入治疗应用血栓抽吸对STEMI患者心肌灌注及临床预后的影响[J]. 河北医科大学学报, 2021, 42(7): 770-778.

ZHANG Fei-fei, SONG Xue-lian, XIE Yue-tao, LIU Li-tian, DANG Yi, QI Xiao-yong. Effect of thrombus aspiration during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction on myocardial reperfusion and clinical prognosis[J]. Journal of Hebei Medical University, 2021, 42(7): 770-778.

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直接经皮冠状动脉介入治疗应用血栓抽吸对STEMI患者心肌灌注及临床预后的影响

Effect of thrombus aspiration during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction on myocardial reperfusion and clinical prognosis

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