Henriques J P S, Zijlstra F, Ottervanger J P, de Boer M-J, van 't Hof A W J, Hoorntje J C A, Suryapranata H
Department of Cardiology, Isala Klinieken, Hospital De Weezenlanden, Zwolle, The Netherlands.
Eur Heart J. 2002 Jul;23(14):1112-7. doi: 10.1053/euhj.2001.3035.
Although recognized as an important feature of atherosclerotic coronary disease, little is known about the frequency and prognostic importance of distal embolization during primary angioplasty for acute myocardial infarction.
As part of a randomized trial of thrombolysis vs primary angioplasty, 178 patients with acute myocardial infarction were treated with primary angioplasty. In these patients the occurrence of distal embolization after angioplasty was assessed. Embolization was defined as a distal filling defect with an abrupt 'cutoff' in one of the peripheral coronary artery branches of the infarct-related vessel, distal to the site of angioplasty. We analysed myocardial blush grade, ST-T segment elevation resolution, enzymatic infarct size and left ventricular ejection fraction in patients with and without distal embolization. Clinical information was collected for a mean of 5 years. Distal embolization was present in 27 patients (15.2%). Mean age and gender were not different from patients without distal embolization. Angiographic success (thrombolyis in myocardial infarction flow grade 3 and residual stenosis <50%) after primary angioplasty was less frequently observed in patients with distal embolization (70% vs 90%, P<0.01). Myocardial blush and ST-T segment elevation resolution after angioplasty were reduced when distal embolization was present. Patients with distal embolization had a larger enzymatic infarct size (mean cumulative lactate dehydrogenase measured over 72 h, 1612 vs 847, P<0.05) and a lower left ventricle ejection fraction at discharge (42% vs 51%, P<0.01). Long-term mortality was higher in patients with distal embolization (44% vs 9%, P<0.001).
Distal embolization in patients treated with primary angioplasty is visible on the coronary angiogram in 15.2% of patients. It is related to reduced myocardial reperfusion, more extensive myocardial damage and a poor prognosis. Additional pharmacological interventions and/ or mechanical devices should be studied to prevent and/or treat distal embolization.
尽管远端栓塞被认为是动脉粥样硬化性冠心病的一个重要特征，但对于急性心肌梗死直接血管成形术中远端栓塞的发生率及其预后意义却知之甚少。
作为溶栓与直接血管成形术随机试验的一部分，178例急性心肌梗死患者接受了直接血管成形术治疗。评估这些患者血管成形术后远端栓塞的发生情况。栓塞定义为梗死相关血管的外周冠状动脉分支之一在血管成形术部位远端出现突然“截断”的远端充盈缺损。我们分析了有或无远端栓塞患者的心肌灌注分级、ST-T段抬高的恢复情况、酶学梗死面积及左心室射血分数。收集平均5年的临床信息。27例患者（15.2%）出现远端栓塞。其平均年龄和性别与无远端栓塞患者无差异。直接血管成形术后血管造影成功（心肌梗死溶栓血流3级且残余狭窄<50%）在有远端栓塞患者中观察到的频率较低（70%对90%，P<0.01）。存在远端栓塞时，血管成形术后心肌灌注及ST-T段抬高的恢复情况降低。有远端栓塞的患者酶学梗死面积更大（72小时内测得的平均累积乳酸脱氢酶，1612对847，P<0.05），出院时左心室射血分数更低（42%对51%，P<0.01）。有远端栓塞患者的长期死亡率更高（44%对9%，P<0.001）。
直接血管成形术治疗的患者中，15.2%的患者在冠状动脉造影上可见远端栓塞。它与心肌再灌注减少、心肌损伤更广泛及预后不良有关。应研究额外的药物干预和/或机械装置以预防和/或治疗远端栓塞。
