急性心肌梗死患者直接经皮冠状动脉腔内血管成形术后心肌微循环障碍的早期检测：冠状动脉血流速度与锝-甲氧基异丁基异腈灌注成像对比

Early detection of myocardial microcirculatory disturbances after primary PTCA in patients with acute myocardial infarction: coronary blood flow velocity versus sestamibi perfusion imaging.

作者信息

Stempfle Hans-Ulrich, Schmid Rupert, Tausig Andreas, Auer Veronika, Hacker Markus, Schiele Thomas M, Hahn Klaus, Klauss Volker

机构信息

Abteilung Kardiologie Medizinische Klinik Innenstadt Ludwig-Maximilians Universität München Ziemssenstrasse 1 80336 Munich, Germany.

出版信息

Z Kardiol. 2002;91 Suppl 3:126-31. doi: 10.1007/s00392-002-1323-z.

DOI:10.1007/s00392-002-1323-z

PMID:12641027

Abstract

BACKGROUND

The extent of myocardial salvage after primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI) is variable and can not be predicted on the basis of vessel patency. The aim of this study was to evaluate the tissue salvage and the microvascular integrity after successful intervention in AMI by coronary blood flow velocity and sestamibi perfusion imaging.

METHODS

Twenty-two patients (17 m, 5f; mean age 57 +/- 14 yrs.) undergoing primary PTCA and stent implantation for AMI were studied. 99mTc Sestamibi was injected intravenously before intervention and single photon emission computed tomography (SPECT) was performed immediately after successful reperfusion to determine the area at risk before PTCA due to the minimal 99mTc Sestamibi redistribution. Sestamibi SPECT was repeated 3 days and 6 months after AMI. Area at risk (%) was determined automatically by myocardial perfusion tomography (PERFIT) with the use of a multistage, 3D iterative inter-subject registration of patient images to normal templates (2SD) and myocardial salvage was calculated. Coronary flow velocity was measured using a Doppler-tipped guidewire in the infarct-related artery after successful completion of primary PTCA and in an angiographically normal reference vessel. Absolute coronary flow reserve (CFR) and relative CFR (rCFR) were calculated using hyperemic to basal average peak velocity.

RESULTS

Despite successful reperfusion of the target vessel (TIMI grade III flow) CFR and rCFR remained impaired (1.8 +/- 0.9 and 0.77 +/- 0.21). Area at risk decreased significantly from 21 +/- 9% to 9 +/- 10% (p < 0.05) corresponding to 11 +/- 8% myocardial salvage. Acute CFR and rCFR showed no correlation with the area at risk before and after primary PTCA. The increase of CFR within 6 months correlated with the myocardial salvage (p < 0.05).

CONCLUSIONS

Despite successful primary PTCA in AMI, CFR and rCFR often remain impaired because of a significant loss of microvascular integrity. The long-term success of primary PTCA can be assessed by myocardial salvage and the change of CFR which might be a useful parameter for additional reperfusion strategies such as glycoprotein IIb/IIIA receptor inhibition.

摘要

背景

急性心肌梗死（AMI）患者接受直接经皮冠状动脉腔内血管成形术（PTCA）后心肌挽救的程度存在差异，无法根据血管通畅情况进行预测。本研究的目的是通过冠状动脉血流速度和心肌灌注显像评估急性心肌梗死成功干预后的组织挽救情况和微血管完整性。

方法

对22例（17例男性，5例女性；平均年龄57±14岁）因急性心肌梗死接受直接PTCA和支架植入的患者进行研究。在干预前静脉注射99m锝甲氧基异丁基异腈（99mTc sestamibi），成功再灌注后立即进行单光子发射计算机断层扫描（SPECT），以确定由于99mTc sestamibi最小再分布导致的PTCA前的危险区域。在急性心肌梗死后3天和6个月重复进行心肌灌注显像。使用心肌灌注断层扫描（PERFIT）自动确定危险区域（%），该方法采用患者图像与正常模板的多阶段、三维迭代受试者间配准（2SD），并计算心肌挽救情况。在成功完成直接PTCA后，使用带有多普勒探头的导丝在梗死相关动脉以及血管造影正常的参照血管中测量冠状动脉血流速度。使用充血期与基础期平均峰值速度计算绝对冠状动脉血流储备（CFR）和相对冠状动脉血流储备（rCFR）。

结果

尽管靶血管成功再灌注（TIMI 3级血流），CFR和rCFR仍受损（分别为1.8±0.9和0.77±0.21）。危险区域从21±9%显著降至9±10%（p<0.05），对应心肌挽救率为11±8%。急性CFR和rCFR与直接PTCA前后的危险区域均无相关性。6个月内CFR的增加与心肌挽救相关（p<0.05）。