Isaaz Karl, Robin Christophe, Cerisier Alexis, Lamaud Michel, Richard Laure, Da Costa Antoine, Sabry Mohamed Hassan, Gerenton Claude, Blanc Jean Louis
Division of Cardiology, University of Saint Etienne, Saint Etienne, France.
Coron Artery Dis. 2006 May;17(3):261-9. doi: 10.1097/00019501-200605000-00010.
No reflow has been reported in 12-30% of the patients directly revascularized by angioplasty for acute ST elevation myocardial infarction with the highest incidence after primary stenting in patients with initial thrombolysis in myocardial infarction (TIMI) grade 0 flow. We hypothesized that a minimalist immediate mechanical intervention (MIMI) based on the use of very small size balloons to avoid both large dissection and distal embolization may be sufficient to restore flow in emergency and that recanalization may be sustained by maximized antithrombotic regimen (abcximab, clopidogrel, aspirin and heparin) allowing one to postpone stenting in better conditions.
MIMI was performed in 93 patients for ST elevation myocardial infarction with initial TIMI grade 0 flow.
MIMI resulted in a TIMI grade 3 flow in 77/93 patients (83%). Immediate stenting was performed in the 16 patients with failed MIMI and resulted in a TIMI grade 3 flow in nine (56%). The residual stenosis after MIMI was 81+/-11% and ST segment resolution (> or =50%) at 1 h after reperfusion was obtained in 84%. Stenting was performed the following days in 52 patients with a post-stenting TIMI grade 3 flow in 50 (96%; 100% when stenting done beyond 24 h). No reocclusion occurred between MIMI and stenting. Among the 25 patients without stenting, six had mild stenosis at control angiogram and underwent medical treatment whereas 19 had multiple vessel disease and underwent bypass surgery.
MIMI combined with maximized antithrombotic therapy results in immediate and sustained recanalization with a high rate of ST resolution in a majority of patients with ST elevation myocardial infarction. This approach allows one to postpone stenting in more stable conditions with a low rate of TIMI flow deterioration or to schedule more appropriate medical or surgical alternative management.
在接受血管成形术直接血运重建的急性ST段抬高型心肌梗死患者中，12% - 30%的患者出现无复流现象，在初始心肌梗死溶栓治疗（TIMI）0级血流的患者中，初次置入支架后无复流发生率最高。我们推测，基于使用非常小尺寸球囊以避免大的夹层形成和远端栓塞的极简即刻机械干预（MIMI）可能足以在紧急情况下恢复血流，并且再通可能通过最大化抗血栓治疗方案（阿昔单抗、氯吡格雷、阿司匹林和肝素）得以维持，从而使人们能够在更好的条件下推迟置入支架。
对93例初始TIMI 0级血流的ST段抬高型心肌梗死患者进行MIMI。
MIMI使77/93例患者（83%）实现TIMI 3级血流。16例MIMI失败的患者接受即刻置入支架，其中9例（56%）实现TIMI 3级血流。MIMI后的残余狭窄为81±11%，再灌注后1小时ST段回落（≥50%）的比例为84%。52例患者在随后几天接受置入支架，支架置入后TIMI 3级血流的比例为50例（96%；超过24小时进行支架置入时为100%）。MIMI与支架置入之间未发生再闭塞。在25例未进行支架置入的患者中，6例在对照血管造影时显示轻度狭窄并接受药物治疗，而19例有多支血管病变并接受搭桥手术。
MIMI联合最大化抗血栓治疗可使大多数ST段抬高型心肌梗死患者即刻且持续再通，ST段回落率高。这种方法使人们能够在更稳定的条件下推迟置入支架，TIMI血流恶化率低，或安排更合适的药物或手术替代治疗。
