诊断超声脉冲可改善 STEMI 患者静脉内微泡治疗后的微血管血流。
Diagnostic Ultrasound Impulses Improve Microvascular Flow in Patients With STEMI Receiving Intravenous Microbubbles.
机构信息
Heart Institute (InCor), University of São Paulo, Medical School, São Paulo, Brazil.
Heart Institute (InCor), University of São Paulo, Medical School, São Paulo, Brazil.
出版信息
J Am Coll Cardiol. 2016 May 31;67(21):2506-15. doi: 10.1016/j.jacc.2016.03.542.
BACKGROUND
Pre-clinical trials have demonstrated that, during intravenous microbubble infusion, high mechanical index (HMI) impulses from a diagnostic ultrasound (DUS) transducer might restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI).
OBJECTIVES
The purpose of this study was to test the safety and efficacy of this adjunctive approach in humans.
METHODS
From May 2014 through September 2015, patients arriving with their first STEMI were randomized to either DUS intermittent HMI impulses (n = 20) just prior to emergent percutaneous coronary intervention (PCI) and for an additional 30 min post-PCI (HMI + PCI), or low mechanical index (LMI) imaging only (n = 10) for perfusion assessments before and after PCI (LMI + PCI). All studies were conducted during an intravenous perflutren lipid microsphere infusion. A control reference group (n = 70) arrived outside of the time window of ultrasound availability and received emergent PCI alone (PCI only). Initial epicardial recanalization rates prior to emergent PCI and improvements in microvascular flow were compared between ultrasound-treated groups.
RESULTS
Median door-to-dilation times were 82 ± 26 min in the LMI + PCI group, 72 ± 15 min in the HMI + PCI group, and 103 ± 42 min in the PCI-only group (p = NS). Angiographic recanalization prior to PCI was seen in 12 of 20 HMI + PCI patients (60%) compared with 10% of LMI + PCI and 23% of PCI-only patients (p = 0.002). There were no differences in microvascular obstructed segments prior to treatment, but there were significantly smaller proportions of obstructed segments in the HMI + PCI group at 1 month (p = 0.001) and significant improvements in left ventricular ejection fraction (p < 0.005).
CONCLUSIONS
HMI impulses from a diagnostic transducer, combined with a commercial microbubble infusion, can prevent microvascular obstruction and improve functional outcome when added to the contemporary PCI management of acute STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).
背景
临床前试验已经证明，在静脉内微泡输注期间，诊断超声（DUS）换能器的高机械指数（HMI）脉冲可能恢复急性 ST 段抬高型心肌梗死（STEMI）的心外膜和微血管血流。
目的
本研究旨在测试这种辅助方法在人体中的安全性和有效性。
方法
从 2014 年 5 月至 2015 年 9 月，首次出现 STEMI 的患者随机分为 DUS 间歇性 HMI 脉冲组（n=20），在紧急经皮冠状动脉介入治疗（PCI）前和 PCI 后再进行 30 分钟（HMI+PCI），或仅接受低机械指数（LMI）成像组（n=10），用于 PCI 前后的灌注评估（LMI+PCI）。所有研究均在静脉内全氟丙烷脂质微球输注期间进行。对照组（n=70）在超声检查时间窗外到达，仅接受紧急 PCI（PCI 组）。比较超声治疗组之间初始紧急 PCI 前的心外膜再通率和微血管血流的改善情况。
结果
LMI+PCI 组门到球囊扩张时间中位数为 82±26 分钟，HMI+PCI 组为 72±15 分钟，PCI 组为 103±42 分钟（p=NS）。HMI+PCI 组 20 例患者中有 12 例（60%）在 PCI 前出现血管再通，而 LMI+PCI 组为 10%，PCI 组为 23%（p=0.002）。治疗前微血管阻塞节段无差异，但 HMI+PCI 组 1 个月时阻塞节段比例明显较小（p=0.001），左心室射血分数明显改善（p<0.005）。
结论
诊断换能器的 HMI 脉冲与商业微泡输注相结合，可预防微血管阻塞，并改善急性 STEMI 当代 PCI 治疗的功能结局。（急性冠状动脉疾病的超声治疗；NCT02410330）。
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