Antoniucci D, Santoro G M, Bolognese L, Valenti R, Leoncini M, Fazzini P F
Divisione di Cardiologia, Ospedale di Careggi, Firenze.
G Ital Cardiol. 1995 Oct;25(10):1265-71.
Considerable controversy exists about the therapeutic value of primary coronary angioplasty for acute myocardial infarction. The available data suggest that primary angioplasty may improve the outcome in patients with cardiogenic shock, while some clinical studies have found no benefit in routine angioplasty in patients with acute myocardial infarction that were considered at high risk because of severe left ventricular dysfunction associated with myocardial infarction.
During a 16-month period, 50 patients with acute myocardial infarction and severe left ventricular dysfunction underwent primary coronary angioplasty. Patients were enrolled if angiographic left ventricular ejection fraction was > or = 40% and symptom duration <6 hours, or >6 hours if there was evidence of ongoing ischemia. Optimal angiographic success (<30% stenosis associated with TIMI grade 3 flow) was achieved in 45 patients (90%), and a suboptimal result (>30% and <50% stenosis associated with TIMI grade 3 flow, or <30% stenosis associated with TIMI grade 2 flow) was achieved in 3 patients (6%), while in 2 patients angioplasty failed to reopen the infarct related vessel or was associated with a refractory no-reflow phenomenon. In 5 patients an optimal angiographic result was achieved after coronary stenting. Emergency repeated coronary angioplasty was required in 1 patient with reocclusion of a stented vessel, and after unsuccessful repeated coronary angioplasty, the patient underwent bypass surgery on a semi-elective basis. In 6 patients with multivessel disease, after successful primary angioplasty of the infarct-related vessel, a more complete revasculariziation was achieved with a second coronary angioplasty or bypass surgery before discharge. The in-hospital mortality rate was 6%. The follow-up of 47 patients surviving initial hospitalization was 171 +/- 163 days. There were 2 deaths (4%), both due to congestive heart failure, and 1 nonfatal reinfarction. Two patients (4%), were readmitted to the hospital for recurrent ischemia and both underwent successful repeated coronary angioplasty for restenosis.
The results of this study suggest that in patients with acute myocardial infarction associated with severe left ventricular dysfunction, primary coronary angioplasty may be considered a first choice treatment because of high reperfusion rate, relative low in-hospital mortality and few recurrent myocardial ischemic events.
对于急性心肌梗死患者，直接冠状动脉血管成形术的治疗价值存在很大争议。现有数据表明，直接血管成形术可能改善心源性休克患者的预后，而一些临床研究发现，对于因与心肌梗死相关的严重左心室功能障碍而被视为高危的急性心肌梗死患者，常规血管成形术并无益处。
在16个月期间，50例急性心肌梗死合并严重左心室功能障碍的患者接受了直接冠状动脉血管成形术。入选标准为血管造影显示左心室射血分数≥40%且症状持续时间<6小时，若有持续缺血证据则症状持续时间>6小时。45例患者（90%）获得了最佳血管造影结果（狭窄<30%且TIMI血流3级），3例患者（6%）获得了次优结果（狭窄>30%且<50%且TIMI血流3级，或狭窄<30%且TIMI血流2级），2例患者血管成形术未能开通梗死相关血管或出现难治性无复流现象。5例患者在冠状动脉支架置入术后获得了最佳血管造影结果。1例支架置入血管再闭塞的患者需要紧急重复冠状动脉血管成形术，在重复冠状动脉血管成形术失败后，该患者接受了半择期搭桥手术。6例多支血管病变患者在梗死相关血管直接血管成形术成功后，在出院前通过再次冠状动脉血管成形术或搭桥手术实现了更完全的血运重建。住院死亡率为6%。47例初始住院存活患者的随访时间为171±163天。有2例死亡（4%），均死于充血性心力衰竭，1例非致命性再梗死。2例患者（4%）因复发性缺血再次入院，均接受了成功的重复冠状动脉血管成形术治疗再狭窄。
本研究结果表明，对于合并严重左心室功能障碍的急性心肌梗死患者，直接冠状动脉血管成形术可能因其再灌注率高、住院死亡率相对较低且复发性心肌缺血事件较少而被视为首选治疗方法。
