冠状动脉血栓高负荷初次经皮冠状动脉介入治疗失败的急性ST段抬高心肌梗死患者的治疗

摘要

Objective To observe the efficacy of antithrombotic treatment of acute ST-segment elevation myocardial infarction patients with failure primary percutaneous coronary intervention because of high thrombus burden,and its effect on elective percutaneous coronary intervention.Methods Eight acute ST-segment elevation myocardial infarction patients were enrolled,who suffered from failure of primary percutaneous coronary intervention because of high thrombus burden.Summarize the antithrombotic strategies in perioperative and postoperative period,the operative strategies and the follow-up coronary intervention were recorded and reviewed.Results All the patients were male and most of them had acute inferior myocardial infarction with right coronary occluded because of high thrombus burden.Four patients received thrombus aspiration and balloon dilation.One patient received thrombus aspiration and the other three patients did not receive coronary intervention.Tirofiban were given in perioperative period to all the patients.Low molecular weight heparin was given to 6 patients.Dual antiplatelet therapy was given to 6 patients (aspirin 100 mg/day plus clopidogrel 75 mg/day) and 1 patient required up-titration of aspirin to 200 mg/day.Coronary angiography were repeated (29.00 ± 23.25) days later,and the thrombus in the culprit vessels disappeared in two patients,and coronary stent implantation was performed in three patients.Conclusions The routine antithrombotic strategies play limited roles in thrombus clearance in acute ST segment elevation myocardial infarction patients with failure primary percutaneous coronary intervention because of high thrombus burden.The time for the thrombus to be totally organized and the timing of elective percutaneous coronary intervention are still uncertain and need to be further studied.%目的 观察因血栓高负荷未能行初次经皮冠状动脉介入治疗(PCI)的急性ST段抬高心肌梗死患者围术期抗栓治疗对择期PCI的影响.方法 回顾性分析8例急性ST段抬高心肌梗死患者初次行冠状动脉造影术,因靶血管血栓高负荷不能行支架置入术.分析所有患者围术期抗栓治疗方案、术中处理方案及随访情况.结果 所有8例患者均为男性,平均年龄(51.25±10.81)岁.吸烟史是最常见的危险因素.右冠状动脉大量血栓堵塞导致急性下壁心肌梗死最多见.3例患者未行PCI,1例仅行单纯血栓抽吸,4例患者行血栓抽吸及球囊扩张术.7例患者术中、术后均给予替罗非班治疗;术后6例患者给予低分子肝素抗凝;7例患者常规双联抗血小板治疗(阿司匹林100 mg、每日1次+氯吡格雷75 mg、每日1次或替格瑞洛90 mg、每日1次),1例患者阿司匹林剂量增加至200 mg,氯吡格雷增加至每日2次.平均(29.00±23.25)d后复查冠状动脉造影,2例患者因仍存在血栓高负荷,未尝试行PCI;1例患者因血管扭曲,球囊不能送至闭塞病变处,未能成功置入支架;2例患者因血栓负荷过重,球囊扩张后,未行支架置入术;3例患者成功行支架置入术.结论 急性ST段抬高心肌梗死患者因靶血管血栓高负荷初次开通血管失败,常规抗栓治疗方案对血栓高负荷的清除作用有限,血栓完全机化、择期PCI的时机尚不清楚,仍需进一步研究探讨.