不同侧支循环患者冠状动脉完全闭塞病变择期经皮冠状动脉介入治疗术后冠状动脉微循环的差异及近期预后的比较

摘要

目的：比较不同侧支循环患者冠状动脉完全闭塞病变择期经皮冠状动脉介入治疗( PCI)术后冠状动脉微循环的差异及近期预后。方法选择2012年1月至2015年12月在青岛市市立医院心内科住院的非ST段抬高心肌梗死( NSTEMI)或者ST段抬高心肌梗死( STEMI)错过血运重建时间半月以上仍有症状的患者42例,根据Rentrop分级将所有患者分为侧支循环形成不良组( A组,Rentrop 0~1级,17例)和侧支循环形成良好组( B组,Rentrop 2~3级,25例)。 PCI术后采用压力导丝测定冠状动脉(罪犯血管)的微循环阻力指数( IMR),PCI术后及术后3个月采用超声心动图测定左心室舒张末期内径(LVEDd)和左心室射血分数(LVEF)。结果(1)A组患者IMR均值明显高于B组,差异有统计学意义(32.53±8.0比20.88±4.6,P﹤0.001)；冠状动脉侧支循环分级与IMR呈负相关(r＝-0.671,P﹤0.05)。(2)术后3个月LVEDd的变化值,A组平均为5.76 mm,B组平均为-0.28 mm,差异有统计学意义( P ﹤0.001)。(3)术后3个月 LVEF 的变化值, A 组平均为-3.82％,B组平均为5.36％,差异有统计学意义(P﹤0.001)。(4)冠状动脉侧支循环分级与术后3个月LVEDd变化值呈负相关(r＝-0.669,P﹤0.001),与术后3个月 LVEF 变化值呈正相关(r ＝0.657,P﹤0.001)。(5)IMR与术后3个月LVEDd变化值呈正相关(r＝0.686,P﹤0.001),线性回归方程为：LVEDd 变化值＝0.366× IMR -7.213；IMR 与术后3个月 LVEF 变化值呈负相关( r ＝-0.664,P﹤0.001),线性回归方程为：LVEF变化值＝-0.554× IMR＋15.812。结论侧支循环不良患者与侧支循环良好患者相比,更容易发生微循环功能受损,开通梗死区域相关血管,侧支循环良好、微循环功能良好的患者心功能恢复情况优于侧支循环不良、微循环功能受损的患者。%Objective To evaluate the difference in coronary microcirculation and short term prognosis in patients with different collateral circulation and underwent elective percutaneous coronary intervention ( PCI) with complete occlusion of coronary artery. Methods The study included 42 patients who had been admitted in our hospital for NSTEMI or STEMI between 01/2012 to 12/2015 without receiving revascularization treatment and whose symptoms persisted for over 6 months. According to the results of coronary angiography and the Rentrop grade, the patients were divided into 2 groups: poor collateral circulation formation group (group A, Rentrop=0 -1, n=17) and well established collateral circulation group (group B, Rentrop=2-3, n=25). The basic clinical data and the result of coronary angiography were compared. A pressure-temperature sensor wire was used to measure index of mierocirculatory resistance ( IMR) immediately after PCI. An echocardiograph was used to measure left ventricular end systolic diameter ( LVEDd) and left ventricular ejection fraction ( LVEF) postoperatively and again at 3 months after operation to evaluate the changes in cardiac function. Results The IMR value of group A was significantly higher than group B (P﹤0. 05), the grade of collateral circulation had negative correlation with IMR value (r=-0. 671, P﹤0. 05). The mean changes in LVEDd in 3 months in group B was -0. 28 mm, while in group A was 5. 76 mm (P﹤0. 05). The mean changes in LVEF in 3 mouths in group B was 5. 36% and in group A was -3. 82% (P﹤0. 05). The grading of coronary collateral circulation had negative correlation with the changes of LVEDd in 3 months (r= -0. 669, P﹤0. 05), but had positive correlation with the changes of LVEF (r=0. 657, P ﹤0. 05). The IMR value had positive correlation with the changes of LVEDd in 3 months (r=0. 686, P﹤0. 05), but had negative correlation with the changes of the LVEF (r= -0. 664, P﹤ 0. 05 ) . Conclusions Patients with poor collateral circulation was more prone to coronary microcirculatory injury than patients with good collateral circulation. Patients with good collateral circulation and microcirculation had better prognosis after the revascularization of the infarction-related vessel.