Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction without On-Site Cardiac Surgery-A Single Hospital Experience in Taitung

急性心肌梗塞予以無心臟外科在場之立即性經皮冠狀動脈介入性治療－在台東之單一醫院經驗

鄭曉揚(Hsiao-Yang Cheng) ； 葉宏一(Hung-I Yeh) ； 侯嘉殷(Charies Jai-Yin Hou) ； 蔡正河(Cheng-Ho Tsai) ； 王光德(Kuang-Te Wang)

《Acta Cardiologica Sinica》 23卷3期 (2007/09) Pp. 160-168

摘要

立即性經皮冠狀動脈介入性治療對急性心肌梗塞提供優於血栓溶解劑之預後。但是在台灣缺乏任何研究顯示，在無心臟外科在場之醫院，予以立即性經皮冠狀動脈介入性治療對急性心肌梗塞之價值。
目的　對於急性心肌梗塞予以無心臟外科在場之立即性經皮冠狀動脈介入性治療，調查其安全性及結果。
方法　在2003年9月至2005年9月間，無心臟外科在場之馬偕紀念醫院台束分院共有175名診斷為急性心肌梗塞之病患，凡心電圖顯示ST段上升或新發現左側束枝傳導阻滯，於症狀發生12小時內接受立即性經皮冠狀動脈介入性治療者，納入本研究。臨床病程及血管攝影特徵之資料均予以記錄及分析。
結果 聘有38名（64±13歲，含6名女性）急性心肌梗塞之病患接受立即性經皮冠狀動脈介入性治療。心肌梗塞相關之動脈為左前降支佔40%、左迴旋支佔5%、右冠狀動脈佔55%。支架置放率為82%。無緊急接受冠狀動脈繞道手術之需求發生。血管攝影介入性治療成功率為92%。經介入性治療過程成功出院之比例為97%。1名(3%)病患於住院第四十六天敗血症死亡，其餘皆存活一年以上。這一年內，3名(8%)病患轉院接受選擇性冠狀動脈繞道手術，3名(8%)病患發生非致死性心肌梗塞，7名病患（18%，含5名發生支架內再狹窄）再度接受心肌梗塞相關動脈之介入性治療。一年臨床成功率為71%。有5名急性心肌梗塞之病患接受血栓溶解劑治療，其心肌梗塞相關之動脈為左主幹佔20%、左前降支佔60%、右冠狀動脈佔20%。l名病患接受對左前降支之選擇性介入性治療。除了1名左主幹冠狀動脈病變之病患於心肌梗塞翌日轉院接受緊急冠狀動脈燒道手術，術後44日因心室性心律不整死亡，其餘皆存活一年以上。
結論　在馬偕紀念醫院台東分院，無心臟外科在場之立即性經皮冠狀動脈介入性治療，對於ST段上升或左側束枝傳導阻滯之急性心肌梗塞，是安全且有效之策略。

關鍵字

急性心肌梗塞 ； 立即性經皮冠狀動脈介入性治療 ； 無心臟外科在場

並列摘要

Primary percutaneous coronary intervention (PCI) provides outcomes superior to fibrinolytic therapy in acute myocardial infarction (AMI), but no registry or study in Taiwan has demonstrated its use in hospital without on-site cardiac surgery.
Objectives: To investigate the safety and outcome of primary PCI for AMI without on-site cardiac surgery.
Methods: Between September 2003 and September 2005, 175 patients were diagnosed as AMI in the Mackay Memorial Hospital, Taitung Branch, in which there was no on-site cardiac surgical backup. Of them, those whose electrocardiograms showed ST-elevation or new left bundle branch block (LBBB) presented within 12 hours of symptom onset and treated with primary PCI and fibrinolysis were enrolled into the study. Data of clinical course and angiographic characteristics were recorded and analyzed.
Results: There were 38 patients (64±13 years old, 6 females) treated with primary PCI for infarct-related artery (IRA), among which were left anterior descending artery (LAD), 40%, left circumflex artery (LCX), 5%, and right coronary artery (RCA), 55%. The stent rate was 82%, and no emergency coronary artery bypass graft (CABG) was needed. The angiographic success rate was 92%, and the procedural success rate was 97%. All patients survived at least 1 year, except 1 (3%), who died due to sepsis on day 46 of admission. Within 1 year of the PCI, 3 (8%) patients were transferred out for elective CABG, 3 (8%) patients had non-fatal MI, and 7 (18%) patients had re-IRA PCI, including 5 (13%) patients with in-stent restenosis, leaving the clinical success rate 71% at 1 year. There were 5 patients treated with fibrinolysis among which were left main (LM), 20%, LAD, 60%, and RCA, 20%. One of them underwent elective PCI to LAD. All patients survived at least 1 year, except 1 (20%), who had LM disease, was transferred to a tertiary center for emergency CABG at the next day of index MI, and died due to ventricular arrhythmia on day 44 post-operation.
Conclusions: Primary PCI for patients with AMI having ST-elevation or new LBBB is a safe and effective strategy in Mackay Memorial Hospital, Taitung Branch, even without on-site cardiac surgery.

並列關鍵字

Acute myocardial infarction ； Primary percutaneous coronary intervention ； On-site cardiac surgery