Title

分析急性心肌梗塞病人,行緊急心導管治療時,使用AngioJet行血栓移除術對心肌血流灌注及病人六個月存活率的影響

Translated Titles

Analysis of AngioJet Thrombectomy on Myocardial Perfusion and Six-month Survival for Patients with Acute ST-elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

DOI

10.6834/CSMU.2012.00047

Authors

張永明

Key Words

急性心肌梗塞 ; AngioJet血栓清除術 ; MBG血流 ; Acute ST-elevation myocardial infarction ; AngioJet thrombectomy ; myocardial blush grade ( MBG )

PublicationName

中山醫學大學醫學研究所學位論文

Volume or Term/Year and Month of Publication

2012年

Academic Degree Category

碩士

Advisor

林中生;林志立

Content Language

繁體中文

Chinese Abstract

研究目的: 急性ST上升心肌梗塞的發生, 如果愈早達成心肌血液的再灌流, 可以減少心肌受損的範圍, 這對於住院及中長期的預後都有幫助, 也可以降低對左心收縮功能的傷害. AngioJet行血栓清除術的使用, 是希望減少心導管治療時, 因為使用氣球擴張或支架的置入, 造成血栓往遠端栓塞, 使得冠狀動脈血流變差, 心肌的血液灌流變差. 研究方法及資料: 本研究收錄病人的時間, 是從2003年1月到2007年10月, 收錄的病人為急性ST節段上升心肌梗塞, 於彰化基督教醫院進行緊急心導管手術者. 我們分析接受AngioJet行血栓清除術, 會不會比傳統治療者, 得到較好的心肌血流灌注及六個月的存活率. 研究結果: 在基本資料方面, 使用AngioJet這組病人, 有較高的男性比例; 雖然兩組病人的左心射出率相似, 但使用AngioJet 這組病人最高的心肌酵素酶, 比沒有使用AngioJet 這組病人較高. 比較心導管治療後可以達成血流狀態最好的 TIMI 3 flow, 在使用AngioJet 組有94.1%的病人, 若沒使用AngioJet治療的, 則只有80.9%的病人達成. 另外, MBG 血流狀態也得到類似的結果. MBG血流狀態為3者, 在使用AngioJet 組, 占56.2%, 相較之下, 沒有使用AngioJet 組卻只有39.4%可以達到最好的心肌組織血流灌注. 這兩種治療方式對於MBG血流的影響, 是有明顯差異的. 而在六個月存活率的比較, 使用AngioJet 組是93.2%, 沒有使用AngioJet 組則是 91.5%, 兩組並沒有明顯的差異. 結論與建議: 使用AngioJet血栓清除術, 確實可以改善病人心膜外冠狀動脈的血流, 及心肌組織的血液灌流, 這兩個指標已被證實與急性心肌梗塞的病人預後有相關性. 本篇研究仍然肯定AngioJet 血栓清除術所帶來的好處, 建議應慎選病人及由熟練的醫師及團隊操作, 才能發揮這種治療最大的好處.

English Abstract

Objective: Patients with acute ST-elevation myocardial infarction may have persistent impairment of microvascular blood flow even after successful primary percutaneous coronary intervention ( PCI ). Distal embolization is a possible mechanism of microvascular dysfunction and impaired myocardial perfusion. There has been increasing interest in adjunctive mechanical thrombectomy to improve outcomes in primary PCI. The aim of the present report is to study the role of AngioJet thrombectomy in primary PCI for acute ST-elevation myocardial infarction . Method and Materials: This is a retrospective cohort study. Patients presented with acute ST-elevation myocardial infarction and received primary PCI in ChangHua Christian Hospital between Jan. 2003 and Oct. 2007 were enrolled. Totally 313 patients were included, 219 patients are in the AngioJet group and the other 94 patients are in the control group. The baseline characteristics, angiographic findings and 6-months survival in these two groups were recorded. Results: Patients in the AngioJet group have more male, cardiac enzymes elevation and angiographically visible thrombus. The angiographic findings showed that 94.1% in the AngioJet group have TIMI 3 flow after primary PCI, but only 80.9% in the control group have the same TIMI 3 flow. Besides, we also find the similar MBG flow between two groups. MBG 3 flow was achieved in 56.2% of the AngioJet group and 39% of the control group. The 6-months survival did not show significant difference between groups ( 93.2% versus 91.5% ). Conclusion and Suggestion: AngioJet thrombectomy in primary PCI for patients with acute ST-elevation MI can improve TIMI flow and MBG flow. But it remains to be established weather the device improves outcomes. The current evidence does not support the routine use of the AngioJet system in primary PCI. But in selected patients with large burden of thrombus, it still can provide clinical benefit as an adjunct to primary PCI.

Topic Category 醫藥衛生 > 醫藥總論
醫學院 > 醫學研究所
Reference
  1. [1] Lambert L, Brown K, Segal E, et al. Association between timeliness of reperfusion therapy and clinical outcomes in ST-elevation myocardial infarction. JAMA 2010;303:2148-55.
    連結:
  2. [2] Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003;361:13-20.
    連結:
  3. [3] Cannon CP, Gibson CM, Lambrew CT, et al. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA 2000;283:2941-7.
    連結:
  4. [4] Saif SR, Jeptha PC, Jersey C, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. BMJ 2009;338:b1807.
    連結:
  5. [5] Francesco B, Maria DV, Youlan LG, et al. Clinical impact of thrombectomy in acute ST-elevation myocardial infarction: an individual patient-data pooled analysis of 11 trials. Eur Heart J. 2009;30,2193-2203.
    連結:
  6. [6] Michal C, Jerzy P, Anna T, et al. Aspiration Coronary Thrombectomy for Acute Myocardial Infarction Increases Myocardial salvage: Single center randomized study. Catheter Cardiovasc Interv. 2011;78:523-531.
    連結:
  7. [7] Eric JT, Jay SY. Recognition of the Importance of Embolization in Atherosclerotic Vascular Disease. Circulation 2000;101:570-580.
    連結:
  8. [8] Angeja BG, Gunda M, Murphy SA, et al. TIMI myocardial perfusion grade and ST segment resolution: association with infarct size as assessed by single photon emission computed tomography imaging. Circulation 2002;105(3):282-5.
    連結:
  9. [9] Henriques JP, Zijlstra F, Ottervanger JP, et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J. 2002;23:1112-7.
    連結:
  10. [10] De Luca G, van 't Hof AW, de Boer MJ, et al. Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty. Eur Heart J 2004;25:1009-13.
    連結:
  11. [11] Babu K, Joel D, Kunadian V, et al. Meta-analysis of randomized trials comparing anti-embolic devices with standard PCI for improving myocardial reperfusion in patients with acute myocardial infarction. Catheter Cardiovasc Interv 2007;69:488–496.
    連結:
  12. [12] Gu YL , Fokkema ML , Zijlstra F. The emerging role of thrombus aspiration in the management of acute myocardial infarction. Circulation 2008;118:1780-2.
    連結:
  13. [13] Tone S, Pieter JV, M.Sc., et al. Thrombus Aspiration during Primary Percutaneous Coronary Intervention. N Engl J Med 2008;358:557-567.
    連結:
  14. [15] Cindy LG, Teresa RN, Robert DS, et al. A Bayesian Meta-Analysis Comparing AngioJet® Thrombectomy to Percutaneous Coronary Intervention Alone in Acute Myocardial Infarction. J Interven Cardiol 2008;21,459–482.
    連結:
  15. [16] Arshad A, David C, Nabil, et al. Rheolytic Thrombectomy With Percutaneous Coronary Intervention for Infarct Size Reduction in Acute Myocardial Infarction. J Am Coll Cardiol 2006;48,:244-52.
    連結:
  16. [17]. Angela M, Amerigo S, Alfredo ER, et al. Comparison of AngioJet Rheolytic Thrombectomy Before Direct Infarct Artery Stenting With Direct Stenting Alone in Patients With Acute Myocardial Infarction. The JETSTENT Trial. J Am Coll Cardiol 2010;56;1298-1306.
    連結:
  17. [18] De Luca, van’t Hof AW, de Boer MJ, et al. Impaired myocardial perfusion is a major explanation of the poor outcome observed in patients undergoing primary angioplasty for ST-segment-elevation myocardial infarction and signs of heart failure. Circulation 2004;109:958-61.
    連結:
  18. [19] The TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) trial: phase I findings. N Engl J Med 1984;33:523-530.
    連結:
  19. [20] The TIMI Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) trial: phase II trial. N Engl J Med 1989;320:618-627.
    連結:
  20. [21] Van’t Hof AWJ, Liem A, Suryapranata H, et al. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for myocardial infacrtion: myocardial blush grade: Zwolle Myocardial Infarction Study Group. Circulation 1998;97:2302-2306.
    連結:
  21. [22] Henriques JP, Zijlstra F, van 't Hof AW, et al. Angiographic Assessment of Reperfusion in Acute Myocardial Infarction by Myocardial Blush Grade. Circulation 2003;107:2115-2119.
    連結:
  22. [23] Theophilus E Owan, Matthew T Roe, John CM, et al. Contemporary Use of Adjuctive Thrombectomy During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction in the United States. Catheter Cardiovasc Interv. 2012,17 APR. DOI:1.1002/ccd.24306.
    連結:
  23. [14] Michael SL, Varinder S, James RW, et al. AngioJet thrombectomy. J Invasive Cardiol 2004;16:587-591.