本文關(guān)鍵詞： 急性ST段抬高型心肌梗死 血栓抽吸 血栓病理類型 梗死相關(guān)動脈 預(yù)后　出處：《安徽醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景2015年《中國心血管病報告》顯示:目前導(dǎo)致我國居民死亡的首要疾病是心腦血管疾病,心腦血管疾病的死亡人數(shù)約占全國死亡人數(shù)的43.8%。急性心肌梗死是造成心血管疾病死亡的最主要原因。血栓形成導(dǎo)致冠狀動脈急性閉塞是急性ST段抬高型心肌梗死(STEMI)的主要病理學(xué)基礎(chǔ)。富含脂核的斑塊破裂或糜爛激活不穩(wěn)定的血小板聚集,早期纖維素的形成加速了這一過程,紅細胞和炎癥細胞大量聚集在纖維網(wǎng)狀結(jié)構(gòu)中,形成血栓。血栓形成最終導(dǎo)致冠狀動脈血流中斷和遠端栓塞。當(dāng)前,治療STEMI的主要措施為直接經(jīng)皮冠狀動脈內(nèi)介入治療(PCI)。機械損傷血栓或斑塊,其碎屑脫落造成的微栓塞,引發(fā)急性微循環(huán)損傷是“無復(fù)流、慢血流”出現(xiàn)的原因之一�！盁o復(fù)流、慢血流”的現(xiàn)象,降低了直接PCI術(shù)后5年存活率。直接PCI術(shù)中血栓抽吸旨在清除冠狀動脈血栓,降低“無復(fù)流、慢血流”發(fā)生率,同時使冠狀動脈內(nèi)血栓體外研究成為現(xiàn)實,為冠狀動脈內(nèi)抗血小板或溶栓治療提供平臺。目的通過對冠狀動脈內(nèi)抽吸血栓行病理學(xué)分析,結(jié)合STEMI患者一般特征,缺血時間及梗死相關(guān)動脈情況,并分析患者預(yù)后,探討STEMI患者冠狀動脈血栓病理類型與缺血時間及梗死相關(guān)動脈之間的關(guān)系,以及不同血栓類型對患者預(yù)后的影響。方法連續(xù)入選2012年9月-2016年4月于我院行急診PCI并術(shù)中行血栓抽吸術(shù)的高血栓負荷STEMI患者82例(剔除缺血時間大于36h、未抽出足量血栓樣物質(zhì)、溶栓術(shù)后等的患者)。詳細記錄患者癥狀發(fā)作到血栓抽吸終止時間等基本信息。診斷性造影明確梗死相關(guān)動脈,判定存在高血栓負荷,根據(jù)術(shù)中患者病變情況選擇抽吸導(dǎo)管進行血栓抽吸。沿導(dǎo)絲送抽吸導(dǎo)管至病變上游開始抽吸,并通過病變達其下游,往返數(shù)次直至注射器充滿血液性抽吸物,重復(fù)抽吸2~7次。將血栓抽吸物立即置于10%福爾馬林溶液固定,24h內(nèi)送病理科,制作標(biāo)本切片。通過梯度酒精脫水、二甲苯透明、浸蠟、石蠟包埋成塊。沿標(biāo)本長軸進行中心水平切片,切片厚度為5μm,蘇木素-伊紅(HE)染色。按照血栓類型分為三組,白色血栓組(血小板/纖維素為主)、紅色血栓組(紅細胞為主)、混合血栓組(紅細胞與血小板/纖維素含量相近),比較不同血栓類型其梗死相關(guān)動脈分布的差異。并評估3組患者術(shù)后心肌灌注指標(biāo)(TIMI血流分級、心肌呈色分級、矯正TIMI血流幀數(shù))、術(shù)后7天、1年心臟左室功能(包括LVEF及LVEDD)及主要不良心腦血管事件(MACCE)。結(jié)果1.3組不同血栓類型的患者年齡、性別、心梗危險因素等基線資料無統(tǒng)計學(xué)差異。2.3組血栓標(biāo)本HE染色光鏡下觀察白色血栓、混合血栓、紅色血栓構(gòu)成比分別為:43.9%(36/82)、46.3%(38/82)、9.8%(8/82)。3.不同血栓類型缺血時間分布:白色血栓在≤4h、4-7h、7h占比分別為:61.12%(22/36)、19.44%(7/36)、19.44%(7/36),P=0.009;混合血栓在≤4h、4-7h、7h占比分別為:52.63%(11/38)、28.95%(20/38)、18.42%(7/38),P=0.013;紅色血栓占比比分別為:37.5%(3/8)、37.5%(3/8)、25.0%(2/8),P=0.895;白色血栓、混合血栓分別在≤4h、4-7h比例差異有統(tǒng)計學(xué)意義。4.不同血栓類型的梗死相關(guān)動脈分布:白色血栓組在LAD、LCX、RCA的分布為:63.88%(23/36)、5.55%(2/36)、30.55%(11/36),P0.01;混合血栓組在LAD、LCX、RCA的分布為:26.32%(10/38)、2.63%(1/38)、71.05%(27/38),P0.01;紅色血栓組在LAD、LCX、RCA的分布為:12.50%(1/8)、12.50%(1/8)、75.00%(6/8),P0.05。白色血栓組及混合血栓組分別在LAD及RCA分布有統(tǒng)計學(xué)差異。5.不同血栓類型其術(shù)后心肌灌注情況:白色血栓組、混合血栓組、紅色血栓組術(shù)后TIMI血流3級率分別為:88.89%、81.58%、62.50%,P0.05;MBG3級率分別為:58.33%、47.36%、37.50%,P0.05;c TFC分別為:27.75±7.19、31.32±7.98、31.43±6.32,P0.05,均未達統(tǒng)計學(xué)差異。6.3組心臟彩超結(jié)果顯示:術(shù)后7天白色血栓組、混合血栓組、紅色血栓組LVEF分別為:54.44±6.86%、54.35±7.34%、53.55±7.36%,P0.05;LVEDD分別為:53.00±3.88 mm、51.16±4.75 mm、54.16±6.27 mm,P0.05。術(shù)后1年白色血栓組、混合血栓組、紅色血栓組LVEF分別為:57.25±5.99%、55.80±4.34%、59.5±6.65%,P0.05;LVEDD分別為:50.42±4.54 mm、48.50±3.95 mm、46.75±4.42mm,P0.05。術(shù)后7天及1年左室心功能指標(biāo)均未見明顯統(tǒng)計學(xué)差異。7.白色血栓組、混合血栓組、紅色血栓組1年MACCE發(fā)生率分別為:3.33%、16.00%、0,P0.05,3組比較未見明顯統(tǒng)計學(xué)差異。結(jié)論不同血栓類型在不同缺血時間段分布不同,白色血栓缺血時間短,混合血栓缺血時間較長。不同血栓類型其主要梗死相關(guān)動脈分布不同,白色血栓多發(fā)生于前降支,混合血栓多發(fā)生于右冠狀動脈。心血管介入醫(yī)生可根據(jù)缺血時間或梗死相關(guān)動脈對血栓類型行初步判斷,據(jù)此選擇急診PCI術(shù)中冠狀動脈內(nèi)抗血小板或溶栓策略,可能會改善STEMI患者的預(yù)后。
[Abstract]:On the background of 2015 China cardiovascular disease report < > show: currently the leading cause of death in China is the disease of cardiovascular and cerebrovascular diseases, cardiovascular disease deaths accounted for about the deaths of 43.8%. in patients with acute myocardial infarction is the major cause of death from cardiovascular disease. Thrombosis leads to acute coronary artery occlusion is acute ST elevation myocardial infarction (STEMI). The main pathological basis of lipid rich plaque rupture or erosion of the nuclear activation of unstable platelet aggregation, the formation of accelerated the process of early cellulose, red blood cells and inflammatory cells gathered in the fiber network structure, the formation of thrombus. Thrombosis resulting in coronary blood flow interruption and distal embolization at present, the main measures for the treatment of STEMI direct percutaneous coronary intervention (PCI). The mechanical damage of thrombosis and plaque, the loss caused by debris Micro embolism caused by Acute Microcirculatory injury is no reflow, one of the reasons for slow flow "." no reflow, slow flow phenomenon, reduce the rate of direct PCI survived 5 years after operation. The direct PCI intraoperative thrombus aspiration to remove coronary artery thrombosis, reduce no reflow, slow blood flow "at the same time the incidence of coronary thrombosis in vitro to become a reality, provide a platform for intracoronary antiplatelet or thrombolysis therapy. Objective to intracoronary thrombus aspiration for pathological analysis, combined with the general characteristics of STEMI patients with ischemia time and infarct related artery, and to analyze the prognosis of the patients, to investigate the relationship between coronary STEMI arterial thrombosis in patients with pathological type and ischemia time and the infarct related artery thrombosis, and effects of different types of patient's prognosis. Methods consecutive September 2012 -2016 year in April in our hospital and underwent emergency PCI Thrombus aspiration high thrombus load 82 STEMI patients (excluding the ischemia time is greater than 36h, without taking adequate thrombus like material, etc. the patients after thrombolysis). A detailed record of the onset of symptoms to patients with thrombus aspiration. The basic information of the termination time of diagnostic angiography infarct related artery thrombosis, determine the existence of high load, according to the patients with lesions intraoperative aspiration catheter for thrombus aspiration. Along the guide wire suction catheter to the lesion starts upstream suction, and through the lesion as its downstream, and several times until the syringe filled with blood aspirates, repeat 2~7 times. The aspiration of thrombus aspiration were immediately placed in 10% formalin fixed, 24h send pathology, making specimens. By gradient alcohol dehydration, xylene transparent, paraffin, paraffin embedded blocks. Center horizontal slice specimens along the long axis, the slice thickness was 5 m, hematoxylin and eosin (HE) staining. According to the type of thrombosis were divided into three groups, white thrombus group (platelet / cellulose), red thrombus group (red cell mainly), mixed thrombus group (red blood cell and platelet / cellulose content, similar) to compare the differences among different types of infarction related artery thrombosis. The distribution and assessment of myocardial perfusion index in 3 groups of patients (TIMI flow grade, myocardial blush grade, corrected TIMI frame), 7 days after operation, 1 years of left ventricular function (including LVEF and LVEDD) and major adverse cardiovascular events (MACCE). The results of 1.3 groups of different types of thrombosis patient age, gender, risk factors of myocardial infarction baseline observation of non white thrombus under the light microscope, statistical difference between.2.3 group were stained with HE mixed thrombus thrombus, red thrombus accounted for 43.9% (36/82), 46.3% (38/82), 9.8% (8/82) of different types of.3. thrombosis ischemia time distribution: white thrombus in less than 4h, 4-7h, 7h accounted for 61. .12%(22/36),19.44%(7/36),19.44%(7/36),P=0.009;娣峰悎琛，

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