急性ST段抬高型心肌梗死冠状动脉内血栓病理分析及预后研究

发布时间：2018-02-04 22:12

  本文关键词： 急性ST段抬高型心肌梗死 血栓抽吸 血栓病理类型 梗死相关动脉 预后　出处：《安徽医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究背景2015年《中国心血管病报告》显示:目前导致我国居民死亡的首要疾病是心脑血管疾病,心脑血管疾病的死亡人数约占全国死亡人数的43.8%。急性心肌梗死是造成心血管疾病死亡的最主要原因。血栓形成导致冠状动脉急性闭塞是急性ST段抬高型心肌梗死(STEMI)的主要病理学基础。富含脂核的斑块破裂或糜烂激活不稳定的血小板聚集,早期纤维素的形成加速了这一过程,红细胞和炎症细胞大量聚集在纤维网状结构中,形成血栓。血栓形成最终导致冠状动脉血流中断和远端栓塞。当前,治疗STEMI的主要措施为直接经皮冠状动脉内介入治疗(PCI)。机械损伤血栓或斑块,其碎屑脱落造成的微栓塞,引发急性微循环损伤是“无复流、慢血流”出现的原因之一。“无复流、慢血流”的现象,降低了直接PCI术后5年存活率。直接PCI术中血栓抽吸旨在清除冠状动脉血栓,降低“无复流、慢血流”发生率,同时使冠状动脉内血栓体外研究成为现实,为冠状动脉内抗血小板或溶栓治疗提供平台。目的通过对冠状动脉内抽吸血栓行病理学分析,结合STEMI患者一般特征,缺血时间及梗死相关动脉情况,并分析患者预后,探讨STEMI患者冠状动脉血栓病理类型与缺血时间及梗死相关动脉之间的关系,以及不同血栓类型对患者预后的影响。方法连续入选2012年9月-2016年4月于我院行急诊PCI并术中行血栓抽吸术的高血栓负荷STEMI患者82例(剔除缺血时间大于36h、未抽出足量血栓样物质、溶栓术后等的患者)。详细记录患者症状发作到血栓抽吸终止时间等基本信息。诊断性造影明确梗死相关动脉,判定存在高血栓负荷,根据术中患者病变情况选择抽吸导管进行血栓抽吸。沿导丝送抽吸导管至病变上游开始抽吸,并通过病变达其下游,往返数次直至注射器充满血液性抽吸物,重复抽吸2~7次。将血栓抽吸物立即置于10%福尔马林溶液固定,24h内送病理科,制作标本切片。通过梯度酒精脱水、二甲苯透明、浸蜡、石蜡包埋成块。沿标本长轴进行中心水平切片,切片厚度为5μm,苏木素-伊红(HE)染色。按照血栓类型分为三组,白色血栓组(血小板/纤维素为主)、红色血栓组(红细胞为主)、混合血栓组(红细胞与血小板/纤维素含量相近),比较不同血栓类型其梗死相关动脉分布的差异。并评估3组患者术后心肌灌注指标(TIMI血流分级、心肌呈色分级、矫正TIMI血流帧数)、术后7天、1年心脏左室功能(包括LVEF及LVEDD)及主要不良心脑血管事件(MACCE)。结果1.3组不同血栓类型的患者年龄、性别、心梗危险因素等基线资料无统计学差异。2.3组血栓标本HE染色光镜下观察白色血栓、混合血栓、红色血栓构成比分别为:43.9%(36/82)、46.3%(38/82)、9.8%(8/82)。3.不同血栓类型缺血时间分布:白色血栓在≤4h、4-7h、7h占比分别为:61.12%(22/36)、19.44%(7/36)、19.44%(7/36),P=0.009;混合血栓在≤4h、4-7h、7h占比分别为:52.63%(11/38)、28.95%(20/38)、18.42%(7/38),P=0.013;红色血栓占比比分别为:37.5%(3/8)、37.5%(3/8)、25.0%(2/8),P=0.895;白色血栓、混合血栓分别在≤4h、4-7h比例差异有统计学意义。4.不同血栓类型的梗死相关动脉分布:白色血栓组在LAD、LCX、RCA的分布为:63.88%(23/36)、5.55%(2/36)、30.55%(11/36),P0.01;混合血栓组在LAD、LCX、RCA的分布为:26.32%(10/38)、2.63%(1/38)、71.05%(27/38),P0.01;红色血栓组在LAD、LCX、RCA的分布为:12.50%(1/8)、12.50%(1/8)、75.00%(6/8),P0.05。白色血栓组及混合血栓组分别在LAD及RCA分布有统计学差异。5.不同血栓类型其术后心肌灌注情况:白色血栓组、混合血栓组、红色血栓组术后TIMI血流3级率分别为:88.89%、81.58%、62.50%,P0.05;MBG3级率分别为:58.33%、47.36%、37.50%,P0.05;c TFC分别为:27.75±7.19、31.32±7.98、31.43±6.32,P0.05,均未达统计学差异。6.3组心脏彩超结果显示:术后7天白色血栓组、混合血栓组、红色血栓组LVEF分别为:54.44±6.86%、54.35±7.34%、53.55±7.36%,P0.05;LVEDD分别为:53.00±3.88 mm、51.16±4.75 mm、54.16±6.27 mm,P0.05。术后1年白色血栓组、混合血栓组、红色血栓组LVEF分别为:57.25±5.99%、55.80±4.34%、59.5±6.65%,P0.05;LVEDD分别为:50.42±4.54 mm、48.50±3.95 mm、46.75±4.42mm,P0.05。术后7天及1年左室心功能指标均未见明显统计学差异。7.白色血栓组、混合血栓组、红色血栓组1年MACCE发生率分别为:3.33%、16.00%、0,P0.05,3组比较未见明显统计学差异。结论不同血栓类型在不同缺血时间段分布不同,白色血栓缺血时间短,混合血栓缺血时间较长。不同血栓类型其主要梗死相关动脉分布不同,白色血栓多发生于前降支,混合血栓多发生于右冠状动脉。心血管介入医生可根据缺血时间或梗死相关动脉对血栓类型行初步判断,据此选择急诊PCI术中冠状动脉内抗血小板或溶栓策略,可能会改善STEMI患者的预后。
[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，

本文编号：1491285