微创医学

目的探讨靶血管局部肿瘤坏死因子-α(TNF-α)对急性心肌梗死患者行急诊冠脉介入(primary percutaneous coronary intervention,PPCI)术后心肌灌注的影响。方法行急诊PCI术、并行血栓抽吸术的急性ST段抬高性心肌梗死(STEMI)患者,男性116例,女性32例,平均年龄(59.7±22.8)岁。冠脉造影前,经动脉鞘取血3 mL;PCI术前,采用Export XT血栓抽吸导管在靶血管内抽吸血栓、过滤栓子等成分,分离血清备用。按照常规方法植入支架。主要终点为术后心肌呈色分级,次要终点为ST段回落幅度。血清TNF-α采用ELISA法检测。结果 MBG 0～1级患者局部TNF-α浓度为(340.7±55.4)pg/L,MBG 2级为(207.5±42.1)pg/L,MBG 3级为(137.3±33.2)pg/L,差异有显著性(P=0.00)。ST段回落≥70%患者局部TNF-α浓度为(159.2±52.4)pg/L,ST段回落<70%为(308.6±43.9)pg/L,差异有显著性(P=0.00)。外周动脉血中的TNF-α浓度与MBG分级、ST段是否完全回落没有显著相关(P>0.05)。Logistic回归显示,TNF-α最高四分位区间是心肌灌注不良的唯一预测因子,与最低的四分位区间相比,发生心肌灌注不良的几率增加2.1倍(95%置信区间:1.17～7.81)。结论急性心肌梗死患者中,靶血管局部TNF-α浓度升高与急诊PCI术后心肌灌注不良有关,全身的TNF-α浓度对术后心肌灌注的影响不显著。

Objective To investigate the effect of local tumor necrosis factor-α ( TNF-α) in infarction related artery ( IRA) on myocardial perfusion after primary percutaneous coronary intervention ( PCI) in myocardial infarction patients． Methods 114 male and 32 female，averaging 59． 7 ± 22． 8 years old， myocardial infarction patients with acute ST segment elevation were performed with primary PCI and thromboaspiration． Periphery arterial blood were collected from artery sheath before angiography． Blood in IRA were collected through thrombus aspiration catheter( Export XT) and were filtered before serum separation．Drug-eluting stents were implanted routinely． Primary endpoint was myocardial blush grades ( MBG) ． Secondary endpoint was ST-segment resolution ( STR) ． TNF-αlevels were measured by ELISA． Results IRA TNF-α levels in MBG 0 － 1 grades patients were 340． 7 ± 55． 4pg /L，which was significantly higher than those in MBG 2 grade group( 207． 5 ± 42． 1pg /L) and MBG 3 grade group( 137． 3 ± 33． 2pg /L) ，P = 0． 00． IRA TNF-α levels in patients with complete STR( ≥70%) were lower than that in incomplete STR( ＜ 70%) patients ( 159． 2 ± 52． 4pg /L vs 308． 6 ± 43． 9pg /L，P = 0． 00) ． There was no significant correlation between TNF-αlevels in periphery arterial blood，MBG grade or whether or not ST segment complete regression． Logistic analysis indicated that TNF-α was solitary independent risk factor of impaired myocardial perfusion ( quartile 4 vs quartile 1，OR = 2． 1，95% CI: 1． 17 － 7． 81) ． Conclusion Increased IRA TNF-αlevel，but not periphery arterial TNF-αlevel，is accompanied with impaired myocardial perfusion in patients with acute myocardial infarction underwent primary percutaneous coronary intervention．