病例1
●病史及入院情况●
●患者男性，75岁，主诉胸痛、胸闷、气短3个月，3个月前于当地医院行冠状动脉造影发现严重三支血管病变，转入我科。既往高血压10余年。心脏彩超EF值32%。外院造影结果示LAD弥漫性钙化病变，近 段80%～90%狭窄，中 段80%～90%狭窄，远 端80%～90%，LAD—D1和D2分别为90%狭窄；LCX近段100%狭窄；RCA近段100%狭窄，并可见全程钙化。患者Syntax评分48分，与心外科医生沟通，患者外科STS评分5分，Euro ScoreⅠ4.5分，Euro ScoreⅡ14分，术后风险为中—高危，心功能较差，外科医生不建议行搭桥术，同时家属也拒绝外科手术。心血管医生团队讨论后决定行机械循环支持下PCI术。
●手术策略分析●
①患者高龄，心功能差；②冠状动脉病变极其复杂，LAD近中远段弥漫性钙化病变，狭窄为80%～90%，LCX 近段100%；RCA近段100%。可见LAD—RCA逆向侧支血管。Syntax评分48分，外科手术风险为中—高危；外科和家属不同意搭桥术；③拟行ECMO+IABP支持PCI术，首先处理LAD病变和LCX病变，改善缺血状态，但LAD钙化较重，旋磨准备好，术中发生缺血、心脏崩溃风险较高；如手术顺利，尝试开通RCA CTO，正向首先尝试，失败后可行逆向开通，尽量实现部分或完全血运重建。术前股动脉彩超、中心静脉压测定等均完善。右侧和左侧股动脉分别安装ECMO和IABP，ECMO开始流量1.5 L/min（图18—0—1A和B）。右侧桡动脉放置7F SAL 1.0，左侧肱动脉放置7F EBU 3.75。具体过程见图18—0—1。
●手术过程详解●
1.双侧造影详细评估血管病变情况，如是否涉及左主干及分叉，闭塞病变开口和病变长度，是否有逆向侧支，登陆区有无病变等（图18—0—1C和D）。
2.RCA和LCX CTO可见来自LAD逆向侧支，LAD近中远弥漫钙化病变，处理LAD过程风险较大，避免长时间扩张及慢/无复流发生和夹层形成（图18—0—1E和F）。
3.LCX CTO 应用Fielder XT—A尝试失败，改为GAIA Third尝试通过病变，因为病变较弥漫，仅进行球囊扩张，保持血流TIMI 2～3级（图18—0—1G）。
4.LAD病变从远—近段进行球囊扩张，于中远段植入2.5mm×35mm DES（图18—0—1H和I）。
5.RCA CTO病变首先正向尝试，Fielder XT—A/GAIA Third均失败，逆向Sion通过穿隔支进入闭塞段远端，Pilot 200导丝尝试不能通过闭塞段，Conquest Pro通过闭塞段反复尝试不能进入正向导管内（图18—0—1J）。
6.采用RCA正向Guidezilla导管支撑下迎接逆向导丝，Guidezilla推送过程中心电图显示心脏停搏，立即提高Guiding 导管，心电监护再次显示三度房室传导阻滞，心率20～30次/分；立即提高ECMO流量从1.5 L/min 到3.0 L/min，给予肾上腺0.3mg，心律失常发生过程中患者意识一直清醒，没实施CPR（图18—0—1K和L）。心率逐渐恢复到90～120次/分，血压150～180/80～100mmHg，后恢复正常；考虑可能原因为Guidezilla推送过程中阻力较大，使Guiding后退压迫主动脉瓣，造成冠状动脉血流骤减，引起心律失常发生。随后逆向Pilot 200导丝进入正向导管内，随后逆向Corsair导管进入正向导管内，RG3导丝实现体外化（图18—0—1M）。
7.沿RG3导丝和Guidezilla导管序贯植入2.25mm×30mm、3.0mm×36mm、3.5mm×36mm DES 3枚（图18—0—1N和O）。于LM—LAD植入3.0mm×33mm DES（图18—0—1P）。
图18—0—1 ECMO+IABP支持下RCA和LCX CTO及LAD严重狭窄PCI治疗
8.在ECMO+IABP支持下处理3支血管，完成部分血运重建。术中给予红细胞4 U。
9.术后ECMO流量1 L/min，观察30 min，血压维持90/60mmHg 以上，卸载ECMO，IABP继续使用。
10.手术处理3支血管，PCI术花费时间为3.5 h，ECMO支持4 h，造影剂400 ml。入ICU 2天，IABP使用2天，总住院时间10天出院。
总之，对高危CTO PCI患者机械循环辅助装置使术者能安全完成手术，实现部分或完全血运重建。PCI中MCS选择依赖于血流动力学支持程度、解剖因素、合并疾病、设备可用性和操作人员经验。需要大型临床随机对照研究从临床、血流动力学和手术特征方面综合考虑哪些患者血流动力学崩溃风险高，择期MCS可能会获益。
参考文献
［1］Hochman JS, Sleeper LA, Webb JG, et al.Early revascularization in acute myocardial infarction complicated by cardiogenicshock.SHOCK Investigators.Should we emergently revascularize occluded coronaries for cardiogenicshock［J］.N Engl J Med, 1999, 341(9): 625—634.
［2］van Diepen S, Katz JN, Albert NM, et al.Contemporary management of cardiogenicshock: ascientificstatement from the American Heart Association［J］.Circulation, 2017, 136(16): e232—e268.
［3］Nguyen HL, Yarzebski J, Lessard D, et al.Ten-year (2001—2011) trends in the incidence rates andshort term outcomes of early versus late onset cardiogenicshock after hospitalization for acute myocardial infarction［J］.J Am Heart Assoc, 2017, 6(6): e005566.
［4］Goldberg RJ, Gore JM, Alpert JS, et al.Cardiogenicshock after acute myocardial infarction.Incidence and mortality from a community-wide perspective, 1975 to 1988［J］.N Engl J Med, 1991, 325(16): 1117—1122.
［5］Waldo SW, Secemsky EA, O’Brien C, et al.Surgical ineligibility and mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention［J］.Circulation, 2014, 130(25): 2295—2301.
［6］Gössl M, Faxon DP, Bell MR, et al.Complete versus incomplete revascularization with coronary artery bypass graft or percutaneous intervention instable coronary artery disease［J］.Circ Cardiovasc Interv, 2012, 5(4): 597—604.
［7］Nellis SH, Liedtke AJ, Whitesell L.Small coronary vessel pressure and diameter in an intact beating rabbit heart using fixed-position and free-motion techniques［J］.Circ Res, 1981, 49(2): 342—353.
［8］Barron HV, Every NR, Parsons LS, et al.Investigators in the National Registry of Myocardial Infarction 2.The use of intra-aortic balloon counterpulsation in patients with cardiogenicshock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2［J］.Am Heart J, 2001, 141(6): 933—939.
［9］Ohman EM, Nanas J, Stomel RJ, et al.Thrombolysis and counterpulsation to improvesurvival in myocardial infarction complicated by hypotension andsuspected cardiogenicshock or heart failure: results of the TACTICS Trial［J］.J Thromb Thrombolysis, 2005, 19(1): 33—39.
［10］Thiele H, Zeymer U, Neumann FJ, et al.Intraaortic balloonsupport for myocardial infarction with cardiogenicshock［J］.Indian Heart Journal, 2012, 367(14): 1287—1296.
［11］Perera D, Stables R, Thomas M, et al.Elective intra-aortic balloon counterpulsation during high-risk percutaneous coronary intervention: a randomized controlled trial［J］.JAMA, 2010, 304(8): 867—874.(https://www.daowen.com)
［12］Romeo F, Acconcia MC, Sergi D, et al.Lack of intra-aortic balloon pump effectiveness in high-risk percutaneous coronary interventions without cardiogenicshock: a comprehensive meta-analysis of randomised trials and observationalstudies［J］.Int J Cardiol, 2013, 167(5): 1783—1793.
［13］Tsao NW, Shih CM, Yeh JS, et al.Extracorporeal membrane oxygenation-assisted primary percutaneous coronary intervention may improvesurvival of patients with acute myocardial infarction complicated by profound cardiogenicshock［J］.J Crit Care, 2012, 27(5): 530.e1—11.
［14］Goyal D, Nadar SK, Wrigley B, et al.Successful use of intra-aortic counter pulsation therapy for intractable ventricular arrhythmia in patient withsevere left ventricular dysfunction and normal coronary arteries［J］.Cardiol J, 2010, 17(4): 401—403.
［15］Gregoric ID, Bruckner BA, Jacob L, et al.Techniques and complications of TandemHeart ventricular assist device insertion during cardiac procedures［J］.Asaio Journal, 2009, 55(3): 251—254.
［16］Seyfarth M, Sibbing D, Bauer I, et al.A randomized clinical trial to evaluate thesafety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenicshock caused by myocardial infarction［J］.J Am Coll Cardiol, 2008, 52(19): 1584—1588.
［17］Ouweneel DM, Eriksen E, Sjauw KD, et al.Percutaneous mechanical circulatorysupport versus intra-aortic balloon pump in cardiogenicshock after acute myocardial infarction［J］.J Am Coll Cardiol, 2017, 69(3): 278—287.
［18］Dixon SR, Henriques JPS, Mauri L, et al.A Prospective Feasibility Trial Investigating the Use of the Impella 2.5 System in Patients Undergoing High-Risk Percutaneous Coronary Intervention (The PROTECT I Trial): Initial U.S.Experience［J］.JACC Cardiovascular Interventions, 2009, 2(2): 91—96.
［19］Sjauw KD, Konorza T, Erbel R, et al.Supported high-risk percutaneous coronary intervention with the Impella 2.5 device the Europella registry［J］.Journal of the American College of Cardiology, 2009, 54(25): 2430—2434.
［20］Dangas GD, Kini AS, Sharma SK, et al.Impact of hemodynamicsupport with Impella 2.5 versus intra-aortic balloon pump on prognostically important clinical outcomes in patients undergoing high-risk percutaneous coronary intervention (from the PROTECT Ⅱ randomized trial)［J］.American Journal of Cardiology, 2014, 113(2): 222—228.
［21］Burkhoff D, Cohen H, Brunckhorst C, et al.A randomized multicenter clinicalstudy to evaluate thesafety and efficacy of the TandemHeart percutaneous ventricular assist device versus conventional therapy with intraaortic balloon pumping for treatment ofcardiogenicshock［J］.Am Heart J, 2006, 152(3): 469.e1—8.
［22］Thiele H, Sick P, Boudriot E, et al.Randomized comparison of intra-aortic balloonsupport with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenicshock［J］.Eur Heart J, 2005, 26(13): 1276—1283.
［23］Vranckx P, Schultz CJ, Valgimigli M, et al.Assisted circulation using the TandemHeart during very high-risk PCI of the unprotected left main coronary artery in patients declined for CABG［J］.Catheterization & Cardiovascular Interventions, 2010, 74(2): 302—310.
［24］Alli OO, Singh IM, Holmes DR Jr, et al.Percutaneous left ventricular assist device with TandemHeart for high-risk percutaneous coronary intervention: the Mayo Clinic experience［J］.Catheter Cardiovasc Interv, 2012, 80(5): 728—734.
［25］Nichol G, Karmy-Jones R, Salerno C, et al.Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenicshockstates［J］.Resuscitation, 2006, 70(3): 381—394.
［26］Takayama H, Truby L, Koekort M, et al.Clinical outcome of mechanical circulatorysupport for refractory cardiogenicshock in the current era［J］.J Heart Lung Transplant, 2013, 32(1): 106—111.
［27］Sheu JJ, Tsai TH, Lee FY, et al.Early extracorporeal membrane oxygenator- assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenicshock［J］.Crit Care Med, 2010, 38(9): 1810—1817.
［28］Vainer J, Van OV, Maessen J, et al.Elective high-risk percutaneous coronary interventionssupported by extracorporeal lifesupport［J］.American Journal of Cardiology, 2007, 99(6): 771—773.
［29］Fefer P, Knudtson ML, Cheema AN, et al.Current perspectives on coronary chronic total occlusions: The Canadian Multicenter Chronic Total Occlusions Registry［J］.J Am Coll Cardiol, 2012, 59: 991—997.
［30］Khan MF, Wendel CS, Thai HM, et al.Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: A meta-analysis comparingsuccessful versus failed percutaneous intervention for chronic total occlusion［J］.Catheter Cardiovasc Interv, 2013, 82: 95—107.
［31］Galassi AR, Boukhris M, Toma A, et al.Percutaneous coronary intervention of chronic total occlusions in patients with low left ventricular ejection fraction［J］.JACC Cardiovasc Interv, 2017, 10: 2158—2170.
［32］Alidoosti M, Saroukhani S, Lotfi-Tokaldany M, et al.Objectifying the level of incomplete revascularization by the residual SYNTAXscore and evaluating its impact on the one-year outcome of percutaneous coronary intervention in patients with multi-vessel disease［J］.Cardiovasc Revasc Med, 2016; 17: 308—312.
［33］Karmpaliotis D, Karatasakis A, Alaswad K, et al.Outcomes with the use of the retrograde approach for coronary chronic total occlusion interventions in a contemporary multicenter US registry［J］.Circ Cardiovasc Interv, 2016; 9(6).
［34］Danek BA, Karatasakis A, Karmpaliotis D, et al.Development and validation of ascoringsystem for predicting periprocedural complications during percutaneous coronary interventions of chronic total occlusions: the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) Complications Score［J］.J Am Heart Assoc, 2016; 5(10).
［35］O’Neill WW, Kleiman NS, Moses J, et al.A prospective, randomized clinical trial of hemodynamicsupport with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT IIstudy［J］.Circulation, 2012; 126: 1717—1727.
［36］Riley RF, McCabe JM, Kalra S, et al.Impella-assisted chronic total occlusion percutaneous coronary interventions: A multicenter retrospective analysis［J］.Catheter Cardiovasc Interv, 2018, 92(7): 1261—1267.
［37］Danek BA, Basir MB, O’Neill WW, et al.Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Multicenter U.S.Registry［J］.J Invasive Cardiol, 2018, 30(3): 81—87.
［38］Davila CD, Sharma S, Krishnamoorthy P, et al.Prevalence and clinical correlates of extended mechanicalsupport in patients undergoing high-risk percutaneous coronary intervention in current clinical practice: Insights from the cVAD registry［J］.Cardiovasc Revasc Med, 2019.
［39］Patel VG, Brayton KM, Tamayo A, et al.Angiographicsuccess and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 18, 061 patients from 65studies［J］.JACC Cardiovasc Interv, 2013, 6: 128—136.
［40］Tsuchikane E, Katoh O, Kimura M, et al.The first clinical experience with a novel catheter for collateral channel tracking inretrograde approach for chronic coronary total occlusions［J］.JACC Cardiovasc Interv, 2010, 3: 165—171.
［41］Brott BC.Prevention of myocardialstunning during percutaneous coronary interventions: novel insights from pre-treatment with glucagon-like peptide-1［J］.JACC Cardiovasc Interv, 2015; 8: 302—304.