心肌梗死后室间隔穿孔:非选择性病例的外科临床结果

doi:10.19723/j.issn.1671-167X.2019.06.022

摘要/Abstract

摘要：

目的探讨急性心肌梗死后室间隔穿孔患者的临床预后与外科治疗结果,分析相关危险因素及治疗方式与时机。方法自2006年1月至2019年2月,选取北京大学人民医院心外科连续非选择性收治的急性心肌梗死合并室间隔穿孔病例23例,其中男性12例(52.2%),女性11例(47.8%),平均年龄(64.26±11.09)岁;接受手术18例,未行手术治疗5例。总结所有患者临床资料和手术相关情况,并进行随访。结果接受手术治疗的患者中,穿孔发生到手术平均时间为(19.39±13.67) d,其中穿孔1周内手术的共6例(33.3%), 2~4周内手术的共6例(33.3%), 4周以上手术的共6例(33.3%)。因血流动力学不稳定行急诊手术11例(61.1%), 择期手术7例(38.9%)。5例患者(27.8%)采用将室间隔穿孔用补片隔绝于左心室腔外,13例患者(72.2%)采用直接扩大补片修补穿孔。18例手术中同期行冠状动脉旁路移植12例(66.7%)。所有手术患者中,住院期间死亡7例(38.9%),相较于生存患者,围手术期死亡患者穿孔发生更早[(1.83±0.75) d vs.(5.22±4.66) d,P=0.019],有更高的急诊手术率(100.0% vs. 36.4%,P=0.009)和更低的同期旁路移植手术率(28.6% vs. 90.1%,P=0.008)。术后随访中位时间2年(3个月~10年),2例患者因心功能不全分别于术后2个月死亡,长期院外存活9例(50.0%)。未手术治疗的5例患者中, 2例在等待手术期间死亡,3例拒绝手术的患者均在出院后1周内死亡。结论外科手术是急性心肌梗死并发室间隔穿孔的患者有效治疗方式;最佳的手术时机需通过实时的评估与监测,结合患者情况综合决定;术中同期冠状动脉旁路移植术对于室间隔穿孔患者可能是有益的。

关键词: 急性心肌梗死, 室间隔穿孔, 危险因素, 手术时机

Abstract:

Objective: To observe the clinical prognosis and surgical treatment results in patients with postinfarction ventricular septal rupture, and to discuss the risk factors,methods & timing of treatment.Methods: From January 2006 to February 2019, 23 patients with postinfarction ventricular septal rupture were admitted to the department of cardiac surgery,Peking University People’s Hospital, including 12 males (52.2%) and 11 females (47.8%), aged (64.26 ±11.09) years. Among them, 18 cases underwent operation, and 5 cases did not receive surgical treatment. The clinical data and follow-up data were summarized retrospectively.Results: Among the patients treated with operation, the average time from perforation to operation was (19.39 ±13.67) d, including 6 cases (33.3%) of perforation within 1 week, 6 cases (33.3%) within 2 to 4 weeks and 6 cases (33.3%) more than 4 weeks. Emergency surgery was performed in 11 cases (61.1%) because of hemodynamic instability, and selective operation in 7 cases (38.9%). Direct enlarged patch was used in 13 cases (72.2%), and some infarct exclusion techniques were used in 5 patients (27.8%). In 18 cases, coronary artery bypass grafting was performed in 12 cases (66.7%). Of all the surgical patients, 7 (38.9%) died during hospitalization. Compared with the survival patients, the perioperative death patients had earlier perforation [(1.83±0.75) d vs. (5.22 ±4.66) d, P=0.019] and higher emergency operation rate (100% vs. 36.4%, P=0.009) and lower simultaneous bypass grafting rate (28.6% vs. 90.1%, P=0.008). The median follow-up time was 2 years (3 months to 10 years). 2 patients died of heart failure in 2 months after operation, and 9 cases (50.0%) survived for a long time. Of the 5 patients who had not been treated, 2 died while waiting for operation, and 3 patients who refused surgery died within 1 week after discharge.Conclusion: Surgery is an effective treatment for patients with acute myocardial infarction complicated with ventricular septum perforation. The best time for operation should be determined by real-time evaluation and monitoring, combined with the situation of patients. Concomitant coronary artery bypass grafting may be beneficial to these patients.

Key words: Acute myocardial infarction, Postinfarction ventricular septal rupture, Risk factors, Operation opportunity

中图分类号:

R654.2

高卿,陈彧,刘刚,陈生龙,董穗欣. 心肌梗死后室间隔穿孔:非选择性病例的外科临床结果[J]. 北京大学学报（医学版）, 2019, 51(6): 1103-1107.

Qing GAO,Yu CHEN,Gang LIU,Sheng-long CHEN,Sui-xin DONG. Clinical results after surgical treatment for non-selective case with postinfarction ventricular septal rupture[J]. Journal of Peking University(Health Sciences), 2019, 51(6): 1103-1107.

图/表 3

表1

围手术期死亡与生存患者比较"

	Death group(n=7)	Survival group(n=11)	Test value	P
Age/years, $x ?$ ±s	63.43±12.34	62.55±12.52	0.277	0.606
Gender,n(%)			-0.470	0.638
Male	3(42.9)	6(54.5)
Female	4(57.1)	5(45.5)
Time from infarction to perforation/d	1.83±0.75	5.22±4.66	7.236	0.019
Cardiogenic shock,n(%)	3(42.9)	4(36.4)	-0.464	0.643
Hypertension,n(%)	5(71.4)	7(63.6)	-0.332	0.740
Hyperlipidemia,n(%)	2(28.6)	3(27.3)	-0.058	0.954
Diabetes,n(%)	1(14.3)	3(27.3)	-0.991	0.322
LVED/cm	5.66±0.91	5.37±0.70	0.803	0.384
LVEF/%	55.60±10.10	55.30±14.60	1.713	0.210
Perforation size/cm	1.31±0.47	1.52±0.53	0.227	0.640
BNP/(ng/L)	1 285.00±946.30	1 490.50±818.00	0.094	0.767
Preoperative IABP,n(%)	6(85.7)	6(54.5)	-1.329	0.184
Preoperative mechanical ventilation,n(%)	0(0)	3(27.3)	-1.471	0.141
Preoperative CRRT,n(%)	0(0)	1(0.09)	-0.798	0.425
Time from perforation to operation/d	15.00±15.67	22.18±12.18	0.919	0.352
Emergency operation,n(%)	7(100.0)	4(36.4)	-2.624	0.009
Simultaneous CABG,n(%)	2(28.6)	10(90.1)	-2.658	0.008
Postoperative residual shunt,n(%)	2(28.6)	3(27.3)	-0.493	0.622

表1

图1

图2

参考文献 13

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