急性心肌梗死后室间隔穿孔的外科治疗

目的总结急性心肌梗死后室间隔穿孔的外科治疗经验,探讨外科手术治疗的时机和方法。方法自1999年1月至2008年12月,外科治疗22例急性心肌梗死后室间隔穿孔患者,其中男17例,女5例;年龄39～78岁,平均年龄61.77岁。前室间隔穿孔18例,后室间隔穿孔4例,均合并室壁瘤。22例患者均行室间隔穿孔修补术及室壁瘤切除术,16例患者同期接受冠状动脉旁路移植术,移植血管2.11±1.57支。结果围术期死亡2例（9.09%）,其中1例术后死于严重低心排血量综合征,1例死于大面积脑栓塞。其余20例患者均治愈出院,出院时心功能分级（NYHA）Ⅲ级4例,Ⅱ级12例,Ⅰ级4例。超声心动图检查提示：未发现有室间隔残余分流,有轻度二尖瓣反流2例。术后左心室舒张期末内径（LVEDD）与术前比较明显减小（50.27±5.33mmvs.57.94±6.79mm,t=4.437,P=0.000）。随访16例,随访时间3～24个月（13.9±6.5个月）,失访4例。随访期间无晚期死亡,无心血管事件发生。心功能分级（NYHA）Ⅱ级11例,Ⅰ级5例。超声心动图提示：LVEDD与术前比较明显缩小（49.50±4.66mm vs.57.94±6.79mm,t=5.041,P=0.000）,左心室射血分数（LVEF）较术前明显提高（55.08%±6.72%vs.45.57%±11.31%,t=2.719,P=0.013）。结论急性心肌梗死后室间隔穿孔是急性心肌梗死的严重并发症之一,掌握适当的手术时机、完善的术前准备、积极的围手术期治疗、正确的手术方法和避免术后并发症的发生,能有效地降低患者的病死率,改善其预后。

Surgical Treatment to Ventricular Septal Rupture after Acute Myocardial Infarction

Objective To summarize the surgical experiences of ventricular septal rupture （VSR） after acute myocardial infarction （AMI） and investigate the time and methods of surgery. Methods From January 1999 to December 2008,22 patients with VSR after AMI underwent surgical procedures. There were 17 male and 5 female with a age of 39-78 years （mean age of 61.77 years）. There were 18 cases with anterior VSR and 4 cases with posterior VSR,all of them combined with left ventricular aneurysm. Twenty-two cases underwent ventricular septal repair and aneurysm resection,16 cases underwent coronary artery bypass grafting concomitantly with a graft of 2.11±1.57. Results There were 2 perioperative deaths （9.09%）,1 died of severe low cardiac output syndrome and 1 died of massive cerebral embolism. The other 20 cases were all cured and discharged. According to cardiac function classification from New York Heart Association（NYHA）,there were 4 cases in grade Ⅲ,12 cases in grade Ⅱ and 4 cases in grade Ⅰ. Echocardiography showed that there were no VSR shunt and 2 cases with mild mitral valve regurgitation. Postoperative left ventricular end-diastolic diameter （LVEDD） reduced significantly compared with that before operation （50.27±5.33 mm vs. 57.94±6.79 mm,t=4.437,P=0.000）. Sixteen cases were followed up,and the follow-up time was 3-24 months （13.9±6.5 months）. Four cases were lost. There was no late death and cardiovascular event during following up. There were 11 cases in cardiac function classification （NYHA） grade Ⅱ and 5 in grade Ⅰ. Echocardiography showed that LVEDD reduced significantly （49.50±4.66 mm vs. 57.94±6.79 mm,t=5.041,P=0.000） and left ventricular ejection fraction （LVEF） increased significantly （55.08%±6.72% vs. 45.57%±11.31%,t=2.719,P=0.013） compared with those before operation. Conclusion VSR after AMI is one of the serious complications of AMI. Proper operation timing,perfect preoperative preparation,appropriate perioperative treatment,right surgical me