急性心梗后室间隔穿孔的临床特征及外科治疗

急性心肌梗塞后室间隔穿孔(简称VSR)是心梗病人一种较少见的并发症,预后极差。我们自1985年5月至1999年10月对12例VSR进行手术治疗。入院后应用强心利尿扩血管及IABP辅助治疗,并在中度低温体外循环下行穿孔修补术。结果死亡5例,死亡率为41.7％。VSR临床表现以右心衰和心源性休克为特征,及早正确的围术期处理和早期手术是治疗的关键。     

急性心肌梗塞伴室间隔穿孔的围手术期处理

８例急性心肌梗塞伴室间隔穿孔并发心源性休克７例，采用主动脉内球囊反搏６例，７例置人Ｓｗａｎ－Ｇａｎｚ导管监测血流动力学。３例经调整心功能１～２周后手术，５例经积极处理病情无明显缓解趋势于入院４８小时内急诊手术。处理好围手术期间诸环节是手术成功的关键；Ｓｗａｎ－Ｇａｎｚ导管用于指导治疗以及术前长时间主动脉内球囊反搏支持循环对减少手术早期死亡率有重要意义。     

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。     

急性心肌梗死并发室间隔穿孔患者的手术时机与评价

室间隔穿孔是急性心肌梗死少见的并发症,却会迅速发生心力衰竭、心源性休克等并发症,预后极差。外科手术治疗是改善预后的根本措施,而手术时机的选择至关重要。其基本指导原则为：部分心肌梗死患者发生室间隔穿孔后会迅速出现双心室功能衰竭和/或心源性休克,经药物等保守治疗循环功能不能维持,又不能耐受外科手术,将会很快死亡,病死率很高;对该类已经失去了手术机会的患者,不宜施行手术治疗;对少数穿孔较小、能平稳控制病情的患者,严格把握手术指征后可给予药物和保守治疗1～4周后再行手术治疗,一旦无法确保病情稳定时,应及时改为急诊手术治疗;其余患者无论处于何种状态,均应立即行外科手术治疗     

急性心肌梗死后室间隔穿孔患者的手术时机与预后分析题录

目的探讨急性心肌梗死后室间隔穿孔(VSR)患者的最佳手术时机以及与患者院内死亡相关的危险因素。方法根据入选及排除标准, 对我院2019年1月至2023年8月期间收治的100例室间隔穿孔患者进行了回顾性分析。比较患者在不同时间手术的病死率以及死亡组与生存组患者在一般临床资料、住院治疗及实验室检查方面的差异。分析与患者预后相关的危险因素采用logistic二元回归模型。结果 100例患者院内病死率56%, 其中手术治疗患者病死率34.9%, 保守治疗患者病死率91.9%, 手术患者中0～3天手术者院内病死率63.6%, 4～14天手术者院内病死率38.1%, 14天以上手术者院内病死率22.6%;死亡组患者在入院心率、急性心肌梗死后血运重建比例、穿孔大小、休克分期、冠状动脉病变严重程度上与生存组差异均有统计学意义(P<0.05);死亡组的C反应蛋白、白细胞计数、B型脑钠肽(BNP)水平、肌酐水平以及血乳酸水平均高于生存组(P<0.05)。二元回归模型中纳入两组比较差异有统计学意义的变量, 结果提示白细胞计数、血乳酸水平、BNP水平与患者死亡呈正相关性。结论手术修复是大多数VSR患者最有效治疗方式, 对于血流动力学稳定且代偿期心衰的VSR患者延迟手术可能有更多获益。此外, VSR患者院内死亡的独立危险因素还包括白细胞计数、血乳酸水平及BNP水平。     

心肌梗死后室间隔穿孔的外科治疗

目的 总结心肌梗死（心梗）后室间隔穿孔的外科治疗方法.方法 自1990年至2004年,外科治疗22例心梗后室间隔穿孔病人,其中前室间隔穿孔19例,后室间隔穿孔3例;合并室壁瘤18例.结果 全组手术死亡8例,其中1999年前13例中死亡7例,1999年后9例中仅死亡1例.余者症状消失,治愈出院.出院时心功能均为Ⅰ～Ⅱ级.结论 心梗后室间隔穿孔是少见而严重的并发症,手术为最佳治疗方法.术前应行冠状动脉造影,如有狭窄,术中应充分进行冠状动脉再血管化.     

5例心肌梗死后室间隔穿孔的外科治疗

目的 总结心肌梗死后室间隔穿孔的手术治疗经验。方法 采用外科手术治疗心肌梗死后室间隔穿孔5例，其中急诊行冠状动脉旁路移植和室间隔穿孔修补术3例，择期行冠状动脉旁路移植和室间隔穿孔修补术2例。结果术后死亡1例，该患者发生心肌梗死室间隔穿孔10d后，因心力衰竭而接受冠状动脉旁路移植（移植2支血管）、室间隔穿孔修补和室壁瘤切除术，心脏复跳后心排血量低，安装主动脉内球囊反搏，最终因心律失常死亡。另有1例心脏复跳后开始行主动脉内球囊反搏支持，术后第3d撤除主动脉内球囊反搏。其余3例患者术后恢复顺利。出院前超声心动图检查提示：未见残余分流。门诊随访4例，随访时间6～15个月，病情较平稳。心功能Ⅰ级1例、Ⅱ级1例、Ⅲ级2例，无残余分流。结论 结合药物、器械辅助和外科手术治疗心肌梗死后室间隔穿孔可以获得基本满意的早期疗效。     

心肌梗死合并室间隔穿孔的外科治疗及预后分析北大核心CSCD

目的探讨心肌梗死合并室间隔穿孔患者的外科治疗方法及手术疗效。方法回顾性分析2009~2018年首都医科大学附属北京安贞医院心脏外科收治的心肌梗死合并室间隔穿孔60例患者的临床资料,其中男39例、女21例,平均年龄(63.3±8.3)岁。结果 43例(71.7%)穿孔位于心尖部,11例(18.3%)位于后间隔,6例(10.0%)位于前间隔。单支冠状动脉病变24例(40.0%)。术前置入主动脉内球囊反搏14例(23.3%),室间隔穿孔至外科手术时间为48.3(3~217)d。所有患者均行室间隔穿孔修补术,其中53例(88.3%)患者同期行室壁瘤缝闭或切除,49例(81.7%)患者同期行冠状动脉旁路移植术(平均远端吻合口数为2个)。术后在院并发症包括8例(13.3%)死亡、8例(13.3%)心力衰竭、5例(8.3%)心室颤动、3例(5.0%)心脏压塞、11例(18.3%)二次开胸以及11例(18.3%)残余分流。除8例在院死亡患者以外,其余52例治愈出院患者均接受随访,中位随访时间为4.9年,患者2年和5年生存率为95.8%,8年生存率为89.0%;主要心血管不良事件发生率为19.2%,包括3例(5.8%)死亡、5例(9.6%)心力衰竭、2例(3.8%)心肌梗死、4例(7.7%)脑血管事件。结论对于心肌梗死后并发室间隔穿孔的患者,外科手术是积极有效的治疗手段,围术期死亡率虽高,但恰当的手术时机和手术方法仍可达到满意的远期疗效。     

穿孔性阑尾炎早期手术治疗体会

目的探讨穿孔性阑尾炎的手术时机。方法对1997年6月，2004年6月间经治的30例穿孔性阑尾炎患者的临床资料进行回顾性分析。结果30例均早期手术治疗，29例治愈，1例好转。结论对于穿孔性阑尾炎，特别是穿孔时间较长形成阑尾周围脓肿的病例，应尽早手术治疗，可缩短病程，减少并发症的发生，减轻患者的痛苦及经济负担，且疗效满意，值得临床应用。     

Technical Improvements in the Repair of Acute Postinfarction Ventricular Septal Rupture

Postinfarction ventricular septal rupture (VSR) is a high-risk complication following myocardial infarction (MI). Surgical treatment has evolved to improve an otherwise poor prognosis. Certain subsets of patients remain a formidable challenge. The presence of cardiogenic shock has consistently been found to have the highest risk. Over a 10-year period, our technique of repair has evolved from established procedures to one we believe confers superior results. Endocardial patching to viable myocardium reinforced with an epicardial patch not only corrects the shunt but maintains ventricular geometry and avoids tension on friable muscle. We report on a series of nine consecutive patients in cardiogenic shock. The operative mortality was 22%, none due to low cardiac output syndrome, shunt recurrence, or bleeding. All patients have been followed with transesophageal echocardiography at a mean period of 14 months (range 3-31 months). One patient is in New York Heart Association (NYHA) Class I, four are in NYHA Class II, and two in NYHA Class III.     

Survival After Repair of Postinfarction Ventricular Septal Defects in Patients Over the Age of 70

Ventricular septal defect (VSD) is an infrequent but extremely serious complication of myocardial infarction. Operative mortality rates tend to be higher in the elderly population; however, long-term follow-up has not been specifically studied. It is, therefore, important to assess not only the early but also the long-term results of VSD repair in patients over 70 years of age to determine its value for the elderly patient. Between June 1968 and May 1991, 86 patients who experienced a myocardial infarction underwent surgical repair of an infarct related VSD at the Massachusetts General Hospital (MGH). Group I (n = 57) includes those patients younger than 70 years, and group II (n = 29) represents those patients age 70 years and older. Follow-up of hospital survivors ranged from 1 month to 24 years and was compiled in April and May, 1991. Three patients were lost to follow-up (4%), and these were younger than 70 years of age. There were no differences in the values of the preoperative variables for the younger and older groups with respect to sex, concomitant procedures performed (bypass vs no bypass), use of an intra-aortic balloon pump (IABP), location of VSD, presence of shock, total hospital days, or days between infarction and operation. There was, however, a difference between the two groups relative to the era when surgery was performed. More patients over the age of 70 underwent surgery after 1978 than before 1978 (p = 0.0012). The majority of survivors are in New York Heart Association (NYHA) Class I or II, and there was no difference between the younger and older groups in functional class at the time of follow-up (83.3% vs 91.7% of survivors in Class I or II, respectively). Using the generalized Wilcoxon test to analyze these survival data, there was no apparent difference in long-term survival (p = 0.97) when comparing the two age groups. The mean follow-up period was 77.02 months for the younger group and 80.52 months for the older group. The fact that more older patients were repaired after we had significant experience in the surgical management of patients with VSDs probably accounted for our excellent results in the older age group. Our data reveal that patients over the age of 70 can expect excellent long-term survival, with over 90% of these survivors remaining in NYHA Functional Class I or II.     

Early Surgical Repair of Acute Complete Rupture of the Proximal Hamstring Tendons

Hamstring injuries are common forms of muscle strains in athletes but a complete rupture of a proximal hamstring origin is rare. Often there is a considerable delay in diagnosis and stringent treatment because of its rarity, difficulty in clinical diagnosis, and initial attempts of conservative care. We report two cases of acute complete rupture of the proximal hamstring tendons treated with early surgical repair. The diagnosis and treatment of this unusual injury are discussed.     

Repair of Delayed Left Ventricular Rupture After Mitral Valve Replacement: Report of a Case

Rupture of the left ventricle (LV) after mitral valve replacement (MVR) is a devastating complication, associated with high mortality. A 64-year-old woman with a type I delayed LV rupture, which occurred after MVR with a 27-mm St. Jude Medical mitral prosthesis for mitral stenosis, was successfully treated by a combination of intracardiac and extracardiac surgical repair techniques. The extracardiac repair involved approximating the edges of myocardium around the tear with large sutures bolstered by strips of Teflon felt, then covering the epicardial hematoma with another porcine pericardial patch, using gelatin resorcinol formaldehyde glue and collagen sheets. The intracardiac repair involved suturing the edges of an oval piece of porcine pericardium to the endocardium around the laceration. No LV pseudoaneurysm was detected postoperatively on echocardiography or computed tomography scans. The patient is well 2 years after the operation.     

特殊室间隔缺损的外科经胸封堵治疗

目的探讨特殊室间隔缺损（ventricular septal defect,VSD）经胸封堵治疗的安全性和手术效果。方法 2010年2~11月,应用外科经胸封堵治疗6例特殊VSD,包括2例不接受锯胸骨和X线辐射的先天性VSD（A组）,3例内科介入封堵失败的先天性VSD（B组）,1例急性心肌梗死室间隔穿孔形成的后天性VSD（C组）。经胸骨下段小切口不锯胸骨（A组）或锯部分胸骨（B组）或正中大切口（C组）行外科经胸封堵术。于右心室表面选择适当的穿刺点,在食道超声实时引导下,用输送鞘将封堵伞送入封堵VSD。术后密切随访病情变化,定期复查超声心动图、心电图和胸部X线片。结果 6例全部封堵成功,无死亡。5例采用对称封堵伞,1例因VSD上缘距主动脉瓣较近采用非对称的偏心封堵伞。4例术后即刻和3个月及9个月复查超声心动图均无分流和其他异常;1例术后即刻复查有3 mm分流,1例术后即刻复查有5 mm分流、3个月复查仍有3 mm分流,仍在随访中。无新发的主动脉瓣和三尖瓣反流、完全性房室传导阻滞、左或右室流出道狭窄,无溶血或血栓形成,无封堵伞移位。结论外科经胸封堵VSD是一种简单有效而又安全的治疗方法,尤其对于一些特殊的VSD病例不失为一种良好的选择。     

Postinfarction Inferior Ventricular Septal Rupture: Surgical Repair Through the Right Atrium

Abstract   Operative mortality of inferior postinfarct ventricular septal rupture (VSR) remains high. Previous reports have described a transatrial approach to access the VSR avoiding a ventriculotomy, thereby reducing the potential risks of myocardial damage, hemorrhage, and ventricular arrhythmias. The transatrial right ventricular patch or direct suture repair, however, is exposed to the left-to-right pressure gradient and is at risk of residual shunting. In this report, a transatrial approach is used, with direct suture of the VSR, patch exclusion of the right ventricle, and biological glue instillation to protect the patch from left ventricular pressures.     

干下漏斗部室间隔缺损的外科治疗

４６例干下漏斗部室间隔缺损，占同期室缺手术治疗的２３．２％（４６／１９８）。缺损位于肺动脉瓣下３４例，漏斗部１２例。用带垫片褥式缝合修补２１例，补片修补２５例。全组无死亡。术后直接缝合组有主动脉关闭不全２例、残余分流２例，残留杂音３例。笔者认为，适时手术，选择适当的进路、应用补片修补、正确判断和处理主动脉瓣病变及对合并肺动脉狭窄者予以流出道补片加宽，是提高本病手术疗效的关键。