Significance of a mitral regurgitation systolic murmur complicating a first acute myocardial infarction in the coronary care unit -- assessment by colour Doppler flow imaging

To determine the prevalence and significance of a systolic mitralmurmur heard after a first acute myocardial infarction (MI),we studied 186 consecutive patients in the coronary care unit(CCU) during a one-year period. Fifteen patients had a murmuras a result of mitral regurgitation (MR) (prevalence 8%) documentedby colour Doppler flow imaging. It was heard before the thirdday of hospitalization in 10 (67%) patients, and on the thirdday itself in the remainder. The severity of MR was graded semi-quantitatively:moderate in 12 (80%) patients, and mild, moderate to severeand severe in three respectivety. The direction of the MR jet,determined by colour flow imaging, improved the informationobtained by two-dimensional echocardiography (2D echo) thatcould only diagnose mitral leaflet abnormality in seven (47%)patients. in 10 of 15 (67%) patients, the 2D echo ejection fractionwas 40% and in eight (53%) the wall motion score obtained byanalysing 11 left ventricular (LV) segments was 8. Two (13%)patients died in tile CCU, four (27%) had LV failure, one anginaand eight (53%) remained asymptomaric in the hospital. Of 171patients without a systolic murmur, 22 (13%) had LV failure,13 (8%) angina and 25 (15%) died during the in-hospital stay(P-NS for these complications between patients with and withoutMR murmur). During a follow-up of 12–24 months, one MRpatient died, and seven (47%) remained asymptomatic. We conclude that the prevalence of MR systolic murmurs in acuteMI patients is low. The LV function and the prognosis of a majorityof these patients is rather good.     

Significance of a mitral regurgitation systolic murmur complicating a first acute myocardial infarction in the coronary care unit--assessment by colour Doppler flow imaging.

To determine the prevalence and significance of a systolic mitral murmur heard after a first acute myocardial infarction (MI), we studied 186 consecutive patients in the coronary care unit (CCU) during a one-year period. Fifteen patients had a murmur as a result of mitral regurgitation (MR) (prevalence 8%) documented by colour Doppler flow imaging. It was heard before the third day of hospitalization in 10 (67%) patients, and on the third day itself in the remainder. The severity of MR was graded semi-quantitatively: moderate in 12 (80%) patients, and mild, moderate to severe and severe in three respectively. The direction of the MR jet, determined by colour flow imaging, improved the information obtained by two-dimensional echocardiography (2D echo) that could only diagnose mitral leaflet abnormality in seven (47%) patients. In 10 of 15 (67%) patients, the 2D echo ejection fraction was greater than or equal to 40% and in eight (53%) the wall motion score obtained by analysing 11 left ventricular (LV) segments was less than or equal to 8. Two (13%) patients died in the CCU, four (27%) had LV failure, one angina and eight (53%) remained asymptomatic in the hospital. Of 171 patients without a systolic murmur, 22 (13%) had LV failure, 13 (8%) angina and 25 (15%) died during the in-hospital stay (P-NS for these complications between patients with and without MR murmur). During a follow-up of 12-24 months, one MR patient died, and seven (47%) remained asymptomatic. We conclude that the prevalence of MR systolic murmurs in acute MI patients is low.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous coronary intervention for acute myocardial infarction with mitral regurgitation

Ischemic mitral regurgitation (IMR) is a common complication of acute myocardial infarction (AMI). Current evidences suggest that revascularization of the culprit vessels with percutaneous coronary artery intervention (PCI) or coronary artery bypass grafting can be beneficial for relieving IMR. A 2.5-year follow-up data of a 61-year-old male patient with ST-segment elevation AMI complicated with IMR showed that mitral regurgitation area increased five days after PCI, and decreased to lower steady level three months after PCI. This finding suggest that three months after PCI might be a suitable time point for evaluating the possibility of IMR recovery and the necessity of surgical intervention of the mitral valve for AMI patient.     

Ventricular septal defect and mitral regurgitation complicating acute myocardial infarction

We report a case of rare incidence of both ventricular septal rupture and mitral regurgitation that followed an acute myocardial infarction in a 77-year-old woman. The literature contains few reports of such cases. The following reports both events and the progression of the clinical events.     

急性心肌梗塞后二尖瓣返流的临床意义

用彩色多普勒超声对91例急性首次心梗3天内患者的二尖瓣返流进行了测定,并对患者进行了平均22.1月的随访.发现伴二尖瓣返流患者占34%,这些患者女性多,年龄大,梗塞面积大,非Q波梗塞多,Ptfv_1小和房性心律失常多,而且使用强心剂及利尿剂患者多,住院期心功能差,心脏事件多和观察期死亡率高,但二尖瓣返流不是预测死亡的独立因素.表明心梗急性期彩色多普勒测定的二尖瓣返流可能只是反映数种危险因素的一个综合性的信息,而非独立于其它因素之外的预后指标.     

二尖瓣反流对急性心肌梗死预后的意义

目的　探讨二尖瓣反流 (MR)对急性心肌梗死 (AMI)患者预后的意义。方法　对 142例 AMI患者住院早期(7天内 )进行超声心动图检查 ,以彩色多普勒定量测定其 MR。并对 MR组及无 MR组的临床资料、超声心动图指标及预后进行对比分析。结果　 142例 AMI患者无 MR90例 (6 3.38%) ,轻度 MR43例 (30 .2 8%) ,中、重度 MR9例 (6 .34 %)。 MR组较无 MR组患者年龄更大、既往心肌梗死患病率及高血压患病率更高 (P均 <0 .0 5 )。 MR组脉冲多普勒 E峰、E/A显著高于无 MR组 (P均 <0 .0 5 )。 MR组 30天及 1年死亡率均显著高于无 MR组 (P<0 .0 5和 P<0 .0 1)。结论　超声心动图证实的 MR对 AMI患者的预后具有预测价值。     

急性心肌梗死合并二尖瓣反流的外科治疗

目的:初步探讨急性心肌梗死(AMI)合并二尖瓣反流(MR)的外科治疗方法。方法:2008年8月至2011年8月,收治AMI合并MR患者34例。男性25例,女性9例;年龄42～75岁,平均(61.5±10.4)岁。EuroScore评分4～12分,平均5.8分。所有患者均经冠状动脉造影证实,为冠状动脉多支病变无法行介入治疗。心功能平均3.1级(NYHA),心源性休克2例,术前主动脉球囊反搏(IABP)3例。体表超声Doppler检查,根据反流面积及缩流径宽度,将MR分为1+～4+级,其中1+～2+级12例,3+级16例,4+级6例;根据反流部位及室壁运动情况结合冠状动脉造影进行Carpentier二尖瓣反流功能分型:Ⅰ型8例,Ⅱ型4例,Ⅲb型22例;根据左心室舒张末期径线及射血分数(LVEF),判断心肌梗死对心脏结构造成的损伤程度,34例左心室舒张末径37～70 mm,平均(51±7.8)mm,其中>65 mm 6例。综合MR分型、分级及左心室径线决定是否同期行二尖瓣手术。本组采用以下标准:(1)CarpentierⅠ型患者,如MR达到4+级;(2)Carpentier II型,MR为3+～4+级患者;(3)CarpentierⅢb型、MR为4+级同时左心室舒张末径>65 mm患者,同期矫正二尖瓣反流。余均采用单纯冠状动脉搭桥手术。本组单纯冠状动脉搭桥手术28例,冠状动脉搭桥合并二尖瓣成型或替换6例。随访时间1～36个月,平均(20.5±8)个月。结果:全组死亡2例(5.9%),其中围手术期死亡1例,术后1年死亡1例。搭桥根数平均为2.3根/例。完全再血管化27例(79.1%),不完全血管化7例(21.9%)。心功能分级平均1.06级(NYHA)。二尖瓣反流随访结果:28例单纯冠状动脉搭桥组,12例MR完全消失或微量,13例MR为3+级患者手术后减少为微量到少量,MR矫正成功率为89.3%;3例MR无改善或恶化,均为不完全血管化患者。冠状动脉搭桥合并二尖瓣成型或替换组,围手术期死亡1例,1例术后为MR 2+级,4例MR消失。结论:通过综合分析MR分型、分级及左心室舒张末期径线,决定对于急性心肌梗死合并二尖瓣反流的患者是否同期矫正二尖瓣反流,可获得满意的临床疗效。完全再血管化是手术的关键。体外循环辅助下不停跳搭桥,是心肌损伤最小化的前提下,保证完全再血管化的重要手段。     

Prognostic influence of mitral regurgitation prior to a first myocardial infarction.

AIMS: Mitral regurgitation (MR) following an acute myocardial infarction (AMI) confers an adverse prognosis during long-term follow-up. There are no studies evaluating the influence of pre-AMI MR in the short- and long-term prognosis of such patients. Our aim was to assess the prognostic value of pre-AMI MR in the short- and long-term follow-up of patients who suffered a first AMI and to assess its influence on left ventricular haemodynamics. METHODS AND RESULTS: Sixty-eight consecutive patients with a first AMI and an echocardiographic study before AMI (<3 months) were included in the study. The pre-AMI echo was performed for various reasons. Of these 68 patients, 42 had pre-AMI MR (Group 1) and 26 showed no pre-AMI MR (Group 2). The presence of degenerative changes at the level of the mitral valve was confirmed in all cases. Patients with any other cause of MR were excluded. Clinical and echocardiographic variables for both phases (pre-AMI and post-AMI) were analysed and patients were followed up. Mean age was 75.5+/-9.5 years; there were 38 males (55.9%). There were no statistical differences in baseline clinical variables between the groups, except for the presence of pre-AMI atrial fibrillation, which was more frequent in Group 1 (21.4 vs. 0%; P = 0.01). After AMI, only end-diastolic left ventricular diameter was significantly larger in Group 1 (54.9 +/- 4.7 vs. 48.1 +/- 5.6 mm; P < 0.001). During long-term follow-up, median survival times were 912 days (interquartile range: 690 days) in Group 1 and 1423 days (interquartile range: 520 days) in Group 2 (Log-rank P = 0.02). The multivariable analysis showed that the presence of pre-AMI MR relates to a statistically significant relationship with a worse post-AMI evolution [relative risk (95% confidence interval): 3.8 (1.1-13.1); P = 0.037]. CONCLUSION: The present study shows that the presence of pre-AMI MR is an independent prognostic marker among those patients suffering a first AMI.     

Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome

Aims The development of mitral regurgitation (MR) after an acutemyocardial infarction (AMI) is a recognized and frequent complicationand its negative impact on survival has been observed. However,few data exist regarding MR after non-ST-segment elevation acutecoronary syndrome (NSTSEACS). Our aim was to investigate theincidence, clinical predictors, and prognostic implicationsof MR in the setting of NSTSEACS. Methods and results We studied 300 consecutive patients (71.7%men, mean age 66.9±13 years) admitted to our coronarycare unit for an NSTSEACS. Every patient underwent an echocardiographicstudy during the first week after the index NSTSEACS and wasclinically followed up. MR was detected in 42% (126 patients;88 men, mean age 71.3±11 years). Mean follow-up was 425.6±194.8days. Only age and left ventricular (LV) ejection fraction (EF)were found as independent markers of the development of MR;no variable was found as an independent predictor of in-hospitalmortality and only MR was found as an independent predictorof long-term outcome. Conclusion MR is frequent after an NSTSEACS. Age and a low LVEF are factors associated to its development. The presence anddegree of MR confer a worse long-term prognosis to patientsafter a first NSTSEACS. Thus, the presence of MR should be specificallyassessed in every patient after an NSTSEACS.     

急性心肌梗死患者二尖瓣返流与心血管事件发生率的相关性

目的研究急性心肌梗死(AMI)患者合并二尖瓣返流(MR)与心力衰竭等严重并发症和死亡率的相关性。方法选取109例AMI患者,住院期间行超声心动检查观察二尖瓣返流情况,测定左心室射血分数(LVEF)、左室舒张末期内径、左房内径,并观察心力衰竭和主要心脏不良事件发生率、住院心源性病死率。结果MR的发生率为46.8%,左室舒张末期内径、左房内径均显著高于非MR组(P<0.01),LVEF显著低于非MR组(P<0.01)。心功能不全(Killip分级Ⅱ～Ⅲ级)、主要心脏不良事件发生率MR组显著高于非MR组(P<0.01)。全部心源性病死率MR组高于非MR组(P<0.05)。结论AMI后合并MR者,心功能差,心力衰竭和主要心脏不良事件发生率高,住院心源性病死率高。     

Severe mitral regurgitation complicating acute myocardial infarction: Clinical and angiographic differences between patients with and without papillary muscle rupture

AIMS: To assess the differential clinical and angiographic characteristicsof patients with severe mitral regurgitation related (n=31)or unrelated (n=16) to papillary muscle rupture complicatingacute myocardial infarction. MEHTODS AND RESULTS: The clinical and angiographic features of patients with myocardialinfarction and severe mitral regurgitation were evaluated. Patientswith papillary muscle rupture were older (67 vs 60 years, P>0·005)and had a lower rate of diabetes (7% vs 38%, P>0·005)and of previous angina or infarction (24% vs 50%, P>0·05).Frequency of inferior infarction was high and comparable inboth groups (papillary muscle rupture, 72% vs non-papillarymuscle rupture, 88%, ns) whereas in-hospital rate of angina/infarctextension prior to mitral regurgitation, also high, tended tobe higher in patients without than in those with papillary musclerupture (67% vs 39%, ns). Incidence of multivessel disease tendedto be higher in patients without papillary muscle rupture (87%vs 56%, P>0·06) and they had a lower ejection fraction(46 ± 15 vs 61 ± 14%, P>0·03), whereasthe culprit artery was mainly the right or the circumflex coronaryartery in both groups (papillary muscle rupture, 100% vs nonpapillary muscle rupture, 93%, ns). Valve replacement was performedearlier in patients with papillary muscle rupture (1(1; 14)vs 25 (5; 45) days, median, P>0·002) but was associatedwith a similar mortality (papillary muscle rupture 11/24, 46%vs non-papillary muscle rupture, 7/15, 47%, ns). The main causeof death was cardiogenic shock in patients without papillarymuscle rupture (5/7, 71%), and respiratory insufficiency-sepsisin those with papillary muscle rupture (7/11, 64%). CONCLUSIONS: Severe mitral regurgitation in myocardial infarction with orwithout papillary muscle rupture is mostly related to inferiorinfarction and often follows reinfarction, particularly in non-papillarymuscle rupture cases. The main contributors to surgical mortalityappear to be respiratory insufficiency in patients with papillarymuscle rupture and cardiogenic shock, facilitated by a lowerejection fraction, a higher frequency of diabetes and more extensivecoronary disease, in patients without papillary muscle rupture.     

急性心肌梗死早期伴发二尖瓣关闭不全对患者预后影响

目的:探讨急性心肌梗死(AMI)患者伴发二尖瓣关闭不全(MR)的临床意义及预后。方法:将2年来我院收治的AMI患者145例分为MR组与no-MR组;根据梗死部位分为前壁AMI组与下壁AMI组,前、下壁各组又根据是否伴发MR分为:前壁MR组与前壁no-MR,下壁MR组与下壁no-MR组4个亚组。观察各组的临床情况与心血管事件。结果:MR组63例,占43.4%,与no-MR组相比,其年龄、左心室射血分数、终点心血管事件及随访期间心血管事件均差异具有统计学意义(P<0.05)。亚组间相比,前壁AMI-MR组与下壁AMI-MR组与相应的no-MR组比较终点心血管事件差异具有统计学意义,且该2组间随访期间临床心血管事件差异具有统计学意义(P<0.05);下壁AMI-MR组与no-MR组2组间的终点心血管事件差异具有统计学意义(P<0.05)。结论:AMI患者伴发MR提示预后不良,AMI患者伴有MR与梗死部位有关,且其部位与预后密切相关。     

Surgical treatment of ventricular septal rupture and mitral regurgitation complicating acute myocardial infarction: Report of a case and review of the literature

Coexisting ventricular septal rupture (VSR) and severe mitral regurgitation following myocardial infarction is rare; only ten cases have been documented in the English literature. Present refinements in myocardial preservation and surgical techniques have markedly improved the results of surgery in this group of desperately ill patients. Early repair of both lesions is advocated and exemplified by a case report.     

The prognostic role of mitral regurgitation after primary percutaneous coronary intervention for acute ST-Elevation myocardial infarction

Objectives : The aim of this study was to elucidate the prognostic significance of mitral regurgitation (MR) after primary percutaneous coronary intervention (PCI) for acute ST‐elevation myocardial infarction (STEMI). Background : MR has prognostic implications after myocardial infarction (MI). However, for STEMI patients receiving primary PCI, the influence of MR on long‐term (3–5 years) outcome is unknown. Methods : We examined 888 STEMI patients receiving primary PCI enrolled in a prospective database at a regional STEMI center, who had an echocardiogram within 72 hr following successful primary PCI. MR was graded by color Doppler as none/trace vs. mild vs. moderate/severe. Mean ± SD follow‐up was 3.1 ± 1.4 years. Results : For patients with none/trace (n = 469), mild (n = 325), and moderate/severe (n = 94) MR, mortality at 3 years was 8.1%, 13.6%, and 25.7% and at 5 years was 12.7%, 18.3%, and 33.5%, respectively (P < 0.0001, log‐rank test). Patients with moderate/severe MR tended to be older (P < 0.0001) with lower ejection fraction (P < 0.0001) and were less likely to have had an anterior MI (P < 0.001). Independent predictors of mortality included age, creatinine, and heart rate. Conclusions : Following primary PCI for STEMI, echocardiographic detected MR in the first 72 hr following PCI stratifies mortality risk. However, when accounting for age, MR is not an independent predictor of mortality. © 2011 Wiley Periodicals, Inc.     

急性心肌梗死后二尖瓣返流与心房纤颤的关系

目的:探讨急性心肌梗死（AMI）后缺血性二尖瓣返流与初发心房纤颤（atrial fibrillation,AF）的关系。方法: 回顾性分析269例AMI患者的临床资料,排除既往有AF和原发瓣膜病的病例,根据二尖瓣返流程度分为2组:无返流组（n=165）和返流组(n=104)。AF通过住院期间心电图或心电监护诊断。结果: 无返流组和返流组新发AF分别为15例(9.1%)和22例(21.2%)(P<0.01)。结论: AMI后二尖瓣返流与AF发生有密切的关系。     

初发急性心肌梗死患者二尖瓣返流的发生率及预后——单中心6年回顾性研究

目的:探讨初发急性心肌梗死(AMI)患者缺血性二尖瓣返流的发生率及其对患者住院期间死亡及出院患者远期预后的影响. 方法:回顾性入选2000年1月至2006年1月间入院治疗的初发AMI患者,根据住院期间心脏超声检查结果,将患者分为二尖瓣无返流组、轻度、轻-中度、中-重度返流组,随访患者的远期预后.结果:在448例AMI患者中,急性期院内死亡者24例.住院期间心超结果发现二尖瓣返流发生率为67.2%,其中轻度返流为51.1%、轻-中度为9.4%、中一重度为6.7%.门诊或电话随访到患者268例(59.8%),平均随访(33.8±19.6)月,共发生死亡37例(13.8%),其中心源性死亡19例(7.1%),非心源性死亡18例(6.8%).经多因素回归分析,死亡与二尖瓣返流的严重程度呈正相关(RR=1.504,95%CI:1.002～2.256,P=0.049),心源性死亡与缺血性二尖瓣返流显著正相关(RR=3.088,95%CI:1.767～5.395,P<0.001),均独立于入院时心功能分级(NYHA)、左室射血分数及有无靶血管重建. 结论:缺血性二尖瓣返流在初发AMI患者中有较高的发生率,其对预测AMI患者的远期死亡有意义,建议纳入AMI预后的危险分层,指导今后的临床治疗.     

急性心肌梗死后二尖瓣反流与左心室大小和功能的相关分析

目的探讨急性心肌梗死（AMI）二尖瓣反流（MR）患者左心室功能与远期预后的关系。方法入选143例AMI患者,平均入院5d内行超声心动图检查,检测MR情况、左室舒张期末内径（LVEDD）、左室收缩期末内径（LVESD）、左房内径（LAD）、左室射血分数（LVEF）、E／A比值。根据LVEF大小将患者分为2组（≥50％组和〈50％组）;随访的中位数时间为432d,观察两组心力衰竭、再发心肌梗死、再发心绞痛、心因性死亡等心血管事件的发生率与LVEF的相关性。结果AMI患者MR发病率73．4％。MR的发生及程度与Killip分级、LVEF值、LVEDD、LVESD、LAD、E／A比值等相关。左心室大小和功能与AMI后心血管事件显著相关。生存分析显示,AMI后MR患者LVEF〈50％是远期死亡的独立危险因素（P〈0．01）。结论AMI后基线水平MR的严重程度与左室功能和大小显著相关,左室功能恶化是远期死亡的显著预测因子。     

Intracoronary streptokinase therapy in the coronary care unit for acute myocardial infarction

Intracoronary streptokinase was offered and preliminary coronary angiography performed in 14 patients who were seen with the clinical diagnosis of acute myocardial infarction within 4 h of onset of symptoms. The procedure was performed in the Coronary Care Unit (CCU) of St. Peter's Medical Center with the use of a portable C-arm fluoroscope. Angiography was recorded on video tape. Service was provided by an "on-call" team consisting of two physicians, a CCU nurse, and a radiology technician, on a 24-h service basis. Adequate visualization of coronary anatomy was obtained in all patients. Patency of occluded vessels was achieved in 10 of 11 patients who received intracoronary streptokinase. The initial streptokinase bolus was administered at a mean interval of 4.1 h from onset of symptoms. It is concluded that speedy and effective coronary thrombolytic therapy can be provided in the CCU on a 24-h service basis by an on-call team. The use of CCU for this purpose will make this therapy widely available across the country, without the need for Cardiac Catheterization Laboratory.     

多普勒组织成像技术在心肌梗死心功能评价中的应用

目的:研究多普勒组织成像(DTI)技术评价心肌梗死的临床应用价值。方法:回顾性分析应用DTI及彩色多普勒超声心动图(UCG)检查30例急性心肌梗死(AMI)患者的资料。结果:①AMI后2周,3个月,6个月时左室舒张功能显著减退(P<0.01),而左室收缩功能在2周时显著降低(P<0.01),随时间的推移略有改善;②AMI患者DTI速度图显像能更直观反应梗死相关局部的心肌室壁病变;③AMI患者2周时DTI频谱图特征:收缩波,舒张早期波E波和E／A(舒张晚期波)振幅比值降低(P均<0.01)。结论:DTI技术为观察AMI后心肌的室壁运动,心脏的收缩和舒张功能提供了一个直观,而且重复性好的有效方法。     

初发急性心肌梗死患者二尖瓣返流的发生率及预后——单中心6年回顾性研究

目的：探讨初发急性心肌梗死（AMI）患者缺血性二尖瓣返流的发生率及其对患者住院期间死亡及出院患者远期预后的影响。方法：回顾性入选2000年1月至2006年1月间入院治疗的初发AMI患者,根据住院期间心脏超声检查结果,将患者分为二尖瓣无返流组、轻度、轻-中度、中-重度返流组,随访患者的远期预后。结果：在448例AMI患者中,急性期院内死亡者24例。住院期间心超结果发现二尖瓣返流发生率为67．2％,其中轻度返流为51．1％、轻-中度为9．4％、中-重度为6．7％。门诊或电话随访到患者268例（59．8％）,平均随访（33．8±19．6）月,共发生死亡37例（13．8％）,其中心源性死亡19例（7．1％）,非心源性死亡18例（6．8％）。经多因素回归分析,死亡与二尖瓣返流的严重程度呈正相关（RR=1．504,95％CI：1．0022．256,P=0．049）,心源性死亡与缺血性二尖瓣返流显著正相关（RR=3．088,95％CI：1．767～5．395,P〈0．001）,均独立于入院时心功能分级（NYHA）、左室射血分数及有无靶血管重建。结论：缺血性二尖瓣返流在初发AMI患者中有较高的发生率,其对预测AMI患者的远期死亡有意义,建议纳入AMI预后的危险分层,指导今后的临床治疗。