急性心肌梗死并发室间隔穿孔患者的临床特征分析

目的 探讨急性心肌梗死（AMI）并发室间隔穿孔（VSR）患者的临床特征及冠状动脉病变特点,为早期识别高危患者提供理论依据。方法 入选1995年1月至2010年1月解放军总医院心内科收治的AMI患者2544例,将并发VSR的患者作为VSR组（n＝40）;同时采用单纯随机抽取的方法,在同期住院的其余AMI患者中选出120例患者作为对照组（n＝120）。回顾性地分析两组患者的临床资料及冠状动脉造影特征。结果 VSR组患者中女性所占比例（62.5% vs 36.4%,P＜0.01）和年龄[（66.85±10.92） vs （60.79±12.65）岁,P＜0.01] 均显著高于对照组患者。 VSR组的C?反应蛋白（CRP）、D?二聚体、血肌酐（SCr）、肌钙蛋白T（TnT）均显著高于对照组,而血红蛋白（Hb）、红细胞压积（Hct）和红细胞计数（RBC）均显著低于对照组,差异均具有统计学意义（P＜0.05）。结论 女性,高龄,CRP、D?二聚体、SCr、TnT升高,Hb、Hct、RBC降低,可作为AMI并发VSR的高危因素。     

Identification of patients prone to infarct expansion by the degree of regional shape distortion on an early two-dimensional echocardiogram after myocardial infarction

Early detection of potential expanders (patients who develop clinically significant infarct expansion with acute left ventricular (LV) dilatation and failure but no necrosis) after acute myocardial infarction (AMI) is necessary in order to apply preventive therapy. To determine whether the degree of regional shape distortion (RSD), or dilatation, on early two-dimensional echocardiogram (2-D echo) after AMI can identify potential expanders, serial clinical and echocardiographic data were studied prospectively in 244 consecutive patients with a first Q-wave AMI. Initial (mean 2 days) and final (mean 10 days) two-dimensional echocardiograms were compared for regional LV asynergy, RSD, and conventional indices of expansion measured on endocardial diastolic outlines of mid-LV short-axis sections. Analysis of clinical and 2-D echo data revealed 51 expanders and 193 nonexpanders. Expanders showed greater LV dysfunction and more inhospital deaths (27% vs. 8%, p less than 0.001) compared with nonexpanders; conventional indices of expansion showed more marked increase between initial and final two-dimensional echo in expanders, but initial indices were not predictive. In contrast, the new RSD index Pk, a measure of the outward bulge, was markedly greater in expanders than nonexpanders on both initial (16.5 vs. 2.4 mm, p less than 0.001) and final echo. Furthermore, expanders with greater than or equal to 30% increase in Pk (to 21 mm) developed rupture of the ventricular septum (n = 10) or free wall (n = 2). Also, 50 of 51 expanders compared with 3 of 193 nonexpanders had a Pk greater than or equal to 10 mm on the initial echo. A simpler index, the depth of RSD (rd), provided similar discrimination as Pk. Thus, the degree of diastolic RSD on an early 2-D echo after AMI can identify potential expanders.     

Live three-dimensional transthoracic echocardiographic delineation of ventricular septal rupture following myocardial infarction

We present an elderly patient with ventricular septal rupture following myocardial infarction in whom live three-dimensional transthoracic echocardiography allowed comprehensive noninvasive assessment of the location, shape, and size of the septal defect, which could be clearly visualized en face from both left and right ventricular aspects.     

急性心肌梗死后室间隔穿孔的外科治疗长期随访结果

摘要 目的 评估心肌梗死后室间隔穿孔的外科治疗长期随访结果。方法 回顾性分析2011年6月至2019年6月北部战区总医院接受外科手术治疗的心梗后合并室间隔穿孔患者26例,其中男性17例（65.4%）,女性9例（34.6%）,平均年龄（62.1±9.4）岁。全部患者均接受全麻低温体外循环下施行室间隔穿孔心内修复,同期行冠状动脉旁路移植术23例,左心室成形8例,二尖瓣置换术2例,三尖瓣成形2例。观察围术期手术疗效及进行随访时间3～96个月,平均33.0±30.1个月。结果 全组患者无手术死亡,效果良好。体外循环时间69～184（129.4±40.0）min,升主动脉阻断时间41～100（66.0±18.3）min。术前出现肾功能不全行持续血液净化（CRRT）3例,持续至术后,均无需长期透析。术前体外膜肺氧合（extracorporeal membrane oxygenation,ECMO） 1例。随访期间术后2月、60个月因心衰分别死亡1例,术后24个月因胃癌晚期及27个月结肠癌晚期各死亡1例,存活22例患者心功能分级(NYHA)Ⅰ级17例,Ⅱ级4例;Ⅳ级1例,为ECMO及CRRT抢救患者,1年后仍存活,残余漏1.2cm;2例术后36月脑出血,患肢肌力均Ⅳ级。结论 室间隔穿孔外科治疗具有满意的长期疗效。     

急性心肌梗死并发室间隔穿孔的临床特点分析

目的分析急性心肌梗死并发室间隔穿孔的临床特点,判断患者预后。方法我院1994年6月～2006年7月共收治2027例急性心肌梗死患者,其中17例患者出现室间隔穿孔,并对其临床和超声心动图资料进行回顾性分析。结果我院急性心肌梗死并发室间隔穿孔的发病率为0.84%。17例室间隔穿孔患者中,9例合并高血压;12例前壁心肌梗死。11例冠状动脉造影检查均为2支以上血管病变;10例患者的梗死相关血管闭塞。超声心动图检查左心室平均直径(54.1±6.2)mm,左心室射血分数(40.4±10.8)%;10例室壁瘤形成,穿孔位置多在室间隔近心段的1/3处,穿孔直径(9.5±3.9)mm。内科保守治疗疗效较差,病死率82.35%。结论急性心肌梗死并发室间隔穿孔多发生在老年前壁心肌梗死患者,内科保守治疗病死率高。     

心肌梗死后室间隔穿孔患者的外科治疗体会

目的分析急性心肌梗死（acute myocardial infarction,AMI）后室间隔穿孔患者的外科手术治疗方法和疗效。方法回顾性分析自2006年1月至2009年12月10例AMI后室间隔穿孔患者的临床资料,其中5例患者同期行室壁瘤切除术,1例患者同期接受冠状动脉旁路移植术,着重分析外科手术治疗的疗效。结果手术死亡2例,手术死亡率20%（2/10）,均死于严重低心排血量综合征。超声心动图检查提示所有患者未发现有室间隔残余分流,7例有轻度二尖瓣反流。术后左心室舒张期末内径（LVEDD）与术前比较有减小,差异无统计学意义[（54.0±8.2）mm vs.（48.0±8.3）mm,t=1.6262,P=0.1213];左心室射血分数（LVEF）较术前有提高,差异无统计学意义（48%±12%vs.50%±6.2%,t=0.4682,P=0.6452）。结论外科手术是AMI后室间隔穿孔的有效治疗手段。手术时机的合理选择,围手术期的积极治疗能明显提高术后患者的生存率。     

Simultaneous assessment of segmental and global left ventricular function by two-dimensional echocardiography in acute myocardial infarction

Both segmental and global left ventricular performance were assessed simultaneously in 29 patients with acute myocardial infarction using two-dimensional echocardiography. Comparisons were made between left ventricular wall motion versus peak CK-MB, site of infarction, and occurrence of heart failure. Two-dimensional echocardiography identified areas of dyssynergy which corresponded to electrocardiographic areas of infarction in 89% of all cases. Patients with heart failure had more dyssynergic segments, and these segments manifested more severe dyssynergy than patients without heart failure. Patients with severe global dysfunction manifested higher peak CK-MB values, and those with anterior infarction had more global dyssynergy than did those patients with inferior infarction. These observations suggest that two-dimensional echocardiography is a useful technique for localization and assessment of segmental and global dyssynergy in acute myocardial infarction. Information so derived correlates with the clinical status of patients with acute myocardial infarction, and may offer important insights into both prognosis and treatment.     

急性心肌梗死合并室间隔穿孔临床分析

目的 探讨急性心肌梗死（acute myocardial infarction,AMI）后发生室间隔穿孔（ventricular septal rupture, VSR）患者的临床特点、治疗方法及其预后情况.方法 对2000年11月至2013年4月就诊于大连医科大学附属第一医院的23例确诊为AMI合并VSR患者的临床资料进行回顾性分析.结果 此期间共收治AMI患者5 300例,其中合并VSR 23例,发生率为0.43％.其中男性15例（65.2％）,年龄（71±10）岁.合并原发性高血压14例,前壁心肌梗死15例,左心室射血分数34.2％±20.1％.诊断VSR的平均时间为3.6 d.5例患者择期手术治疗.COX回归模型发现女性（P=0.009）、心率（P=0.002）是影响患者生存期的主要因素.结论 AMI合并VSR在临床中并不多见,内科保守治疗效果较差,内科保守治疗维持血流动力学稳定后行手术治疗可提高生存率.     

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.     

老年急性心肌梗死并发室间隔穿孔7例临床分析

目的分析急性心肌梗死（AMI）并发室间隔穿孔的临床病例特点,为该并发症的早期诊断和治疗提供依据。方法对7例室间隔穿孔患者的临床特征、治疗和预后进行回顾性分析。结果AMI并室间隔穿孔患者室间隔破裂穿孔常发生于前壁心肌梗死的患者,穿孔部位多位于室间隔近心尖部。高危因素包括高血压、年龄（60～69岁）、女性、缺乏侧支循环和广泛前壁透壁性心肌梗死和右室梗死（常可导致低血压）、无心绞痛病史。患者多存在房性快速型心律失常,新出现右束支传导阻滞提示预后严重不良。室间隔破裂的预后很差。内科保守治疗的院内死亡率高。结论注重体征及尽早行超声心动检查是早期诊断该并发症的关键,进行积极的内科治疗并力争外科手术的机会能降低死亡率。     

Left ventricular thrombus following acute myocardial infarction: A prospective serial echocardiographic study of 96 patients

In a prospective serial study of 96 patients with acute myocardialinfarction, two dimensional echocardiography identified leftventricular thrombus in 18 patients. The majority of thrombi(15) developed within the first 4 days after admission. In threepatients thrombi were identified for the first time 4 monthsafter the acute episode. All 18 patients had received therapeuticanticoagulants on admission and had large anterior wall infarctionscomplicated by serve pump failure and motion abnormalities echocardiographically.None of the patients had systemic embolisation during the studyperiod. Thus, left ventricular thrombus is a not uncommon thoughsilent complication of acute anterior wall infarction even whenpatients receive therapeutic anticoagulants.     

A rare long-term survival of the life-threatening trio: silent myocardial infarction complicated by ventricular septal rupture,type 2 diabetes mellitus and chronic bronchitis

Silent myocardial infarction followed by ventricular septal rupture (VSR) is a rare phenomenon. In the absence of a timely diagnosis and surgical correction, the short term mortality of such patients is greater than 90%. We present one such unique case of a patient with an asymptomatic myocardial infarction complicated by VSR, type 2 diabetes mellitus and chronic bronchitis. Unfortunately, this possibly life-threatening condition had been misdiagnosed for more than one month after initial medical contact. Lack of typical symptoms of chest pain and chronic bronchitis is primarily responsible for this long-time misdiagnosis. We want to emphasize the importance of systematic diagnostic work-up, high vigilance for possibility of VSR complicating myocardial infarction in aged patients with diabetes and chronic bronchitis, which may mislead doctors’ judgments and put patients at high risk.     

Spontaneous closure of ventricular septal defect complicated with acute myocardial infarction

A 79-year-old man was followed in our hospital for 4 years following primary percutaneous coronary intervention at another hospital to deploy two stents at the left anterior descending coronary artery for acute myocardial infarction (AMI). At the first visit in our hospital, echocardiography revealed a small ventricular septal defect (VSD, 0.8 to 1.0 cm) in the apicoseptal wall with an aneurysm that was probably the result of the AMI. There was no hemodynamic decompensation, and because the patient refused surgical correction we instead placed him under close follow-up observation in the outpatient clinic. A second follow-up echocardiography 6 months later still revealed a VSD. However, after 3 years the VSD murmur was no longer audible and follow-up echocardiography showed the defect to be nearly closed .     

The prognostic value of predischarge quantitative two-dimensional echocardiographic measurements and the effects of early lisinopril treatment on left ventricular structure and function after acute myocardial infarction in the GISSI-3 Trial

BACKGROUND: Left ventricular dilatation and a low ejection fraction afteracute myocardial infarction are independent indicators of apoor prognosis. ACE inhibitors have been shown to decrease leftventricular dilatation after myocardial infarction. In the GISSI-3trial, patients were randomlyassigned, within 24 h of onsetof myocardial infarction symptoms, to 6 weeks of treatment withlisinopril, nitroglycerin, both or neither, in an open, 2 x2 factorial design. The study showed that early treatment inrelatively unselected patients with lisinopril decreases mortalityat 6 weeks and severe left ventricular dysfunction. We assessed(1) the prognostic value of pre-discharge 2-D echocardiographicvariables, and (2) the effects of lisinopril on the progressionof left ventricular dilatation. METHODS AND RESULTS: 2-D echocardiograms were available pre-discharge in 8619 GISSI-3trial patients discharged alive. In 6405 of these patients,a 2-D echocardiographic study was also available at 6 weeks,and at 6 months. Pre-discharge end-diastolic and end-systolicvolumes, and ejection fraction predicted 6-month mortality andnon-fatal clinical congestive heart failure (P<0.01). Theincrease in left ventricular volumes over time was significantlyreduced by 6 weeks' lisinopril treatment in patients with wallmotion asynergy pre-discharge of 27%. Patients with wall motionasynergy <27% showed no dilatation and lisinopril did notaffect volumes at 6 months. Patients randomized to lisinoprilalso had smaller volumes after withdrawal of treatment at 6weeks. Lisinopril did not affect left ventricular ejection fraction. CONCLUSIONS: 2-D echocardiography independently contributes to pre-dischargerisk stratification in terms of 6-month mortality and clinicalheart failure after myocardial infarction, and early, short-termtreatment with lisinopril in unselected myocardial infarctionpatients attenuates left ventricular dilatation; an effect evidentin patients with larger infarcts. These results probably onlypartly explain the effect of lisinopril on total mortality concentratedin the first week after infarction.     

Hemodynamic complications of ventricular septal rupture after acute myocardial infarction.

Ventricular septal rupture (VSR) is a rare but serious complication following acute myocardial infarction (MI). Patients may present with a new murmur associated with a thrill. Right heart catheterization will demonstrate elevated right atrial and pulmonary artery pressures as well as an oxygen step-up at the right ventricular level. Patients with a right ventricular infarction or cardiogenic shock and a ventricular septal rupture have high in-hospital mortality rates. Prompt diagnosis followed by surgical repair is essential for patients with VSR following MI.     

Successful repair of combined septal and biventricular free wall rupture after acute myocardial infarction

The following case is the first report of successful repair of combined left and right ventricular free wall and ventricular septal rupture. Reports of left ventricular free wall and septal rupture and reports of right ventricular free wall and septal rupture have been published both with and without successful surgical repair. This case demonstrates the presence of left and right ventricular free wall rupture along with septal rupture based upon cardiac catheterization and operative findings. In spite of her severe mechanical complications and prolonged hospital course, the patient is completely functional 1 year after surgical repair.     

急性心肌梗死并发室间隔破裂的临床特征及冠状动脉造影特点分析

目的分析急性心肌梗死并发室间隔破裂的临床特征及冠状动脉造影特点,为该并发症的防治提供证据。方法对46例急性心肌梗死并发室间隔破裂患者的临床特征、冠状动脉造影特点、保守或外科手术疗效与生存率等数据资料进行回顾性分析,采用SPSS11．0软件统计。结果急性心肌梗死并发室间隔破裂的发病率约为1．88％;好发因素有：高龄（61～70岁）,未行再灌注治疗,无既往心绞痛／心肌梗死史,伴随高血压及高血脂等;易于发生室间隔破裂的最常见梗死部位为同时累及前壁和下壁的大面积梗死;大多数患者中性粒细胞比例、C反应蛋白及红细胞沉降率升高。胸片肺水肿者约30％,约半数患者入院时血流动力学不稳定（心功能Killip分级Ⅲ-Ⅳ级）。累及前壁梗死者其破裂部位多为前间隔远段,下壁＋后壁／右心室梗死者破裂部位多为后间隔基底段。冠状动脉造影提示室间隔破裂者多为前降支单支或三支病变,侧支循环少见。罪犯血管以前降支最为多见,其中又以前降支中段居多。保守治疗的住院死亡率高达65％,外科手术治疗的住院死亡率仅3．85％。结论尽早、成功的再灌注治疗是预防其发生的关键,心脏超声是敏感且简便易行的确诊手段,外科手术治疗明显提高生存率,早期外科手术（梗死后1个月左右）可行。     

Differences between echocardiographic measurements of left ventricular dimensions and function by local investigators and a core laboratory in a 2-year follow-up study of patients with an acute myocardial infarction.

AIMS: To examine differences in measurements of left ventricular dimensions and function, and prognostic value between local investigators and a core laboratory in a multicentre serial echocardiographic study. METHODS AND RESULTS: Seven hundred and fifty-six patients with acute myocardial infarction and preserved left ventricular function were examined at baseline and after 3 months with measurements by the biplane Simpson's method, and followed prospectively from 3 to 24 months. At baseline and 3 months local investigators relative to the core laboratory measured lesser end-diastolic volume by 8 and 6 ml (P<0.001), end-systolic volume by 3 and 2 ml (P<0.01), and ejection fraction by 0.0 and 0.6% (P<0.01), respectively. Local investigators and the core laboratory measured an increase in left ventricular end-diastolic volume of 8.6 and 6.9 ml, and in left ventricular end-systolic volume of 5.2 and 4.3 ml, and a decrease in left ventricular ejection fraction of 0.6 and 0.0%. Using the Cox proportionate hazards model, the prognostic value for subsequent clinical endpoints was significant both for the 3-month values (P<0.05) and changes (P<0.005) measured by the core laboratory, but not by local investigators. CONCLUSION: Only measurements in the core laboratory had significant prognostic value for subsequent clinical endpoints. These results strongly support the use of a core laboratory in studies employing echocardiographic measurements.     

Primary transcatheter closure of post-myocardial infarction ventricular septal rupture using amplatzer atrial septal occlusion device: A study from tertiary care in South India

ObjectiveThe study investigated effectiveness of transcatheter closure of post-myocardial infarction (MI) ventricular septal rupture (VSR) using atrial septal device (ASD) occluder in a cohort of patients admitted at our institute.MethodThis was a retrospective, observational and single center study, which included patients who were treated with transcatheter closure for post-MI VSR at our tertiary care center between May 2000 and August 2014 depending upon inclusion and exclusion criteria. Primary outcome was all-cause mortality at 30-days follow-up. The MELD-XI (Model for End Stage Liver Disease) score was used as a predictor for poor outcome in these patients.ResultsA total of 21 patients (mean age 66.4 ± 5.9 years) were included in the study. Study cohort predominantly included male patients (n = 15; 71.4%) and patients with single vessel disease (n = 15; 71.4%). Revascularization of the culprit lesion, before VSR closure, was attempted in 6 patients. Except one patient (treated with Cera^® occluder), all patients were treated with Amplatzer^® ASD occluders. Average diameter of VSR was 20.8 ± 6.9 mm. Diameter of the device used in the study ranged from 10 mm to 30 mm. Residual defect was detected in 13 patients (62%). All-cause mortality at 30-day follow-up was observed in 9 (42.9%) patients. Time to VSR closure, diameter of VSR, and serum creatinine levels were significantly related to the 30-day mortality. MELD-XI score was found to be strongly associated with increased risk of mortality.ConclusionPrimary transcatheter VSR closure using ASD occluders is a feasible approach which can provide reasonable survival outcomes along with equitable mortality rates.     

Bidirectional flow in congenital ventricular septal defect: a Doppler echocardiographic study

The purpose of this study was to demonstrate the value of combined two-dimensional and pulsed Doppler echocardiography (echo) in localizing and recording bidirectional flow in congenital ventricular septal defect. Eight children, aged 8 months to 16 years, with clinical signs of a ventricular septal defect, underwent two-dimensional and pulsed Doppler echo study prior to cardiac catheterization. The ventricular septal defect was documented anatomically by two-dimensional echo in all eight patients. Flow patterns in systole and diastole through the ventricular septal defect and on both sides of the defect were carefully studied. In all eight children, systolic, high velocity, pathologic, left to right flow was documented when the sampling volume was positioned on the right ventricular side of the defect. When the sampling volume was positioned inside the defect, to and fro flow, left to right in systole and right to left in diastole, was observed. In children with moderate to large defects, the diastolic flow had a peak in early diastole. Increased pressure in the right ventricle over the left ventricle during the same period was demonstrated by cardiac catheterization and coincided with the Doppler flow. The direction of flow across the defect was affected by the size of the defect and the magnitude of the net shunt. Two-dimensional and pulsed echo Doppler were shown to be useful in demonstrating the ventricular septal defect and estimating its size and hemodynamic significance noninvasively.