心肌梗死后缺血性二尖瓣返流

缺血性二尖瓣返流是急性心梗后的常见并发症,也是一种包括局部和整体左室重构等多因素、多过程参与的疾病,发病率在11%～59%.虽然很多研究在设计、入选标准、随访时间和评估二尖瓣返流的技术各不相同,但是结果都表明心梗后缺血性二尖瓣返流是一种不良预后因素,可导致心衰及死亡发生率增加,并且独立于已知的心梗后危险因素.     

心肌梗死后缺血性二尖瓣返流

缺血性二尖瓣返流是急性心梗后的常见并发症,也是一种包括局部和整体左室重构等多因素、多过程参与的疾病,发病率在11%～59%。虽然很多研究在设计、入选标准、随访时间和评估二尖瓣返流的技术各不相同,但是结果都表明心梗后缺血性二尖瓣返流是一种不良预后因素,可导致心衰及死亡发生率增加,并且独立于已知的心梗后危险因素。     

急性心肌梗死并缺血性二尖瓣返流的临床特征分析

目的：探讨初发急性心肌梗死并缺血性二尖瓣返流（IMR）的临床特征。方法：对初发AMI363例患者的临床资料进行回顾性分析,根据心脏超声检查和二尖瓣返流情况分为2组,二尖瓣返流组119例,无二尖瓣返流组244例,比较2组临床特征、左房直径、左室舒张末期直径、左室收缩末期直径、左室射血分数和心血管事件发生率。结果：单因素分析结果显示年龄、性别、吸烟、Killip分级、下壁心肌梗死、β受体阻滞剂和ACEI/ARB应用、直接冠状动脉介入治疗、主动脉内球囊反搏应用、左房直径、左室舒张末期直径、左室收缩末期直径、左室射血分数、房颤发生率及住院病死率2组资料比较差异有统计学意义。多因素分析显示二尖瓣返流与年龄（P〈0.01）、左室舒张末期直径、左室收缩末期直径（P〈0.05）及早使用β受体阻滞剂和ACEI/ARB、直接冠状动脉介入治疗密切相关（P〈0.01）。结论：AMI并IMR多见于老年患者,与左室直径大小密切相关,及早应用β受体阻滞剂和ACEI/ARB,直接冠脉介入治疗可能会减少二尖瓣返流的发生。     

心肌梗死后室壁瘤形成280例临床分析

目的分析心肌梗死（MI）后室壁瘤形成的危险因素及临床特点。方法连续收集我院2003年3月至2007年9月心肌梗死后室壁瘤形成280例[平均年龄（64．2±10．4）岁]住院患者的临床资料,对其进行回顾性分析。结果广泛前壁、前侧壁心肌梗死249例（88．9％）,室壁瘤形成位于心尖部269例（96．1％）,二尖瓣反流124例（44．3％）,207例（73．9％）左室收缩功能减退,左室射血分数（EF）≤40％。心肌梗死后有不同程度心绞痛、心力衰竭178例（63．6％）,合并恶性室性心律失常24例（8．6％）,左室附壁血栓54例（19．3％）。冠状动脉造影检查147例（48．2％,147／280）,其中累及前降支117例（79．6％,117／147）。住院期间死亡11例（3。9％）,死亡原囚主要为心力衰竭和恶性室性心律失常。结论前壁心肌梗死是室壁瘤形成的危险因素。心肌梗死后室壁瘤形成预后不良,罪犯血管为前降支。     

心肌梗死后室壁瘤并附壁血栓抗栓治疗随访

目的通过对心肌梗死后室壁瘤内附壁血栓形成的患者进行随访,评价抗血小板药物及抗凝药物对室壁瘤附壁血栓患者预后的影响。方法回顾性分析2002年3月-2009年2月,确诊为心肌梗死后室壁瘤内附壁血栓形成的66例内科治疗患者,其中单服阿斯匹林25例,阿斯匹林＋波立维（1年）27例,长期单纯华法林口服4例,阿斯匹林＋华法林6例,阿斯匹林＋华法林＋波立维（1年）3例。服用华法林者INR维持在1．8—3．0。出院后均继续规律服药,进行电话和门诊随访,并行Kaplan-Meier生存分析。结果66例中8例死亡：其中脑血栓、室间隔穿孔、脑出血及咯血各1例;猝死2例;心衰2例;存活58例中脑栓塞者2例;1例下肢血管栓塞及肺柃塞;1例下肢动脉栓塞,服用阿司匹林或华法林发生栓塞事件比率无差别,而联合抗栓治疗出血事件多,左心室射血分数〈35％事件发生率高。结论室壁瘤心功能差患者栓塞事件发生率高,阿斯匹林和华法林在预防心肌梗死后室壁瘤血栓栓塞脱落效果相似,但需更大样本和更长时间随访进一步证实。     

卡托普利对急性心肌梗死后室壁瘤形成的影响

目的:观察口服卡托普利对急性心肌梗死(AMI)后室壁瘤(VA)形成的影响。方法:住院首发AMI患者151例,年龄≥60岁,按是否口服卡托普利随机分为观察组及对照组。于病后4周行心脏二维超声检查.其中7例经左室造影,观察VA形成情况。结果:观察组89例,有VA形成9例,占10％;对照组62例,有VA形成21例,占34％(P<0.05)。心功能(killip)Ⅱ～Ⅲ级者:观察组6.7％(6/89),对照组18％(11/62),(P<0.05)。结论:口服卡托普利能减轻、延缓心室重构程度,减少VA形成,降低病死率。     

二尖瓣脱垂与二尖瓣返流

问:二尖瓣脱垂综合征(二脱)是什么?答:二脱是指病人有异常杂音,二尖瓣异常肥厚,脱垂,出现临床症状(如胸痛)。有些病人因胸痛来诊,并没有典型心脏杂音或超声心动图所见,不应诊断为二脱。问:二脱的体征有哪些?答:关键体征是收缩中期喀喇音,因二尖瓣脱垂引起,喀喇音之后有收缩中期至晚期的二尖瓣返流性杂音,因二尖瓣脱入左房引起。问:临床有什么操作可增加二尖瓣脱垂和杂音?答:凡增加左室充盈容积的操作,使脱垂在收缩后期才出现,喀喇音出现较晚,杂音较弱。凡减少左室充盈时容积,脱垂在收缩早期出现杂音也较强。　蹲位:增加左室充盈容积,喀喇音…     

缺血性二尖瓣返流的研究进展

缺血性二尖瓣返流的研究进展同济医科大学心血管病研究所心内科樊红，程龙献综述曹子寿涂源淑审校缺血性二尖瓣返流（ｍｉｔｒａｌｒｅｇｕｒｇｉｔａ－ｔｉｏｎ，ＭＲ）是冠心病常见的并发症之一，急性心肌梗塞并发ＭＲ尤为常见，发生率可高达５０％。本文就其发生机理及...     

不同部位急性心肌梗死出现二尖瓣返流时对判断预后价值的研究

急性心肌梗死(AMI)后,出现不同程度的二尖瓣返流(Mitral regurgitation,MR)是一种常见表现。但AMI早期并发MR与梗死部位的关系及其对预后的影响,国内资料较少。我们用彩色Doppler血流显像仪观察不同部位早期AMI并MR的程度并对患者进行短期随访,旨在探讨AMI的部位与MR的关系以及对患者预后的影响。     

经皮球囊二尖瓣成形术后二尖瓣返流（附8例报告）

经皮球囊二尖瓣成形术后二尖瓣返流（附８例报告）广西玉林地区人民医院（５３７０００）李平，陈丽芬，张少富，刘强，陈蓉，黄为我院自１９９２年起已完成经皮球囊二尖瓣成形术（ＰＢＭＶ）６０例，其中８例术后并发二尖瓣返流（ＭＲ），本文就共发生的原因、机制作一分...     

急性心肌梗死合并左心室附壁血栓患者经皮冠状动脉介入术后的抗栓治疗

目的分析急性心肌梗死（AMI）并发左心室附壁血栓（LvT）行经皮冠脉介入治疗（PCI）患者的临床特征及抗栓治疗。方法收集煤炭总医院2005年8月至2012年2月确诊为急性心肌梗死并发左室附壁血栓并行PCI治疗的12例患者的临床资料,对其进行回顾性分析。结果广泛前壁心肌梗死、前壁心肌梗死9例（75％）,左室射血分数低于40％共7例（58％）,冠脉造影检查三支及以上血管病变7例（58％）。6例给予华法林、阿司匹林、氯吡格雷三联抗栓,2例给予西洛他唑、阿司匹林及氯吡格雷三联抗血小板治疗,随访期间血栓均消失。4例双联抗血小板治疗者l例发生脑梗死后加用华法林,3例患者血栓消失,1例血栓机化。12例患者均未出现严重出血现象。结论急性心肌梗死并发左心室附壁血栓并接受PCI治疗患者,充分衡量获益及出血风险,按照个体化原则给予抗栓治疗安全有效。     

Infection of cardiac mural thrombus associated with left ventricular aneurysm

Infection is a rare complication of cardiac mural thrombus andmay prove difficult to diagnose and treat. We describe a patientwith infected thrombus associated with a left ventricular aneurysm,involving Salmonella typhimurium. Cross-sectional echocardiographyproved helpful in establishing the diagnosis.     

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。     

Early mitral regurgitation after acute myocardial infarction does not contribute to subsequent left ventricular remodeling

BACKGROUND: It is well known that mitral regurgitation may lead to left ventricular dilation; however, the relationship between progressive left ventricular dilation after acute myocardial infarction (MI) and mitral regurgitation has not yet been clarified. HYPOTHESIS: This study tested the hypothesis that early mitral regurgitation contributes to left ventricular remodeling after acute MI. METHODS: We prospectively evaluated 131 consecutive patients by serial two-dimensional and Doppler echocardiography on Days 1, 2, 3, and 7, after 3 and 6 weeks, 3 and 6 months, and 1 year following acute MI. Patients were divided into two groups: those with mitral regurgitation in the first week after acute MI (Group 1, n = 34) and those without mitral regurgitation (Group 2, n = 81). RESULTS: Over 1 year, a significant increase in end-diastolic volume index (from 62.1 +/- 12.9 to 70.5 +/- 23.6 ml/m2, p = 0.001) with a strong linear trend (F = 15.1, p < 0.001) was noted. Initial end-diastolic volume index was higher in Group 1 (65.6 +/- 13.3 vs. 60.4 +/- 12.5 ml/m2, p = 0.047), but this difference remained constant throughout the study (F = 1.76, p = NS). Therefore, the pattern of end-diastolic volume changes was similar in both groups during the period of observation. CONCLUSIONS: These data indicate that early mitral regurgitation after acute MI does not contribute to subsequent left ventricular remodeling in the first year after myocardial infarction.     

Abciximab and left ventricular thrombus formation in early period of acute myocardial infarction treated with successful primary stenting

Background Left ventricular (LV) thrombus related to acute myocardial infarction (AMI) has been rarely diagnosed since primary stenting has become the routine treatment. The salvage of myocardium at risk is considered as a reason for low frequency of this complication. The impact of glycoprotein IIb/IIIa inhibitors on LV thrombus formation remains unknown. This study investigated the relationship between abciximab treatment and presence of LV thrombus in the first few days after primary stenting. Methods and results A total of 3,078 patients with AMI, who underwent successful primary stenting, were retrospectively analyzed. There were 1,614 patients, who received abciximab and 1,414 treated without it. All patients received aspirin and clopidogrel. LV thrombus was diagnosed by two-dimensional echocardiography within 3–5 days after invasive treatment. This complication appeared equally frequently in both the abciximab and no-abciximab group (2.9% vs. 2.1%, respectively). According to results of multiple log-regression analysis, both groups did not differ in predictors of thrombus formation, such as infarct size and degree of LV dysfunction. Treatment with abciximab was not proved to be an independent predictor of LV thrombus absence. Conclusion Abciximab does not have a direct influence on LV thrombus formation in the early period of AMI.     

Determinants of left ventricular thrombus formation after primary percutaneous coronary intervention for anterior wall myocardial infarction

Previous studies have reported that left ventricular (LV) thrombus is a complication in 10–56% of ST-segment elevation acute anterior wall myocardial infarctions (AWMI). Data suggest that changes in acute myocardial infarction management such as early anticoagulation, thrombolysis, and most recently, primary percutaneous coronary intervention (PCI), may decrease thrombus occurrence. Early time to reperfusion has been shown to decrease mortality and improve LV function recovery. To determine if door-to-balloon time (DTBT) affects the incidence of LV thrombus, we retrospectively analyzed data on 43 consecutive patients who underwent successful PCI of a primary acute ST-segment elevation AWMI. Transthoracic echocardiography was performed for detecting LV thrombus and measuring LV ejection fraction (EF) within 5 days on all patients (average time: 2.17 days post event). Nineteen patients underwent PCI within 2 h of arrival to the Emergency Department (Group A, average 88 min) and 24 patients underwent PCI with DTBT of more than 2 h (Group B, average 193 min). Clinically significant LV thrombus was detected in 35% of all patients. The incidence of LV thrombus formation in Group A was not significantly different from that in Group B (42.1% vs. 29.0%, respectively; P = 0.52). The risk of LV thrombus was independent of in-hospital anticoagulation and medical management, peak enzyme levels, and LVEF but did relate to age (odds ratio = 1.96, 95% CI 1.03–3.73, P = 0.04 per decade). No embolic events in hospital were observed (average hospital stay 9.2 days). We conclude that the incidence of LV thrombus remains high despite PCI. Also, we find that DTBT in patients presenting with an ST-segment elevation AWMI does not affect the incidence of LV thrombus formation. Increased age, however, does appear to increase the risk of LV thrombus development.     

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。     

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.