冠心病心肌梗死合并室壁瘤室间隔穿孔1例

患者 男,65岁,高血压病史2年,吸烟史 20年.2014-02-26 因冠心病急性心肌梗死于外院行PCI术,左前降支置入支架1枚.术后1月余再发胸闷、不能平卧,入本院急诊.听诊二尖瓣区 3/6 级全收缩期杂音,向左腋下传导.超声心动图示左室壁节段性运动异常,左室心尖部室壁瘤,室间隔前部穿孔,最大径1.2 cm(图1).急诊心脏 CT 血管成像(心脏CTA)示陈旧性左心室前壁心肌梗死伴室壁瘤形成;室间隔前部穿孔,最大径1.9 cm;左前降支支架开通(图2,3).行内科抗血小板聚集、调节血脂、利尿、营养心肌等治疗,症状明显好转后出院.后于 6个月内 3 次入本院内科治疗.2014-08-18再次入院,为进一步明确支架情况、穿孔部位、大小、心功能等,复查心脏CTA和超声心动图,结果同前.拟行室间隔穿孔修补、室壁瘤切除术.术中见心尖部与心包粘连,室壁明显变薄,室间隔前部穿孔,最大径1.9 cm.术后7 d复查超声心动图,未见异常分流.术后14个月复查心脏 CTA 示室间隔处未见交通,左前降支支架开通(图4).     

Diagnosis of left ventricular free-wall rupture after acute myocardial infarction using CT

In patients with acute myocardial infarction, left ventricular free-wall rupture (LVFWR) is a well-recognized complication associated with high mortality. Accurate diagnosis of LVFWR allows successful surgical treatment and may improve survival rates. We report on two patients initially evaluated with a presumed diagnosis of thoracic aortic dissection. In both cases CT revealed the presence of LVFWR.     

Quantification of the curvature and shape of the interventricular septum.

The interventricular septum (IVS) occupies a unique position within the heart, lying between the left (LV) and right (RV) ventricular cavities. Changes in its normal geometry may signify not only abnormalities of the septal myocardium, but also abnormal pressure differences between the LV and RV. Flattening of the IVS has been noted with cross-sectional imaging in association with pulmonary hypertension, but the septal curvature and shape have not previously been measured in three dimensions. This paper describes a method to model the RV surface of the IVS from spatially registered cross-sectional images for measurements of curvature. A smoothing 2D spline surface is constructed through the RV septal surface at regular times during the cardiac cycle, and the principal curvatures, as well as the Gaussian and mean curvatures, shape index, and curvedness, are calculated. Vector and color surface maps and graphs of average curvature and shape indices are constructed. Consistent curvature patterns were observed in four normal subjects. This method of measuring septal geometry can provide potentially useful new information on the effects of RV disease. We examine the problem of describing septal motion, and describe a simple measure of septal curvature that may be of clinical value.     

急性心肌梗死并发室间隔穿孔彩色多普勒超声心动图特征研究

目的:探寻急性心肌梗死并发室间隔穿孔(VSR)彩色多普勒超声心动图(CDE)特征.方法:应用CDE检查30例急性心肌梗死并发VSR.26例行心血管造影检查,19例行VSR封堵术介入治疗,3例行冠状动脉搭桥和VSR修复术治疗.结果:根据CDE特征对30例中老年急性心肌梗死并发VSR全部做出正确诊断.急性心肌梗死并发VSR的CDE特征明显:①二维超声心动图间接特征显示左心房、左心室内径明显增大,室间隔和/或左室壁节段运动异常,合并室壁瘤患者显示左心室下部心肌变薄,且向外膨出,呈矛盾运动;直接特征显示肌部室间隔不同大小回声失落;②彩色多普勒血流显像(CDFI)显示间接特征显示过二、三尖瓣五彩镶嵌反流束血流信号;直接特征显示过室间隔左向右五彩镶嵌反分流束血流信号;③自患者发病起CDE连续观察VSR直径在一定范围内逐渐增大;④实施VSR封堵术后CDFI仍显示过室间隔封堵器周围少量左向右五彩镶嵌分流束血流信号,但患者临床症状明显减轻.结论:急性心肌梗死并发VSR的CDE特征明显,CDE对急性心肌梗死并发VSR有特异性诊断价值.     

Papillary muscle rupture due to acute myocardial infarction followed by cardiogenic shock, pulmonary edema, and acute renal failure

AIM: The case of successfull surgical treatment of anterolateral papillary muscle rupture due to acute myocardial infarction with cardiogenic shock, pulmonary edema and acute renal failure. CASE REPORT: A 62-year old male from Belgrade with chest pain, hypotension and a new heart murmur refused hospitalization at the Military Medical Academy. On the third day of his illness he was readmitted to MMA as an emergency due to hemoptysis. Examination revealed mitral valve anterolateral papillary muscle rupture. The patient, with signs of cardiogenic shock and acute renal failure, was immediately operated on. The surgery was performed using extracorporeal circulation. An artificial mitral valve was implanted, and myocardial revascularization accomplished with one venous graft of the left anterior descending artery. On the second postoperative day, hemodialysis was carried out due to acute renal failure. On the 28th postoperative day, the patient was discharged from the hospital being hemodynamically stable with normal renal function and balanced anticoagulation. The case is interesting in terms of unrecognized papillary muscle rupture that led to the development of cardiogenic shock, hemoptysis and acute renal failure. CONCLUSION: Papillary muscle rupture is a fatal complication of acute myocardial infarction. Early recognition and urgent surgical intervention were life-saving in the case of complete papillary muscle rupture. Surgical treatment, regardless of high risk, is the procedure of choice.     

Simultaneous assessment of coronary stenosis, myocardial perfusion, and ventricular function in a patient with acute myocardial infarction

Cardiac CT angiography (CTA) is an ideal tool to investigate cardiac and noncardiac causes of acute chest pain. In this case, careful planning of the CTA acquisition and reconstruction limits permitted not only the exclusion of aortic dissection and provided high resolution images of coronary anatomy but also showed a concordant abnormality in myocardial perfusion and ventricular function in the setting of an acute coronary syndrome. Detailed planning of every CTA acquisition reconstruction protocol is essential to obtain the information necessary for clinical decision-making strategies and interventions in the patient with chest pain.     

A clinical feature of myocardial stunning associated with acute myocardial infarction

We report a case of myocardial stunning after acute myocardial infarction. In the hyperacute phase of myocardial infarction, the patient’s coronary arteries showed normal features on coronary angiography during extensive ST-segment elevation observed on a standard 12-lead electrocardiogram and extensive akinesis observed on a left ventriculogram. Thallium-201 emission computed tomography revealed extensive perfusion abnormality. In the chronic phase, the perfusion abnormality was markedly improved. However, the electrocardiogram demonstrated poor R wave progression, and the left ventriculography revealed slight hypokinesis in the anterolateral wall. The acetylcholine provocation test disclosed coronary vasospasm of the left anterior descending coronary artery. About six months thereafter, left ventricular wall motion became completely normal and no poor R wave progression was observed on the electrocardiogram. The findings in this case indicate that myocardial stunning resulted from brief but severe ischemia due to vasospasm which led to cardiogenic shock, and that the recovery of findings for thallium-201 perfusion might be followed by those of electrocardiography and left ventriculography in the stunned myocardium.     

Elevated 18F-fluorodeoxyglucose uptake in the interventricular septum is associated with atrioventricular block in patients with suspected cardiac involvement sarcoidosis

Purpose

Cardiac involvement in sarcoidosis is one of the leading causes of death associated with abnormalities of the conduction system. ¹⁸F-FDG PET is useful for detecting inflammatory lesions in cardiac sarcoidosis. However, the relationship between ECG abnormalities and focal ¹⁸F-FDG uptake has not been studied. The aim of this study was to evaluate the relationship between electrocardiogram (ECG) abnormalities and the location of elevated myocardial ¹⁸F-FDG uptake in patients with sarcoidosis.

Methods

Included in the study were 50 patients (56.3?±?14.9 years old) with histologically proven sarcoidosis with suspected cardiac involvement based on ECG or echocardiography. All patients had fasted for at least 6 h and were given unfractionated heparin (50 IU/kg) intravenously to reduce the physiological ¹⁸F-FDG uptake in the myocardium. The left ventricle (LV) wall was divided into 17 segments by visual analysis. Obvious accumulation in each segment was defined as positive.

Results

Of the 50 patients, 33 showed some ECG abnormalities, including atrioventricular (AV) block in 13. Patients with abnormal ECG findings had a higher number of regions with ¹⁸F-FDG uptake than patients without ECG abnormality (3.48?±?2.73 vs. 1.41?±?2.09 regions, p?=?0.0051). Among ECG abnormalities, the predictor for interventricular septum wall ¹⁸F-FDG involvement was AV block (p?=?0.0025).

Conclusion

Patients with ECG abnormalities showed a higher number of abnormal ¹⁸F-FDG myocardial uptake regions than patients without ECG abnormalities. In particular, focal ¹⁸F-FDG uptake in the interventricular septum in cardiac sarcoidosis was associated with AV block. Therefore, determination of regional ¹⁸F-FDG distribution might contribute to patient management in cardiac sarcoidosis.     

老年心肌梗死伴与不伴心脏破裂的临床病理特点分析

目的探讨老年心肌梗死伴与不伴心脏破裂的临床病理差异。方法将107例尸检证实的老年人心肌梗死分为心脏破裂与未破裂两组(破裂组22例,未破组85例),并进行临床病理对照。结果破裂组年龄(79·1±9·1岁)高于未破组(71·8±10·9岁,P<0·01),女性(11例,50·0%)多于未破组(21例,24·6%,P<0·05),有心绞痛史者(10例,45·5%)明显少于未破组(74例,87·1%,P<0·01),初发性心肌梗死(17例,77·3%)多于未破组(44例,52·3%,P<0·05),冠状动脉主要分支明显狭窄(36支,40·9%,平均1·64支/人)明显少于未破组(194支,57·1%,平均2·28支/人,P<0·01),单支病变(13例,59·1%)多于未破组(29例,33·8%,P<0·05)。心脏破裂部位以前壁近心尖处多见。结论高龄、女性、初发、既往无心绞痛史、冠脉单支病变者心脏破裂常见,破裂部位多见于前壁近心尖处。     

Cardiopulmonary resuscitation does not cause left ventricular rupture of the heart with acute myocardial infarction: a pathological analysis of 77 autopsy cases

Cardiac rupture during acute myocardial infarction (AMI) is one of the most frequent causes of sudden cardiac death. However, some reports have indicated the possibility that the cardiac rupture during AMI may occur by external cardiac massage. We pathologically examined the hearts of 77 patients who died suddenly due to ventricular free wall rupture during AMI (51 men and 26 women; aged 47-94 years; mean age: 69.9 years). We divided the cases into two groups, 44 cases with and 33 cases without cardiopulmonary resuscitation (CPR), and compared the two groups with respect to 12 pathological items. There were no statistical differences in any of the investigated items between the two groups (P>0.05). In addition, mural thrombi were identified along the rupture tract in all cases. Moreover, they were more matured at the subendocardial zone than at the subepicardial or middle zone, irrespective of the groups. From the pathological findings, we concluded that the rupture of the left ventricle during AMI originates from the subendocardial region and precedes the external cardiac massage. Our present study strongly suggests that CPR does not cause the left ventricular rupture of the heart during AMI.     

法洛四联症:外科修补术后室间隔偏移对左心室收缩期功能和纤维化的影响

目的量化法洛四联症修补术后标志心室间相互作用的室间隔偏移,评估其与左心室射血分数、左室间隔增厚及左室纤维化的相关性。材料与方法研究符合HIPAA法案,经学术委员会审核批准。采用心血管MRI测量室间隔偏移程度。研究对象包括82例接受修补术的法洛四联症病人和10名健康志愿者。分析室间隔偏移是否与左心室射血分     

急性心肌梗死合并心脏破裂患者危险因素分析

目的探讨急性心肌梗死(AMI)合并心脏破裂(CR)的危险因素。方法选取自2012年1月至2017年12月北部战区总医院心血管内科收治的AMI合并CR的84例患者为CR组,同时选取与CR组患者同年入院且未发生CR的AMI患者503例为非CR组。采用Logistic回归分析探讨AMI合并CR的危险因素。结果 CR组患者的白细胞计数、高密度脂蛋白、C反应蛋白高于非CR组,肌酐清除率(CCr)、低密度脂蛋白、血红蛋白低于非CR组,差异均有统计学意义(P<0.05)。Logistic回归分析显示,高龄、发病至就诊时间延长、白细胞计数升高、贫血、高密度脂蛋白升高为AMI合并CR的独立危险因素;完全血运重建为保护因素。结论 AMI合并CR独立危险因素包括高龄、发病至就诊时间延长、白细胞计数升高、贫血、高密度脂蛋白升高;完全血运重建为其保护因素。