陈旧性心肌梗死患者腹部手术围手术期处理

目的总结陈旧性心肌梗死患者腹部手术围手术期处理体会。方法对35例行腹部手术的陈旧性心肌梗死患者围手术期处理进行回顾性分析，胆囊切除9例，胆囊切除＋胆管探查T管引流8例，肝部分切除1例；胃癌根治7例，直结肠癌根治7例，胃穿孔修补1例，十二指肠漏旷置1例，胰十二指肠切除1例。结果合并高血压22例（62．8％），心律失常14例（40％），糖尿病11例（31．4％），脑血栓6例（17．1％），完全右束支传导阻滞4例（11．4％），慢性支气管炎并肺气肿2例（5．7％），风湿性心瓣膜病并心力衰竭1例（2．9％）。术中出现血压剧烈波动10例，低血压5例。术后出现心律失常3例，心肌缺血4例，心力衰竭2例。治愈34例，再发心肌梗死死亡1例。结论陈旧性心肌梗死患者实施腹部手术时充分的术前准备非常必要，术中要防止低血压，术后要防止心肌缺血和心功能衰竭。     

Endovascular stent-graft repair of aortic dissection

Between October 2000 and January 2002, 9 consecutive male patients with subacute or chronic aortic dissection underwent stent-graft placement. The indication for surgery was continuous pain or aneurysm development. One patient had a type A dissecting aortic aneurysm with a primary tear in the ascending thoracic aorta; the other 8 had type B dissection. Placement of an endovascular stent-graft was technically successful in 8 patients, and one underwent an open procedure for abdominal aortic fenestration. The entry site was sealed and the false lumen disappeared in 8 cases, and thrombosis of the false lumen was obtained. Rupture of an iliac artery dissecting aneurysm occurred in one patient 2 days after stent-graft placement; abdominal aortic fenestration with prosthetic replacement of the distal abdominal aorta was performed. One patient died of myocardial infarction 3 days after the stent-graft procedure. During a mean follow-up period of 7 months (1-16 months), one patient died of acute myocardial infarction at 11 months. It was concluded on the basis of these short-term results that endovascular repair of aortic dissection is a promising treatment, and abdominal aortic fenestration is a useful adjuvant procedure.     

Left ventricular aneurysmal repair within 30 days after acute myocardial infarction: early and mid-term outcomes

For safe resection, left ventricular aneurysmal repair after acute myocardial infarction is usually delayed. However, delaying surgery may not be possible or prudent in some patients who are clinically unstable after acute myocardial infarction. We retrospectively reviewed the early and mid-term outcomes of left ventricular aneurysmal repair in patients who had experienced acute myocardial infarction <30 days before the repair. From September 2001 through May 2006, 127 consecutive post-infarction patients underwent concurrent anteroapical left ventricular aneurysmal repair and coronary artery bypass grafting. In Group I (38 clinically unstable patients), the surgery was performed <30 days after myocardial infarction. In Group II, 89 patients underwent the surgery > or = 30 days after infarction. The mean follow-up period was 26.16 +/- 16.41 months. One Group I patient (2.6%) died in the hospital due to graft-versus-host reaction. Three Group II patients (3.4%) died: 2 of low cardiac output and 1 of multiple-organ failure. Hospital mortality rates were not statistically significant between groups (P=0.582). All patients required similar perioperative inotropic support, intra-aortic balloon pump support, and re-exploration for bleeding or cardiac tamponade. The actuarial survival rates were 94.7% (Group I) and 94.4% (Group II). Postoperative New York Heart Association functional class improved similarly in both groups. We infer that left ventricular aneurysmal repair with coronary revascularization < 30 days after a recent myocardial infarction is a feasible procedure, with acceptable morbidity and mortality rates. Our mid-term results were comparable with those for patients who underwent this surgery > or = 30 days after acute myocardial infarction.     

Combined coronary artery and abdominal aortic surgery without cardiopulmonary bypass

To determine the effects of beating heart surgery on patients undergoing simultaneous coronary artery bypass grafting and abdominal aortic surgery, we performed such surgery on 20 patients (mean age, 64.55+/-796 SD years). Abdominal aortic disease was defined as an abdominal aortic aneurysm larger than 5 cm in diameter or as end-stage aortic occlusive disease. Hemodynamic measurements, inotropic requirements, and incidence of perioperative myocardial infarction and arrhythmias were recorded, as were subsystem clinical outcomes, length of intensive care unit and hospital stays, blood loss, and transfusion requirements. There was no incidence of death, perioperative myocardial infarction, stroke, or acute renal failure. The mean number of grafts per patient was 1.95+/-0.69. Only 4 minor postoperative complications were observed: three patients (15%) had evidence of supraventricular tachyarrhythmias, and 1 patient (5%) had chest infection that required a longer-than-average intubation period. Six patients (30%) required minimal-to-moderate inotropic support. The mean blood loss was 673+/-246.8 mL and transfusion requirements were low. The mean intensive care unit and hospital lengths of stay were 2. 12+/-0.33 days and 708+/-1.44 days, respectively. Clinical follow-up (mean, 10 months) showed all patients to be in New York Heart Association functional class I or II with no late cardiac or abdominal events. We conclude that simultaneous coronary artery bypass grafting and abdominal aortic surgery on the beating heart is safe and effective, and has a low perioperative clinical morbidity rate. To our knowledge, ours is the 1st report on this procedure. Larger studies with longer follow-up are needed.     

A method of diagnosis in posterior myocardial infarct

Based on the results of examination of 58 patients with myocardial infarction, the authors propose a method for diagnosing posterior myocardial infarction by abdominal electrocardiographic mapping. The anterior abdominal wall shows the area from which one may record the direct markers of posterior myocardial infarction: abnormal Q wave, R wave regression, abnormal QS complex, as well as ST segment elevation which is typical of acute myocardial infarction. The anterior abdominal wall also defines the areas from which direct signs of inferior and lateral myocardial infarctions may be recorded.     

The role of surgical reperfusion in myocardial infarction

The role of coronary artery bypass graft surgery during myocardial infarction is unclear. This article reviews worldwide results with this form of therapy. Included in the analysis are the effects of surgical reperfusion on left ventricular function, anginal classification following reperfusion, the effects of early versus late reperfusion, and an in-depth mortality analysis from multiple medical centers. It is concluded that surgery can be performed with a very low mortality in most patients with acute myocardial infarction, but the most appropriate form of therapy of acute myocardial infarction that will result in low mortality and morbidity remains a challenge for future investigation.     

An uncommon cause of renovascular hypertension

Renovascular hypertension is usually due to an atherosclerotic artery stenosis or a fibromuscular dysplasia. We describe an uncommon cause of renal ischemia. A 66-year-old woman was admitted for severe hypertension. During her stay, she presented an acute myocardial infarction with normal coronary angiography. After a flank pain, a contrast-enhanced abdominal computed tomography scan was performed which revealed a stenosis of the left main renal artery. However, renal angiography displayed a thrombosis. Transesophageal echocardiography showed a mobile mass attached to the mitral valve. A diagnosis of renal artery thrombosis and acute myocardial infarction both resulting from a cardiac tumour embolism was established.     

Myocardial rupture following acute myocardial infarction

Ten patients, eight males and two females, suffered myocardial rupture following acute myocardial infarction and required surgery. There were five ventricular septal ruptures, four papillary muscle ruptures and one free wall rupture. Ventricular septal rupture was suspected clinically by the appearance of a new systolic murmur, usually associated with a thrill at the left sternal border. A left to right shunt was confirmed by bedside oximetry using a Swan-Ganz catheter. The mean pulmonary to systemic flow ratio was 3.04:1. Following cardiac catheterization all patients underwent corrective surgery with or without aortocoronary bypass grafting. Three patients with inferior wall myocardial infarction died. Papillary muscle rupture was suspected clinically following the abrupt onset of hypotension with severe acute pulmonary edema accompanied by a new systolic murmur. The diagnosis was confirmed by cardiac catheterization. All underwent surgery for mitral valve replacement with or without aortocoronary bypass grafting. One patient died postoperatively of multiorgan failure. Free wall rupture was suspected clinically by the sudden onset of loss of consciousness, apnea, junctional bradycardia and severe hypotension leading to electromechanical dissociation. The diagnosis was confirmed by demonstrating a significant pericardial effusion by two dimensional echocardiography. Immediate surgery was performed. This patient is totally asymptomatic on no drug treatment six months following discharge. Ten patients underwent emergency surgery for myocardial rupture. Operative mortality was 40%. Patients with ventricular septal rupture associated with an inferior myocardial infarction had a poor prognosis.     

Acute myocardial infarction due to coronary spasm associated with L-thyroxine therapy

A 63-year-old man with hypothyroidism is described. He had been receiving L-thyroxine therapy following mitral valve surgery. About three weeks into the therapy regimen, he complained of severe retrosternal chest oppression. Electrocardiographic findings and laboratory data indicated a diagnosis of acute myocardial infarction due to the L-thyroxine therapy. Emergency selective coronary angiography was performed. Comparing his coronary angiograms with those obtained before surgery indicated a severely spastic left coronary artery. We believe this is the first report of myocardial infarction due to coronary spasm, demonstrated by angiography associated with L-thyroxine therapy.     

Silent ST segment elevation myocardial infarction with multi-segmental renal infarction: an unusual presentation

A 36-year-old diabetic man came to our institution presenting with constant left flank pain. Left renal embolic infarction was found by abdominal computed tomography. Silent ST segment elevation myocardial infarction was noted on 12-lead electrocardiogram. Emergent coronary angiography revealed large thrombus burdens with complete occlusion at the left anterior descending artery ostium, which may be the embolic origin. Silent ST segment elevation myocardial infarction with acute flank pain and multiple segmental renal infarction is an unusual presentation. High vigilance may prevent delay of the "golden hour" to treat acute myocardial infarction.     

Surgical therapy of acute myocardial infarction

All over the world the therapy of acute myocardial infarction has concentrated upon saving the ischaemically injured, but still viable cells of the myocardium. Also the acute coronary surgery, which among our groups of coronary-surgical patients has a proportion of 3.5% with 41 patients, answers this purpose. The preferred indication groups for acute coronary-surgical operations are the occlusion of the vessel after coronary dilation and the condition after intracoronary fibrinolysis. In these 22 patients the hospital lethality was only 4.5%. The reasonable active approach in acute myocardial infarction, particularly the combination fibrinolysis - acute coronary surgery, is a hopeful enlargement of the previous therapy for the highly imperilled patients with myocardial infarction.     

Ischemic myocardial injury during cardiopulmonary bypass surgery

ECG's and serum levels of SGOT, LDH, and CPK were examined during the immediate postoperative period in 126 patients who had cardiac surgery during cardiopulmonary bypass. None had coronary disease and valve replacement was performed in 97 patients. Miscellaneous procedures not involving the coronary arteries were performed in 29. In surviving patients, ECG signs of acute myocardial infarction appeared in 8 (7 per cent) and changes compatible with acute ischemic injury were seen in 38 (30 per cent). Elevation of SGOT exceeding 90 units occurred in 32 per cent of patients and LDH levels over 900 units occurred in 37 per cent. In patients with ECG evidence of postoperative infarction or ischemia, 70 per cent had abnormal SGOT levels and 70 per cent had abnormal LDH levels. In 40 patients with SGOT levels exceeding 90 units, 80 per cent had ECG evidence of acute infarction or ischemia. In 80 patients without ECG changes, only 10 per cent had SGOT levels exceeding 90 units. CPK levels correlated poorly with ECG evidence of ischemia or infarction. Patients who demonstrated ECG and serum enzyme evidence of ischemic injury or myocardial infarction had longer total perfusion times during surgery (P < 0.001) but no relationship to aortic cross clamp time was observed. ECG evidence of acute myocardial ischemia with elevation of serum enzymes is frequently observed following cardiopulmonary bypass surgery. Serial ECG's and measurements of postoperative serum enzymes provide useful information regarding myocardial injury and the effectiveness of bypass perfusion in protecting the myocardium during cardiopulmonary bypass sugery.     

Left coronary artery spasm causing severe left ventricular dysfunction without myocardial infarction

This report describes a patient with persistent, recurrent left anterior descending coronary artery spasm, which causes marked left ventricular dysfunction in a clinical course that is typical of acute myocardial infarction with hyperacute electrocardiographic changes. However, after emergency coronary artery bypass surgery, the patient had complete reversal of left ventricular dysfunction, with no residual evidence of acute myocardial infarction by electrocardiograph or gated blood pool imaging and no CPK enzyme rise. The patient therefore demonstrates that coronary spasm in some instances clearly precedes the sequence of pathophysiologic events leading to acute myocardial infarction. Our report also demonstrates for the first time in man that massive left ventricular dysfunction may occur in this intermediate coronary syndrome, presenting clinically as impending myocardial infarction. With aggressive surgical intervention and emergency bypass surgery, left ventricular function was restored to normal. Despite the semantic problems of categorizing such patients as having impending myocardial infarction, the severe left ventricular dysfunction and alarming course of this patient's illness was resolved by emergency surgery, suggesting that, in some instances, aggressive therapy is warranted.     

Results of coronary surgery after failed elective coronary angioplasty in patients with prior coronary surgery

The results of coronary artery bypass surgery after failed elective coronary angioplasty in patients who have undergone prior coronary surgery are unknown. Coronary angioplasty may be performed to relieve angina after surgery either to the native coronary vessels or to grafts. Failure of attempted coronary angioplasty may mandate repeat coronary surgery, often in the setting of acute ischemia. From 1980 to 1989, 1,263 patients with prior coronary bypass surgery underwent angioplasty; of these patients, 46 (3.6%) underwent reoperation for failed angioplasty during the same hospital stay. Of the 46 patients who underwent reoperation, 33 had and 13 did not have acute ischemia. In the group with ischemia, 3 patients (9.1%) died and 14 (42.4%) died or had a Q wave myocardial infarction in the hospital compared with no deaths (p = NS) and no deaths or Q wave myocardial infarction (p = 0.005) in the group without ischemia. At 3 years, the actuarial survival rate was 88 +/- 6% in the group with ischemia, whereas there were no deaths in the group without ischemia (p = NS), and freedom from death or myocardial infarction was 51 +/- 10% in the group with ischemia, versus no events in the group without ischemia (p = 0.006). In most patients with prior coronary bypass surgery, coronary angioplasty was performed without the need for repeat coronary bypass surgery. Should coronary angioplasty fail, reoperation in patients without acute ischemia can be performed with overall patient survival comparable to that of elective reoperative coronary bypass without coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of patients after thrombolytic therapy for acute myocardial infarction

The coronary artery thrombus that causes acute myocardial infarction can be lysed, and reperfusion can be achieved, in the first few hours after infarction. However, the infarct vessel will reocclude in 15-30% of patients, and this event is frequently associated with pain, reinfarction, arrhythmias, or death. The risk of reocclusion is greatest in patients with high-grade residual stenosis after thrombolysis. Percutaneous coronary angioplasty may be performed safely after thrombolytic therapy. Angioplasty effectively decreases the degree of residual stenosis, and may thereby reduce the risk of reocclusion and consequent ischemic events. However, a substantial proportion of patients with acute infarction are not suitable candidates for angioplasty. Coronary artery bypass surgery has also been safely performed within several days after thrombolytic therapy. Further studies are needed to determine which patients will benefit most from this aggressive approach to acute myocardial infarction.     

Acute inferolateral myocardial infarction as the first manifestation of left atrial myxoma -- a case report

A case of a young patient admitted to our hospital due to acute myocardial infarction is presented. Coronary angiography revealed normal coronary arteries. Echocardiography performed immediately after coronary angiography showed the presence of the left atrial myxoma. Three days later the patient underwent urgent surgery with a favourable outcome. The role of echocardiography in detecting atrial myxoma and mechanisms of myocardial infarction caused by this anomaly are discussed.     

Treatment by redilatation and thrombolysis of occlusion occurring during percutaneous coronary angioplasty

In patients who develop acute coronary occlusion during or after percutaneous coronary angioplasty, surgery is not mandatory, and other treatments may be considered, namely redilatation and/or thrombolysis. Between June, 1984 and January, 1988 we performed 500 dilatations of coronary arteries, not counting the attempts made in the acute phase of myocardial infarction. Acute coronary occlusion without angiographic image of occlusive dissection occurred in 31 patients (6.2%) and was treated by attempted redilatation and intracoronary thrombolysis. In 10 patients (group A) either the occlusion could not be removed and emergency surgery was tried (5 cases with 2 infarctions and 1 death), or the occlusion was removed but myocardial infarction took place (5 cases). In 21 patients (group B), the occlusion was removed and the outcome was favourable without myocardial infarction. Altogether, myocardial infarction or death occurred in only 8 cases, or 26% of acute occlusions. The clinical and angiographic features of the two groups before and after angioplasty were compared; two of them differentiated group A from group B: (1) unstable angina, 7/10 in group A, 4/21 in group B (p less than 0.01), and (2) degree of stenosis, 93.1% in group A, 78% in group B (p less than 0.01). When coronary occlusion occurs during or after coronary angioplasty and is poorly tolerated with fall in blood pressure, surgery must be contemplated at once, even after recanalization of the vessel and subsidence of ischaemia. In all other cases, treatment with both redilatation and thrombolysis should restore the benefits of angioplasty without myocardial infarction.     

Acute left main coronary artery occlusion. Survival following emergent coronary bypass

Emergent aortocoronary bypass surgery for acute myocardial infarction is controversial. We describe a patient with total occlusion of the left main coronary artery associated with acute anterior wall infarction and refractory cardiogenic shock. The patient underwent successful emergent coronary bypass surgery to manage refractory cardiogenic shock. He has subsequently experienced a prolonged survival (60 months postsurgery). This report suggests that emergent aortocoronary bypass surgery should be considered in patients with acute myocardial infarction with refractory cardiogenic shock in whom other forms of reperfusion are unsuccessful.     

Splenic hemorrhage: a complication of tissue plasminogen activator treatment

Thrombolytic therapy with tissue plasminogen activator (tPA) for acute myocardial infarction may result in major bleeding complications such as gastrointestinal or intracranial bleeding. A case is described of severe splenic hemorrhage and rupture which developed 3 h after completion of tPA infusion for suspected acute myocardial infarction. The patient developed hypovolemic shock with abdominal pain and distension and further evidence of myocardial necrosis. A computed tomography scan of the abdomen was helpful in elucidating the diagnosis, and surgical splenectomy resulted in a good patient outcome, though the period of hypotension had increased the extent of myocardial necrosis.     

Unstable angina and evolving myocardial infarction following coronary bypass surgery: pathogenesis and treatment with interventional catheterization

Effective therapy for patients with unstable angina or evolving myocardial infarction following coronary bypass surgery requires accurate delineation of the pathoanatomy and prompt intervention. We therefore performed cardiac catheterization in 10 consecutive patients: four with acute myocardial infarction and six with refractory unstable angina (NYHA class IV). All patients with acute myocardial infarction were found to have completely thrombosed vein grafts supplying totally occluded native coronary arteries. In three patients with evolving myocardial infarction occurring within 4 weeks of coronary bypass surgery, graft thrombosis was caused by venous valves in two patients and a suboptimal anastomosis in a third. The fourth patient sustained a myocardial infarction 7 years after coronary bypass surgery with atherosclerotic plaque rupture causing vein graft thrombosis. Therapy with intragraft streptokinase resulted in complete clearing of thrombus, pain relief, and control of injury current in all four patients. Rest angina with concomitant ST and T wave changes occurred in six patients. In two patients symptoms occurred early (within 6 months), whereas angina developed 4 to 10 years after coronary bypass graft surgery in four patients. In the two patients with early recurrence of symptoms suboptimal anastomosis was found in one, while the other patient had a venous valve in the vein graft in conjunction with a stenosis in the native coronary artery. In three of four patients with late recurrence of angina, symptoms developed as a result of atherosclerotic stenosis in their vein grafts; in the fourth patient an occluded graft was found to supply a stenosed native coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)