心肌梗死并发室间隔穿孔的外科治疗

目的:探讨提高心肌梗死并发室间隔穿孔(VSR)外科治疗疗效的方法.方法:回顾性分析1994年10月至2007年10月37例接受手术治疗的VSR患者的临床资料.男性24例,女性13例,平均年龄(63.4±7.6)岁.其中VSR修补合并同期冠状动脉再血管化26例(再血管化组),单纯VSR修补11例(单纯修补组).结果:围手术期再血管化组病死率15.4%(4/26),低于单纯修补组的63.6%(7/11),P=0.006.出院患者26例均获得随访,平均随访(34.0±29.8)个月,总随访时间57人年.再血管化组晚期死亡2例,单纯修补组3例.再血管化组6～8年生存率为(64.3 ±21.0)%,单纯修补组4年生存率为(25.0±21.7)%,组间差异有统计学意义.21例患者获得中长期生存,心功能Ⅰ～Ⅱ级17例,Ⅲ～Ⅳ级4例.再发VSR 4例.多因素分析发现未冉血管化、心源性休克、急诊手术为早期死亡危险因子,未再血管化、术后低心排是晚期死亡的危险因子.结论:VSR修补术同期施行再血管化手术可提高围手术期生存率和中长期生存率,合理选择手术时机、手术方法,对提高VSR围手术期生存率、减少VSR再发非常重要.

The early and middle-long term clinical results of surgical treatment for ventricular septal rupture

Objective To explore the way of promoting the efficacy of surgical treatment for ventricular septal rupture (VSR) after acute myocardium infarction in terms of perioperative and long term survival. Methods The clinic data of 37 VSR cases underwent surgical treatment from October 1994 to October 2007 were analyzed retrospectively. There were 24 male and 13 female, and the age was (63.4 ± 7.6) years old. The whole group was divided into the VSR repair plus revascularization group ( group A, 26 cases ) and simple VSR repair group ( group B, 11 cases). Results There were 4 operative deaths in group A ( 15.4% ), 7 deaths in group B ( 63.6% ), P = 0. 006. With the follow-up of ( 34.0 ± 29. 8 ) months ranged from 2 to 103 months of the 26 operational survivors, there were 5 late deaths, of which 2 deaths in group A and 3 deaths in group B. According to the Kaplan-Meier survival curve, the actuarial survival rate at 6 to 8 year was ( 64. 3 ± 21.0 ) % for group A and the actuarial survival rate at 4 year was ( 25.0 ± 21.7 ) % for group B, P=0.011. Of the 21 mid-long term survivors, 17 cases were in NYHA class Ⅰ to Ⅱ and 4 cases in NYHA class Ⅲ to Ⅳ. There were 4 cases suffered from VSR recurrence. According to Logistic regression, the risk factors for the early death were unadoptive of revascularization, cardiogenic shock and emergency surgical procedure, while the risk factors for late death were unadoptive of revascularization and low cardiac output after the procedures. Conclusions VSR repair plus revascularization could improve the perioperative and mid-long term survival for the surgical treatment of VSR. The appropriate timing and procedures of the surgical operation are very important to promote perioperative survival and to prevent VSR recuiTence.