心肌梗塞后室间隔穿孔的手术治疗

Surgical Repair of Postinfarction Ventricular Septal Rupture

探讨急性心肌梗塞后室间隔穿孔的手术时机选择及影响手术疗效的因素。１６例急性心肌梗塞后室间隔穿孔病人接受了手术治疗。平均年龄５４．５岁。术前合并心源性休克５例，充血性心力衰竭伴肺水肿１例。１４例行冠状动脉造影，单支病变８例，多支病变６例，合并室壁瘤１３例。急症手术４例，择期手术１２例。行穿孔直接缝合２例，补片修补１３例，双侧补片修补１例；同期冠脉搭桥９例，室壁瘤切除或折叠１３例。术后应用主动脉内球囊反搏（ＩＡＢＰ）者８例。２例急症手术者早期死亡。结论：室间隔穿孔应先行内科治疗控制心源性休克，包括应用ＩＡＢＰ或左心室辅助等，使病人能坚持到穿孔４８小时后再积极手术。分流量小者应延至３～６周后手术。

Aim:To review the experience of surgical repair of ventricular septal repture(VSR)after acute myocardial infarction(AMI)and to evaluate the risk factors influencing surgical outcome.Clinical material and method:From 1973 through 1996,16 patients with postinfarction VSR were treated surgically.There were 14 males and 2 females with a mean age of 54.5 years(range 38 to 66 years).All patients had typical symptoms of AMI.5 patients were associated with cardiogenic shock,11 had congestive heart failure associated with acute pulmonary edema and 2 received intraaortic balloon counterpusation(IABP)before surgery.The diagnosis was made by Doppler echocardiography.14 patients received coronary artery angiography.The results showed 6 patients had triple vessel diseases,8 had single vessel diseases.13 patients were associated with postinfarct ventricular aneurysm.Surgical repair was performed in all cases including 4 emergency operation and 12 elective operation.Concomitant procedures included resection of post infarction ventricular aneurysm in 12 and coronary artery grafting bypass in 9.Eight patients required IABP postoperatively.Result:There were two early deaths with a operative mortality of 12.5%.For the two deceased patients,they both had preexisting cardiogenic shock and received emergency operation.The causes of death were consistent low cardiac output syndrome in 1 and uncontrollable arrhythmia in 1.The mean duration of cardiopulmonary bypass was 135.6 minutes(range 59 to 236 minutes).10 patients were followed up from 1 month to 10 years,their heart function were improved significantly.There were no late deaths and complications.Conclusion:Surgery plays an important role in treatment of postinfarction VSR.The early operative mortality is closely related to preoperative cardiogenic shock.In order to reduce operative mortality and morbidity,preoperative cardiogenic shock should be well controlled by either medications or IABP,or both before surgery.