急性心肌梗死并发室间隔穿孔的外科治疗——附6例报告

The surgical treatment of ventricular septal rupture after acute myocardial infarction—report of 6 cases

目的：总结６ 例急性心肌梗死后室间隔穿孔的手术治疗方法与体会。方法：６ 例心肌梗死并发室间隔穿孔的病人，术前均经右心漂浮导管和冠状动脉造影证实。使用正性肌力药物和／或主动脉内球囊反搏维持循环。其中５ 例在穿孔后１０ ｈ～４ 周内手术，另１ 例在穿孔后３ 个月手术。术中心肌保护选择冷晶体停跳液５ 例，低温室颤１ 例。修补穿孔采用左室入路５ 例，右房入路１ 例，合并室壁瘤切除５ 例，冠状动脉搭桥５ 例。结果：手术死亡２例，分别为心功能衰竭和肾功能衰竭。术后随访２ 月～７ 年，死亡２ 例，其中１ 例为穿孔再通。其余２ 例心功能满意。结论：（１） 室间隔穿孔多由前降支完全阻塞引起，穿孔常常发生于心肌梗死后２ ～４ ｄ，并常常合并室壁瘤；（２）由于病情较危重，掌握手术时机十分重要，穿孔２ 周以上修补穿孔者比较容易；（３） 合并室壁瘤和冠状动脉病变应积极处理；（４） 加强心肌保护和主动脉内球囊反搏泵的应用，能明显提高术后生存率。

Objective: To analyse 6 cases of ventricular septal rupture(VSR) after myocardial infarction and their surgical treatment. Methods: For the 6 patients with VSR after myocardial infarction, Swan Ganz catheters and coronary angiography were used to diagnose and evaluate their conditions. To maintain the hemodynamics, the inotropic agents and/or intraaortic balloon pump(IABP) were used. Operations were performed 10 hours to 3 months after perforation. In myocardial protection, cold crystal cardioplegia was adopted in 5 patients and hypothermic ventricular fibrillation in the other patient. 5 perforations were closed through left ventricle and the other through right atria. Meantime, 5 left ventricular aneurysms were removed and 5 revascularizations were carried out. Results: In the 6 cases, 2 patients died after operation, of whom 1 died from heart failure and 1 from renal failure. 2 patients died during the follow up, of whom 1 might suffer the reopening of the perforation. Conclusion: (1) VSR was often induced by the total occlusion of left anterior descending artery and accompanied by ventricular aneurysms. (2) It may be easier to perform the operation up to 2 weeks after perforation, but it may be wise not to delay operations. (3) The accompanied aneurysms and coronary lesion should be dealed with actively. (4) The myocardial protection should be strengthened and IABP used.