急性心肌梗死并发亚急性心脏破裂的外科治疗

Surgical treatment for postinfarction subacute left ventricular free wall rupture

目的总结非体外循环下直接黏合修补并同期冠状动脉搭桥术治疗急性心肌梗死（AMI）所致亚急性心脏破裂的临床经验。方法2005-01～2010-12收治10例AMI并发亚急性心脏破裂的患者，男性6例，女性4例，年龄58—72岁，平均（64±8．6）岁，均存在心脏压塞症状。通过床旁超声心动图确诊，其中8例在心脏破裂之前曾行冠状动脉造影。所有患者确立诊断后即急诊手术，非体外循环下将牛心包作为补片，用化学胶直接粘连修补心肌破裂口，其中8例同期行冠状动脉旁路移植术。结果所有患者手术过程顺利，心肌破口修补满意，无手术相关死亡。随访4．2年（1．1～6．8年），9例患者症状改善，心功能Ⅰ～Ⅱ级，无再发心肌梗死、心脏破裂、假性室壁瘤形成及室壁运动受限，近中期效果满意。1例患者仍存在劳力型心绞痛，活动量受限，给予内科药物治疗。结论非体外循环下，直接黏合修补术治疗AMI所致的亚急性心脏破裂简单、有效，同期行冠状动脉血运重建有利于缓解心肌缺血的相关症状，改善心功能，预防心肌梗死的再发。

Objective To summarize clinical experience of surgical treatment for postinfarction subacute left ventricular free wall rupture using sutureless technique with comitant revascularizationwithout extracorporeal circulation. Methods From January 2005 to December 2010, 10 consecutive patients with subaeute left ventricular free wail rupture （LVFWR） were treated at our hospital. The mean age was（64 ＋ 8.6）years （ranging from 58 to 72 years ） ; there were 6 males and 4 females. All patients presented cardiogenic shock due to cardiac tamponade and left ventricle failure confirmed on eehocardiography. Coronary angiography was performed in 8 patients before the onset of cardiac rupture. Surgical invention was carried out soon after establishment of diagnosis. After opening the chest and identification of the site of rupture, we used heterologous bovine perieardial with Enbucrilate surgical glue to cover the rupture zone. Simultaneous coronary revascularization was performed in 8 patients. Results Effective control of bleeding was achieved in all cases. There were no operation deaths. Intra - aortic balloon pumping was placed in 4 cases preoperatively and inotropic drugs support was used in 8 patients postoperatively to stabilize hemodynamic condition. On follow - up at a median of 4.2 years （interquartile range, 1.1 to 6.8 years）, 9 patients were free from ischemie - relative symptoms and heart functions （NYHA） were in class I to class II. Reinfarction and rerupture were not found in these cases. Follow - up echoeardiography did not reveal any evidence of left ventricle pseudoaneurysm and restriction to left ventricular free wall motion. The short - term and mid - term results were excellent. One patient presented angina pectoris on exertion and treated by medication. Conclusion The sutureless technique is a simple and effective option for the surgical treatment for subacute left ventricle free wall rupture, with excellent short- term and mid -term results. Simultaneous coronary revascularization contributes to the improvement of heart function, elimination of symptoms and prevention of reinfarction.