急性心肌梗死并发室间隔穿孔部位形态学特征及介入封堵术疗效观察

The morphological characteristics of ventricular septal rupture in patients with acute myocardial infarction and efficacy observation of transcatheter interventricular septal perforation

目的分析急性心肌梗死(AMI)并发室间隔穿孔(VSR)部位形态学特征,观察VSR穿孔介入封堵疗效。方法纳入2012年12月至2017年8月由新疆维吾尔自治区人民医院心内科行介入封堵术治疗的6例AMI并发VSR患者,分析VSR部位形态学特征,观察介入封堵VSR的疗效,随访半年至5年不等。结果6例患者中男性4例,女性2例,最大年龄76岁,最小年龄43岁,罪犯血管为前降支5例,右冠状动脉1例。6例患者均有左向右室间隔膨出瘤。在左前斜45°+头20°投照体位下左心室造影提示4例膨出瘤位于室间隔中1/3、2例膨出瘤位于室间隔心尖部1/3;三维超声心动图证实舒张期瘤体直径最小值23.40 mm,最大值52.12 mm;收缩期瘤体直径最小值20.40 mm,最大值49.12 mm;筛状穿孔数4(1,7)个;舒张期最大穿孔孔径最小值14.40 mm,最大值18.30 mm;收缩期最大穿孔孔径最小值11.90 mm,最大值16.60 mm。6例患者于AMI后56(7,99)d行VSR封堵术,1例患者术前行主动脉内球囊反搏术,1例患者术前行体外膜肺氧合。5例(5/6)成功置入封堵器,置入封堵器直径16(12,22)mm,此5例置入封堵器前均对罪犯血管行经皮冠状动脉介入治疗(PCI);1例(1/6)因下壁心肌梗死,穿孔部位位于室间隔与心室肌后壁交界处,选最大直径30 mm室间隔封堵伞固定困难,封堵失败,1个月后因反复心力衰竭、心原性休克死亡,患者置入封堵器前未对罪犯血管行PCI。术后即刻造影示完全关闭3例(3/5);少量残余分流1例(1/5),择期行降落伞左心室减容术,残余分流消失;中度残余分流1例(1/5)行二次室间隔封堵后残余分流消失。5例成功封堵的患者全部存活,术前术后对比,左心室舒张末期直径明显变小,左心室射血分数、脑钠肽水平明显提高。结论AMI并发VSR部位呈左向右膨出瘤,三维超声心动图证实瘤体多数可能呈喀斯特地貌溶洞样筛状多孔,介入封堵术可能相对安全有效。

Objective To analyze the morphological characteristics of ventricular septal rupture(VSR)in patients with acute myocardial infarction(AMI)and observe the efficacy of transcatheter interventricular septal perforation.Methods A total of 6 patients with AMI complicated with VSR underwent interventional therapy by Department of Cardiology,People’s Hospital of Xinjiang Uygur Autonomous Region,from December 2012 to August 2017,were enrolled into the study.The morphological characteristics on the perforation position was analyzed,and the efficacy of transcatheter interventricular septal perforation was observed,within a follow-up duration from six months to five years.Results There were 4 males and 2 females of the 6 patients,among which,the maximum age is76 years and the minimum was 43 years.In addition,there were 5 cases of anterior descending coronary artery and 1 right coronary artery as the culprit vessels.The minimum diameter of the aneurysm during systole was 20.40 mm,while the maximum was 49.12 mm,with 4(1,7)areas of perforation.Besides,the maximum perforation diameter during diastole was 14.40 mm,and the maximum was 18.30 mm.Moreover,the minimum and maximum diameter of the biggest pore during systole was 11.90 mm and16.60 mm respectively.VSR occlusion was performed 56(7,99)days after MI,among which one patient underwent intra-aortic balloon counter pulse before operation,whereas another patient underwent ECMO insertion prior to operation.Six patients underwent occlusion,in which 5 patients(5/6)were successfully occluded,and were treated with PCI before inserting the occlude.As for the remaining patient(1/6),due to the inferior myocardial infarction and that the perforation position is located at the junction of the interventricular septum and the posterior wall of the ventricular muscle,it was difficult to seal even though the interventricular septum occlude with a maximal diameter of 30 mm was applied,and it ended up with failure,which caused the patient to die from repeated heart failure and cardiogenic shock.Besides,the dead patient was not treated with PCI for the culprit vessel before placing the occlusion device.In the operation,the occlude of 16(12,22)mm diameter was placed into patients,3 cases of which showed complete closure(3/5),according to the instant angiography images after the operation.A case that indicated a small amount of residual shunt(1/5)took the scheduled parachute left Room volume reduction surgery,it showed disappeared residual shunt.Moreover,one case suf fered from moderate residual shunt(1/5)also recovered after taking the secondary interventricular septum closure operation.All the 5 patients who were successfully occluded survived.The postoperative left ventricular end diastolic diameter was signifi cantly smaller than that prior to operation,and LVEF and BNP were signifi cantly increased as well.Conclusions The septal perforation site of acute myocardial infarction was a left-to-right aneurysm.Threedimensional ultrasound confi rmed that the aneurysm was karst geomorphological sac-like squamous cell.Also,the treatment of interventional occlusion is relatively safe and ef fective.