急性心肌梗死后室间隔穿孔患者的手术时机与预后分析

Optimal repair timing and predictors of death in patients with ventricular septal rupture post myocardial infarction

目的探讨急性心肌梗死后室间隔穿孔(VSR)患者的最佳手术时机以及与患者院内死亡相关的危险因素。方法根据入选及排除标准, 对我院2019年1月至2023年8月期间收治的100例室间隔穿孔患者进行了回顾性分析。比较患者在不同时间手术的病死率以及死亡组与生存组患者在一般临床资料、住院治疗及实验室检查方面的差异。分析与患者预后相关的危险因素采用logistic二元回归模型。结果 100例患者院内病死率56%, 其中手术治疗患者病死率34.9%, 保守治疗患者病死率91.9%, 手术患者中0~3天手术者院内病死率63.6%, 4~14天手术者院内病死率38.1%, 14天以上手术者院内病死率22.6%;死亡组患者在入院心率、急性心肌梗死后血运重建比例、穿孔大小、休克分期、冠状动脉病变严重程度上与生存组差异均有统计学意义(P<0.05);死亡组的C反应蛋白、白细胞计数、B型脑钠肽(BNP)水平、肌酐水平以及血乳酸水平均高于生存组(P<0.05)。二元回归模型中纳入两组比较差异有统计学意义的变量, 结果提示白细胞计数、血乳酸水平、BNP水平与患者死亡呈正相关性。结论手术修复是大多数VSR患者最有效治疗方式, 对于血流动力学稳定且代偿期心衰的VSR患者延迟手术可能有更多获益。此外, VSR患者院内死亡的独立危险因素还包括白细胞计数、血乳酸水平及BNP水平。

Objective The main objective of this study was to analyze the optimal timing for repair of post-AMI ventricular septal rupture(VSR).Secondary endpoints were to determine which factors could influence in-hospital mortality in the patients with VSR.Methods We designed an observational,retrospective study,selecting 100 patients with post-AMI VSR between January 1,2019 and August 31,2023,with inclusion and exclusion criteria.Analyzed the usefulness and appropriate timing of surgery in this patient cohort.Compared the background characteristics,treatment and laboratory data between survival and death group.The risk factors for in-hospital mortality were assessed using multivariate analysis with a logistic regression model.Results The overall in-hospital mortality rate was 56%,the mortality rate of surgical patients was 34.9%,and the mortality rate of conservative patients was 91.9%.Patients operated on very early(0-3 days)had significantly poor results with a mortality rate of 63.6%while those operated within 2 weeks,had a mortality rate of 38.1%,and those operated later(>14 days)showed 22.6%mortality.There were statistically significant differences between the two groups in terms of heart rate,ratio of revascularization,size of VSR,shock stage and severity of coronary artery lesions(P<0.05),and the C-reactive protein,WBC count,BNP level,creatinine level and blood lactate level in the death group were higher than those in the survival group(P<0.05).Logistic regression analysis revealed that the level of white blood cell count,lactate and brain natriuretic peptide were independent risk factors for in-hospital mortality.Conclusion In our study,we observed that surgery is the definitive therapy for the majority of patients.For patients who are hemodynamically stable and have compensated heart failure,there may be more benefit from delayed ventricular septal rupture repair.The risk factors for in-hospital mortality were the elevated lactate levels,BNP levels and WBC count.