A Sandwich Technique Employing Right Ventricular Incision to Repair Posterior Ventricular Septal Rupture with Right Ventricular Wall Dissection: A Case Report

Background: Ventricular septal rupture (VSR) leading to right ventricular (RV) wall dissection is an extremely rare and life-threatening complication of inferior myocardial infarction (MI) with posterior VSR. Its rare incidence and complex pathology make it difficult to select the appropriate surgical procedures to prevent fatalities. Case Presentation: A 68-year-old woman was transferred to our hospital because of a post-infarction VSR 12 days after symptom onset. Short-axis image obtained using transthoracic echocardiography demonstrated a large posterior VSR. Moreover, the VSR was continuous, with a large echo-free space in the posterior wall of the right ventricle. Color echocardiography showed blood flowing into the echo-free space through the septal defect and blood flowing out into the RV lumen. Coronary angiography revealed complete occlusion of the second segment of the right coronary artery. Thus, dissection of the posterior wall of the right ventricle that continued into the RV lumen was considered to have been caused by the posterior VSR caused by an inferior MI. The patient underwent urgent surgery to repair the VSR using the sandwich double-patch technique by making a posterior RV incision that was repaired using a third patch. No additional procedure was required to block the flow from the cavity of the RV wall dissection into the RV lumen. Postoperative echocardiography and contrast-enhanced computed tomography demonstrated that the VSR was closed securely and the RV wall dissection was almost completely thrombosed. Conclusion: In this case, a patient with a posterior VSR and RV wall dissection was successfully treated using the sandwich double-patch technique with a posterior RV incision. No additional procedure may be needed for RV wall dissection when a secure VSR repair is complete;however, close follow-up is essential to improve the long-term prognosis.

Impact of cardiac magnet resonance imaging on management of ventricular septal rupture after acute myocardial infarction

A 74-year-old man was admitted to the cardiac catheterization laboratory with acute myocardial infarction. After successful angioplasty and stent implantation into the right coronary artery, he developed cardiogenic shock the following day. Echocardiography showed ventricular septal rupture. Cardiac magnet resonance imaging (MRI) was performed on the critically ill patient and provided detailed information on size and localization of the ruptured septum by the use of fast MRI sequences. Moreover, the MRI revealed that the ventricular septal rupture was within the myocardial infarction area, which was substantially larger than the rupture. As the patient's condition worsened, he was intubated and had intra-aortic balloon pump implanted, and extracorporeal membrane oxygenation was initiated. During the following days, the patient's situation improved, and surgical correction of the ventricular septal defect could successfully be performed. To the best of our knowledge, this case report is the first description of postinfarction ventricular septal rupture by the use of cardiac MRI in an intensive care patient with cardiogenic shock and subsequent successful surgical repair.

Noncoronary sinus of Valsalva rupture into the right atrium with a coexisting perimembranous ventricular septal defect

Ruptured sinus of Valsalva is very uncommon,and is < 1% of all congenital defects.The incidence ranges from 0.1%-3.5%.There is a male to female predominance of 4:1,with the highest incidence in the Asian population.Higher incidence is also seen in patients with Marfan's syndrome and Ehlers Danlos syndrome.There is a higher association of ruptured sinus of Valsalva with ventricular septal defect(VSD),aortic stenosis,and bicuspid valve defect.While most patients with VSD often have rupture of their right coronary sinus of Valsalva into the right ventricle due to poor structural integrity,we present a rare case of a patient with VSD who had rupture of his noncoronary sinus of Valsalva into the right atrium.

Hybrid Repair of Two Consecutive Acute Ventricular Septal Ruptures after Evolving Myocardial Infarction: Case Report

Background: Acute Ventricular septal rupture is one of dreadful complications of acute evolving myocardial infarction. Despite urgent management is lifesaving, it is still challenging and has a high risk of mortality particularly if recurrent or residual defects occurred. Evolving of skillfulness in transcatheter intervention of heart diseases paved the way for successful hybrid management of challenging cardiac cases specially for residual complicated cases post cardiac surgery. Case Presentation: We described here a successful hybrid two stage technique (surgical then transcatheter approach) to close two consecutive acute ventricular septal ruptures in 75 years old female presented with cardiogenic shock post evolving myocardial infarction. Conclusion: Hybrid repair by surgical and transcatheter interventions may be a good therapeutic modality for acute septal ruptures specially for residual or new defects after initial closure.

Total Transmural Sutures (TTS) Method, Modified Infarction Exclusion Technique for Ventricular Septal Rupture after Extensive Myocardial Infarction

The infarction exclusion technique using endoventricular continuous sutures for ventricular septal rupture after acute myocardial infarction may be a difficult surgical technique and create residual shunt due to fragile myocardium. We present a patient of ventricular septal rupture (VSR) after extensive anteroseptal myocardial infarction who underwent successful repair using a modified infarction exclusion technique. In our procedure interrupted mattress sutures were placed through the ventricular wall in a way as to exclude the VSR and infarcted muscle of the left ventricle. A heterogeneous pericardial patch is sutured to healthy endocardium in the free and septal wall all around the infarcted area. We describe a procedure for repairing postinfarction VSR, by the infarction exclusion technique with total transmural sutures (TTS) method.

Restrictive perimembranous ventricular septal defect with left to right Shunt post urgent aortic balloon valvuloplasty and transcatheter aortic valve replacement

An 86-year-old male patient was admitted in our cardiology ward with signs of congestive biventricular heart failure. The patient presented with deteriorating dyspnea on mild exertion and at rest the last days, compatible with class NYHA Ⅲ-Ⅳ heart failure, bilateral peripheral oedema, increased NT-proBNP （9198 pg/mL）, mildly elevated Troponin （TnT 64 pg/mL）, interstitial pulmonary oedema and bilateral pleural effusions in chest X ray.

甘油三酯葡萄糖指数与心肌梗死后室间隔穿孔患者30天预后的相关性研究患者的临床特征及预后比

目的探讨甘油三酯葡萄糖指数(TyG)与心肌梗死后室间隔穿孔患者30天全因死亡率的关系。方法回顾性分析2009年1月至2023年10月中国医学科学院阜外医院和新疆维吾尔自治区人民医院冠心病重症监护病区收治的急性心肌梗死合并室间隔穿孔患者(n=132)的临床资料及30天预后情况,根据TyG均值分为低TyG组(TyG≤9.25,n=71)和高TyG组(TyG>9.25,n=61)。采用多因素Cox回归分析及Kaplan-Meier分析来验证TyG指数的应用价值。结果与低TyG组(TyG≤9.25)相比,高TyG组患者组年龄更大[(67.6±8.4)岁比(64.0±10.2)岁,P=0.028],男性比例更高(50.8%比31.0%,P=0.020),白细胞水平上升幅度更大[(13.54±5.55)×10^(9)/L比(11.03±4.45)×10^(9)/L,P=0.005],30天全因死亡率更高(57.4%比36.6%,P=0.017)。多因素回归分析提示,低TyG指数(HR=0.502,95%CI 0.302~0.835,P=0.008)是30天全因死亡的保护性预测因素。结论TyG指数是急性心肌梗死合并室间隔穿孔30天全因死亡的潜在预测指标。

机械辅助循环在心肌梗死后室间隔穿孔治疗中的临床应用进展

心肌梗死后室间隔穿孔(post-infarct ventricular septal rupture,PIVSR)是心肌梗死的严重并发症,常表现为心源性休克,即使提供及时干预,患者院内病死率仍极高。目前指南建议对所有患者立即进行手术,但理想的干预时机仍存在争议。近年来,包括IABP、体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)、Impella和TandemHeart等在内的现代机械循环支持(mechanical circulatory support,MCS)技术发展迅速,为患者提供稳定血流动力学支持的同时使延迟手术治疗成为可能,其可能成为PIVSR患者成功救治的新希望。然而,相关临床证据的缺乏一定程度上限制了MCS的进一步推广,不同MCS策略的比较和选择也成为PIVSR患者救治过程中丞待解决的关键性问题,基于这些疑问本文就PIVSR患者中MCS的辅助治疗作一综述。

急性心肌梗死合并室间隔穿孔的临床特征及短期预后分析

目的观察急性心肌梗死(AMI)合并室间隔穿孔(VSR)患者的临床特征及分析影响短期预后的相关因素。方法纳入空军军医大学第一附属医院2010年1月~2023年6月因急性心肌梗死合并室间隔穿孔住院患者87例,根据不同标准将研究对象划分为好转组(n=46)与死亡组(n=41)或药物保守组(n=70)与手术干预组(n=17)。对其临床资料进行回顾性分析,对比院内生存组及死亡组,分析影响短期预后的因素。结果与好转组比较,死亡组男性比例低(P<0.05)、吸烟史比例低(P<0.05)、穿孔大小数值低(P<0.05)、谷草转氨酶数值高(P<0.01)、谷丙转氨酶数值高(P<0.05)、肌酐数值高(P<0.05)、肌钙蛋白I数值高(P<0.01)、NT-proBNP数值高(P<0.05)、住院时间长(P<0.01)、合并心源性休克比例高(P<0.01),且外科手术比例低(P<0.05)。手术干预组与药物保守组比较,明显改善短期预后情况:好转率高,死亡率低,两组比较有统计学意义(P<0.05)。Logistic回归分析显示心源性休克是VSR患者发生短期内死亡的独立危险因素。结论急性心肌梗死合并室间隔穿孔患者多数预后不良,女性、多脏器功能衰竭者死亡率高。心源性休克是VSR患者发生短期内死亡的独立危险因素,适时选择手术能改善短期预后。

心肌梗死后室间隔穿孔经皮介入封堵治疗时机的选择

目的 探讨经皮介入封堵(transcatheter closure,TCC)心肌梗死(acute myocardial infarction,AMI)后室间隔穿孔(ventricular septal rupture,VSR)适宜手术时机。方法 回顾性分析2013年1月至2019年7月河南省人民医院心脏中心TCC治疗心肌梗死后室间隔穿孔(postinfarction ventricular septal rupture,PIVSR)51例患者临床资料,根据术后30 d内是否死亡分为存活组和死亡组。采用logistic回归及Cox回归分析30 d死亡及远期死亡的危险因素。利用ROC曲线评价VSR至TCC时间对30 d死亡的预测价值,通过计算约登指数的最大值得出最佳截断值,并根据截断值将人群分为两组(早期组与延迟组),采用Kaplan-Meier法进行生存分析,分析两组患者的长期预后。结果 TCC治疗VSR患者51例,平均年龄为(66.73±7.77)岁,其中女性32人(62.7%),中位随访时间[490(107,1019)]d。AMI至VSR的平均时间间隔为[2(1,3)]d,VSR至TCC的平均时间间隔为[23(17,32)]d。高N末端B型利钠肽原(NT-proBNP)、高敏肌钙蛋白升高、心源性休克是患者死亡的危险因素,而术前较高射血分数(EF)值、延迟手术是其保护因素(P<0.05)。将VSR至TCC时间纳入30 d死亡ROC曲线得出最佳截断值为21 d。早期组(≤3周)术后生存率(62.50%,15/24)低于延迟组(>3周)(96.30%,26/27)(χ^(2)=9.496,Log-rank P=0.002)。结论 延迟手术是患者死亡的保护因素,对于病情较稳定的PIVSR患者,建议发生VSR 3周后进行TCC手术,减少死亡事件发生。

急性心肌梗死后室间隔穿孔患者的临床特点分析

目的探讨急性心肌梗死(acute myocardial infarction,AMI)后发生室间隔穿孔(ventricular septal rupture,VSR)患者的临床特点。方法入选2010年12月至2018年12月南京医科大学附属南京医院明确诊断为AMI的患者4221例,其中发生VSR的患者50例(VSR组),按照1∶10匹配原则,随机选取未发生室间隔穿孔(且未发生左心室游离壁破裂)的患者500例作为非VSR组,比较两组患者的临床特点。结果(1)AMI患者中出现VSR的风险为1.18%。(2)与非VSR组相比,VSR组女性患者较多,前壁心肌梗死较多,心功能更差,院内病死率较高,差异有统计学意义(P<0.05)。(3)41例(82.0%)患者VSR发生在AMI起病1周之内,其中12例(24%)24 h内发生VSR;7例(14%)发生于1~2周之间。(4)Logistic回归发现:女性(HR=8.451,95%CI:3.433~20.807,P<0.001)、累及前壁心肌梗死(HR=3.069,95%CI:1.051~8.962,P=0.040)、ST段抬高型心肌梗死(HR=10.412,95%CI:1.057~102.525,P=0.045)、入院前胸痛时间大于37 h(HR=6.953,95%CI:2.778~17.405,P<0.001)和就诊时心率快(大于均值80.88次/min)(HR=3.293,95%CI:1.186~9.142,P=0.022)。结论急性心肌梗死发生VSR的风险约为1.18%,而且通常发生在心肌梗死1周内。VSR的危险因素包括累及前壁的心肌梗死、ST段抬高型心肌梗死、入院前胸痛时间大于37 h和就诊时心率快,而男性是AMI患者VSR的保护因素。

主动脉内球囊反搏有效改善急性心肌梗死合并室间隔穿孔患者的循环

目的:探讨主动脉内球囊反搏(IABP)对急性心肌梗死(AMI)并发室间隔穿孔(VSR)患者循环的影响。方法:回顾性分析59例AMI合并VSR患者的临床资料,其中42例患者植入IABP辅助循环为IABP组,17例患者予以药物保守治疗为药物治疗组。比较IABP组与药物治疗组间患者一般血流动力学(包括IABP植入前、后平均血压、心率、无创心功能指标)、血乳酸水平、心脏超声等指标。根据患者是否存在休克状态,将59例患者分为休克组(40例)与非休克组(19例),比较休克组与非休克组间一般血流动力学(包括IABP植入前、后平均血压、心率、无创心功能)、血乳酸水平、心功能等指标,并观察30d临床预后。结果:IABP治疗组患者在植入24 h后平均心率下降、平均动脉血压升高、血乳酸水平下降、心脏超声左室射血分数(LVEF)值提升、无创心功能心脏指数升高(P均<0.05);药物治疗组上述指标无明显改变。IABP治疗组与药物治疗组30 d死亡率比较,差异无统计学意义(P>0.05)。结论:对于AMI合并VSR患者,植入IABP可显著改善患者血流动力学、酸中毒、临床心功能及循环状态。

Clinical analysis and risk stratification of ventricular septal rupture following acute myocardial infarction

Background Ventricular septal rupture （VSR） remains an infrequent but devastating complication of acute myocardial infarction （AMI）. The best time to undergo surgical repair is controversial and there is currently no risk stratification for patients with VSR to guide treatment. The purpose of this study was to review the clinical outcomes of 70 patients with VSR, to analyze the short-term prognosis factors of VSR following AMI, and to make a risk stratification for patients with VSR.

急性心肌梗死后合并室间隔穿孔不同术式的回顾分析

目的回顾分析急性心肌梗死(acute myocardial infarction,AMI)后合并室间隔穿孔(postinfarction ventricular septal rupture,PIVSR)行外科修补手术或介入封堵术治疗的临床特征及预后情况。方法回顾性分析自2017-2020年于河南省人民医院心脏中心就诊并确诊为PIVSR的64例患者的临床资料,根据手术方式的不同分为介入封堵术组(n=50)和外科修补手术组(n=14),分析两组患者的基线资料、术前、术中、术后相关结果及随访结局等。结果与外科修补手术组相比,介入封堵术组女性多、穿孔(VSR)直径小、病情相对轻、住院费用低、手术时间短、ICU滞留时间短、术后残余分流比例高。随访结果显示,两组患者的左室舒末径(LVEDD)、左心室射血分数(LVEF)、6 min步行试验术后1个月和6个月之间的差异及随访无死亡事件生存率差异均无统计学意义(P>0.05)。在Cox回归分析中显示心功能Killip分级(Ⅱ-Ⅳ级)是影响两组患者生存的危险因素。结论PIVSR患者接受介入封堵术预后好,术后患者创伤小,恢复快,住院费用低,远期生存率较高,介入封堵术作为一种微创、有效的治疗方法,很可能成为外科手术修复的一种有价值的替代治疗。

Ventricular septal rupture and partial left ventricular posterior wall tear resulted from blunt chest trauma

Cardiac contusion and valvular injuries are the most common cardiac injuries after a blunt traumatic chestinjury.1 But ventricular septal rupture （VSR） is a rare finding after a blunt chest wall trauma.2 Here we report a 16 years old young man with no medical history who sustained a chest wall injury after a bookshelf falling on his left chest. He was hospitalized because of his chest pain and heaviness. Initial physical examination showed parasternal Ⅲ-Ⅳ systolic murmur. ECG showed a complete right bundle branch conduction blockage.

主动脉内球囊反搏抢救急性心肌梗死后室间隔穿孔患者的疗效分析

目的 探讨主动脉内球囊反搏（IABP）抢救急性心肌梗死（AMI）后发生室间隔穿孔（VSR）患者的疗效及作用.方法 对我院心内科2007-07~2012-04收治的20例急性ST段抬高性心肌梗死（STEMI）并室间隔穿孔患者的临床资料进行回顾性分析.结果 20例AMI合并室间隔穿孔患者均给予药物治疗,其中14例药物治疗的同时给予IABP支持,其即刻血流动力学改善率为57.1%,3例行介入封堵术,2例行外科手术治疗,均存活;1例病情稳定出院,其余6例于住院期间死亡.结论 IABP在抢救AMI后VSR患者时能够暂时稳定患者血流动力学,为手术争取时间,最终降低病死率,是手术前重要的过渡手段.

急性心肌梗死合并室间隔穿孔的临床及预后分析

目的探讨急性心肌梗死(AMI)后发生室间隔穿孔的临床特征、冠状动脉造影表现、治疗方法及预后情况。方法我院1996年1月至2003年12月期间收治急性透壁心肌梗死1881例,发生室间隔穿孔13例,穿孔发生率069%。另有22例因AMI已并发室间隔穿孔而转来我院的患者,共35例进行分析。其中男性24例(686%),女性11例(314%)。结果资料分析结果21例(600%)合并高血压病,18例(514%)有吸烟史。前壁心肌梗死31例(886%),下后壁心肌梗死4例(114%)。22例患者施行了冠状动脉造影,梗塞相关血管前降支占818%,完全闭塞占727%。心原性休克21例(600%),心功能Ⅳ级26例(743%),Ⅲ级9例(257%)。室间隔穿孔多发生在AMI后1周内(914%)。超声心动图提示室间隔缺损,穿孔直径范围05～28cm,多数位于室间隔近心尖部。7例(20%)进行溶栓治疗,但未成功。21例(60%)施行外科手术治疗,全部存活。14例药物治疗,仅1例存活,死亡13例,总病死率371%,药物治疗病死率929%。结论AMI并发室间隔破裂并不常见,多发生在广泛前壁心肌梗死的患者,多数迅速发展至心原性休克,内科治疗病死率很高;如药物治疗能维持血流动力学稳定至穿孔后4周手术,外科治疗可提高生存率。

急性心肌梗死并发游离壁破裂和室间隔穿孔患者的临床特征及预后比较

目的:分析急性心肌梗死(AMI)并发游离壁破裂和室间隔穿孔患者的临床特征及60天预后。方法:回顾性分析2008年10月至2017年12月中国医学科学院阜外医院冠心病重症监护病房收治的7 315例AMI患者,比较游离壁破裂和室间隔穿孔患者的一般临床资料、住院相关检查结果、手术治疗(冠状动脉旁路移植术+室间隔穿孔修补术或游离壁破裂心脏修补术)及60天预后等情况。结果:共83例(1.13%)患者发生心脏破裂(包括游离壁破裂和室间隔穿孔),不同年份的发生率相似。其中33例(0.68%)发生游离壁破裂,50例(0.45%)发生室间隔穿孔。游离壁破裂的发生时间早于室间隔穿孔[(3.3±2.6)d vs(4.1±3.6)d,P=0.01]。仅2例(6.1%)游离壁破裂患者成功接受外科手术治疗,25例(50.0%)室间隔穿孔患者成功接受外科手术治疗。游离壁破裂患者60天生存率明显低于室间隔穿孔患者(12.1%vs 48.0%,P=0.002)。结论:室间隔穿孔患者接受外科手术率更高,预后更好,对AMI合并室间隔穿孔患者更应重视积极的内外科联合治疗以达到更好的预后。

70例急性心肌梗死合并室间隔穿孔患者的临床分析

目的：总结急性心肌梗死（AMI）合并室间隔穿孔（VSR）患者的临床特点及预后。方法：我院2002—01到2010—09间收治的AMI患者共12354例，其中合并VSR患者70例占收治AMI患者的0．57％，其中男33例（47．1％），女37（52．9％），平均年龄（68．1±8．5）岁。对这70例AMI合并VSR患者的临床资料进行回顾性分析。结果：70例AMI合并VSR患者，继发于前壁心肌梗死者54例（77．1％）。VSR患者30天死亡率为55．7％，1年死亡率为64．3％；保守治疗49例，30天死亡率为77．6％，1年死亡率为87．8％；手术治疗21例，30天死亡率为4．8％，1年死亡率为9．5％；接受手术治疗患者的30天及1年死亡率均显著优于接受保守治疗患者（P〈0．005）.仅1例AMI后6天行急诊手术治疗的患者于围术期死亡，所有AMI后2周以上行外科手术治疗的患者均好转出院。结论：VSR是AMI少见但严重的并发症，手术治疗的近期及远期预后均显著优于保守治疗，AMI后2周以上行外科手术治疗成功率高，对于强化内科保守治疗后仍出现血流动力学不稳定、预计不能存活至AMI后4-6周的危重患者，可适当提前外科手术时间，以挽救更多患者的生命。

介入治疗急性心肌梗死合并室间隔穿孔六例

目的评价急性心肌梗死（AMI）合并室间隔穿孔（VSR）经导管介入治疗的疗效。方法对6例明确诊断的患者按常规方法行VSR封堵治疗，并根据病情行冠状动脉介入治疗（PCI）。结果VSR发生至封堵的时间为3～30d。6例中2例封堵失败，住院期间因心源性休克死亡，余4例成功封堵的患者随访0．5～4年，心功能较术前改善。结论经导管介入治疗AMI合并VSR安全可行，可以改善预后。