缺血性二尖瓣反流课件

1、 ISCHEMIC MITRAL REGURGITATION IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION 急性心肌梗死合并缺血性二尖瓣反流 ISCHEMIC MITRAL REGURGITATIOMechanical Complications ofAcute Myocardial InfarctionPrimary PCI as the principal reperfusion strategy following STEMI, the incidence of mechanical complications has reduced sign

2、ificantly to less than 1%Rupture of the left ventricular free wall (0.52%)Papillary muscle (0.26%)Ventricular septum (0.17%)Mechanical Complications ofAcSurvival after Mechanical complicationSurvival after Mechanical compACUTE MITRAL REGURGITATION（MR）Mild to moderate chronic MR is found in 15% to 45

3、% of patients after AMI，usually transient and asymptomaticAcute MR secondary to papillary muscle rupture is a life-threatening complication with a poor prognosisOccurs in 0.25% of patients following AMI and represents up to 7% of patients in cardiogenic shock following AMIDiagnosed between 2 to 7 da

4、ys after AMI，the median time to papillary muscle rupture is approximately 13 hoursIntroductionACUTE MITRAL REGURGITATION（MR）Following AMI,in combination with changes in LV shape and regional wall function, results in acute MREven slight modifications of LV geometry caused by regional wall-motion abn

5、ormality may contribute to the increased frequency of MR after AMICommonly following an inferior MI，owing to the single blood supply to the posteromedial papillary muscle from the PDPathophysiologyFollowing AMI,in combination wPrevalence of mitral regurgitation (MR) with respect to posterior papilla

6、ry muscle (PM) perfusion pattern and inferior myocardial infarction (MI). Paolo Voci et al. Circulation. 1995;91:1714-1718Copyright American Heart Association, Inc. All rights reserved.Prevalence of mitral regurgitaImmediate pulmonary edema, hypotension, and,in some cases, cardiogenic shock A new pa

7、nsystolic murmur is heard loudest at the cardiac apexElectrocardiography usually confirms an inferior or posterior MIChest radiography demonstrates pulmonary edema, which occasionally is localized to the right upper lobeDiagnosisImmediate pulmonary edema, hypDiagnosisDiagnosisPrompt diagnosis with i

8、mmediate initiation of aggressive medical therapy is vital until emergent surgical intervention can be performedConcomitant revascularization during mitral valve surgery is associated with improved short-term and long-term outcomesTreatmentPrompt diagnosis with immediatConcomitant revascularization

9、during mitral valve surgery is associated with improved short-term and long-term outcomesKaplan-Meier graphs demonstrating (A) perioperative and (B) 15-year actuarial survival benefit in patients undergoing concomitant coronary revascularization following acute postinfarction mitral regurgitation. (

10、A From Chevalier P, Burri H,Fahrat F, et al. Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation. Eur J Cardiothorac Surg 2004;26(2):332; and B Adapted from Lorusso R, Gelsomino S, De Cicco G, et al. Mitral valve surgery in emergency for severe acut

11、e regurgitation: analysis of postoperative results from a multicentre study.Eur J Cardiothorac Surg 2008;33(4):577, with permission.)Concomitant revascularization Treatment with MRMedical therapy Aims to reduce the afterload,with a resultant decreased regurgitant fraction and increased forward strok

12、e volume and cardiac outputVasodilators and inodilators, such as nitrites, sodium nitroprusside, diuretics, and phosphodiesterase-3 inhibitorsTreatment with MRMedical theramechanical cardiac supportIABPImpella Recover deviceECMO circuit,VADPositive-pressure ventilation is used with great effect mech

13、anical cardiac supportAcute postinfarction MR is associated with an inhospital mortality of between 70% and 80% with medical treatmentAcute postinfarction MR is assEmergent surgery remains the cornerstone of treatmentEmergent surgery remains the c缺血性二尖瓣反流课件The largest series of patients who underwen

14、t surgical intervention for papillary muscle rupture：from April 1985 to June 2002 were reviewed,55 consecutive patients were includedPatients with acute MR (defined as occurring within 1 month of the infarction)The largest series of patientsThe mean delay between AMI and mitral valve surgery was 7.3

15、 7.4 days (range 133 days)Surgery took place within :the first 24 h of diagnosis of MR in 24 patientsBetween the second and the fourteenth day in 27 casesAfter the second week in 4 casesThe mean delay between AMI andKaplan-Meier graph showing perioperative (thirty-day) survival according to revascul

16、arisation status.Philippe Chevalier et al. Eur J Cardiothorac Surg 2004;26:330-3352004 by Oxford University PressPerioperative mortality was 24%No difference in early mortality between patients undergoing concomitant CABG and No revascularized group (CABG 27.3% vs no CABG 26.4%; P.9)Kaplan-Meier gra

17、ph showing perKaplan-Meier graph showing long-term mortality of patients who survived the perioperative period.Philippe Chevalier et al. Eur J Cardiothorac Surg 2004;26:330-3352004 by Oxford University Presslong-term survivalimproved in patients undergoing concomitant revascularization at 15 years (

18、CABG 64% vs no CABG 23%; P0.5)concomitant CABGThe trend afte Late survival in operative survivors of surgery for post-MI PMR (dashed line) vs patients with MI without PMR (solid line) and matched for age, sex, EF, year, and location of MI, as well as survivorship of the first 30 days. Antonio Russo et al. Circulation. 2008;118:1528-1534Copyright American Heart Association, Inc. All rights reserved. Late survival in operative su缺血性二尖瓣反流课件Summary of A