《缺血性二尖瓣反流》

ISCHEMICMITRALREGURGITATIONINPATIENTSWITHACUTEMYOCARDIALINFARCTION急性心肌梗死合并缺血性二尖瓣反流编辑pptMechanicalComplicationsof

AcuteMyocardialInfarctionPrimaryPCIastheprincipalreperfusionstrategyfollowingSTEMI,theincidenceofmechanicalcomplicationshasreducedsignificantlytolessthan1%Ruptureoftheleftventricularfreewall(0.52%)Papillarymuscle(0.26%)Ventricularseptum(0.17%)编辑pptSurvivalafterMechanicalcomplication编辑pptACUTEMITRALREGURGITATION（MR）MildtomoderatechronicMRisfoundin15%to45%ofpatientsafterAMI，usuallytransientandasymptomaticAcuteMRsecondarytopapillarymuscleruptureisalife-threateningcomplicationwithapoorprognosisOccursin0.25%ofpatientsfollowingAMIandrepresentsupto7%ofpatientsincardiogenicshockfollowingAMIDiagnosedbetween2to7daysafterAMI，themediantimetopapillarymuscleruptureisapproximately13hoursIntroduction编辑pptFollowingAMI,incombinationwithchangesinLVshapeandregionalwallfunction,resultsinacuteMREvenslightmodificationsofLVgeometrycausedbyregionalwall-motionabnormalitymaycontributetotheincreasedfrequencyofMRafterAMICommonlyfollowinganinferiorMI，owingtothesinglebloodsupplytotheposteromedialpapillarymusclefromthePDPathophysiology编辑pptPrevalenceofmitralregurgitation(MR)withrespecttoposteriorpapillarymuscle(PM)perfusionpatternandinferiormyocardialinfarction(MI).PaoloVocietal.Circulation.1995;91:1714-1718Copyright©AmericanHeartAssociation,Inc.Allrightsreserved.编辑pptImmediatepulmonaryedema,hypotension,and,insomecases,cardiogenicshockAnewpansystolicmurmurisheardloudestatthecardiacapexElectrocardiographyusuallyconfirmsaninferiororposteriorMIChestradiographydemonstratespulmonaryedema,whichoccasionallyislocalizedtotherightupperlobeDiagnosis编辑pptDiagnosis编辑pptPromptdiagnosiswithimmediateinitiationofaggressivemedicaltherapyisvitaluntilemergentsurgicalinterventioncanbeperformedConcomitantrevascularizationduringmitralvalvesurgeryisassociatedwithimprovedshort-termandlong-termoutcomesTreatment编辑pptConcomitantrevascularizationduringmitralvalvesurgeryisassociatedwithimprovedshort-termandlong-termoutcomes

Kaplan-Meiergraphsdemonstrating(A)perioperativeand(B)15-yearactuarialsurvivalbenefitinpatientsundergoingconcomitantcoronaryrevascularizationfollowingacutepostinfarctionmitralregurgitation.([A]FromChevalierP,BurriH,FahratF,etal.Perioperativeoutcomeandlong-termsurvivalofsurgeryforacutepost-infarctionmitralregurgitation.EurJCardiothoracSurg2004;26(2):332;and[B]AdaptedfromLorussoR,GelsominoS,DeCiccoG,etal.Mitralvalvesurgeryinemergencyforsevereacuteregurgitation:analysisofpostoperativeresultsfromamulticentrestudy.EurJCardiothoracSurg2008;33(4):577,withpermission.)编辑pptTreatmentwithMRMedicaltherapyAimstoreducetheafterload,witharesultantdecreasedregurgitantfractionandincreasedforwardstrokevolumeandcardiacoutputVasodilatorsandinodilators,suchasnitrites,sodiumnitroprusside,diuretics,andphosphodiesterase-3inhibitors编辑pptmechanicalcardiacsupportIABPImpellaRecoverdeviceECMOcircuit,VADPositive-pressureventilationisusedwithgreateffect编辑pptAcutepostinfarctionMRisassociatedwithaninhospitalmortalityofbetween70%and80%withmedicaltreatment编辑pptEmergentsurgeryremainsthecornerstoneoftreatment编辑ppt编辑pptThelargestseriesofpatientswhounderwentsurgicalinterventionforpapillarymusclerupture：fromApril1985toJune2002werereviewed,55consecutivepatientswereincludedPatientswithacuteMR(definedasoccurringwithin1monthoftheinfarction)编辑pptThemeandelaybetweenAMIandmitralvalvesurgerywas7.3±7.4days(range1–33days)Surgerytookplacewithin:thefirst24hofdiagnosisofMRin24patientsBetweenthesecondandthefourteenthdayin27casesAfterthesecondweekin4cases编辑pptKaplan-Meiergraphshowingperioperative(thirty-day)survivalaccordingtorevascularisationstatus.PhilippeChevalieretal.EurJCardiothoracSurg2004;26:330-335©2004byOxfordUniversityPressPerioperativemortalitywas24%NodifferenceinearlymortalitybetweenpatientsundergoingconcomitantCABGandNorevascularizedgroup(CABG27.3%vsnoCABG26.4%;P>.9)编辑pptKaplan-Meiergraphshowinglong-termmortalityofpatientswhosurvivedtheperioperativeperiod.PhilippeChevalieretal.EurJCardiothoracSurg2004;26:330-335©2004byOxfordUniversityPresslong-termsurvivalimprovedinpatientsundergoingconcomitantrevascularizationat15years(CABG64%vsnoCABG23%;P<.001)编辑pptPhilippeChevalieretal.EurJCardiothoracSurg2004;26:330-335OnlytheAbsenceofRevascularisationwassignificantlypredictiveofincreasedperioperativemortalityFactorspredictiveofperioperativemortality编辑pptmitralvalverepairormitralvalvereplacement?编辑ppt编辑pptBaselineandOperativeCharacteristicsofPatientsWhoUnderwentSurgeryforPMR编辑pptPreoperativeangiography,performedinallpatientsexcept1single-vesselCADin17patients(31%)2-vesselCADin19patients(35%)3-vesselCADin14patients(26%)LeftmainCADin3patients(6%)编辑pptOperativemortalityaftersurgeryforpost-MIPMRstratifiedaccordingtopredictorsoflowmortality(surgeryperformedafter1990withassociatedCABG).AntonioRussoetal.Circulation.2008;118:1528-1534Copyright©AmericanHeartAssociation,Inc.Allrightsreserved.Improveoperativemortality(OR0.18;95%CI0.04–0.83;P=.011).编辑pptOverall(includingoperativemortality)long-termsurvival(solidline)andlong-termsurvivalfreeofCHF(dashedline)aftersurgeryforpost-MIPMR.Thenumberswitheachcurveindicatethe5-and10-yearestimatedsurvivalandsurvivalfreeofCHF(±SE).AntonioRussoetal.Circulation.2008;118:1528-1534Copyright©AmericanHeartAssociation,Inc.Allrightsreserved.编辑pptMRepVS.MVRMRepandMVRintermsofsurvival(5-yrs,62±13%versus66±7%;P=0.48)TrendforhighersurvivalfreeofCHFwithMRep(5-yrs,62±13%versus49±8%;P=0.13)Earlyaftersurgery,9patientsmilddegreeofMR,7afterMRepand1afterMVR(P=0.01),and1patienthadsevereMRintheMRepgroupThroughoutfollow-up,6patientsdevelopedsignificantMR,4intheMRepgroupand2intheMVRgroup(P=0.021).Reoperationforanyreasonwasperformedin3patients,2patientsafterMVRand1patientafterMRep.编辑pptconcomitantCABGThetrendafterconcomitantCABGforhigheroverallsurvival(5-yearsurvival,71±7%versus42±14%;P=0.16)andforhighersurvivalfreeofCHF(5-yearsurvival,57±8%versus33±14%;P=0.18)Afterpropensity-scoreadjustmentforage,sex,EF,severityofCAD,andyearofsurgery,CABGshowedonlyaweaktrendtowardlowerlong-termmortality(adjustedrelativerisk,0.45;95%CI,0.20to1.1;P=0.077).Thepatientsoperatedonbeyondthefirstmonthdisplayednobenefitinlong-termoutcome(allP>0.5)编辑ppt

Latesurvivalinoperativesurvivorsofsurgeryforpost-MIPMR(dashedline)vspatient