心脏破裂的预测和预防.ppt

心脏破裂的预测和预防,分类,室间隔破裂乳头肌断裂心室游离壁破裂,在再灌注时代之前，室间隔破裂发生率1-3%在GUSTO-1研究，应用SK/tPA时代，室间隔穿孔的发生率0.34%，确诊的为0.2%提示再灌注治疗降低了室间隔破裂的发生率,室间隔破裂的危险因素,前壁心梗比其他部位的心梗更容易发生溶栓时代之前的常见危险因素：高血压、高龄（60-69）、女性和无心绞痛及心梗病史（首次心梗！）女性高龄心梗患者溶栓，容易发生！大面积心梗、右室心梗也是危险因素！心绞痛常意味着预适应和侧枝形成，不利于破裂。,病理学改变,破裂部位的室间隔变薄和坏死中性粒细胞浸润凋亡分解酶的释放解聚心肌组织病理改变呈现时间依赖性，24为凝固性坏死早期破裂发生在粘膜内有巨大血肿的梗塞,病理学,游离壁破裂分了三型：室壁没有变薄而突然撕裂破裂之前心肌糜烂但有血栓覆盖心肌明显变薄，继发室壁瘤形成，然后在瘤的中央穿孔-BeckerandvanMantgem,病理学,破裂的大小：数毫米到几个厘米简单破裂和复杂破裂,Figure1.FindingsatAutopsyinaPatientwithaSimpleVentricularSeptalRupture.Thereisadiscretedefectwithadirectthrough-and-throughcommunicationacrosstheseptum.Theperforationisatthesamelevelonbothsidesoftheseptum:theleftventricularaspectoftheinterventricularseptum(LVS),andtherightventricularaspectoftheinterventricularseptum(RVS).MVdenotesmitralvalve.,前壁心梗的简单破裂,好发时段,没有再灌注的第一周内容易破裂破裂有两个高峰：心梗第一天；3-5天罕见于两周以后溶栓的患者好发的中位时间为24小时溶栓虽然缩小心肌梗塞面积，但加重血肿促发撕裂,造影所见,多支病变患者多发?但GUSTO-1研究发现，室间隔破裂者中57%为单支病变侧支降低破裂风险,临床表现,胸疼心衰表现，恶心，欲呕粗糙、全收缩期杂音，胸骨左缘向背部、心尖区或胸骨右缘放射半数患者可触及胸骨旁震颤S3奔马律常见,诊断,心梗病人出现泵衰时，可见于好多情况超声的敏感性和特异性几乎100%机械通气的患者可能需要经食道超声肺动脉导管-右心室血氧饱和度增加左心室造影,治疗和预后,非常的差！,FrequencyUnitedStates,Myocardialrupturecomplicatesupto10%ofAMIs.Approximately6-10%ofpenetratingchestwoundsand15-75%ofbluntchesttraumasareassociatedwithcardiacinjury.Myocardialruptureoccursin10-15%offatalmotorvehicleaccidents.Incidenceofcardiacrupturefollowingblunttraumais0.5-2%amonghospitaltraumaadmissions.,Mortality/Morbidity,Myocardialruptureisresponsiblefornearly15%ofallin-hospitaldeathsamongpatientswithAMI.Itisthesecondmostcommoncause,afterpumpfailure,ofin-hospitalmortalityamongpatientswithAMI.HistoryMyocardialruptureafterAMImayoccurfrom1dayto3weeksafterinfarction.Mostrupturesoccur3-5daysafterinfarction.,Causes：AcutemyocardialinfarctionRiskfactorsformyocardialrupturefollowingAMIincludearelativelysmallfirstAMI,femalesex,ageolderthan60years,hypertension,useofnonsteroidalanti-inflammatorydrugs(NSAIDs)orsteroidsduringtheacutephaseofAMI(interferencewiththehealingprocess),latethrombolysis(11h),postinfarctanginaandelevatedpeakserumC-reactiveprotein.ProtectivefactorsincludeLVhypertrophy,historyofpreviousinfarcts,congestiveheartfailure,historyofchronicischemicheartdisease,earlyuseofbeta-blockersafterAMI,andsuccessful(andtimely)primarypercutaneouscoronaryintervention.,Causes：Trauma,Traumamaybebluntorpenetrating.Traumaalsomaybeiatrogenicinnature,resultingfrom(1)diagnosticcatheterization,includingtransseptalpunctureandendomyocardialbiopsy;(2)balloonvalvuloplasty;(3)pericardiocentesis;(4)placementoftemporaryorpermanentpacingcatheters;and(5)cardiacsurgery,especiallymitralvalvereplacement.,Causes：Infection,RuptureofamyocardialabscessorAMIsecondarytocoronaryembolismofthevegetativematerialmayoccurinpatientswithinfectiveendocarditis.Otherinfectionsmayincludetuberculosis,echinococcalcysts,andmyocarditis.,causes,AorticdissectionAorticdissectionisalsoacause.MalignancyPrimarycardiactumorsmaybepresent.Patientsmayhavesecondaryormetastatictumorsoftheheart.Patientsmayhavelymphomaoracutemyeloblasticleukemia.SarcoidosisSarcoidosishasbeennoted.,辅助检查,Chestradiographinposteroanteriorprojectionshowingalargepseudoaneurysmmanifestingasabulgeintheleftcardiacborder,Electrocardiogram,Evidencefortransmural(STelevation)AMIispresentinmostpatientswithischemicmyocardialrupturepriortotheevent.PersistentSTsegmentelevationfollowingAMIisassociatedwithhigherincidenceofmyocardialrupture.InthesettingofananteriorAMI,STelevationordevelopmentofQwavesininferiorleads(asaresultofocclusionofalarge,wrap-aroundleftanteriordescendingcoronaryartery)isassociatedwithanincreasedriskofVSD.Followingtraumaticcardiacinjury,ECGchangesusuallyarenonspecific.,Freewallruptureisoftenassociatedwithasuddenonsetofbradycardiaandelectromechanicaldissociation(pulselesselectricalactivity).,Inpericardialtamponade,theECGmayshowlow-voltageQRScomplexes,especiallyintheprecordialleads.Electricalalternans,commonlyseenwithlarge,slowlyaccumulatingeffusions,isoftenabsentinthesettingofacutehemorrhagicpericardialtamponade.,RightbundlebranchblockisfrequentlyobservedinpatientswithVSD.Lessfrequently,patientsmayhavecompleteheartblock.PatientswithpseudoaneurysmmaydemonstrateST-segmentelevation,nonspecificSTchanges,orpathologicQwavesonECG.AllpatientswithsignificantthoracicblunttraumashouldhaveECGandcardiacmonitoring.TheECGmayshowSTelevationornonspecificST-Tchanges.NormalECGfindingsdonotexcludemyocardialinjuryfollowingblunttrauma.,最有意义的提示,69岁患者无明显冠心病危险因素。因胸疼就诊，因心电图和酶学正常而出院。5天后胸疼持续急诊入院，心电图心梗后演变加酶学有意义，诊断亚急性下壁心肌梗塞。因胸疼严重而行急诊手术右冠状动脉TIMI2血流，成功一枚DES症状发作7天（PCI后第二天）后，心电图有了新的变化。,于是复查了心肌酶，但和PCI后的比较无增高但CRP和WBC轻度升高病人一般情况出奇的好！于是床旁TTE:少到中量的心包积液，下壁和后壁稍多。,Acanaliculartractfromendotopericardiumwasseenalongtheinterfacebetweenthenecroticandthenormalcontractingmyocardium(Figure3,Additionalfile2,Additionalfile3,Additionalfile4).,Power-DopplerevaluationadditionallysuggestedanabnormalbloodleakacrosstheinferiorLVwall(Figure4,Additionalfile5)and,onthebasisofthesefindings,aLVFWRwassuspected.Whilethetransoesophageal,Whilethetransoesophagealechocardiogramwithintravenousechocontrastbroughtnofurtherinput,cardiacMRIimages(Fi