《缺血性二尖瓣反流》

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急性心肌梗死合并缺血性二尖瓣反流整理课件Mechanical Complications ofAcute Myocardial Infarction Primary PCI as the principal reperfusion strategy following STEMI, the incidence of mechanical complications has reduced significantl

2、y to less than 1% Rupture of the left ventricular free wall %) Papillary %) Ventricular septum %)整理课件Survival after Mechanical complication整理课件ACUTE MITRAL REGURGITATION（MR）Mild to moderate chronic MR is found in 15% to 45% of patients after AMI，usually transient and asymptomaticAcute MR secondary t

3、o 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 days after AMI，the median time to papillary muscle rupture is approximately 13 h

4、oursIntroduction整理课件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 abnormality may contribute to the increased frequency of MR after AMI Commonly following an inferior MI，owi

5、ng to the single blood supply to the posteromedial papillary muscle from the PDPathophysiology整理课件Prevalence of mitral regurgitation (MR) with respect to posterior papillary muscle (PM) perfusion pattern and inferior myocardial infarction (MI). Paolo Voci et al. Circulation. 1995;91:1714-1718Copyrig

6、ht American Heart Association, Inc. All rights reserved.整理课件Immediate pulmonary edema, hypotension, and,in some cases, cardiogenic shock A new pansystolic murmur is heard loudest at the cardiac apexElectrocardiography usually confirms an inferior or posterior MIChest radiography demonstrates pulmona

7、ry edema, which occasionally is localized to the right upper lobeDiagnosis整理课件Diagnosis整理课件 Prompt diagnosis with immediate initiation of aggressive medical therapy is vital until emergent surgical intervention can be performed Concomitant revascularization during mitral valve surgery is associated

8、with improved short-term and long-term outcomesTreatment整理课件Concomitant revascularization 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 con

9、comitant coronary revascularization following acute postinfarction mitral regurgitation. (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 Lo

10、russo R, Gelsomino S, De Cicco G, et al. Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study.Eur J Cardiothorac Surg 2008;33(4):577, with permission.)整理课件Treatment with MR Medical therapy Aims to reduce the afterload,with a res

11、ultant decreased regurgitant fraction and increased forward stroke volume and cardiac output Vasodilators and inodilators, such as nitrites, sodium nitroprusside, diuretics, and phosphodiesterase-3 inhibitors整理课件 mechanical cardiac support IABP Impella Recover device ECMO circuit, VAD Positive-press

12、ure ventilation is used with great effect 整理课件 Acute postinfarction MR is associated with an inhospital mortality of between 70% and 80% with medical treatment整理课件Emergent surgery remains the cornerstone of treatment整理课件整理课件 The largest series of patients who underwent surgical intervention for papi

13、llary muscle rupture：from April 1985 to June 2002 were reviewed,55 consecutive patients were included Patients with acute MR (defined as occurring within 1 month of the infarction)整理课件 The mean delay between AMI and mitral valve surgery was 7.3 7.4 days (range 133 days) Surgery took place within : t

14、he first 24 h of diagnosis of MR in 24 patients Between the second and the fourteenth day in 27 cases After the second week in 4 cases整理课件Kaplan-Meier graph showing perioperative (thirty-day) survival according to revascularisation status.Philippe Chevalier et al. Eur J Cardiothorac Surg 2004;26:330

15、-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)整理课件Kaplan-Meier graph showing long-term mortality of patients who survived the perioperative

16、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 (CABG 64% vs no CABG 23%; P0.5)整理课件 Late survival in operative survivors of surgery for post-MI PMR (dash

17、ed 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.整理课件整理课件Summary of Acute MRPatients presenting with the catastrophic mechanical complication of acute MR secondary to PMR following MI benefit from combined mitral valve surgery and myocardial revascularization, with satisfactory early and late outcomes despit