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

AcuteMyocardialInfarctionPrimaryPCIastheprincipalreperfusionstrategyfollowingSTEMI,theincidenceofmechanicalcomplicationshasreducedsignificantlytolessthan1%Ruptureoftheleftventricularfreewall(0.52%)Papillarymuscle(0.26%)Ventricularseptum(0.17%)編輯pptSurvivalafterMechanicalcomplication編輯pptACUTEMITRALREGURGITATION（MR）MildtomoderatechronicMRisfoundin15%to45%ofpatientsafterAMI，usuallytransientandasymptomaticAcuteMRsecondarytopapillarymuscleruptureisalife-threateningcomplicationwithapoorprognosisOccursin0.25%ofpatientsfollowingAMIandrepresentsupto7%ofpatientsincardiogenicshockfollowingAMIDiagnosedbetween2to7daysafterAMI，themediantimetopapillarymuscleruptureisapproximately13hoursIntroduction編輯pptFollowingAMI,incombinationwithchangesinLVshapeandregionalwallfunction,resultsinacuteMREvenslightmodificationsofLVgeometrycausedbyregionalwall-motionabnormalitymaycontributetotheincreasedfrequencyofMRafterAMICommonlyfollowinganinferiorMI，owingtothesinglebloodsupplytotheposteromedialpapillarymusclefromthePDPathophysiology編輯pptPrevalenceofmitralregurgitation(MR)withrespecttoposteriorpapillarymuscle(PM)perfusionpatternandinferiormyocardialinfarction(MI).PaoloVocietal.Circulation.1995;91:1714-1718Copyright?AmericanHeartAssociation,Inc.Allrightsreserved.編輯pptImmediatepulmonaryedema,hypotension,and,insomecases,cardiogenicshockAnewpansystolicmurmurisheardloudestatthecardiacapexElectrocardiographyusuallyconfirmsaninferiororposteriorMIChestradiographydemonstratespulmonaryedema,whichoccasionallyislocalizedtotherightupperlobeDiagnosis編輯pptDiagnosis編輯pptPromptdiagnosiswithimmediateinitiationofaggressivemedicaltherapyisvitaluntilemergentsurgicalinterventioncanbeperformedConcomitantrevascularizationduringmitralvalvesurgeryisassociatedwithimprovedshort-termandlong-termoutcomesTreatment編輯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.)編輯pptTreatmentwithMRMedicaltherapyAimstoreducetheafterload,witharesultantdecreasedregurgitantfractionandincreasedforwardstrokevolumeandcardiacoutputVasodilatorsandinodilators,suchasnitrites,sodiumnitroprusside,diuretics,andphosphodiesterase-3inhibitors編輯pptmechanicalcardiacsupportIABPImpellaRecoverdeviceECMOcircuit,VADPositive-pressureventilationisusedwithgreateffect編輯pptAcutepostinfarctionMRisassociatedwithaninhospitalmortalityofbetween70%and80%withmedicaltreatment編輯pptEmergentsurgeryremainsthecornerstoneoftreatment編輯ppt編輯pptThelargestseriesofpatientswhounderwentsurgicalinterventionforpapillarymusclerupture：fromApril1985toJune2002werereviewed,55consecutivepatientswereincludedPatientswithacuteMR(definedasoccurringwithin1monthoftheinfarction)編輯pptThemeandelaybetweenAMIandmitralvalvesurgerywas7.3±7.4days(range1–33days)Surgerytookplacewithin:thefirst24hofdiagnosisofMRin24patientsBetweenthesecondandthefourteenthdayin27casesAfterthesecondweekin4cases編輯pptKaplan-Meiergraphshowingperioperative(thirty-day)survivalaccordingtorevascularisationstatus.PhilippeChevalieretal.EurJCardiothoracSurg2004;26:330-335?2004byOxfordUniversityPressPerioperativemortalitywas24%NodifferenceinearlymortalitybetweenpatientsundergoingconcomitantCABGandNorevascularizedgroup(CABG27.3%vsnoCABG26.4%;P>.9)編輯pptKaplan-Meiergraphshowinglong-termmortalityofpatientswhosurvivedtheperioperativeperiod.PhilippeChevalieretal.EurJCardiothoracSurg2004;26:330-335?2004byOxfordUniversityPresslong-termsurvivalimprovedinpatientsundergoingconcomitantrevascularizationat15years(CABG64%vsnoCABG23%;P<.001)編輯pptPhilippeChevalieretal.EurJCardiothoracSurg2004;26:330-335OnlytheAbsenceofRevascularisationwassignificantlypredictiveofincreasedperioperativemortalityFactorspredictiveofperioperativemortality編輯pptmitralvalverepairormitralvalvereplacement?編輯ppt編輯pptBaselineandOperativeCharacteristicsofPatientsWhoUnderwentSurgeryforPMR編輯pptPreoperativeangiography,performedinallpatientsexcept1single-vesselCADin17patients(31%)2-vesselCADin19patients(35%)3-vesselCADin14patients(26%)LeftmainCADin3patients(6%)編輯pptOperativemortalityaftersurgeryforpost-MIPMRstratifiedaccordingtopredictorsoflowmortality(surgeryperformedafter1990withassociatedCABG).AntonioRussoetal.Circulation.2008;118:1528-1534Copyright?AmericanHeartAssociation,Inc.Allrightsreserved.Improveoperativemortality(OR0.18;95%CI0.04–0.83;P=.011).編輯pptOverall(includingoperativemortality)long-termsurvival(solidline)andlong-termsurvivalfreeofCHF(dashedline)aftersurgeryforpost-MIPMR.Thenumberswitheachcurveindicatethe5-and10-yearestimatedsurvivalandsurvivalfreeofCHF(±SE).AntonioRussoetal.Circulation.2008;118:1528-1534Copyright?AmericanHeartAssociation,Inc.Allrightsreserved.編輯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.編輯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)編輯ppt

Latesurvivalinoperativesurvivorsofsurgeryforpost-MIPMR(dashedline)vspatient