急性心肌梗死并发游离壁破裂的诊断与治疗三例报告  

The diagnosis and treatment of acute myocardial infarction complicated with left ventricular wall rupture:a report of three cases

作　　者：高明东[1] 肖健勇[1] 朱延波[2] 骆永娟[2] 关欣[2] 王连群[3] 张擎[4] 刘寅[1] 孙根义[1] GAO Mingdong;XIAO Jianyong;ZHU Yanbo;LUO Yongjuan;GUAN Xin;WANG Lianqun;ZHANG Qing;LIU Yin;SUN Genyi(Department of Coronary Care Unite Tianjin Chest Hospital, Tianjin 300022, China;Department of Ultrasonography ,Tianjin Chest Hospital, Tianjin 300022, China;Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin 300022, China;Tianjin First Aid Center)

机构地区：[1]天津市胸科医院CCU科,300022 [2]天津市胸科医院超声科,300022 [3]天津市胸科医院心外科,300022 [4]天津市急救中心

出　　处：《天津医药》2016年第12期1452-1455,共4页Tianjin Medical Journal

基　　金：2015年天津市卫生行业重点攻关项目(15KG128)

摘　　要：目的探讨急性心肌梗死(AMI)后左心室游离壁破裂(LVWR)患者的诊断与治疗。方法回顾分析我院2015年12月—2016年4月AMI后LVWR患者的临床特征、综合诊断以及成功治疗过程。结果入选患者3例。例1为AMI后心脏超声诊断心肌筛孔样破裂,因合并心源性休克行急诊血运重建,开通梗死相关动脉,术后在血流动力学监测下以血管活性药物治疗,降低心室压力负荷和容量负荷以降低室壁张力,同时少用或停用抗凝血、抗血小板聚集药物,促进心室破裂局部血栓机化愈合。例2为再发AMI患者,血运重建后2 d超声诊断心脏破裂并形成血栓包裹,支架术后在血流动力学监测下药物治疗,病情稳定后查心脏CT进一步确定诊断。例3为AMI后4 d超声诊断LVWR并形成血栓包裹,患者血流动力学稳定,择期冠脉造影后行外科手术修补破裂成功。结论有效的药物治疗联合冠状动脉介入治疗和外科修补可以降低AMI后LVWR患者的死亡风险。Objective To investigate the diagnosis and treatment in patients with acute myocardial infarction (AMI) and complicated left ventricular wall rupture (LVWR). Methods A retrospective analysis was made on the clinical features, diagnosis and successful treatment in three AMI patients with LVWR from December 2015 to April 2016.Results Three cases were included in this study. Case 1, the mesh like cardiac rupture after AMI was diagnosed by ultrasonic Doppler. Emergency revascularization was performed due to the combined cardiac shock, and the infarct relatedartery was opened. The vasoactive drugs were used after revascularization to reduce ventricular pressure load and volumeload in the haemodynamic monitoring, and anticoagulation, antiplatelet agents were less used or discontinued to promotelocal thrombus healing of ventricular rupture. Case 2 was a recurrent myocardial infarction patient. LVWR was diagnosed by ultrasonic Doppler one day after emergency operation. The ruptured ventricular wall was encapsulated by thrombus. The drug therapy was effective in hemodynamic monitoring. LVWR was further confirmed by cardiac CT after clinical stabilization. Case 3 was diagnosed LVWR by ultrasonic Doppler four days after AMI. Because the ruptured ventricular wall was limited by incompletely organized thrombus, and the haemodynamic condition was stable, selective surgical repair of rupture after coronary angiography was performed. Conclusion The effective drug therapy combined with percutaneous coronary intervention and surgical repair can reduce the risk of death in patients with LVWR after AMI.

关 键 词：心肌梗死 心脏破裂 心脏破裂 梗死后 心脏室壁瘤 左室游离壁破裂 

分 类 号：R541.4[医药卫生—心血管疾病]