《缺血性二尖瓣反流》PPT課件

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 Mechanical Complications of Acute Myocardial Infarction Primary PCI as the principal reperfusion strategy following STEMI, the incidence of mechanical complications has reduced significantly to less than 1%

2、Rupture of the left ventricular free wall %) Papillary %) Ventricular septum %) Survival after Mechanical complication ACUTE MITRAL REGURGITATION（MR） Mild to moderate chronic MR is found in 15% to 45% of patients after AMI，usually transient and asymptomatic Acute MR secondary to papillary muscle rup

3、ture is a life- threatening complication with a poor prognosis Occurs in 0.25% of patients following AMI and represents up to 7% of patients in cardiogenic shock following AMI Diagnosed between 2 to 7 days after AMI，the median time to papillary muscle rupture is approximately 13 hours Introduction F

4、ollowing AMI,in combination with changes in LV shape and regional wall function, results in acute MR Even 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，owing to the single blo

5、od supply to the posteromedial papillary muscle from the PD Pathophysiology 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;91:1714-1718 Copyright American Heart Ass

6、ociation, Inc. All rights reserved. Immediate pulmonary edema, hypotension, and,in some cases, cardiogenic shock A new pansystolic murmur is heard loudest at the cardiac apex Electrocardiography usually confirms an inferior or posterior MI Chest radiography demonstrates pulmonary edema, which occasi

7、onally is localized to the right upper lobe Diagnosis Diagnosis 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 with improved short-term and

8、 long-term outcomes Treatment Concomitant revascularization during mitral valve surgery is associated with improved short-term and long-term outcomes Kaplan-Meier graphs demonstrating (A) perioperative and (B) 15-year actuarial survival benefit in patients undergoing concomitant coronary revasculari

9、zation 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 Lorusso R, Gelsomino S, De Cicc

10、o 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.) Treatment with MR Medical therapy Aims to reduce the afterload,with a resultant decreased regurgitant fra

11、ction and increased forward stroke volume and cardiac output Vasodilators and inodilators, such as nitrites, sodium nitroprusside, diuretics, and phosphodiesterase-3 inhibitors mechanical cardiac support IABP Impella Recover device ECMO circuit, VAD Positive-pressure ventilation is used with great e

12、ffect Acute postinfarction MR is associated with an inhospital mortality of between 70% and 80% with medical treatment Emergent surgery remains the cornerstone of treatment The largest series of patients who underwent surgical intervention for papillary muscle rupture： from April 1985 to June 2002 w

13、ere reviewed,55 consecutive patients were included Patients with acute MR (defined as occurring within 1 month of the infarction) The mean delay between AMI and mitral valve surgery was 7.3 7.4 days (range 133 days) Surgery took place within : the first 24 h of diagnosis of MR in 24 patients Between

14、 the second and the fourteenth day in 27 cases After the second week in 4 cases Kaplan-Meier graph showing perioperative (thirty-day) survival according to revascularisation status. Philippe Chevalier et al. Eur J Cardiothorac Surg 2004;26:330-335 2004 by Oxford University Press Perioperative mortal

15、ity 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) Kaplan-Meier graph showing long-term mortality of patients who survived the perioperative period. Philippe Chevalier et al. Eur J Cardiothorac Surg

16、 2004;26:330-335 2004 by Oxford University Press long-term survival improved in patients undergoing concomitant revascularization at 15 years (CABG 64% vs no CABG 23%; P0.5) Late survival in operative survivors of surgery for post-MI PMR (dashed line) vs patients with MI without PMR (solid line) and

17、 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;118:1528-1534 Copyright American Heart Association, Inc. All rights reserved. Summary of Acute MR Patients 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 ou