室间隔穿孔的外科治疗课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,室间隔穿孔的外科治疗,surgical Strategy of Ventricular Septal Rupture(VSR),北京XX医院心脏外科,XX医师,室间隔穿孔的外科治疗,1,急性心梗后机械并发症,Mechanical Complications of Acute Myocardial Infarction,游离壁破裂,Rupture of ventricular free wall,发病率:总发生率难估计,临床与尸检结果差别大,室间隔穿孔,溶栓前时代:约6%,游离壁破裂34%,Rupture of ventricular septum,溶栓时代: GRACE统计STEM中09%,游离壁破裂0,室间隔穿孔026%,PC时代:国外文献,5745例EM直接PC(0. 2-0.34% with thrombolytic ther,3.9% among patients with cardiogenic shock,Circum ex,Risk Factors,Antao?,O Large transmural infarctions,2 Anterior-apical, inferior-basal,Posterior,3 Virtually all patients have severe, multi-vessel CAD,FitM,eniac at,Birnbaum, Y, et al, Ventricular septal rupture after acute myocardial infarction. N Engl J Med, 2002. 347(18): P. 1426-32,室间隔穿孔,3,自然病程,r Without intervention, 1/4 of pts die in 24 hours,Rupture to death interval (months),1/2 succumb to illness within 1st week,2/3 die within 2 weeks,3/4 die within 1 month,Only 7% survive longer than one year,自然病程,4,药物治疗V手术治疗,Medical treatmant,pulsen, SH, et al, Ventricular septal rupture complicating acute myocardial infarction: clinical characteristics and contemporary,outcome. Ann Thorac Surg, 2008. 85(53: p. 1591-6,药物治疗V手术治疗,5,d Guideline(ACCF/AHay,2004,2013 ACCF/AHA Guideline for the Management,ACC/AHA Guidelines for the Management of Patients With,of sT-elevation Mvocardial Infarction,ST-Elevation Mvocardial Infarction,A Report of the American College of Cardiology Foune,Report ot the American College of Cardiology/ American Heart Asscciation Task Fnce on,Heart Association Task Force on Practice Guidelines,ients With Acute Myocardi al Infarction),Deveiepec in Cntlabomation H h the American Cowee o Emergency Physicians and,coned in Collaborato link the CanAdian Carcionaseuiar society,Societ tor Cenionascwlar Ang agruplry aid lniervetionty,Class I,Emergency surgical repair is necessary, even in,Patients with STEMI complicated by the development of a,hemodynamically stable patients, because the,VSR should be considered for urgent cardiac surgical repair, site can expand abruptly, resulting in sudden,unless further support is considered futile because of the,atients wishes or contraindications/unsuitability for further,The surgical mortality rate remains high, esp,invasive care. Level of Evidence:,among patients with shock, ranging from 20% to 87%,reported series,d Guideline(ACCF/AHay,6,d Guideline(eSo,2017 ESC Guidelines for the management of,acute myocardial infarction in patients,presenting with ST-g,segment elevation,The Task Force for the manas,nt of acu,in patients presenting with ST-segment elevation of the European,Society of Cardiology(EsC),irgical repair may be required urgently, but there is no consensus on the optimal timing for surgery,Early surgery is associated with,High mortality rate(20-40%),Delayed surgery,Allows easier septal repair in scarring tissue,i Carries the risk of rupture extension and death while waiting for surgery,d Guideline(eSo,7,急性心梗后室间隔穿孔,Acute post-MI VSRS,传统方式=手术治疗,死亡率:高达50%,术后残余分流率:20%,手术成功的相关因素,梗死面积大小 Extent of tissue necrosis,右心衰程度 Right ventricular failure,是否存在多器官功能不全 Multiple organ failue,年龄Age,急性心梗后室间隔穿孔,8,手术时机选择,Ventricular Septal Rupture Complicating Acute,Myocardial Infarction: Clinical Characteristics and,Optimal Timing for Surgery,Contemporary outcome,Steen Hvitfeldt Poulsen, MD, DMSci, Michael Prastholm, MD, Kim Munk, MD,er Wierup, MD, DMSci, Henrik Egeblad, MD, DMSci, an,Jens Erik Nielsen-Kudsk, MD, DMSci,Lace surgery (2 dayst,Early surgery(e 2 days,180,270,Number at risk,Time (days,Poulsen, S H, et al, Ventricular septal rupture complicating acute myocardial infarction: clinical characteristics and contemporary,outcome. Ann Thorac Surg, 2008. 85(5): p. 1591-6,手术时机选择,9,Surgical Repair of Ventricular Septal Defect after Myocardial,Infarction: Outcomes from the Society of Thoracic Surgeons,National Database,Sciortino,MD,PhD1, Patrick M. Mccarthy, MD mothy . George, MD, Christopher M,George J. Amaoutakis, MD, Yue Zhao, PhD2, Tim,d John v Conte, MD,r N=2,876 patients(men 56.5%, mean age =68),Prior CABG 215(7.5%),Prior PCI 950(33%),Pre-op IABP1869(65.0,Surgical status Urgent in 1,007 pts(35%),gent in 1,430 pts (49.7/%),Concomitant CABG 63.9%,i Operative mortality repair 7 days 54.1%,days 18.4%,Arnaoutakis et al, Ann Thorac Surg. 2012 Aug: 4(2) 436-43,Surgical Repair of Ventricular,10,室间隔穿孔的外科治疗课件,11,室间隔穿孔的外科治疗课件,12,室间隔穿孔的外科治疗课件,13,室间隔穿孔的外科治疗课件,14,室间隔穿孔的外科治疗课件,15,室间隔穿孔的外科治疗课件,16,室间隔穿孔的外科治疗课件,17,室间隔穿孔的外科治疗课件,18,室间隔穿孔的外科治疗课件,19,室间隔穿孔的外科治疗课件,20,室间隔穿孔的外科治疗课件,21,室间隔穿孔的外科治疗课件,22,室间隔穿孔的外科治疗课件,23,室间隔穿孔的外科治疗课件,24,室间隔穿孔的外科治疗课件,25,室间隔穿孔的外科治疗课件,26,室间隔穿孔的外科治疗课件,27,室间隔穿孔的外科治疗课件,28,室间隔穿孔的外科治疗课件,29,室间隔穿孔的外科治疗课件,30,室间隔穿孔的外科治疗课件,31,室间隔穿孔的外科治疗课件,32,室间隔穿孔的外科治疗课件,33,室间隔穿孔的外科治疗课件,34,室间隔穿孔的外科治疗课件,35,室间隔穿孔的外科治疗课件,36,室间隔穿孔的外科治疗课件,37,室间隔穿孔的外科治疗课件,38,室间隔穿孔的外科治疗课件,39,室间隔穿孔的外科治疗课件,40,