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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 of left ventricular free wall rupture (LVWR) after acute myocardial infarction (AMI). Methods The clinical features, comprehensive diagnosis and successful treatment of patients with LVWR after AMI from December 2015 to April 2016 in our hospital were retrospectively analyzed. Results Selected patients in 3 cases. In case 1, cardiac echocardiography was used to diagnose myocardial rupture of the mesh after AMI. Emergency revascularization was performed in patients with cardiogenic shock. Infarct-related arteries were opened. Vasoactive drugs were administered under hemodynamic monitoring to reduce the load of ventricular pressure And capacity load to reduce wall tension, while less or disable anticoagulant, anti-platelet aggregation drugs, and promote local ventricular thrombosis healing. In case 2, patients with AMI were recurred. The heart was reconstructed 2 days after revascularization to diagnose cardiac rupture and thrombosis. After stent treatment, the patients underwent hemodynamic monitoring and drug therapy. After the condition was stable, cardiac CT was further confirmed. In case 3, LVWR was diagnosed by ultrasonography 4 days after AMI and thrombus was formed. The patients were hemodynamically stable. Surgical repair and rupture were successful after elective coronary angiography. Conclusion Effective drug therapy combined with coronary intervention and surgical repair can reduce the risk of death in patients with LVWR after AMI.