急性心肌梗死合并室间隔穿孔患者的临床特点及近期预后因素分析

发布时间：2018-06-10 07:36

本文选题：室间隔穿孔 + 急性心肌梗死　；参考：《北京协和医学院》2013年硕士论文

【摘要】：第一部分70例急性心肌梗死合并室间隔穿孔患者的临床特点分析背景室间隔穿孔(VSR)是一种少见但又凶险的急性心肌梗死(AMI)后的机械并发症。国内对VSR的报道多为个案报道或小样本研究,罕有大样本临床研究,故目前VSR的临床数据多引用国外文献。本研究回顾性地分析了我院70例AMI合并VSR患者的临床特点、治疗及预后情况。方法我院2002-01到2010-09间收治的AMI患者共12354人,其中合并VSR患者70例(0.57%),男性33例(47.1%),女性37例(52.9%),平均年龄68.1岁。对这70例AMI合并VSR患者的临床资料进行回顾性分析。结果70例AMI合并VSR患者,继发于前壁心肌梗死者54例(77.1%)。VSR患者30天病死率为55.7%,1年病死率为64.3%；保守治疗49例,30天病死率为77.6%,1年病死率均为87.8%=%；手术治疗21例,30天病死率为4.8%,1年病死率为9.5%；接受手术治疗患者的30天及1年病死率显著优于接受保守治疗患者(P0.005)。仅1例AMI后6天行急诊手术治疗的患者于围术期死亡,所有AMI后2周以上行外科手术治疗的患者均好转出院。结论VSR是AMI少见但严重的并发症,手术治疗的近期及远期预后均显著优于保守治疗,AMI后2周以上行外科手术治疗成功率高,对于强化内科保守治疗后仍出现血流动力学不稳定、预计不能存活至AMI后4-6周的危重患者,可适当提前外科手术时间,以挽救更多患者的生命。第二部分急性心肌梗死合并室间隔穿孔的近期预后因素分析背景室间隔穿孔(ventricular septal rupture, VSR)是一种急性心肌梗死(acute myocaridal infarction, AMI)后机械并发症。既往文献均显示外科手术治疗的长期预后显著优于保守治疗,但因心肌梗死后早期手术难度大、围术期死亡率高,故国内尚未对最佳手术时机达成共识。目前临床上一般建议VSR患者尽量内科保守治疗至4-6周后再行外科手术治疗。但很多病情危重的VSR患者陆续在等待手术期间死亡。因此,在入院即刻对患者进行危险分层进而采取相对个体化的治疗极为重要。本研究回顾性分析阜外心血管病医院70例AMI合并VSR患者存活≤30天的危险因素,并对VSR患者进行危险分层,为临床进一步治疗提供依据。方法回顾性入选2002年1月至2010年10月在阜外心血管病医院确诊为AMI合并VSR患者70例。比较AMI后VSR患者存活≤30天及存活30天患者的年龄、性别、病史、检验结果等临床指标,分析研究存活≤30天患者的危险因素。根据Logistic多元回归分析结果制定VSR患者近期预后危险评分(short-term prognosis index of VSR, SPIV)。结果单因素分析发现,存活≤30天的危险因素(P0.05)包括：女性、前壁心肌梗死、心功能(≥Ⅲ级)、室间隔穿孔位置(心尖部)、不合并室壁瘤。Logistic多元回归分析发现：女性(P=0.013)、前壁心肌梗死(P=0.023)、Killip分级≥Ⅲ级(P=0.022)、不合并室壁瘤(P=0.023)、不合并糖尿病(P=0.009)、AMI发病到诊断VSR时间≤4天(P=0.027)为VSR患者存活≤30天的独立危险因素。SPIV≥9分为高危患者,30天病死率为77.4%；≤8分为低危患者,30天病死率为28.6%；8-9分为中危患者。结论AMI合并VSR患者存活≤30天的独立危险因素包括女性、前壁心肌梗死、不合并室壁瘤、不合并糖尿病、Killip分级≥Ⅲ级及AMI发病到诊断VSR时间≤4天,对于高危患者应采取更积极的治疗方案以挽救生命。
[Abstract]:Part one clinical characteristics of 70 patients with acute myocardial infarction complicated with ventricular septal perforation
Background interventricular septal perforation (VSR) is a rare but dangerous mechanical complication after acute myocardial infarction (AMI). The domestic reports of VSR are mostly case reports or small sample studies. There is a rare large sample of clinical study, so the clinical data of VSR are often cited in foreign literature. This study reviewed 70 cases of AMI with VSR in our hospital. Clinical characteristics, treatment and prognosis.
Methods a total of 12354 AMI patients were treated in our hospital from 2002-01 to 2010-09, including 70 (0.57%) patients with VSR, 33 males (47.1%), 37 women (52.9%) and an average age of 68.1 years. The clinical data of the 70 patients with AMI combined with VSR were analyzed retrospectively.
Results 70 cases of AMI combined with VSR, secondary to anterior wall myocardial infarction, 54 cases (77.1%) of.VSR patients were 55.7%, 1 year fatality rate 64.3%, 49 conservative treatment, 77.6% fatality rate, 77.6% fatality rate, 87.8%=%, 21 cases, 30 days fatality rate and mortality rate. The annual mortality rate was significantly better than that of patients receiving conservative treatment (P0.005). Only 1 patients who underwent emergency surgery for 6 days after AMI were died in the perioperative period. All the patients who underwent surgical treatment at 2 weeks after AMI were all better discharged from hospital.
Conclusion VSR is a rare but serious complication of AMI. The short-term and long-term prognosis of surgical treatment is significantly better than that of conservative treatment. 2 weeks after AMI, the successful rate of surgical treatment is high. The hemodynamic instability still appears after conservative treatment in the intensive medicine, and the critical patients who are not expected to survive to the next 4-6 weeks of AMI can be properly advanced surgical hands. Time to save more people's life.
The second part is the short-term prognostic factors of acute myocardial infarction with ventricular septal perforation.
Background ventricular septal perforation (ventricular septal rupture, VSR) is a mechanical complication after acute myocardial infarction (acute myocaridal infarction, AMI). The previous literature showed that the long-term prognosis of surgical treatment was significantly better than that of conservative treatment. However, early operation after myocardial infarction was difficult and the perioperative mortality was high. There is a common consensus on the timing of a good operation. Currently, VSR patients are generally recommended to be treated as conservative as possible until 4-6 weeks after surgery. But many critically ill VSR patients are waiting to die during the operation. Therefore, it is very important to carry out dangerous stratification and then adopt a relatively individualized treatment at the time of admission to the hospital. The risk factors of 70 cases of AMI combined with VSR patients survived for less than 30 days in Fuwai Hospital of Cardiovascular Disease were analyzed retrospectively, and the risk stratification of patients with VSR was carried out to provide the basis for further clinical treatment.
Methods 70 patients with AMI combined with VSR in Fuwai Hospital of Cardiovascular Disease from January 2002 to October 2010 were selected to compare the age, sex, history and test results of VSR patients who survived for less than 30 days and 30 days of survival after AMI, and to analyze and study the risk factors of patients who survived for less than 30 days. According to Logistic multiple regression analysis, the results were analyzed. Results short-term prognosis index of VSR (SPIV) was established for VSR patients.
Results single factor analysis found that the risk factors (P0.05) that survived for less than 30 days included women, anterior wall myocardial infarction, cardiac function (more than grade III), ventricular septal perforation (apical), and no ventricular aneurysm combined with.Logistic regression analysis: Women (P=0.013), anterior wall myocardial infarction (P=0.023), Killip classification (P=0.022), and no combination of ventricular wall. Tumor (P=0.023), without diabetes (P=0.009), AMI onset to the diagnosis of VSR time less than 4 days (P=0.027) for the survival of VSR patients less than 30 days of independent risk factor.SPIV more than 9 to high-risk patients, 30 days of death rate of 77.4%; less than 8 in low risk patients, 30 days death rate 28.6%; 8-9 divided into middle risk.
Conclusion the independent risk factors of AMI combined with VSR patients surviving less than 30 days include women, anterior wall myocardial infarction, no ventricular aneurysm, no diabetes, Killip grade more than grade III and AMI to the diagnosis of VSR less than 4 days, and more active treatment should be taken to save life for high-risk patients.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R542.22

【参考文献】