Russo Antonio, Suri Rakesh M, Grigioni Francesco, Roger Véronique L, Oh Jae K, Mahoney Douglas W, Schaff Hartzell V, Enriquez-Sarano Maurice
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
Circulation. 2008 Oct 7;118(15):1528-34. doi: 10.1161/CIRCULATIONAHA.107.747949. Epub 2008 Sep 22.
Papillary muscle rupture (PMR) is an infrequent but catastrophic complication of acute myocardial infarction (MI). Although always considered, surgical treatment is often denied because of high operative mortality. Moreover, the effects of surgery for PMR on long-term outcome, particularly compared with expected outcome after MI, are undefined.
Fifty-four consecutive patients (age, 70+/-8 years; 74% male) underwent mitral surgery for post-MI PMR from January 1980 through December 2000. Severe presentation (cardiogenic shock, pulmonary edema, or cardiac arrest) was noted in 91% preoperatively. Performance of coronary artery bypass graft was associated with lower operative mortality (odds ratio, 0.18; 95% CI, 0.04 to 0.83; P=0.011), whereas there was a trend for lower mortality after surgery after 1990 (odds ratio, 0.28; 95% CI, 0.06 to 1.3). Thus, operative mortality (overall, 18.5%) decreased from 67% up to 1990 without coronary artery bypass graft to 8.7% after 1990 with coronary artery bypass graft. Overall 5-year survival was 65+/-7%, and survival free of congestive heart failure was 52+/-7%. Five-year survival of 30-day operative survivors was 79+/-4%, identical (P=0.24) to that of matched controls with MI (similar age, sex, ejection fraction, MI location, and MI year). Survival free of congestive heart failure was similar in PMR cases and MI controls (10-year survival, 28+/-8% versus 36+/-6%; P=0.46).
Surgery for post-MI PMR involves a notable operative mortality, but there are recent trends for lower operative risk, particularly with associated coronary artery bypass graft. Long term after surgery, outcome is restored to that of similar MI without PMR. These encouraging observations emphasize the importance of prompt diagnosis and aggressive therapeutic approach for patients incurring PMR after MI.
乳头肌破裂（PMR）是急性心肌梗死（MI）一种罕见但灾难性的并发症。尽管一直被考虑，但由于手术死亡率高，手术治疗常被拒绝。此外，PMR手术对长期预后的影响，特别是与MI后预期预后相比，尚不明确。
从1980年1月至2000年12月，连续54例患者（年龄70±8岁；74%为男性）因MI后PMR接受二尖瓣手术。术前91%患者表现严重（心源性休克、肺水肿或心脏骤停）。冠状动脉旁路移植术与较低的手术死亡率相关（优势比，0.18；95%可信区间，0.04至0.83；P = 0.011），而1990年后手术死亡率有降低趋势（优势比，0.28；95%可信区间，0.06至1.3）。因此，手术死亡率（总体为18.5%）从1990年以前未行冠状动脉旁路移植术时的67%降至1990年后行冠状动脉旁路移植术时的8.7%。总体5年生存率为65±7%，无充血性心力衰竭生存率为52±7%。30天手术幸存者的5年生存率为79±4%，与匹配的MI对照者（年龄、性别、射血分数、MI部位和MI年份相似）相同（P = 0.24）。PMR病例和MI对照者无充血性心力衰竭生存率相似（10年生存率，28±8%对36±6%；P = 0.46）。
MI后PMR手术有显著的手术死亡率，但近期手术风险有降低趋势，特别是联合冠状动脉旁路移植术时。手术后长期来看，预后恢复到与无PMR的类似MI患者相同。这些令人鼓舞的观察结果强调了对MI后发生PMR患者进行及时诊断和积极治疗方法的重要性。
