From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial College Healthcare National Health Service Trust, London, UK (I.M.); University Hospitals Bristol National Health Service Foundation Trust, Bristol, UK (M.T.); Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK (S.K.); University Hospital Southampton National Health Service Foundation Trust, Southampton, UK (G.R.V.); Walsgrave Hospital Coventry, Coventry, UK (M.B.); University Hospital North Staffordshire National Health Service Trust, Stoke-on-Trent, UK (R.B.); Leeds Teaching Hospitals National Health Service Trust, Leeds, UK (J.T.); King's College Hospital National Health Service Foundation Trust, London, UK (J.B., P.M.); Liverpool Heart and Chest Hospitals National Health Service Foundation Trust, Liverpool, UK (L.M.); and University Hospital of South Manchester, Manchester, UK (B.B.).
Circulation. 2014 Jun 10;129(23):2395-402. doi: 10.1161/CIRCULATIONAHA.113.005839. Epub 2014 Mar 25.
Postinfarction ventricular septal defect carries a grim prognosis. Surgical repair offers reasonable outcomes in patients who survive a healing phase. Percutaneous device implantation represents a potentially attractive early alternative.
Postinfarction ventricular septal defect closure was attempted in 53 patients from 11 centers (1997-2012; aged 72±11 years; 42% female). Nineteen percent had previous surgical closure. Myocardial infarction was anterior (66%) or inferior (34%). Time from myocardial infarction to closure procedure was 13 (first and third quartiles, 5-54) days. Devices were successfully implanted in 89% of patients. Major immediate complications included procedural death (3.8%) and emergency cardiac surgery (7.5%). Immediate shunt reduction was graded as complete (23%), partial (62%), or none (15%). Median length of stay after the procedure was 5.0 (2.0-9.0) days. Fifty-eight percent survived to discharge and were followed up for 395 (63-1522) days, during which time 4 additional patients died (7.5%). Factors associated with death after postinfarction ventricular septal defect closure included the following: age (hazard ratio [HR]=1.04; P=0.039), female sex (HR=2.33; P=0.043), New York Heart Association class IV (HR=4.42; P=0.002), cardiogenic shock (HR=3.75; P=0.003), creatinine (HR=1.007; P=0.003), defect size (HR=1.09; P=0.026), inotropes (HR=4.18; P=0.005), and absence of revascularization therapy for presenting myocardial infarction (HR=3.28; P=0.009). Prior surgical closure (HR=0.12; P=0.040) and immediate shunt reduction (HR=0.49; P=0.037) were associated with survival.
Percutaneous closure of postinfarction ventricular septal defect is a reasonably effective treatment for these extremely high-risk patients. Mortality remains high, but patients who survive to discharge do well in the longer term.
心肌梗死后室间隔缺损预后不佳。对于存活过愈合期的患者，手术修复可获得较好的结果。经皮器械植入术代表了一种有吸引力的早期替代方法。
在 11 个中心（1997-2012 年）对 53 例心肌梗死后室间隔缺损患者进行了尝试关闭手术（年龄 72±11 岁，42%为女性）。19%的患者之前已进行过手术修复。心肌梗死部位为前壁（66%）或下壁（34%）。从心肌梗死后到手术的时间为 13（第一和第三四分位数，5-54）天。89%的患者成功植入器械。主要的即刻并发症包括操作过程中死亡（3.8%）和紧急心脏手术（7.5%）。即刻分流减少程度分级为完全（23%）、部分（62%）或无（15%）。术后中位住院时间为 5.0（2.0-9.0）天。58%的患者存活至出院，并接受了 395（63-1522）天的随访，在此期间，又有 4 名患者死亡（7.5%）。与心肌梗死后室间隔缺损闭合后死亡相关的因素包括：年龄（风险比[HR]=1.04；P=0.039）、女性（HR=2.33；P=0.043）、纽约心脏协会（NYHA）心功能分级Ⅳ级（HR=4.42；P=0.002）、心源性休克（HR=3.75；P=0.003）、血肌酐（HR=1.007；P=0.003）、缺损大小（HR=1.09；P=0.026）、正性肌力药物（HR=4.18；P=0.005）以及未进行再血管化治疗（HR=3.28；P=0.009）。既往手术修复（HR=0.12；P=0.040）和即刻分流减少（HR=0.49；P=0.037）与生存相关。
经皮闭合心肌梗死后室间隔缺损是治疗这些极高危患者的一种合理有效的方法。死亡率仍然较高，但存活至出院的患者在长期预后中表现良好。
