Cheung Koon Ho, Graham Colin A, Alexander Colin Graham
Accident and Emergency Department, Prince of Wales Hospital, Hong Kong.
Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong.
Clin Exp Emerg Med. 2017 Sep 30;4(3):178-181. doi: 10.15441/ceem.16.172. eCollection 2017 Sep.
A previously healthy 61-year-old man presented to the emergency department with chest pain and dyspnoea for 6 hours. Examination revealed distress with an apical pansystolic murmur. Initial electrocardiogram showed sinus tachycardia and ST elevation in leads II, III, and aVF compatible with an inferior ST-elevation myocardial infarction. Point-of-care echocardiography in the emergency department showed a flail anterior mitral leaflet and severe mitral regurgitation, leading to a provisional diagnosis of papillary muscle rupture. Emergency cardiac catheterization showed 100%, 80%, and 70% occlusion of the middle right coronary, left anterior descending, and left circumflex arteries, respectively. An emergency triple vessel coronary artery bypass grafting and mitral valve replacement was performed. Posteromedial papillary muscle rupture resulting in mitral regurgitation was confirmed intraoperatively. The patient recovered uneventfully. In the absence of primary percutaneous coronary intervention, thrombolysis decisions should be made with extreme caution if mechanical complications of ST-elevation myocardial infarction are suspected.
一名61岁既往健康的男性因胸痛和呼吸困难6小时就诊于急诊科。体格检查发现患者痛苦面容，心尖部全收缩期杂音。初始心电图显示窦性心动过速，Ⅱ、Ⅲ、aVF导联ST段抬高，符合下壁ST段抬高型心肌梗死。急诊科床旁超声心动图显示二尖瓣前叶连枷样运动及严重二尖瓣反流，初步诊断为乳头肌破裂。急诊心脏导管检查显示右冠状动脉中段、左前降支和左旋支动脉分别有100%、80%和70%的闭塞。遂行急诊三支冠状动脉搭桥术和二尖瓣置换术。术中证实为后内侧乳头肌破裂导致二尖瓣反流。患者术后恢复顺利。在没有直接经皮冠状动脉介入治疗的情况下，如果怀疑ST段抬高型心肌梗死存在机械性并发症，溶栓决策应极其谨慎。
