David Tirone E
Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada.
Ann Cardiothorac Surg. 2022 May;11(3):261-267. doi: 10.21037/acs-2021-ami-111.
Coronary reperfusion therapies have led to a reduction in the incidence of mechanical complications of acute myocardial infarction (AMI), but the associated mortality of these complications has remained high. Ventricular septal rupture is the most common mechanical complication after myocardial infarction and occurs in approximately 0.21% with ST-segment elevation myocardial infarction and in 0.04% with non-ST-segment elevation myocardial infarction. Surgery is the only definitive treatment but it is associated with high operative mortality and morbidity and, in some centers, alternative treatment with mechanical support of circulation and trans-catheter closure of the defect is being used. We continue to believe that immediate surgery offers the best opportunity for long-term survival. Patients should be taken directly to the operating room or via the heart catheterization laboratory if the coronary artery anatomy is unknown. This should be done as soon as the diagnosis is made, as acute rupture of the interventricular septum is a surgical emergency. The operative technique of infarct exclusion has been our preferred method and when performed in hemodynamically stable patients, the operative mortality is around 10%, although much higher in patients in cardiogenic shock. Patch dehiscence and persistent shunts are uncommon after closure of the defect using this technique. Delaying operative intervention in hemodynamically stable patients frequently leads to cardiogenic shock and multi-organ failure. Transcatheter closure of these acute septal lesions is complex, not necessarily feasible in all patients, and there is no evidence that the results are superior to surgery.
冠状动脉再灌注治疗已使急性心肌梗死（AMI）机械并发症的发生率有所降低，但这些并发症相关的死亡率仍然很高。室间隔破裂是心肌梗死后最常见的机械并发症，在ST段抬高型心肌梗死患者中的发生率约为0.21%，在非ST段抬高型心肌梗死患者中的发生率为0.04%。手术是唯一的确定性治疗方法，但手术死亡率和发病率都很高，在一些中心，正在采用循环机械支持和经导管封堵缺损的替代治疗方法。我们仍然认为，立即手术为长期生存提供了最佳机会。如果冠状动脉解剖结构不明，患者应直接送往手术室或通过心脏导管实验室。一旦确诊，应尽快进行，因为室间隔急性破裂是外科急症。梗死灶切除术是我们首选的手术技术，在血流动力学稳定的患者中进行时，手术死亡率约为10%，尽管在心源性休克患者中要高得多。使用该技术封堵缺损后，补片裂开和持续分流并不常见。在血流动力学稳定的患者中延迟手术干预常常会导致心源性休克和多器官功能衰竭。经导管封堵这些急性间隔缺损很复杂，并非对所有患者都可行，而且没有证据表明其结果优于手术。
