Grollier G, Scanu P, Babatasi G, Agostini D, Lécluse E, Saloux E, Valette B, Maïza D, Khayat A, Potier J C
Service de soins intensifs de cardiologie, CHU Côte de Nacre, Caen.
Arch Mal Coeur Vaiss. 1993 Dec;86(12):1729-38.
Three distinct forms of rupture of the heart may be identified after myocardial infarction: sudden rupture with massive intrapericardial haemorrhage, and sudden death with clinical signs of electromechanical dissociation; rupture into the pericardium resulting in a false aneurysm, the treatment of which is surgical; subacute rupture which accounts for 30% of cases in which bleeding into the pericardium is slow and/or repeated. Over an 8 year period and in a series of 2,400 consecutive infarcts admitted to the intensive care unit, 10 cases of subacute rupture of the heart were diagnosed. They were 6 men and 4 women, with a mean age of 73.6 years. The clinical presentation was isolated chest pain in 5 cases, syncope alone in 2 cases and the association of pain and syncope in 3 cases. Six patients were in shock on admission. In two cases, shock developed after admission. The infarction was confirmed biologically by a significant elevation of creatinine kinase in 9 out of 10 cases. Transmural infarction was observed in 9 cases: the infarct was electrocardiographically non-transmural in 1 case. Emergency echocardiography showed pericardial effusion in all cases, usually moderate, but sometimes compressive with an intrapericardial echogenic mass suggesting a thrombus. Haemodynamic improvement was obtained by medication allowing cardiac catheterisation which showed adiastole in 3 cases. Coronary angiography was performed in 7 cases. In 5 of the 7 cases, apart from occlusion of the artery presumed to be responsible for the infarct, the coronary vessels were diffusely infiltrated without significant stenosis. Left ventriculography was performed in 7 cases. In 6 of the 7 cases regional akinesis was demonstrated: the 7th case showed dyskinesia of the anterior wall. In two cases, contrast medium was observed to fill the pericardium during ventriculography, indicating myocardial rupture. The diagnosis of subacute rupture, suggested by clinical and paraclinical (particularly echocardiography), was confirmed in 9 cases at surgery and in the 10th case at autopsy. Surgery consisted of repairing the rupture. In the last two cases, biological glue was used to reinforce the surgical repair. The clinical outcome was good after surgery in 6 cases with a follow-up of 5 months to 8 years. The diagnosis of subacute rupture should therefore be made on clinical and echocardiographic criteria, as these results suggest that surgery is often possible, with a good prognosis.
突然破裂伴大量心包内出血，并伴有电机械分离临床体征的猝死；破裂进入心包形成假性动脉瘤，其治疗方法为手术治疗；亚急性破裂占心包内出血缓慢和/或反复病例的30%。在8年期间，在收入重症监护病房的连续2400例梗死病例系列中，诊断出10例心脏亚急性破裂。他们中有6名男性和4名女性，平均年龄为73.6岁。临床表现为5例仅有胸痛，2例仅有晕厥，3例为疼痛与晕厥并存。6例患者入院时处于休克状态。2例患者入院后出现休克。10例中有9例通过肌酸激酶显著升高从生物学上证实了梗死。9例观察到透壁梗死：1例梗死在心电图上为非透壁性。急诊超声心动图显示所有病例均有心包积液，通常为中度，但有时有压迫性，心包内有回声团块提示血栓形成。通过药物治疗实现血流动力学改善后进行心导管检查，3例显示舒张期。7例进行了冠状动脉造影。7例中的5例，除了推测为梗死责任动脉的闭塞外，冠状动脉弥漫性受累但无明显狭窄。7例进行了左心室造影。7例中的6例显示局部运动减弱：第7例显示前壁运动障碍。2例在心室造影时观察到造影剂充盈心包，提示心肌破裂。临床和辅助检查（特别是超声心动图）提示的亚急性破裂诊断，9例在手术时得到证实，第10例在尸检时得到证实。手术包括修复破裂处。在最后2例中，使用生物胶加强手术修复。6例手术后临床结果良好，随访时间为5个月至8年。因此，应根据临床和超声心动图标准做出亚急性破裂的诊断，因为这些结果表明手术通常可行，预后良好。
