Oliva P B, Hammill S C, Edwards W D
Heart Research and Education Association of Colorado, Rose Medical Center, Denver 80220.
J Am Coll Cardiol. 1993 Sep;22(3):720-6. doi: 10.1016/0735-1097(93)90182-z.
To test the hypothesis that certain clinical events may precede free wall myocardial rupture and allow its prediction, we conducted a retrospective and prospective study of 70 patients with rupture.
Rupture of the left ventricular free wall develops in approximately 10% of patients with fatal acute transmural myocardial infarction. Clinically, its occurrence has been considered precipitous and unexpected. Pathologically, however, rupture appears to be a stuttering, progressive process characterized in many instances by an infiltrating intramural hemorrhage and a thrombus within the tear of > or = 1 day's duration.
The clinical course and evolutionary electrocardiographic (ECG) changes in 70 consecutive patients with rupture and 100 comparison patients with acute myocardial infarction but without rupture were reviewed to ascertain whether certain clinical symptoms, signs and ECG alterations occur in patients prone to develop rupture, allowing its anticipation. In addition, a correlation was established between the site of infarction indicated by the ECG and the site of rupture determined at autopsy or surgery.
Patients with rupture had a significantly greater incidence of pericarditis, repetitive emesis and restlessness and agitation than did patients without rupture. More than 80% of patients with rupture had two or more symptoms compared with 3% of patients without rupture (p < 0.002). A deviation from the expected evolutionary T wave pattern occurred in 94% of patients with rupture and 34% of control patients (p < or = 0.02). An abrupt transient episode of hypotension and bradycardia, probably due to the initial tearing of the epicardium with a resultant small hemopericardium, was observed in 21% of patients with rupture. Rupture of the midlateral wall was most common (32%) and usually occurred in the setting of an inferoposterolateral infarction related to an acute left circumflex artery occlusion. On the basis of these clinical and ECG changes, rupture was confirmed by echocardiography and pericardiocentesis in the two most recent patients, and the defect was successfully repaired.
Rupture is often preceded by particular symptoms, signs--namely, one or more episodes of abrupt, transient hypotension and bradycardia and unexpected alterations of the T waves, especially directional changes of the latter. Patients displaying these symptoms, signs and ECG changes require a bedside echocardiogram and echocardiographically guided pericardiocentesis if fluid is visualized. If the pericardiocentesis identifies the fluid as blood, immediate surgery is indicated.
为了验证某些临床事件可能先于游离壁心肌破裂并使其得以预测这一假说，我们对70例心肌破裂患者进行了一项回顾性和前瞻性研究。
在致命性急性透壁性心肌梗死患者中，约10%会发生左心室游离壁破裂。临床上，其发生一直被认为是突然且难以预料的。然而，从病理学角度来看，破裂似乎是一个渐进性的过程，在许多情况下其特征为壁内出血浸润以及持续时间≥1天的撕裂处有血栓形成。
回顾了70例连续性心肌破裂患者以及100例急性心肌梗死但未发生破裂的对照患者的临床病程及演变的心电图（ECG）变化，以确定在易于发生破裂的患者中是否会出现某些临床症状、体征及ECG改变，从而实现对破裂的预判。此外，还建立了ECG所示梗死部位与尸检或手术确定的破裂部位之间的相关性。
与未发生破裂的患者相比，发生破裂的患者心包炎、反复呕吐以及烦躁不安的发生率显著更高。超过80%的破裂患者有两种或更多症状，而未发生破裂的患者中这一比例为3%（p<0.002）。94%的破裂患者出现与预期演变的T波形态不符的情况，而对照患者中这一比例为34%（p≤0.02）。21%的破裂患者出现了可能由于心包膜最初撕裂导致少量心包积血而引起的突然短暂性低血压和心动过缓。侧壁中部破裂最为常见（32%），通常发生在与急性左旋支动脉闭塞相关的下后壁梗死的情况下。基于这些临床和ECG变化，对最近的两名患者通过超声心动图和心包穿刺术确诊为破裂，并成功修复了缺损。
破裂之前常常会出现特定的症状和体征，即一次或多次突然短暂性低血压和心动过缓发作以及T波的意外改变，尤其是后者的方向改变。出现这些症状、体征及ECG变化的患者需要进行床边超声心动图检查，若发现有液体，则需在超声心动图引导下进行心包穿刺术。如果心包穿刺术确定液体为血液，则应立即进行手术。
