Sakurai H, Maeda M, Sai N, Iwase J, Takemura H
Department of Cardiovascular Surgery, Shakaihoken Chukyo Hospital, Nagoya, Japan.
Nihon Kyobu Geka Gakkai Zasshi. 1997 Jan;45(1):73-8.
A 78-year-old woman was operated on with a diagnosis of oozing-type cardiac rupture after an acute anteroseptal myocardial infarction. Pericardial drainage was performed and hemostasis was obtained by dressing with local hemostatics. As hemodynamics improved, elevation of pulmonary artery pressure and a step-up in oxygen concentration in the pulmonary artery from a Swan-Ganz catheter sample appeared. A left-to-right shunt was observed in the operative field with color Doppler echocardiography and a diagnosis of ventricular septal perforation (VSP) was made. Subsequently, intracavitary repair with two sheets of equine pericardial patch, sutured using interrupted mattress sutures with felt pledgets, was performed. Her early course after operation was satisfactory in spite of a small residual shunt. However, thirty-one days later she was returned to surgery because of an increasing residual shunt. Looseness of several interrupted mattress sutures and thrombus adherent to the internal surface of the pericardial patch were observed. The thrombus was removed and the patch was reattached using both interrupted mattress sutures with felt pledgets and continuous suture. She had an uneventful recovery thereafter. As double rupture is not a rare complication after myocardial infarction, a careful hemodynamic examination is necessary and important in the diagnosis and treatment of cardiac rupture. We consider that interrupted mattress sutures are a better technique for early repair of the VSP to reduce a risk of residual shunt due to the weakness and unclear border of infarcted myocardial tissue, and continuous suture is acceptable to repair the VSP 3 to 4 weeks later after infarction. Long-term anticoagulant therapy is necessary after intracavitary repair using equine pericardial patch.
一名78岁女性因急性前间隔心肌梗死后被诊断为渗血型心脏破裂而接受手术。进行了心包引流，并通过局部止血剂敷料实现了止血。随着血流动力学改善，出现肺动脉压升高以及经 Swan-Ganz 导管取样显示肺动脉氧浓度升高。经彩色多普勒超声心动图在手术视野中观察到左向右分流，诊断为室间隔穿孔（VSP）。随后，使用两片马心包补片进行心腔内修复，采用带毡垫的间断褥式缝合进行缝合。尽管存在小的残余分流，但她术后早期病程顺利。然而，31天后她因残余分流增加而再次接受手术。观察到数根间断褥式缝合线松动以及血栓附着于心包补片内表面。清除血栓，并使用带毡垫的间断褥式缝合线和连续缝合重新固定补片。此后她恢复顺利。由于心肌梗死后双重破裂并非罕见并发症，在心脏破裂的诊断和治疗中进行仔细的血流动力学检查是必要且重要的。我们认为，间断褥式缝合是早期修复VSP更好的技术，可降低因梗死心肌组织薄弱和边界不清导致残余分流的风险，而在梗死后3至4周修复VSP时连续缝合是可以接受的。使用马心包补片进行心腔内修复后需要长期抗凝治疗。
