Yaginuma G, Yahagi T, Okada Y, Abe K, Araki T, Goto T, Yokoyama K, Ottomo M
Department of Cardiovascular Surgery, Yamagata Prefectural Central Hospital, Japan.
Kyobu Geka. 1997 Sep;50(10):848-53.
We studied 19 cases of Left Ventricular Free Wall Rupture (LVFWR) following acute myocardial infarction, admitted to our CCU between 1987 and 1996. We were able to treat 15 patients and diagnosed 4 cases as LVFWR at postmortem after sudden deaths. Of the treated 15 patients, 11 survived: 1 out of 2 repaired under cardiopulmonary bypass (CPB), 5 out of 7 repaired without CPB, and 5 out of 6 non-surgically treated. Although the survival rate for those able to be treated was 73%, overall rate was 58%. There were 7 cases of blow-out type: 4 of which were sudden deaths, and 3 were operated. Thoracotomy and direct closure of rupture without CPB was done at bed-side in 2 cases. Even though hemostasis was successful, they did not survive. The 3rd case survived with the patch closure under CPB. In this case, the circulation was maintained pre-operatively with the pericardial-central venous bypass drainage method. This method seems to be extremely effective in saving blow-out cases. There were 12 subacute patients. Although 2 cases were lost, total of 10 patients were saved, including 2 direct suture closures of rupture without CPB, 3 median sternotomy and fibrin-glue fixations, 1 where only pericardial drainage was done, and 4 in whom percutaneous intrapericardial fibrin-glue fixation therapy was utilized. Since the risk of secondary damage to the fragile infarcted are from direct suturing of ruptured myocardium exists in LVFWR, we changed to the Infarction Exclusion Technique under CPB during surgical repair, based on our experiences with ruptured intraventricular septum. In general, the only treatment believed to be available for LVFWR has been surgical. However, our experiences suggest that other treatments may also be effective. If the best suitable method could be chosen from various therapies, it may contribute to improving outcome statistics. The reduction of left ventricular pressure in the treatment is extremely important, being the key to improving survival rate.
我们研究了1987年至1996年间入住我院冠心病重症监护病房(CCU)的19例急性心肌梗死后左心室游离壁破裂(LVFWR)患者。我们成功治疗了15例患者,另外4例在猝死尸检后被诊断为LVFWR。在接受治疗的15例患者中,11例存活:2例在体外循环(CPB)下修复成功1例,7例非体外循环修复成功5例,6例非手术治疗成功5例。虽然能够接受治疗的患者存活率为73%,但总体存活率为58%。有7例为破裂型:其中4例猝死,3例接受手术治疗。2例在床边进行了开胸手术,未使用CPB直接缝合破裂处。尽管止血成功,但患者仍未存活。第3例在CPB下使用补片修补存活。在该病例中,术前采用心包 - 中心静脉旁路引流法维持循环。该方法在挽救破裂型病例方面似乎极为有效。有12例亚急性患者。虽然有2例失访,但总共10例患者获救,包括2例未使用CPB直接缝合破裂处,3例正中开胸并用纤维蛋白胶固定,1例仅进行心包引流,4例采用经皮心包内纤维蛋白胶固定治疗。由于LVFWR中直接缝合破裂心肌对脆弱梗死区域存在二次损伤风险,基于我们对室间隔破裂的经验,在手术修复期间我们改为在CPB下采用梗死灶隔离技术。一般来说,人们认为LVFWR唯一可用的治疗方法是手术。然而,我们的经验表明其他治疗方法也可能有效。如果能从各种治疗方法中选择最合适的方法,可能有助于改善治疗结果统计。治疗中降低左心室压力极为重要,是提高存活率的关键。