Madsen J C, Daggett W M
Division of Cardiac Surgery, Massachusetts General Hospital, Boston 02114-2696, USA.
Semin Thorac Cardiovasc Surg. 1998 Apr;10(2):117-27. doi: 10.1016/s1043-0679(98)70005-x.
Postinfarction ventricular septal defects complicate approximately 1% to 2% of cases of acute myocardial infarction and account for about 5% of early deaths after myocardial infarction. By differentiating the surgical treatment of these acquired lesions from the surgical approaches used to repair congenital ventricular septal defects and realizing the significance of differing anatomic locations of postinfarction ventricular septal defects, techniques have been developed that have improved salvage of patients suffering this catastrophic complication of myocardial infarction. The principles underlying these surgical techniques include (1) expeditious establishment of total cardiopulmonary bypass with moderate hypothermia and meticulous attention to myocardial protection; (2) transinfarct approach to ventricular septal defect with the site of ventriculotomy determined by the location of the transmural infarction; (3) thorough trimming of the left ventricular margins of the infarct back to viable muscle to prevent delayed rupture of the closure; (4) conservative trimming of the right ventricular muscle as required for complete visualization of the margins of the defect; (5) inspection of the left ventricular papillary muscles and concomitant replacement of the mitral valve only if there is frank papillary muscular rupture; (6) closure of the septal defect without tension, which in most instances will require the use of prosthetic material; (7) closure of the infarctectomy without tension with generous use of prosthetic material as indicated, and epicardial placement of the patch to the free wall to avoid strain on the friable endocardial tissue; and (8) buttressing of the suture lines with pledgets or strips of Teflon felt or similar material to prevent sutures from cutting through friable muscle.
心肌梗死后室间隔缺损约使1%至2%的急性心肌梗死病例变得复杂，并占心肌梗死后早期死亡病例的约5%。通过将这些后天性病变的外科治疗与用于修复先天性室间隔缺损的手术方法区分开来，并认识到心肌梗死后室间隔缺损不同解剖位置的重要性，已开发出一些技术，这些技术提高了患有这种心肌梗死灾难性并发症患者的救治率。这些外科技术的基本原则包括：（1）迅速建立中度低温下的全心肺转流，并精心关注心肌保护；（2）经梗死心肌入路处理室间隔缺损，心室切开部位由透壁梗死的位置决定；（3）彻底修剪梗死心肌的左心室边缘至存活心肌，以防止封堵延迟破裂；（4）根据完全显露缺损边缘的需要，保守修剪右心室心肌；（5）检查左心室乳头肌，仅在存在明显乳头肌破裂时同时置换二尖瓣；（6）无张力地关闭室间隔缺损，在大多数情况下这将需要使用人工材料；（7）无张力地关闭梗死心肌切除术切口，根据需要大量使用人工材料，并将补片置于心外膜至游离壁，以避免脆弱的心内膜组织受到牵拉；（8）用棉垫或特氟龙毡条或类似材料支撑缝线，以防止缝线切割脆弱的心肌。
