1、 ISCHEMIC MITRAL REGURGITATION IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION 急性心肌梗死合并缺血性二尖瓣反流Mechanical Complications ofAcute Myocardial Infarction Primary PCI as the principal reperfusion strategy following STEMI,the incidence of mechanical complications has reduced significantly to less than 1%Rupt
2、ure of the left ventricular free wall(0.52%)Papillary muscle(0.26%)Ventricular septum(0.17%)Survival after Mechanical complicationACUTE MITRAL REGURGITATION（MR）Mild to moderate chronic MR is found in 15%to 45%of patients after AMI，usually transient and asymptomaticAcute MR secondary to papillary mus
3、cle rupture is a life-threatening complication with a poor prognosisOccurs in 0.25%of patients following AMI and represents up to 7%of patients in cardiogenic shock following AMIDiagnosed between 2 to 7 days after AMI，the median time to papillary muscle rupture is approximately 13 hoursIntroductionF
4、ollowing AMI,in combination with changes in LV shape and regional wall function,results in acute MREven slight modifications of LV geometry caused by regional wall-motion abnormality may contribute to the increased frequency of MR after AMICommonly following an inferior MI，owing to the single blood
5、supply to the posteromedial papillary muscle from the PDPathophysiologyPrevalence of mitral regurgitation(MR)with respect to posterior papillary muscle(PM)perfusion pattern and inferior myocardial infarction(MI).Paolo Voci et al.Circulation.1995;91:1714-1718Copyright American Heart Association,Inc.A
6、ll rights reserved.Immediate pulmonary edema,hypotension,and,in some cases,cardiogenic shock A new pansystolic murmur is heard loudest at the cardiac apexElectrocardiography usually confirms an inferior or posterior MIChest radiography demonstrates pulmonary edema,which occasionally is localized to
7、the right upper lobeDiagnosisDiagnosis Prompt diagnosis with immediate initiation of aggressive medical therapy is vital until emergent surgical intervention can be performed Concomitant revascularization during mitral valve surgery is associated with improved short-term and long-term outcomesTreatm
8、entConcomitant revascularization during mitral valve surgery is associated with improved short-term and long-term outcomesKaplan-Meier graphs demonstrating(A)perioperative and(B)15-year actuarial survival benefit in patients undergoing concomitant coronary revascularization following acute postinfar
9、ction mitral regurgitation.(A From Chevalier P,Burri H,Fahrat F,et al.Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation.Eur J Cardiothorac Surg 2004;26(2):332;and B Adapted from Lorusso R,Gelsomino S,De Cicco G,et al.Mitral valve surgery in emerge
10、ncy for severe acute regurgitation:analysis of postoperative results from a multicentre study.Eur J Cardiothorac Surg 2008;33(4):577,with permission.)Treatment with MR Medical therapy Aims to reduce the afterload,with a resultant decreased regurgitant fraction and increased forward stroke volume and
11、 cardiac output Vasodilators and inodilators,such as nitrites,sodium nitroprusside,diuretics,and phosphodiesterase-3 inhibitors mechanical cardiac support IABP Impella Recover device ECMO circuit,VAD Positive-pressure ventilation is used with great effect Acute postinfarction MR is associated with a
12、n inhospital mortality of between 70%and 80%with medical treatmentEmergent surgery remains the cornerstone of treatment The largest series of patients who underwent surgical intervention for papillary muscle rupture：from April 1985 to June 2002 were reviewed,55 consecutive patients were included Pat
13、ients with acute MR(defined as occurring within 1 month of the infarction)The mean delay between AMI and mitral valve surgery was 7.3 7.4 days(range 133 days)Surgery took place within:the first 24 h of diagnosis of MR in 24 patients Between the second and the fourteenth day in 27 cases After the sec
14、ond week in 4 casesKaplan-Meier graph showing perioperative(thirty-day)survival according to revascularisation status.Philippe Chevalier et al.Eur J Cardiothorac Surg 2004;26:330-3352004 by Oxford University PressPerioperative mortality was 24%No difference in early mortality between patients underg
15、oing concomitant CABG and No revascularized group(CABG 27.3%vs no CABG 26.4%;P.9)Kaplan-Meier graph showing long-term mortality of patients who survived the perioperative period.Philippe Chevalier et al.Eur J Cardiothorac Surg 2004;26:330-3352004 by Oxford University Presslong-term survivalimproved
16、in patients undergoing concomitant revascularization at 15 years(CABG 64%vs no CABG 23%;P0.5)Late survival in operative survivors of surgery for post-MI PMR(dashed line)vs patients with MI without PMR(solid line)and matched for age,sex,EF,year,and location of MI,as well as survivorship of the first
17、30 days.Antonio Russo et al.Circulation.2008;118:1528-1534Copyright American Heart Association,Inc.All rights reserved.Summary of Acute MRPatients presenting with the catastrophic mechanical complication of acute MR secondary to PMR following MI benefit from combined mitral valve surgery and myocard
18、ial revascularization,with satisfactory early and late outcomes despite the increased operative mortality.no significant difference in survival has been demonstrated between mitral valve repair or mitral valve replacementPercutaneous vs Surgical Repair of Mitral Valve RegurgitationPercutaneous MVR Percutaneous vs Surgical Repair
