心脏破裂地预测和预防.pptVIP

分类 室间隔破裂 乳头肌断裂 心室游离壁破裂 在再灌注时代之前，室间隔破裂发生率1-3% 在GUSTO-1研究，应用SK/tPA时代，室间隔穿孔的发生率0.34%，确诊的为0.2% 提示再灌注治疗降低了室间隔破裂的发生率 室间隔破裂的危险因素 前壁心梗比其他部位的心梗更容易发生 溶栓时代之前的常见危险因素：高血压、高龄（60-69）、女性和无心绞痛及心梗病史（首次心梗！） 女性高龄心梗患者溶栓，容易发生！ 大面积心梗、右室心梗也是危险因素！ 心绞痛常意味着预适应和侧枝形成，不利于破裂。 病理学改变 破裂部位的室间隔变薄和坏死 中性粒细胞浸润 凋亡 分解酶的释放解聚心肌组织 病理改变呈现时间依赖性，24为凝固性坏死 早期破裂发生在粘膜内有巨大血肿的梗塞 病理学 病理学 破裂的大小：数毫米到几个厘米 简单破裂和复杂破裂 Figure 1. Findings at Autopsy in a Patient with a Simple Ventricular Septal Rupture. There is a discrete defect with a direct through-and-through communication across the septum. The perforation is at the same level on both sides of the septum: the left ventricular aspect of the interventricular septum (LVS), and the right ventricular aspect of the interventricular septum (RVS). MV denotes mitral valve. 前壁心梗的简单破裂 好发时段 没有再灌注的第一周内容易破裂 破裂有两个高峰：心梗第一天；3-5天 罕见于两周以后 溶栓的患者好发的中位时间为24小时 溶栓虽然缩小心肌梗塞面积，但加重血肿促发撕裂 造影所见 多支病变患者多发? 但GUSTO-1研究发现，室间隔破裂者中57%为单支病变 侧支降低破裂风险 临床表现 胸疼 心衰表现，恶心，欲呕 粗糙、全收缩期杂音，胸骨左缘 向背部、心尖区或胸骨右缘放射 半数患者可触及胸骨旁震颤 S3奔马律常见 诊断 心梗病人出现泵衰时，可见于好多情况 超声的敏感性和特异性几乎100% 机械通气的患者可能需要经食道超声 肺动脉导管---右心室血氧饱和度增加 左心室造影 治疗和预后 非常的差！ FrequencyUnited States Myocardial rupture complicates up to 10% of AMIs. Approximately 6-10% of penetrating chest wounds and 15-75% of blunt chest traumas are associated with cardiac injury. Myocardial rupture occurs in 10-15% of fatal motor vehicle accidents. Incidence of cardiac rupture following blunt trauma is 0.5-2% among hospital trauma admissions. Mortality/Morbidity Causes：Trauma Trauma may be blunt or penetrating. Trauma also may be iatrogenic in nature, resulting from (1) diagnostic catheterization, including transseptal puncture and endomyocardial biopsy; (2) balloon valvuloplasty; (3) pericardiocentesis; (4) placement of temporary or permanent pacing catheters; and (5) cardiac surgery, especially mitral valve replacement. Causes：Infection Rupture of a myocardial abscess or AMI secondary to coronary embolism of the vegetative material may occur in patients with infective en