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%Ru
2、pture of the left ventricular free wall (0.52%)Papillary muscle (0.26%)Ventricular septum (0.17%),Survival after Mechanical complication,ACUTE 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 pap
3、illary muscle 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 hours,
4、Introduction,Following 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 th
5、e single blood supply to the posteromedial papillary muscle from the PD,Pathophysiology,Prevalence of mitral regurgitation (MR) with respect to posterior papillary muscle (PM) perfusion pattern and inferior myocardial infarction (MI).,Paolo Voci et al. Circulation. 1995;91:1714-1718,Copyright Americ
6、an Heart Association, Inc. All 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, wh
7、ich occasionally is localized to the right upper lobe,Diagnosis,Diagnosis,Prompt diagnosis with immediate initiation of aggressive medical therapy is vital until emergent surgical intervention can be performedConcomitant revascularization during mitral valve surgery is associated with improved short
8、-term and long-term outcomes,Treatment,Concomitant revascularization during mitral valve surgery is associated with improved short-term and long-term outcomes,Kaplan-Meier graphs demonstrating (A) perioperative and (B) 15-year actuarial survival benefit in patients undergoing concomitant coronary re
9、vascularization following acute postinfarction 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
10、, De Cicco G, et al. Mitral valve surgery in emergency 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 regurg
11、itant fraction and increased forward stroke volume and cardiac outputVasodilators and inodilators, such as nitrites, sodium nitroprusside, diuretics, and phosphodiesterase-3 inhibitors,mechanical cardiac supportIABPImpella Recover deviceECMO circuit,VADPositive-pressure ventilation is used with grea
12、t effect,Acute postinfarction MR is associated with an inhospital mortality of between 70% and 80% with medical treatment,Emergent 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
13、 were reviewed,55 consecutive patients were includedPatients 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 patientsBetween t
14、he second and the fourteenth day in 27 casesAfter the second week in 4 cases,Kaplan-Meier graph showing perioperative (thirty-day) survival according to revascularisation status.,Philippe Chevalier et al. Eur J Cardiothorac Surg 2004;26:330-335,2004 by Oxford University Press,Perioperative mortality
15、 was 24%No difference in early mortality between patients undergoing 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 200
16、4;26:330-335,2004 by Oxford University Press,long-term survivalimproved 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 matc
17、hed for age, sex, EF, year, and location of MI, as well as survivorship of the first 30 days.,Antonio Russo et al. Circulation. 2008;118:1528-1534,Copyright American Heart Association, Inc. All rights reserved.,Summary of Acute MR,Patients presenting with the catastrophic mechanical complication of
18、acute MR secondary to PMR following MI benefit from combined mitral valve surgery and myocardial 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 replacement,Percutaneous vs Surgical Repair of Mitral Valve Regurgitation,Percutaneous MVR,Percutaneous vs Surgical Repair,
