本文選題：室間隔穿孔 + 急性心肌梗死　； 參考：《北京協(xié)和醫(yī)學院》2013年碩士論文

【摘要】：第一部分70例急性心肌梗死合并室間隔穿孔患者的臨床特點分析 背景室間隔穿孔(VSR)是一種少見但又兇險的急性心肌梗死(AMI)后的機械并發(fā)癥。國內(nèi)對VSR的報道多為個案報道或小樣本研究,罕有大樣本臨床研究,故目前VSR的臨床數(shù)據(jù)多引用國外文獻。本研究回顧性地分析了我院70例AMI合并VSR患者的臨床特點、治療及預后情況。 方法我院2002-01到2010-09間收治的AMI患者共12354人,其中合并VSR患者70例(0.57%),男性33例(47.1%),女性37例(52.9%),平均年齡68.1歲。對這70例AMI合并VSR患者的臨床資料進行回顧性分析。 結(jié)果70例AMI合并VSR患者,繼發(fā)于前壁心肌梗死者54例(77.1%)。VSR患者30天病死率為55.7%,1年病死率為64.3%；保守治療49例,30天病死率為77.6%,1年病死率均為87.8%=%；手術(shù)治療21例,30天病死率為4.8%,1年病死率為9.5%；接受手術(shù)治療患者的30天及1年病死率顯著優(yōu)于接受保守治療患者(P0.005)。僅1例AMI后6天行急診手術(shù)治療的患者于圍術(shù)期死亡,所有AMI后2周以上行外科手術(shù)治療的患者均好轉(zhuǎn)出院。 結(jié)論VSR是AMI少見但嚴重的并發(fā)癥,手術(shù)治療的近期及遠期預后均顯著優(yōu)于保守治療,AMI后2周以上行外科手術(shù)治療成功率高,對于強化內(nèi)科保守治療后仍出現(xiàn)血流動力學不穩(wěn)定、預計不能存活至AMI后4-6周的危重患者,可適當提前外科手術(shù)時間,以挽救更多患者的生命。 第二部分急性心肌梗死合并室間隔穿孔的近期預后因素分析 背景室間隔穿孔(ventricular septal rupture, VSR)是一種急性心肌梗死(acute myocaridal infarction, AMI)后機械并發(fā)癥。既往文獻均顯示外科手術(shù)治療的長期預后顯著優(yōu)于保守治療,但因心肌梗死后早期手術(shù)難度大、圍術(shù)期死亡率高,故國內(nèi)尚未對最佳手術(shù)時機達成共識。目前臨床上一般建議VSR患者盡量內(nèi)科保守治療至4-6周后再行外科手術(shù)治療。但很多病情危重的VSR患者陸續(xù)在等待手術(shù)期間死亡。因此,在入院即刻對患者進行危險分層進而采取相對個體化的治療極為重要。本研究回顧性分析阜外心血管病醫(yī)院70例AMI合并VSR患者存活≤30天的危險因素,并對VSR患者進行危險分層,為臨床進一步治療提供依據(jù)。 方法回顧性入選2002年1月至2010年10月在阜外心血管病醫(yī)院確診為AMI合并VSR患者70例。比較AMI后VSR患者存活≤30天及存活30天患者的年齡、性別、病史、檢驗結(jié)果等臨床指標,分析研究存活≤30天患者的危險因素。根據(jù)Logistic多元回歸分析結(jié)果制定VSR患者近期預后危險評分(short-term prognosis index of VSR, SPIV)。 結(jié)果單因素分析發(fā)現(xiàn),存活≤30天的危險因素(P0.05)包括：女性、前壁心肌梗死、心功能(≥Ⅲ級)、室間隔穿孔位置(心尖部)、不合并室壁瘤。Logistic多元回歸分析發(fā)現(xiàn)：女性(P=0.013)、前壁心肌梗死(P=0.023)、Killip分級≥Ⅲ級(P=0.022)、不合并室壁瘤(P=0.023)、不合并糖尿病(P=0.009)、AMI發(fā)病到診斷VSR時間≤4天(P=0.027)為VSR患者存活≤30天的獨立危險因素。SPIV≥9分為高�；颊�,30天病死率為77.4%；≤8分為低�；颊�,30天病死率為28.6%；8-9分為中�；颊摺� 結(jié)論AMI合并VSR患者存活≤30天的獨立危險因素包括女性、前壁心肌梗死、不合并室壁瘤、不合并糖尿病、Killip分級≥Ⅲ級及AMI發(fā)病到診斷VSR時間≤4天,對于高�；颊邞扇「e極的治療方案以挽救生命。
[Abstract]:Part one clinical characteristics of 70 patients with acute myocardial infarction complicated with ventricular septal perforation
Background interventricular septal perforation (VSR) is a rare but dangerous mechanical complication after acute myocardial infarction (AMI). The domestic reports of VSR are mostly case reports or small sample studies. There is a rare large sample of clinical study, so the clinical data of VSR are often cited in foreign literature. This study reviewed 70 cases of AMI with VSR in our hospital. Clinical characteristics, treatment and prognosis.
Methods a total of 12354 AMI patients were treated in our hospital from 2002-01 to 2010-09, including 70 (0.57%) patients with VSR, 33 males (47.1%), 37 women (52.9%) and an average age of 68.1 years. The clinical data of the 70 patients with AMI combined with VSR were analyzed retrospectively.
Results 70 cases of AMI combined with VSR, secondary to anterior wall myocardial infarction, 54 cases (77.1%) of.VSR patients were 55.7%, 1 year fatality rate 64.3%, 49 conservative treatment, 77.6% fatality rate, 77.6% fatality rate, 87.8%=%, 21 cases, 30 days fatality rate and mortality rate. The annual mortality rate was significantly better than that of patients receiving conservative treatment (P0.005). Only 1 patients who underwent emergency surgery for 6 days after AMI were died in the perioperative period. All the patients who underwent surgical treatment at 2 weeks after AMI were all better discharged from hospital.
Conclusion VSR is a rare but serious complication of AMI. The short-term and long-term prognosis of surgical treatment is significantly better than that of conservative treatment. 2 weeks after AMI, the successful rate of surgical treatment is high. The hemodynamic instability still appears after conservative treatment in the intensive medicine, and the critical patients who are not expected to survive to the next 4-6 weeks of AMI can be properly advanced surgical hands. Time to save more people's life.
The second part is the short-term prognostic factors of acute myocardial infarction with ventricular septal perforation.
Background ventricular septal perforation (ventricular septal rupture, VSR) is a mechanical complication after acute myocardial infarction (acute myocaridal infarction, AMI). The previous literature showed that the long-term prognosis of surgical treatment was significantly better than that of conservative treatment. However, early operation after myocardial infarction was difficult and the perioperative mortality was high. There is a common consensus on the timing of a good operation. Currently, VSR patients are generally recommended to be treated as conservative as possible until 4-6 weeks after surgery. But many critically ill VSR patients are waiting to die during the operation. Therefore, it is very important to carry out dangerous stratification and then adopt a relatively individualized treatment at the time of admission to the hospital. The risk factors of 70 cases of AMI combined with VSR patients survived for less than 30 days in Fuwai Hospital of Cardiovascular Disease were analyzed retrospectively, and the risk stratification of patients with VSR was carried out to provide the basis for further clinical treatment.
Methods 70 patients with AMI combined with VSR in Fuwai Hospital of Cardiovascular Disease from January 2002 to October 2010 were selected to compare the age, sex, history and test results of VSR patients who survived for less than 30 days and 30 days of survival after AMI, and to analyze and study the risk factors of patients who survived for less than 30 days. According to Logistic multiple regression analysis, the results were analyzed. Results short-term prognosis index of VSR (SPIV) was established for VSR patients.
Results single factor analysis found that the risk factors (P0.05) that survived for less than 30 days included women, anterior wall myocardial infarction, cardiac function (more than grade III), ventricular septal perforation (apical), and no ventricular aneurysm combined with.Logistic regression analysis: Women (P=0.013), anterior wall myocardial infarction (P=0.023), Killip classification (P=0.022), and no combination of ventricular wall. Tumor (P=0.023), without diabetes (P=0.009), AMI onset to the diagnosis of VSR time less than 4 days (P=0.027) for the survival of VSR patients less than 30 days of independent risk factor.SPIV more than 9 to high-risk patients, 30 days of death rate of 77.4%; less than 8 in low risk patients, 30 days death rate 28.6%; 8-9 divided into middle risk.
Conclusion the independent risk factors of AMI combined with VSR patients surviving less than 30 days include women, anterior wall myocardial infarction, no ventricular aneurysm, no diabetes, Killip grade more than grade III and AMI to the diagnosis of VSR less than 4 days, and more active treatment should be taken to save life for high-risk patients.
【學位授予單位】：北京協(xié)和醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2013
【分類號】：R542.22

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