摘要
目的总结心脏瓣膜置换术后围术期心肌梗死(derioperative myocardial infarction,PMI)的诊断及治疗经验。方法回顾性分析心脏瓣膜置换术后发生PMI 16例的临床症状、心电图变化、实验室检查、治疗和预后。结果本组发生PMI时间:术后24 h内13例,24～48 h内2例,48～72 h内1例。出现低心排血量综合征(低心排)10例(62.50%),恶性室性心律失常9例(56.25%),高乳酸血症9例(56.25%)。16例肌钙蛋白I均明显升高(68.87±63.38)μg/L。心电图检查示病理性Q波形成10例(62.50%),前壁导联R波丢失3例(18.75%),新出现的束支传导阻滞3例(18.75%);前降支缺血12例(75%),右冠状动脉(冠脉)缺血4例(25%)。所有患者均接受肝素和硝酸甘油药物治疗,其中7例接受主动脉内球囊反搏治疗,3例行急诊冠脉旁路移植手术。痊愈11例,死亡3例,自动出院2例。结论围术期出现低心排、室性心律失常、高乳酸血症,心电图提示新出现的病理性Q波、前壁导联R波丢失,新出现的束支传导阻滞等均预示PMI的发生,应积极予肝素抗凝和硝酸酯类药物治疗。主动脉内球囊反搏可作为首选的机械辅助治疗方式,对于上述治疗仍不能改善血流动力学的患者,应急诊行冠脉旁路移植手术。
Objective To summarize diagnosis and treatment experiences of perioperative myocardial infarction （PMI） following heart valve replacement. Methods Clinical symptoms, electrocardiogram changes, laboratory examinations, treatment and prognosis of 16 patients with PMI after heart valve replacement were retrospectively analyzed. Results The occurrence time of PMI ： it occurred in 13 patients within postoperative 24 h, in 2 patients within 24 -48 h, and 1 patient within 48 -72 h. In 16 patients, low cardiac output syndrome （LCOS） occurred in 10 patients （62.50%）, malignant ventricular arrhythmia occurred in 9 patients （56.25%）, and hyperlactacidemia occurred in 9 patients （56.25%）. The average value of troponin I （68.87 ± 63.38 μg/L） was significantly higher than normal. Electrocardiogram examination showed 10 patients （62.50%） with pathological Q wave, 3 patients （ 18.75% ） with lost antetheca lead R wave, and 3 patients （18.75） with new bundle branch block. Electrocardiogram showed 12 patients （75%） with anterior descending branch ischemia, and 4 patients （25%） with right coronary artery ischemia. All the patients received medication of heparin and nitroglycerin, and among whom 7 patients （43.75%） were treated with the intra-aortic balloon counterpulsation therapy, and 3 patients （18.75%） with emergency coronary artery bypass graft surgery. Eleven patients were cured and were discharged, three patients died, and two patients left the hospital voluntarily. Conclusion Perioperative LCOS, ventricular arrhythmia, hyperlactacidemia, new pathological Q wave, lost antetheca lead R wave and new bundle branch block in electrocardiogram foreshow the incidence of PMI, and medication of heparin and nitroglycerin should be given in time. The intra-aortic balloon counterpulsation therapy is the preferred mechanical adjunctive treatment. Patients who have failed the medication and intra-aortic balloon counterpulsation therapy to improve hemodynamics, should undergo emergency CABG.
出处
《临床误诊误治》
2013年第6期66-68,共3页
Clinical Misdiagnosis & Mistherapy
关键词
围术期心肌梗死
瓣膜置换
主动脉内球囊反搏
冠状动脉旁路移植
Perioperative myocardial infarction
Valve replacement
Intra-aortic balloon counterpulsation
Coronary bypass grafting
