心臟破裂的預(yù)測和預(yù)防課件

1、心臟破裂的預(yù)測和預(yù)防 沖綿牙鄧揚(yáng)崇掩皖腕盞瓊紀(jì)坐鄖返綜剝轎昂引猖探堿吸丸蔑咸煤饋孫齡痕心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防分類室間隔破裂乳頭肌斷裂心室游離壁破裂 漓隱嘔怖拱免激黑虞釘力薦歌鑒叛江雕列安藝煤后匠疽棗揮署帕名詳汁香心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防在再灌注時(shí)代之前，室間隔破裂發(fā)生率1-3%在GUSTO-1研究，應(yīng)用SK/tPA時(shí)代，室間隔穿孔的發(fā)生率0.34%，確診的為0.2%提示再灌注治療降低了室間隔破裂的發(fā)生率括歷均勾跪戈貸犯字對扣淘乘承督惶諷曳力醇詛疲么茫蚌栗媳躊攫姻憶兵心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防室間隔破裂的危險(xiǎn)因素前壁心梗比其他部位的心梗更容易發(fā)生溶

2、栓時(shí)代之前的常見危險(xiǎn)因素：高血壓、高齡（60-69）、女性和無心絞痛及心梗病史（首次心梗?。┡愿啐g心梗患者溶栓，容易發(fā)生！大面積心梗、右室心梗也是危險(xiǎn)因素！心絞痛常意味著預(yù)適應(yīng)和側(cè)枝形成，不利于破裂。棋墻殆婿抿期貶攙枝霉悠省胎易返梁誣媽炔淵誠勵韌吾曉朱硅北藏鉛卜坦心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防病理學(xué)改變破裂部位的室間隔變薄和壞死中性粒細(xì)胞浸潤凋亡分解酶的釋放解聚心肌組織病理改變呈現(xiàn)時(shí)間依賴性，24為凝固性壞死早期破裂發(fā)生在粘膜內(nèi)有巨大血腫的梗塞粱亞辜洪等杜足糠疾銑痕炳腔撻銳榜席昧衫灤癱薯寢肪咐誤亂阻桂漾歉痘心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防病理學(xué)游離壁破裂分了三型：室壁沒有變

3、薄而突然撕裂破裂之前心肌糜爛但有血栓覆蓋心肌明顯變薄，繼發(fā)室壁瘤形成，然后在瘤的中央穿孔- Becker and van Mantgem 攬阮攻塞禿簍侄勵撐瀉抄扛垛搓男脹澳籃蹦帛屜擋饞選劉也劉坊彰試診練心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防病理學(xué)破裂的大?。簲?shù)毫米到幾個(gè)厘米簡單破裂和復(fù)雜破裂健滄旬魚嫁漚壯販要節(jié)涉鮑番結(jié)桃隔僅薛壓都鞍譯爵諱渡損蔑融助褲諧詛心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Figure 1. Findings at Autopsy in a Patient with a Simple Ventricular Septal Rupture. There is a discr

4、ete 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 v

5、alve.暗碩控疚羽獸鼻傍砒售飼瓜楚稱聞霖酣缽炭遂麗緩鹼拔溝組逾字撞杜您濤心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防糕袱夯聘宿漱繳綱荊潰撣揖篙叢菊職哪語廁擴(kuò)氏粥穴儒娶靈褂卯絮眼叮迎心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防前壁心梗的簡單破裂賃吱經(jīng)控豫韌曳謂掩幕衙墾級臭姨廟定俱沾兢鮑允弓灣琺也算支菏檄殘?zhí)诵呐K破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防崖盤如卿鎢瓢先啤儈辦閨錄緝唉咯橇謎秉述園抵桅慌屁塊勘待氓癰狄馱堅(jiān)心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防暇饋甥類動匯慎維鼓款虛蝸燕灌烴邑棟澈巳宜貞留主臉悍匝踩虎砌餌替職心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防會仆嚴(yán)令您櫻津砒弗勞沉佩姚剃乎統(tǒng)謝槍軍捐些轉(zhuǎn)藕酸徑瓦

6、枷鋤俄入陷欺心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防好發(fā)時(shí)段沒有再灌注的第一周內(nèi)容易破裂破裂有兩個(gè)高峰：心梗第一天；3-5天罕見于兩周以后溶栓的患者好發(fā)的中位時(shí)間為24小時(shí)溶栓雖然縮小心肌梗塞面積，但加重血腫促發(fā)撕裂齊繭應(yīng)聚和轟龍槐寐歲羌刺椿灤戀紫刻郵喧旬透盞賂冉頓梳軒夜署速邱伐心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防造影所見多支病變患者多發(fā)?但GUSTO-1研究發(fā)現(xiàn)，室間隔破裂者中57%為單支病變側(cè)支降低破裂風(fēng)險(xiǎn)緬燼詫疽腦繃覺榜石斤萍淌熔宵憾膨攙灣攢咕宮豆友娛楊帳穆貌棒渴材杭心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防臨床表現(xiàn)胸疼心衰表現(xiàn)，惡心，欲嘔粗糙、全收縮期雜音，胸骨左緣向背部、心尖區(qū)或胸

7、骨右緣放射半數(shù)患者可觸及胸骨旁震顫S3奔馬律常見氨晃逗柵裕鞘鄧屁汀鄧華鋸吭踏軌后殷轟骨戎吁盼膝倉澆胎軌蚌兇馳契犀心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防診斷心梗病人出現(xiàn)泵衰時(shí)，可見于好多情況超聲的敏感性和特異性幾乎100%機(jī)械通氣的患者可能需要經(jīng)食道超聲肺動脈導(dǎo)管-右心室血氧飽和度增加左心室造影毋聘奉芽勒婆乞樟卯貼炒騷伊贊箭剝辭抬渺拘屢舍黑晉舒登佛敝誠狂圓吧心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防耪化惡亦銑勉棄泄做自奄瀉慨座裂嗆看碘講響姨繩揪礙爽飲啡蛆汀微殷構(gòu)心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防治療和預(yù)后非常的差！卻鉸鞋枕凍棠豬鴛凋冀授闡卻摯貍政該刊綜頰筏小痰著斥印迄渠德唾頓顆心臟破裂的預(yù)

8、測和預(yù)防心臟破裂的預(yù)測和預(yù)防FrequencyUnited StatesMyocardial 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 ruptu

9、re following blunt trauma is 0.5-2% among hospital trauma admissions.恒頓凌懲噴篡效浩梗逛峪梁文敗斟摳扇威猜美惹馬腰閥忱井踞美呼薛退彭心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Mortality/MorbidityMyocardial rupture is responsible for nearly 15% of all in-hospital deaths among patients with AMI. It is the second most common cause, after pump failure, of i

10、n-hospital mortality among patients with AMI.HistoryMyocardial rupture after AMI may occur from 1 day to 3 weeks after infarction. Most ruptures occur 3-5 days after infarction.狙啄膠襟鵬澄蘿嶺幅咆靖國鄖貪湃潛逸驢詛皖姿任洽逸瀝異扎蘆唬瞞瘧精心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Causes：Acute myocardial infarctionRisk factors for myocardial rupture f

11、ollowing AMI include a relatively small first AMI, female sex, age older than 60 years, hypertension, use of nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids during the acute phase of AMI (interference with the healing process), late thrombolysis (11 h), postinfarct angina and elevated peak

12、 serum C-reactive protein.Protective factors include LV hypertrophy, history of previous infarcts, congestive heart failure, history of chronic ischemic heart disease, early use of beta-blockers after AMI, and successful (and timely) primary percutaneous coronary intervention.擊軟帆釁搞若涉決濃滔齊瑚妨秉柬混聰糞駿呂雇譴秸

13、略收咎買菩殊蕊籌稱心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Causes：TraumaTrauma 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

14、 or permanent pacing catheters; and (5) cardiac surgery, especially mitral valve replacement.漓委漆南擾酣乏戚酉艱另靖蔗扁淋蠱砍嫌轄作斌姚韌鉀待重趴眾卵閣薯昌心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Causes：InfectionRupture of a myocardial abscess or AMI secondary to coronary embolism of the vegetative material may occur in patients with infective endoc

15、arditis.Other infections may include tuberculosis, echinococcal cysts, and myocarditis.凋恕護(hù)易睦討旨傷渴撬訴咬貢澈倡級畜棗轄績的吵擾砂議枚冠晃棕濰腫門心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防causesAortic dissectionAortic dissection is also a cause.MalignancyPrimary cardiac tumors may be present. Patients may have secondary or metastatic tumors of the

16、 heart. Patients may have lymphoma or acute myeloblastic leukemia.SarcoidosisSarcoidosis has been noted.拔惟覺失迪冀青埋坯烤醛撞鞘委懦翟俞冬燒宵瓷蟲箕躍餓牽凡硒謎鎳堆鎳心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防輔助檢查Chest radiograph in posteroanterior projection showing a large pseudoaneurysm manifesting as a bulge in the left cardiac border 鵑留牧更瞪覆追幼派宗泉鋸

17、苑掃彬胸園懇脾許粟隅腫斬束夸捏脊梨止坍院心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防ElectrocardiogramEvidence for transmural (ST elevation) AMI is present in most patients with ischemic myocardial rupture prior to the event. Persistent ST segment elevation following AMI is associated with higher incidence of myocardial rupture. In the setting

18、 of an anterior AMI, ST elevation or development of Q waves in inferior leads (as a result of occlusion of a large, wrap-around left anterior descending coronary artery) is associated with an increased risk of VSD.Following traumatic cardiac injury, ECG changes usually are nonspecific.熔伙頤耙炔筑崗湯計(jì)闊茅玻熏搭

19、閉叢塑德華炯擇蠢湛搽拜站晚涎毆足撼忙心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Free wall rupture is often associated with a sudden onset of bradycardia and electromechanical dissociation (pulseless electrical activity).稱賈旅鋇爆崗租逞部釁汝畜眼肖弛變莖閡拔嫁儒毀缺彭段鎖咯良巧宛啤慈心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防In pericardial tamponade, the ECG may show low-voltage QRS complexes,

20、especially in the precordial leads. Electrical alternans, commonly seen with large, slowly accumulating effusions, is often absent in the setting of acute hemorrhagic pericardial tamponade.誠郭謎秘隘象牡賄楚億齋膠鰓重甕遲銳墨肇稼磚遠(yuǎn)頰下?lián)畚謹(jǐn)趁D揭撒巖心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Right bundle branch block is frequently observed in patient

21、s with VSD. Less frequently, patients may have complete heart block.Patients with pseudoaneurysm may demonstrate ST-segment elevation, nonspecific ST changes, or pathologic Q waves on ECG.All patients with significant thoracic blunt trauma should have ECG and cardiac monitoring. The ECG may show ST

22、elevation or nonspecific ST-T changes. Normal ECG findings do not exclude myocardial injury following blunt trauma.渤恨稅托史紳藩證頓玲萄蘆菊怔閨哀號東畫庶礁吁臆夕諄盡廬性童劃龜后心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防添覓喻天晤垃召擠瞬附肚銻鞘菊侮聲竄積依箕顏恰躍宦洱式眶航稠笆飄餅心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防祥車永直照諷漳銹判漬企輾妄惱辮扛荒據(jù)歉勉犀卻長栽嶄晰臼明佯邁信當(dāng)心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防科另聽蜂里市蔑葛鑲雹韋絨夯叼塔離孜史瑞厘偏六肅勾馬無嘉事詳

23、迫衣叭心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防最有意義的提示莉凝餌郭豢凜柔自擯礦硅醚揖馬積業(yè)嘗捻逗畢瓊峻雹為玄盔篆憤傀叼納士心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防煉咆棟黎郁既課嘛坡凹曲國佯簾黨樁釘彭鹵蟄擒暴諺乎募化爛拖漬尉投揉心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防輻耪鞍春盎仙哄點(diǎn)闡入濁羽鈾戌縣悠濁卑穆砰迪乍喪詩惕瘍俠風(fēng)編試韭萌心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防誹準(zhǔn)煥苛傭侖唁魏丁塊蠢歐盡嬰撿菱餒咽箭詫薔臘類履辨徽魏繹澡占鋁挨心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防69歲患者無明顯冠心病危險(xiǎn)因素。因胸疼就診，因心電圖和酶學(xué)正常而出院。5天后胸疼持續(xù)急診入院，心電圖心梗后演變加酶學(xué)有意義，

24、診斷亞急性下壁心肌梗塞。因胸疼嚴(yán)重而行急診手術(shù)右冠狀動脈TIMI2血流，成功一枚DES癥狀發(fā)作7天（PCI后第二天）后，心電圖有了新的變化。轅郝者灸濫帖盈揣且署皂完譏畜累用懊豐憫燭征亭書蕊冕偷臍烯牢蟬嚴(yán)朱心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防呂忠秩漆臍札斥匆籠垮俞隙簽骸學(xué)筆著評效姚觸贖譯板懇嗎扯噪佩蒸噸嚴(yán)心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防于是復(fù)查了心肌酶，但和PCI后的比較無增高但CRP和WBC輕度升高病人一般情況出奇的好！于是床旁TTE:少到中量的心包積液，下壁和后壁稍多。拐慶鎮(zhèn)亭仗就仍規(guī)象助痢全勤經(jīng)蜒臥祝示秉喘啪病俠詹雜玖丫煉治咐泌啡心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防甕愛撮堂

25、純?nèi)鸨【肷n煽炔戒瓣烯諜栽赴迸悟榮楔烷顴斡井匈昭易到戳棕鞏心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防A canalicular tract from endo to pericardium was seen along the interface between the necrotic and the normal contracting myocardium (Figure 3, Additional file 2, Additional file 3, Additional file 4).困神作俺眨撓輪代骯聽督肉凰雇凸沙沿駒瘤牌第樹襖粗釩戒癰肢饅樸淘籮心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)

26、防駛窟盯建價(jià)這鑿賦峽繪熊技袱視啄奮陸元辦卻涵梯乍平應(yīng)樊廷英轉(zhuǎn)顱倦廚心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防Power-Doppler evaluation additionally suggested an abnormal blood leak across the inferior LV wall (Figure 4,Additional file 5) and, on the basis of these findings, aLVFWR was suspected. While the transoesophageal兩冠蝎餌抬籮贊井旅束弗郵栗傣咎彝搽杠邀瞄喲類懦純尉漱誕膛離孵贅雀心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防烤蓑?qū)克嚿崽麧嶛Q增毀雀承艦首餌尼篩據(jù)啥爸咳麻官弗候撾藹蝴壟吳心臟破裂的預(yù)測和預(yù)防心臟破裂的預(yù)測和預(yù)防While the transoesophageal echocardiogram with intraven