背景:急性心肌梗死(AMI)后,左心室游离壁破裂(LVFWR)和室间隔破裂(VSR)的手术具有很高的住院死亡率,随着时间的推移,这种情况没有显著改善。卸载LV对于防止修复部位的过度压力和避免出血等问题至关重要。泄漏,贴片开裂,和LVFWR和VSR复发,因为组织是如此脆弱。我们介绍了2例AMI机械并发症急诊手术后使用Impella5.5进行LV卸载的患者。
方法:一名76岁男性STEMI患者接受了右冠状动脉远端纤溶。三天后,他昏倒了,休克了。超声心动图显示心脏压塞。我们在后外侧壁上发现了渗出型LVFWR,并使用TachoSil进行了非缝合技术处理。在患者离开CPB之前,通过连接到右腋窝动脉的IOmm合成移植物将Impella5.5插入LV。我们将流速保持在4.0至4.5L/min以上,直到POD3以降低LV壁张力,同时最小化搏动性。在POD6上,我们将患者从Impella5.5断奶。术后心脏CT扫描显示LV没有造影剂渗漏。然而,肝素给药期间POD4的脑出血使他住院复杂化。病例2:诊断为由STEMI引起的心源性休克发生在一名84岁男性患者中,在IABP支持下接受LADPCI的患者。PCI术后3天超声心动图显示VSR,患者接受了紧急VSR修复,使用两个单独的贴片,并将BioGlue应用于它们之间的缝合线。在从CPB断奶之前,我们在LV中植入了Impella5.5,并增加了静脉动脉体外膜氧合(VA-ECMO)支持右心衰竭。术后超声心动图显示无残余分流。
结论:因AMI机械并发症而接受急诊手术的患者可能会发现Impella5.5是左心室卸载的有效工具。与Impella联合使用VA-ECMO可能是管理与并发右侧心力衰竭相关的VSR的有效策略。
BACKGROUND: Following an acute myocardial infarction (AMI), surgery for left ventricular free wall rupture (LVFWR) and ventricular septal rupture (VSR) has a high in-hospital mortality rate, which has not improved significantly over time. Unloading the LV is critical to preventing excessive stress on the repair site and avoiding problems such as bleeding, leaks, patch dehiscence, and recurrence of LVFWR and VSR because the tissue is so fragile. We present two cases of patients who used Impella 5.5 for LV unloading following emergency surgery for AMI mechanical complications.
METHODS: A 76-year-old male STEMI patient underwent fibrinolysis of the distal right coronary artery. Three days later, he passed out and went into shock. Echocardiography revealed a cardiac tamponade. We found an oozing-type LVFWR on the posterolateral wall and treated it with a non-suture technique using TachoSil. Before the patient was taken off CPB, Impella 5.5 was inserted into the LV via a 10 mm synthetic graft connected to the right axillary artery. We kept the flow rate above 4.0 to 4.5 L/min until POD 3 to reduce LV wall tension while minimizing pulsatility. On POD 6, we weaned the patient from Impella 5.5. A postoperative cardiac CT scan showed no contrast leakage from the LV. However, a cerebral hemorrhage on POD 4 during heparin administration complicated his hospitalization.
Case 2: A diagnosis of cardiogenic shock caused by STEMI occurred in an 84-year-old male patient, who underwent PCI of the LAD with IABP support. Three days after PCI, echocardiography revealed VSR, and the patient underwent emergency VSR repair with two separate patches and BioGlue applied to the suture line between them. Before weaning from CPB, we implanted Impella 5.5 in the LV and added venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for right heart failure. The postoperative echocardiography revealed no residual shunt.
CONCLUSIONS: Patients undergoing emergency surgery for mechanical complications of AMI may find Impella 5.5 to be an effective tool for LV unloading. The use of VA-ECMO in conjunction with Impella may be an effective strategy for managing VSR associated with concurrent right-sided heart failure.