- 期刊
Ventricular Septal Rupture After Early Successful Thrombolytic Therapy in Acute Myocardial Infarction: A Case Report
急性心肌梗塞的病人在接受早期成功的血栓溶解治療後發生心室中膈缺損－病例報告
摘要
心室中膈缺損對急性心肌梗塞的病人而言是一種嚴重且死亡率高的併發症。此種併發症在早期再灌流的治療方法實施後，發生率已下降，且大部份發生在女性、老年人、前壁梗塞、多條血管病變、梗塞相關之冠狀動脈阻塞不通且欠缺側枝循環，或太晚接受再灌流治療的病人。這裡，我們報告一位六十歲男性病患，因持續的胸痛而住院，經診斷為ST節段上升的急性心肌梗塞。在胸痛發生三小時後，就給予血栓溶解治療。根據胸痛緩解、ST節段下降和心臟酵素早期達到高峰，而確定血栓溶解劑是有達到效果的。但是，在住院的第三天，病人在解便後，發覺會有點喘，經聽診發現在左側胸骨處有新形成的三度全收縮期的心雜音。心臟超音波顯示心尖處的心室中膈發生破損。肺動脈順流導管發現從右心房至右心室有血氧濃度上升6%的現象。冠狀動脈攝影顯示只是一條冠狀動脈的病變且梗塞的冠狀動脈也通暢。接著這位病人接受積極的內科治療，十天後再接受心室中膈缺損修補和冠狀動脈繞道手術。最後完全康復。此病例顯示，雖然早期血栓溶解治療成功地打通梗塞的冠狀動脈，且冠狀動脈攝影顯示只是一條冠狀動脈病變的病人，臨床上還是會發生心室中膈缺損的。
並列摘要
Ventricular septal defect (VSD) is a severe complication of acute myocardial infarction and has a high mortality rate. This complication appears to have declined in the reperfusion era. It has mostly been reported in elderly or female patients who suffer from anterior wall infarction, patients with multivessel coronary artery disease (CAD) or occluded infarct-related artery (IRA) without collateral circulation, or patients who have had delayed reperfusion therapy. Here, we report the case of a 60-year-old male patient who presented with persistent chest pain and Killip I ST-segment-elevation myocardial infarction. Thrombolytic therapy was started 3 hours after the onset of chest pain. Based on the subsidence of chest pain, resolution of the elevated ST segment, and early peak of cardiac enzymes, reperfusion was thought to be successful. However, on the third day of admission, the patient complained of dyspnea after defecation and was found to have new-onset grade 3 pansystolic murmur over the left sternal border. Cardiac echography showed an apical VSD. A Swan-Ganz catheter was inserted into the right side of the heart; analysis of blood oxygen saturation revealed a 6% step-up of oxygen in the right ventricle. Coronary angiography showed only one-vessel CAD and TIMI 3 flow in the IRA. The patient received intensive medical management and underwent VSD repair and internal mammary artery bypass grafting to the left anterior descending artery. His recovery was uneventful. This case illustrates that VSD can be found in patients receiving early successful reperfusion therapy, with one-vessel CAD, and TIMI 3 flow in the IRA.
延伸閱讀
- 許育誠、程俊傑、李世煌、徐國基、林申昌、洪惠風、劉哲仰、管培良（2000）。急性心肌梗塞病患未接受緊急經皮冠狀動脈氣球擴張術之原因及預後之探討。中華民國急救加護醫學會雜誌，11(1)，10-15。https://doi.org/10.30018/JECCM.200003.0002
- Chuang, T. L., Lin, J. W., & Wang, Y. F. (2019). 多支血管冠狀動脈疾病於正常心肌灌注掃描：高短暫性缺血性擴張的重要. 核子醫學暨分子影像雜誌, 32(1), 24-31. https://doi.org/10.6332/ANMMI.201903_32(1).0003
- Wang, Y. C., Law, H. W., Li, A. H., & Chu, S. H. (2004). 原發性心臟血管肉瘤合併心包積水及心因性休克－二病例報告. Acta Cardiologica Sinica, 20(1), 47-51. https://www.airitilibrary.com/Article/Detail?DocID=10116842-200403-20-1-47-51-a
- 陳遠浩、賴聰煌、趙治中、方晃（1979）。心室中隔缺損併發主動脈閉鎖不全一病例報告。Acta Paediatrica Sinica，20(2)，110-114。https://www.airitilibrary.com/Article/Detail?DocID=00016578-197906-20-2-110-114-a
- 陳彥勳（2012）。接受成功立即性冠狀動脈介入治療之ST 波段上升急性心肌梗塞病人早期出院之特徵〔碩士論文，長榮大學〕。華藝線上圖書館。https://doi.org/10.6833/CJCU.2012.00228