Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 130

All mechanical complications are treated by emergent surgical repair and coronary revascularization. Surgery reduces mortality from 90–100% to ~20–50%.

1 MR – Papillary muscle rupture dictates emergent valvular surgery + CABG. Place IABP preoperatively and administer IV vasodilators (nitroprusside) as in all cases of acute severe MR. Mitral valve replacement is most often performed as it is more expeditious than repair, and it is difficult to sew necrotic tissue. The operative mortality is 20–40%.¹²¹When severe acute MR is secondary to acute mitral leaflet tethering, the patient may be treated with percutaneous revascularization, vasodilators and temporary IABP support. It is expected that leaflet tethering improves once the function of the reperfused territory improves.128-130 This is not the case in chronic leaflet tethering seen with chronic infarction. Surgery should be considered a second-line therapy for those patients who do not improve with medical therapy.

2 VSR – The operative mortality is high, ~50%, as it is difficult to sew the necrotic friable septum. Mortality is higher in basal-inferior VSR, because the latter is more serpiginous and often associated with RV infarct. Prepare the patient with IABP/nitroprusside/inotropes. Even a small VSR requires surgical repair, as the tear may rapidly and unpredictably progress to hemodynamic collapse.

The long-term survival of patients who survive any of the three mechanical complications is good.

Figure 2.6 Dynamic left ventricular outflow tract obstruction in apical infarction.