摘要：
目的 分析急性心肌梗死(AMI)合并室间隔穿孔(VSR)患者的临床特点,评估影响室间隔穿孔患者早期死亡的相关危险因素.方法 回顾性分析2007年12月到2017年5月由湘雅二医院、湖南省人民医院、南华大学附属第一医院、南华大学附属第二医院、湘潭市中心医院5家医院确诊的AMI合并VSR患者96例,其中男50例,女46例,年龄43~90(66.2±10.7)岁,收集患者年龄、性别、合并症、心肌梗死史、吸烟史、胸痛发作至就诊时间、AMI后急诊经皮冠状动脉介入治疗或溶栓、Killip分级、心电图、超声心动图、冠状动脉造影等临床资料.根据是否发生院内死亡分为院内死亡组(n＝32)和院内存活组(n＝64),探讨影响AMI合并VSR院内死亡的相关因素;再根据患者存活时间分为早期死亡组(存活≤2周,n＝50)和非早期死亡组(存活>2周,n＝46),采用logistic多元回归分析早期死亡的独立危险因素.结果 71例收集到VSR穿孔部位的患者中,64.0%(32/50)前壁AMI的VSR部位为心尖部或前间隔近心尖部室间隔穿孔,57.1%(12/21)非前壁AMI的VSR部位为后间隔和基底段.与院内存活组比较,院内死亡组患者多为高龄[(69.6±11.3)岁比(64.6±10.1)岁,P＝0.031]、不合并室壁瘤形成[71.9%(23/32)比37.5%(24/64),P＝0.001]和前壁心肌梗死[84.4%(27/32)比62.5%(40/64),P＝0.028].早期死亡组(存活≤2周)与非早期死亡组(存活>2周)比较,年龄、性别、合并心绞痛/心肌梗死病史、Killip分级≥Ⅲ级、合并室壁瘤形成等差异有统计学意义(P2 weeks after admission, n=46). Multivariate logistic regression was used to analyze the independent risk factors of the early death. Results Location of VSR was available in 71 patients, VSR was located at the apical or anterior septum near the apical region in 64.0% (32/50) patients with the anterior AMI, VSR was located at the posterior wall and basal inferior segment in 57.1% (12/21) patients with non-anterior AMI. Compared to the in-hospital survival group, patients in the in-hospital death group were older ((69.6±11.3)years vs. (64.6±10.1) years,P=0.031), incidence of non-ventricular aneurysm (71.9% (23/32) vs. 37.5% (24/64),P=0.001) and anterior AMI (84.4% (27/32) vs. 62.5%(40/64) ,P=0.028) was significantly higher in the in-hospital death group than in the in-hospital survival group. The comparison between the early death group and non-early death group showed that older age, female, no history of angina or myocardial infarction, Killip grade>Ⅲ, and non-ventricular aneurysm were related to increased risk of the early mortality in this patient cohort. Logistic regression analysis revealed that female ( OR=5.109, 95%CI 1.19-22.00, P=0.012), no history of angina or myocardial infarction ( OR=23.34, 95%CI 3.44-158.37, P=0.001), Killip grade>Ⅲ( OR=5.35, 95%CI 1.26-22.66,P=0.019) and non-ventricular aneurysm (OR=6.30,95%CI 1.67-23.73,P=0.005) were independent risk factors for early death in this patient cohort. Conclusion The risk factors of in-hospital death include older age, non-ventricular aneurysm and anterior AMI. Female, no history of angina or myocardial infarction, Killip grade>Ⅲ and non-ventricular aneurysm are independent risk factors for the early death of AMI patients complicating VSR.
