komplikationen des akuten myokardinfarktes · 2008. 6. 17. · komplikationen des akuten...

Komplikationen des akuten Myokardinfarktes


Klaus HolperPaul Libera

Rüdiger Lange

Deutsches Herzzentrum MünchenKlinik an der TU München


Papillarmuskelruptur

Ventrikelaneurysma

Ventrikelseptumdefekt

Ventrikelruptur

Globale Herzinsuffizienz

Übersicht


Globale Herzinsuffizienz


Structure and Function of the Normal Heart

systole

diastoleMall FP Am J Anat 1911


WorkingWorking HeartHeart


Buckberg et al.Seminars in Thoracic andcardiovascularSurgery, Vol 13, 2001

15% muscle shortening⇓ ⇓

60% EF 30% EF

Shape and Function of the Heart


FrequentFrequent ReasonsReasons for Heart for Heart FailureFailure

acuteacute:: •• myocardialmyocardial infarctioninfarction•• myocarditismyocarditis•• acuteacute valve insufficiencyvalve insufficiency•• postoperativepostoperative

chronic:chronic: •• dilatativedilatative CMPCMP•• ischemicischemic CMPCMP•• ventricular ventricular aneurysmaneurysm


Heart FailureSurgical Strategies

revascularisation

mitral mitral valvevalvereconstructionreconstruction

hearttransplantation

ventricularrestoration

mechanicalassist


Ventrikelaneurysma


Dilatation of Dilatation of thethe HeartHeart

contractility↓

volume

pressure

endiastolic pressure/volume↑

Wall tension↑


1. 1. IncissionIncission and„Fontanand„Fontan--suturesuture““

2. „Fontan“ 2. „Fontan“ pursedpursed suturesuture

2. Patch 2. Patch placementplacement

ConceptConcept for for IschemicIschemic CMPCMP

Buckberg et al.Semin Thorac Cardiovask Surg 2001

3. Final 3. Final closureclosure


LV-Aneurysmaruptur nach AMIEndoventrikuloplastik nach Jatene, modifiziert von Dor


Ventrikelplastik nach Dor


Dor- OperationGerman Heart Centre Munich1974 -2000

RESULTS:

hospital mortality 5.9 %

late death 20.6 % (after 4.1 ± 3.8 years)

causes of late death : cardiac 38 % non cardiac 29 % unclear 33 %

reoperation: 4.9 % after 4.3 ± 4.6 yearsMVR n=3, AVR n=1, HTxn=1


Dor- OperationGerman Heart Centre Munich1974 -2000

Overall actuarial survival

0 5 10 15years postop

0.2

0.4

0.6

0.8

1.0

N at risk101 43 14

At 10 years: 55.5 ± 7.9% actuarial survival88 ± 6.9% freedom from reoperation



revascularisation




mechanicalassist


Diagnostik: Herzkatheter

Linke Koronararterien

R. interventricularis anterior (LAD)Hauptstamm

R. circumflexus(RCX)

Vorderwand li. VentrikelVorderes Septum

Lateral- u. Hinterwandli. Ventrikel


Diagnostik: Herzkatheter

Rechte Koronararterie

Rechte Koronararterie(RCA)

Rechter VentrikelSinusknotenHinterwand des li. VentrikelHinteres Septum


Aortocoronarer Venenbypass (ACVB)


Bypass am schlagenden Herzen


PET MyocardialViability Assessment

perfusion

(FDG)

normalsep

antlat

post

stunned hibernating

metabolism

(NH )3

scar


post-OP33.5±12.9

%pre-op26.7 ±5.6%

LVEFLVEF(41 patients)

pre-op post-op


Actuarial Survival Curve

(cardiac deaths)OP with PET

OP witout PET

PET

1,0

0,8

0,6

0,4

0,2

0 12 846036

months

survivalprobability

p < 0,01

102 57 425497

127121

no PET 2330

no operation

8 515no OP


Septumdefekt


Infarkt-VSD


Closure of anteroapical defect

Bradley J. et al., Illusrated Handbook of Cardiac Surgery, 1996


• Repair of anteriorpostinfarctionventricular septaldefect.

• Incision is madethrough theanterolateralinfarctedmyocardium

• Defect is locatedbeneath the incision.

Kirklin, Cardiac Surgery, 2003


Survival after repair of postinfarctionventricular septal defect

Years since repairKirklin, Cardiac Surgery, 2003



revascularisation




mechanicalassist


Papillarmuskelruptur


Papillarmuskelabriss nach Infakt


Mitral ValveRestricted leaflet motion due to LV-

dilatation


MRT – Mitralklappepräop vs. postop


akute Mitralinsuffizienz

Mitralklappenersatz-OP


akute Mitralinsuffizienz

Mitralklappenplastik-OP


Survival after mitral valve replacementand mitral valve repair

for patients with ischemic mitral regurgitation

Kirklin, Cardiac Surgery, 2003


Ventrikelruptur


Komplikation: Ventrikelruptur

Ventrikelruptur nach Infarkt:

• 8-17% der Fälle tödlich• Subakute, gedeckte Rupturen haben die Chance

operiert zu werden.• Abdichtung der Ventrikelwand durch verstärkende

Filzstreifen oder Goretex-Flicken

komplikationen des akuten myokardinfarktes · 2008. 6. 17. · komplikationen des akuten...

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