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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2804_Библиотеки_им_академика_М_И_Перельмана

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effect. Restenosis and stent thrombosis are disease entities unique to patients who have previously undergonePCI.
RestenosisisaresultofneointimalhyperplasiaandoccursmorefrequentlyinpatientswithBMS
placement,diabetics,patientswithlongareasofpriorstenting,andpatientswithstentinginsmall
arteries.
Stentthrombosisisthethromboticocclusionofapreviouslyplacedcoronarystentandpresents
as ACS or sudden cardiac death.Stent thrombosis is associatedwith a high mortalityrate and
poorprognosis.
106,107
□ Acute stent thrombosis occurs within 24 hours and is due to mechanical procedural
complicationsaswellasinadequateanticoagulationandantiplatelettherapies.
□ Subacutestentthrombosis(24hours–30days)isaconsequenceofinadequateplateletinhibition
andmechanicalstentcomplications.CessationofP2Y12inhibitortherapyduringthistimeyields a30-to100-foldriskofstentthrombosis.
□ Late(30days–1year)stentthrombosisandverylatestent thrombosis occursprincipallywith
DESs.
□ NeoatherosclerosisisatheroscleroticplaqueuniquetopriorPCI,occursinpreviouslyplaced
stents,andcanpredisposeapatienttoanginaorplaquerupturewithsubsequentACS. Ischemic MRisa poor prognostic indicator followingMI. Papillarymusclerupture is associated with inferior andposterior infarcts. Theanterior papillarymuscle hasa dual bloodsupply andis less vulnerable to rupture. The mechanism ofchronic MRafter STEMI includes papillarymuscle dysfunctionorleaflettetheringduetoposteriorwallakinesis.
Acute MRfrom papillary muscle rupture is a severe complication of MI associated with high mortality(seebelow). ProgressiveMRfollowingMImaydevelopasaresultofLVchamberdilation,apicalremodeling, orposteriorwalldyskinesis.Thesechangesleadtoleaflettetheringormitralannulardilation. Echocardiographyisthediagnosticmodalityofchoice. Initial treatment of MR involves aggressive afterload reduction and revascularization. Stable
patientsshouldreceiveatrialofmedicaltherapyandundergosurgeryonlyiftheyfailtoimprove. STEMI in the setting of recent cocaine use presents a unique and challenging management situation.
108
 ST elevationcanresultfrom myocardial ischemia due to coronaryvasospasm,insitu thrombusformation,and/or increased myocardial oxygendemand.Thecommonpathophysiologyis excessivestimulationofα-andβ-adrenergicreceptors.Chestpainduetococaineuseusuallyoccurs within3hoursbutmaybeseenseveraldaysfollowinguse.
Oxygen,ASA,andheparin(UFHorLMWH)shouldbeadministeredtoallpatientswithcocaine­associatedSTEMI. Nitrates should be used preferentially to treat vasospasm. Additionally, benzodiazepines may conferadditionalreliefbydecreasingsympathetictone. BBsarecontraindicated;bothselectiveandnonselectiveBBsshouldbeavoided. Phentolamine (α-adrenergic antagonist) and calcium channel blockers may reverse coronary vasospasmandarerecommendedassecond-lineagents. Theuseofreperfusiontherapyis controversialandshouldbereservedforthosepatientswhose symptomspersistdespiteinitialmedicaltherapy. □ Primary PCI is the preferred approach for the patient with persistent symptoms and ECG
changesdespite aggressive medical therapy. Itis importanttonotethatcoronaryangiography andinterventioncarryasignificantriskofworseningvasospasm.
□ FibrinolytictherapyshouldbereservedforpatientswhoareclearlyhavingaSTEMIandwho
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cannotundergoPCI.
Complications
Myocardialdamagepredisposesthepatienttoseveralpotentialadverseconsequencesandcomplications thatshouldbeconsideredifthepatientexperiencesnewclinicalsignsand/orsymptoms.Theseinclude recurrentchestpain,cardiacarrhythmias,cardiogenicshock,andmechanicalcomplicationsofMI.
Recurrentchestpainmay be duetoischemia intheterritoryoftheoriginalinfarction,pericarditis, myocardialrupture,orpulmonaryembolism.
Recurrentanginaisexperiencedby20%–30%ofpatientsafterMIwhoreceivefibrinolytictherapy andupto10%ofpatientsintheearlytimeperiodfollowingpercutaneousrevascularization.These symptomsmayrepresentrecurrenceofischemiaorinfarctextension.
Assessmentofthepatientmayincludeevaluationfornewmurmursorfrictionrubs,ECGtoassess for new ischemic changes, cardiac biomarkers (troponin and CK-MB), echocardiography, and repeatcoronaryangiographyifindicated. Patients with recurrent chest pain should continue to receive ASA, P2Y12 inhibition,
anticoagulants,nitroglycerin,andBBtherapy. If recurrent angina is refractory to medical treatment, urgent repeat coronary angiography and
interventionshouldbeconsidered. Acute pericarditis occurs 24–96 hours after MI in approximately 10%–15% of patients. The associatedchestpainis oftenpleuritic andmaybe relievedintheuprightposition.A frictionrub maybenotedonclinicalexamination,andtheECGmayshowdiffuseST-segmentelevationandPR­segmentdepression.LeadAVRmayhavePRelevation.Treatmentisdirectedatpainmanagement.
High-doseASA(upto650mgqidmaximum)isgenerallyconsideredafirst-lineagent.NSAIDs
suchasibuprofenmaybeusedifASAisnoteffectivebutshouldbeavoidedearlyafteracuteMI.
Colchicine along with ASA may also be beneficial for recurrent symptoms and may also be
superiortoeachagentalone.
Glucocorticoids(prednisone1mg/kgdaily)maybeusefulifsymptomsaresevereandrefractory
toinitialtherapy.Steroidsshouldbeusedsparinglybecausetheymayleadtoanincreasedriskof
recurrenceofpericarditis.Useshouldalsobedeferreduntilatleast4weeksafteracuteMIdueto
theiradverseimpactoninfarcthealingandriskofventricularaneurysm.
Heparin should be avoided in the setting of pericarditis with or without pericardial effusion
becauseitmayleadtopericardialhemorrhage. Dressler syndrome is thought to be an autoimmune process characterized by malaise, fever, pericardial pain, leukocytosis, elevated erythrocyte sedimentation rate, and often a pericardial effusion.Incontrasttoacutepericarditis,Dresslersyndromeoccurs1–8weeksafterMI.Treatment isidenticaltoacutepericarditis. Arrhythmias.CardiacrhythmabnormalitiesarecommonfollowingMIandmayincludeconduction block, atrial arrhythmias, and ventricular arrhythmias. Arrhythmias that result in hemodynamic compromiserequireprompt,aggressiveintervention.Ifthearrhythmiaprecipitatesrefractoryangina orHF, urgent therapyiswarranted.For allrhythmdisturbances,exacerbatingconditionsshouldbe addressed, including electrolyteimbalances,hypoxia, acidosis, andadverse drug effects.Referto sectiononCardiacArrhythmiamanagementforfurtherdetails.Atropineshouldbeattemptedforall bradyarrhythmiasinthesetting ofSTEMI. Bradycardia isa commoncomplicationofintensevagal inputtotheAVnodeasaresultofbaroreceptoractivationinthemyocardium(alsocalledBezold­Jarischreflex). Transcutaneousand transvenouspacing. Conductionsystemdisease thatprogresses tocomplete
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heartblockorresultsinsymptomaticbradycardiacanbeeffectivelytreatedwithcardiacpacing.A transcutaneous pacing device can be used under emergent circumstances; however, a temporary transvenoussystemshouldbeusedforlongerdurationtherapy.
Absolute indications for temporary transvenous pacing include asystole, symptomatic
bradycardia,recurrentsinuspauses,completeheartblock,andincessantpolymorphicVT.
Temporarytransvenouspacingmayalsobewarrantedfornewtrifascicularblock,newMobitzII
block, and patients with LBBB who require a pulmonary artery catheter, given the risk of
developingcompleteheartblock. Implantablecardioverter-defibrillators(ICDs)shouldnot routinelybeimplantedinpatientswith reducedLV function following MI or those with VT/VF in the setting ofischemia or immediately followingreperfusion(<48hours).
RoutineinsertionofICDsintopatientswithreducedLVfunctionimmediatelyfollowingMIdoes
notimproveoutcomes.
109-111
InpatientswithLVEF<35%lessthan40dayspostMI,considerationofawearablecardioverter
defibrillation (e.g., Zoll LifeVest) as a bridge to reevaluation for recovery of EF is
reasonable.
112,113
ICDtherapyisalsoindicatedforpatientswithrecurrentepisodesofsustainedVTorVFafter>48
hoursfollowingcoronaryreperfusion.
Cardiogenicshockisaninfrequent,butserious,complicationofMIandisdefinedashypotensionin thesettingofinadequateventricularfunctiontomeetthemetabolicneedsoftheperipheraltissue.Risk factors include prior MI, older age, diabetes, and anterior infarction. Organ hypoperfusion may manifestas progressive renal failure,dyspnea, diaphoresis, or mental status changes.Hemodynamic monitoringreveals elevatedfilling pressures(wedgepressure>20mmHg),depressedcardiacindex (<2.5L/min/m2),andhypotension.
PatientswithcardiogenicshockinthesettingofMIhaveamortalityrateinexcessof50%. Dobutamine and milrinone are the most frequentlyused medications for inotropic support. They both possess vasodilatory properties (i.e., afterload reducing) and are arrhythmogenic. Milrinone shouldbeavoidedinthesettingofrenalinsufficiency. Dopamine can be used as both a vasopressor and inotrope but increases the risk of atrial arrhythmiasinpatientswithshockandisnotapreferredfirst-lineagent. Norepinephrine and phenylephrine may be required to maintain systemic BP. The use of any vasoconstrictive agents in the setting of cardiogenic shock should prompt an evaluation for mechanicalcirculatorysupport. Epinephrine is a potent vasopressor and inotrope and is frequently used as an adjunct to other medicaltherapies.TheremaybesomepreferentialbenefittoRVfunction,andthus,epinephrinemay beusedforshocksecondarytoRVinfarctorsevereRVdysfunction. Mechanicalcirculatory supportincludesboth temporaryanddurablesupportdevices. Temporary supportdevicesincludeIABP,Impellacatheter,orextracorporealmembraneoxygenation(ECMO). Temporarysupportisofferedasbridgetorecoveryorasbridgetodecisionaboutlong-termdurable mechanicalsupportsuchasanLVassistdevice(seeChapter5,HeartFailureandCardiomyopathy). Thechoiceoftemporarysupportdeviceisnotalwaysclearandshouldbemadebyateamfamiliar withthemanagementofcardiogenicshock. All patients with cardiogenic shock should undergo echocardiography to evaluate for mechanical complicationsofMI(seethefollowingtext). LVthrombusoccursmostofteninsettingofanteriorMIandshouldbetreatedwithanticoagulation. Warfarin is the recommended long-term anticoagulation agent; direct oral anticoagulants (e.g., rivaroxaban, apixaban) have led to conflicting results regarding safety and efficacy compared to
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warfarin.
114,115
Patientsshould receive warfarinfor3–6monthsunlessotherindicationswarrant its
continueduse.YoumayrepeataTTEtoconfirmresolutionoftheLVthrombus.
Mechanicalcomplications
Aneurysm. After MI, the affected area of the myocardium may undergo infarct expansion and
thinning, forming an aneurysm. The wall motion may become dyskinetic, making the endocardial surfacesusceptibletomuralthrombusformation.
LV aneurysm is suggested by persistent ST elevation on the ECG and may be diagnosed by
imagingstudiesincludingventriculography,echocardiography,andMRI.
Anticoagulationiswarrantedtolowertheriskofembolicevents,especiallyifamuralthrombus
ispresent.
SurgicalinterventionmaybeappropriateiftheaneurysmresultsinHForventriculararrhythmias
thatarenotsatisfactorilymanagedwithmedicaltherapy. Ventricular pseudoaneurysm. Incomplete rupture of the myocardial free wall can result in formationofaventricularpseudoaneurysm.Inthiscase,bloodescapesthroughthemyocardialwall andiscontainedwithinthevisceralpericardium.Inthepost-CABGpatient,hemorrhagefromfrank ventricular rupture may be contained within the fibrotic pericardial space producing a pseudoaneurysm.
Echocardiography (TTE with contrast or TEE) is the preferred diagnostic test to assess for a
pseudoaneurysm,oftenallowingdifferentiationfromatrueaneurysm.
Prompt surgical intervention for pseudoaneurysms is advised because of the high incidence of
myocardialrupture. Freewallrupture representsa rare butcatastrophic complicationofSTEMI inthemodernearly­reperfusion era. Rupture typicallyoccurs withinthefirstweek after MI andpresentswith sudden hemodynamic collapse. This complication can occur after anterior or inferior MI and is more commonlyseeninhypertensivewomenwiththeirfirstlargetransmuralMI,inpatientsreceivinglate therapywithfibrinolytics,andpatientsgivenNSAIDsorglucocorticoids.
Echocardiography may identify patients with particularly thinned ventricular walls at risk for
rupture.
Despiteoptimalintervention,mortalityoffreewallruptureremains>90%. Papillarymusclerupture(pleasealsorefertoearlierMRsection)isararecomplicationafterMI andisassociatedwith abruptclinicaldeterioration.Theposteriormedialpapillarymuscle ismost commonlyaffectedduetoitsisolatedvascularsupply,butanterolateralpapillarymusclerupturehas beenreported.Ofnote,papillarymusclerupturemaybeseeninthesettingofarelativelysmallacute MIorevenNSTEMI.
The diagnostic test of choice is echocardiography with Doppler imaging and/or TEE because
physicalexamrevealsamurmurinonly 50%ofcases.
Initialmedicaltherapyshouldincludeaggressiveafterloadreduction.PatientswithrefractoryHF
andthose with hemodynamic instability may require inotropic support with dobutamine and/or
IABP.Surgicalrepairisindicatedinthemajorityofpatients. VentricularseptalruptureismostcommonlyassociatedwithanteriorMIoccurring3–5daysafter MI.Theperforationmayfollowadirectcoursebetweentheventriclesoraserpiginousroutethrough theseptalwall.
DiagnosiscanbemadebyechocardiographywithDopplerimagingandoftenrequiresTEE.
Diagnosisshould be suspectedinthepostinfarctpatientwhodevelopsHFsymptoms andanew
holosystolicmurmur.
Stabilization with afterload reduction, inotropic support, and/or IABP may be necessary for
hemodynamicallyunstablepatientsuntildefinitivetherapywithsurgicalrepaircanbeperformed.
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Inhemodynamicallystablepatients,surgeryisbestdeferredforatleastaweektoimprovepatient
outcome.Leftuntreated,mortalityapproaches90%.
Percutaneousdeviceclosureinthecardiaccatheterization laboratorycanbeperformedinselect
patientswithanunacceptablesurgicalrisk.
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