梗死后室间隔破裂患者的最佳手术时机是什么？
What is the best timing of surgery in patients with post-infarct ventricular septal rupture?
本文采用结构化方案撰写心脏外科最佳证据话题，检索88篇文献后筛选出6篇最佳证据。基于3238例因梗死后室间隔破裂（PIVSR）接受手术的患者，平均年龄67.5岁，多数左心室功能受损。早期手术（梗死后3天至4周内）住院死亡率52.4%，延迟手术（通常1周至4周后）为7.56%。多数作者认为破裂至手术间隔短是预后不良的独立预测因素。共识是多数患者应早期手术，具体时机取决于血流动力学状态。
为什么推荐给您：对手术时机的证据回顾与共识整理，属常规临床问题综述。
不需要生物学背景，多打比方
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摘要Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in which patients with a post-infarct ventricular septal rupture (PIVSR) might immediate surgery give better results than delayed surgery in terms of mortality'? Altogether, 88 papers were found using the reported search criteria, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The recommendations are based on outcomes from 3238 patients undergoing surgery for PIVSR. Mean age was 67.5 ± 8.8 (40-88 years). Left ventricular function was compromised in most patients with mean ejection fraction of 40%. All papers carried out univariate and/or multivariate analyses of variables that contributed to different in-hospital mortalities. Early surgery, i.e. from >3 days to within 4 weeks after MI, had an overall in-hospital mortality of 52.4%; delayed surgery, typically from 1 week to after 4 weeks post-myocardial infarction, had an overall operative in-hospital mortality of 7.56%. Most authors observe that a shorter time between rupture and surgery is an unfavourable predictor of outcome independent of haemodynamic status. The consensus was that nearly all patients with PIVSR, particularly if >15 mm diameter with a significant shunt and resultant haemodynamic deterioration, should undergo early surgical repair. The precise timing of surgery depends on patients' haemodynamic status. Exclusion from surgery should be considered if life expectancy or quality is severely limited by another limiting underlying pathology. If the patient is in cardiogenic shock, due to pulmonary to systemic blood flow ratio shunt rather than infarct size, immediate surgery should follow resuscitation measures and cardiac support. If the patient is haemodynamically stable, surgery could be performed after 3-4 weeks of medical optimization with inotropic and mechanical cardiac support. If there is clinical deterioration, immediate surgery is indicated.