心肌间隔切除术矫治肥厚梗阻型心肌病及围术期治疗策略()
《中国胸心血管外科临床杂志》[ISSN:1007-4848/CN:51-1492/R]
- 期数:
- 2010年第17卷第1期
- 页码:
- 6-9
- 栏目:
- 临床研究论著
- 出版日期:
- 2010-02-25
文章信息/Info
- Title:
- Ventricular Septal Myotomymyectomy on Hypertrophic Obstructive Cardiomyopathy and the Treatment Strategies during Perioperative Period
- 文章编号:
- 1007-4848（2010）01-0006-04
- 作者:
- 崔彬 许建屏 王巍 等
- 中国医学科学院 北京协和医学院 阜外心血管病医院 心血管病研究所 心血管外科， 北京100037
- Author(s):
- CUI Bin; XU Jian-ping; WANG Wei; et al .
- Department of Cardiovascular Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, P. R. China
- Keywords:
- ; Hypertrophic obstructive cardiomyopathy; Ventricular septal myotomymyectomy; Arrhythmia
- 分类号:
- R654.2
- DOI:
- -
- 文献标识码:
- A
- 摘要:
- 目的 总结心肌间隔切除术治疗肥厚梗阻型心肌病（Hypertrophic obstructive cardiomyopathy，HOCM）的临床经验，探讨围术期治疗策略。 方法 1996年10月至2009年6月我科收治了62例HOCM患者，男41例，女21例；年龄6~68岁，平均年龄34.05岁。手术在全身麻醉低温体外循环下完成，按常规经主动脉切口行室间隔心肌切除术（经典或改良Morrow技术），同期行冠状动脉旁路移植术5例，二尖瓣置换术12例，二尖瓣成形术9例，主动脉瓣置换术4例，三尖瓣成形术2例，动脉导管闭合术2例。围术期常规行心脏超声心动图或经食管超声心动图、心电图或动态心电图及胸部X线片检查，评价超声心动图检查指标、二尖瓣的结构和功能改变。结果 全组体外循环时间104.23±47.14 min，主动脉阻断时间66.76±36.32 min，气管内插管时间13.23±11.76 h，术后住监护室时间42.53±37.41 h。全组死亡4例，病死率6.45％（4/62），死于感染性休克合并急性肾功能不全1例，顽固性心律失常、心室颤动、心房扑动合并低心排血量综合征 1例，急性肾功能衰竭 1例，Ⅲ°房室传导阻滞合并低心排血量综合征1例。术后左心房内径(34.56±6.45 mm vs.43.46±7.21 mm，t=6.948, P=0.000)，左心室舒张期末内径(37.14±6.31 mm vs.42.03±6.23 mm，t=3.145,P=0.020)，左心室流出道压差(23.54±17.78 mm Hg vs. 103.84±4404 mm Hg,t=13.618,P=0.000)，室间隔厚度(17.12±5.67 mm vs.26.93±5.23 mm,t=10.694,P=0.000) 与术前比较均减小或降低。二尖瓣关闭好或仅有轻度反流，二尖瓣前向运动(SAM)征基本消失。术后发生的主要心律失常包括完全性左束支传导阻滞、室内传导阻滞、完全性房室传导阻滞和心房颤动等。58例生存患者均痊愈出院，随访53例，随访时间3个月~12年，失访5例。随访期间无远期死亡、并发症及再次手术患者，症状均明显减轻，心功能I~II级，生活质量明显提高。 结论 HOCM心肌间隔切除术可充分疏通左心室流出道，消除二尖瓣SAM征，满意的缓解左心室流出道梗阻，改善患者症状。术后主要心律失常表现为传导束传导异常和心房颤动。精确的手术技术和及时有效的药物治疗可获得满意的疗效。
- Abstract:
- Objective To summary the clinical experiences of ventricular septal myotomymyectomy on hypertrophic obstructive cardiomyopathy(HOCM) and investigate the treatment strategies during perioperative period for better clinical results. Methods From October 1996 to June 2009, 62 patients with HOCM underwent surgical treatment. There were 41 male and 21 female, aged 668 years with mean 34.05 years. The ventricular septal myotomymyectomy operation (Morrow operation or modified Morrow operation) was performed through the aortic incision under general anesthesia and hypothermic cardiopulmonary bypass (CPB). The concomitant operations included coronary artery bypass grafting (5 cases), mitral valve replacement (12 cases), mitral valve plasty(9 cases), aortic valve replacement (4 cases), tricuspid valve plasty(2 cases) and ductus arteriosus closure (2 cases). During the perioperative period, the patients were examined by echocardiography or transesophageal echocardiograph(TEE), electrocardiogram or dynamic echocardiogram and chest radiography. Left atrial diameter，left ventricular enddiastolic [CM(159mm]diameter，left ventricular outflow tract (LVOT) pressuregradient，interventricular septal thickness, ejection fraction[CM)](EF), the changes of mitral valve construction and function were evaluated. Results The time of CPB and aortic occlusion were 104.23±47.14 min and 66.76±36.32 min, respectively. The endotracheal intubation time was 13.23±11.76 h and the postoperative intensive care unit(ICU) stay was 42.53±37.41 h. Four patients died and the mortality was 6.45％(4/62). The main causes of death included septic shock complicated with acute renal failure(1 case), refractory arrhythmia, ventricular fibrillation, atrial flutter complicated with severe low cardiac output syndrome (1 case), severe acute renal failure(1 case) and Ⅲ°atrioventricular(AV) block complicated with low cardiac output syndrome(1 case). Postoperative left atrial diameter (34.56±6.45 mm vs.43.46±7.21 mm，t=6.948,P=0.000), left ventricular enddiastolic diameter (37.14±6.31 mm vs.42.03±6.23 mm，t=3.145,P=0.020), LVOT pressure gradient (23.54±17.78 mm Hg vs. 103.84±44.04 mm Hg,t=13.618,P=0.000) and interventricular septal thickness (17.12±5.67 mm vs.26.93±5.23 mm, t=10.694,P=0.000) decreased significantly compared with those before operation. There was no mitral valve regurgitation, or only mild mitral valve regurgitation. No systolic anterior motion(SAM) was found. The main postoperative arrhythmias included complete left bundle branch block, intraventricular block, complete atrioventricular block and atrial fibrillation. All the 58 cases were cured and discharged. Fiftythree cases were followed up for 3 months12 years, and 5 cases were lost. No death, complication and reoperation were found. Symptoms relieved significantly. The cardiac function was in New York Heart Association grade Ⅰ-Ⅱ. The quality of life improved significantly. Conclusion Most patients with HOCM can achieve satisfactory relief of LVOT obstruction and SAM via ventricular septal myotomymyectomy. The main arrhythmias after operation are bundle branch block and atrial fibrillation. Satisfactory effects can be achieved by accurate surgical technique and effective drug treatments.
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更新日期/Last Update: 2010-03-04