肥厚梗阻型心肌病介入治疗方法的新改进

目的 探讨经皮“室间隔心肌隧道化学消融术（percutaneous transluminal septal tunnel myocardial ablation,PTSTMA）”治疗传统技术不适合的肥厚梗阻型心肌病（hypertrophic obstructive cardiomyopathy,HOCM）的方法及疗效.方法 选择2005年6月至2011年6月期间住院的HOCM患者中的26例为研究对象.观察经PTSTMA治疗的26例HOCM患者术后即刻左心室流出道压力阶差（left ventricular outflow tract pressure gradient,LVOTPG）变化,术后24 h磷酸肌酸激酶同工酶、心电学改变,术后3个月心脏超声指标变化以及随访临床症状的转归.结果 3例通过单支血管消融,17例通过2支血管消融,6例通过3支血管消融.LVOTG由术前（75.6±22.4）mm Hg（1 mm Hg=0.133 kPa）降至（21.4±5.84）mm Hg,差异有统计学意义（P＜0.01）.术后24 h磷酸肌酸激酶同工酶为（1 86±84）μ/L,2例发生Ⅲ＆#176;房-室传导阻滞,均于1周后恢复正常传导,10例发生室性心律失常,12例发生右束支传导阻滞.消融后室间隔厚度减少（16.8±4.2）mm vs.（22.8±5.8）mm,P＜0.01]、左心房内径减少（42.0±8.6）mmvs.（48.0±7.0）mm,P＜0.05],差异均有统计学意义.随访时间为（39.8±8.6）个月.与消融前比较,随访中胸痛、呼吸困难症状明显减少,纽约心脏协会心功能分级明显改善,室性心律失常明显减少,黑蒙症状也有一定改善.结论 冠状动脉造影证实冠状动脉室间隔支解剖形态不适合做传统室间隔心肌化学消融术的HOCM患者,PTSTMA能显著降低LVOTPG,改善临床症状.PTSTMA可作为HOCM心肌化学消融术的一种补充方法,其近、中期安全有效.

A new modified intervention method to treat hypertrophic obstructive cardiomyopathy

Objectives To explore the effect and method of percutaneous transluminal septal tunnel myocardial ablation （PTSTMA） in patients with hypertrophic obstructive cardiomyopathy （HOCM） who was not suitable for percutaneous transluminal septial myocardial ablation （PTSMA）. Methods Totally 26 patients with HOCM hospitalized from June 2005 to June 2011 were chosen. Left ventricular outflow tract pressure gradient （LVOTPG）, phosphoereatine kinase isoenzyme 24 h after operation, change of eleetroeardiology, ultrasound outcome 3 months after operation and follow-ups of the 26 patients with HOCM after PTSTMA were observed. Results Of the 26 patients with HOCM, 3 patients had single-vessel targeted ablation, 17 patients had 2-vessel targeted ablation, and the rest 6 patients had 3-vessel targeted ablation. Immediately after PTSTMA, LVOTPG significantly reduced from （75.6±22.4） mm Hg （ 1 mm Hg=0.133 kPa） to （21.4±5.84） mm Hg （P〈0.01）. Phosphocreatine kinase isoenzyme 24 h after operation was （186_＋84）Ix/L. Two cases had transient 3-degree atrioventricular block after ablation, and they recovered after a week. Ventricular arrhythmia was found in 10 patients and complete right bundle branch block in 12 patients. Three months after ablation, the thickness of septal myocardium significantly reduced from （22.8±5.8） mm to （16.8±4.2） mm （P〈0.01）, left atrial dimension significantly reduced from （48.0±7.0） mm to （42.0±8.6） mm （P〈0.05）. Duration of follow-up was （39.8±8.6） months. Comparing with those of before ablation, ratios of chest pain, expiratory dyspnea, ventricular arrhythmia reduced, New York Heart Association functional class improved and ratio of amaurosis reduced. Conclusions In patients with HOCM whose angiographie features of coronary artery interventricular septal branch are not suitable for PTSMA, PTSTMA can remarkably reduce LVOTPG and relieve the clinical symptoms. PTSTMA is a supplemental method of PTSMA on treating HOCM, which is safe and useful during the short term and metaphase.