经皮经冠状动脉室间隔化学消融术治疗梗阻性肥厚型心肌病的近期疗效观察

目的评价经皮经冠状动脉室间隔化学消融术（PTSMA）治疗梗阻性肥厚型心肌病（HOCM）的近期疗效。方法自1998年8月～1999年11月收治HOCM34例,入选行PTSMA26例。利用Sigwart法行PTSMA,注入96%～99%无水酒精消融间隔支前后记录左室流出道压力阶差变化、心电图变化。在消融前及术后2周通过超声心动图测量室间隔（IVS）厚度及左室流出道宽度。结果术前平均静息左室流出道压力阶差为（72.8±24.6）mmHg（1mmHg=0.133kPa）,术中球囊加压后为（30.6±18.5）mmHg,术后为（24.3±17.6）mmHg,差异有显著性（P<0.001）。术前室间隔平均厚度为（23.00±6.03）mm,术后2周为（20.55±5.38）mm。术前左室流出道宽度为（6.54±2.36）mm,术后2周为（11.36±3.37）mm（P<0.01）。术前心功能（NYHA分级）为3.4±0.6,术后2周为1.6±0.8。术后CPK与CPK-Mb峰值分别为（1050±514）U/L与（131±78）U/L。术中及术后可见短阵室速、结性逸搏心律、三度房室传导阻滞及束支传导阻滞。1例发生永久性三度房室传导阻滞,安装永久性双腔起搏器。出现下壁及前壁心肌梗死心电图表现者各1例。结论PTSMA能显著降低左室流出道压力阶差,治疗HOCM的近期疗效可靠,但尚需进一步完善方法,以减少严重并发症发生,并需继续随访其中、远期疗效。     

Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: Acute results and three-year noninvasive follow-up in 18 patients

OBJECTIVES: To study the acute results and long-term clinical course after percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: In 18 patients (seven women, 11 men; average age 53+/-15 years) with symptomatic and medically refractory HOCM, 1.3+/-0.4 septal branches were occluded with an injection of 3.6+/-1.2 mL of 95% alcohol to ablate the hypertrophied interventricular septum. After three years, noninvasive follow-up results of clinical course, echocardiographic and electrocardiographic findings were determined. RESULTS: The invasively measured left ventricular outflow tract (LVOT) gradients were reduced in all patients, with a mean decrease from 79+/-21 mmHg to 11+/-8 mmHg at rest (P<0.01) and from 136+/-41 mmHg to 49+/-21 mmHg after extrasystole. All patients had angina pectoris for 8 h to 24 h. Eleven patients (61.1%) developed a trifascicular block for 3 min to four days requiring temporary (n=10 [56%]) or permanent dual chamber pacemaker implantation (n=1 [6%]). All patients were discharged after 5.9+/-2.3 days. Clinical, electrocardiographic and echocardiographic follow-up was achieved in all patients after three years (3.1+/-0.5 years). No cardiac complications occurred. Thirteen patients (72%) showed clinical improvement, with a New York Heart Association functional class of 1.5+/-0.8. A further reduction in LVOT gradient was shown in eight patients (44%). CONCLUSIONS: The LVOT gradient was greatly reduced in patients with HOCM undergoing a PTSMA procedure and their symptoms were greatly improved without cardiac complications during three-year follow-up. Possible complications include different degrees of heart block, such as trifascicular blocks, requiring temporary pacemaker implantation. PTSMA is a promising nonsurgical method for the treatment of symptomatic patients with HOCM. Clinical long-term follow-up of a larger series of patients is required to determine the therapeutic significance conclusively.     

梗阻性肥厚型心肌病经皮化学消蚀术后长期随访研究

目的　研究经皮化学消蚀术治疗梗阻性肥厚型心肌病的长期随访结果。方法　 13例不合并高血压的梗阻性肥厚型心肌病患者 ,左心室流出道压力阶差均 >40mmHg ,且长期药物治疗无效。其中 2例肥厚部位同时包括左心室侧壁和右心室。术后每月门诊记录临床症状变化及心电图 1次 ;术后 2 4h及每月行经胸超声检查 1次 ,测定室间隔厚度 (IVST)、心室腔直径 (LVDD)、左心室流出道压力阶差 (LVOTG)及左心室射血分数 (LVEF)。平均随访时间 2 0 (14～ 2 2 )个月。结果　 13例患者术前收缩期二尖瓣前向移动 (SAM)现象平均 3 6级 ;平均酒精注射量为 3 86ml;术后即刻左心室流出道压力阶差平均下降到 31mmHg ,术后 1个月室间隔厚度降低程度最大平均 (3 0± 0 4)mm ;术后 1个月时SAM分级平均下降到 1 4级 (平均下降 2 2级 ) ;无一例需要再次另外一支间隔支消蚀的 ;2例患者出现进行性左心室扩大 ,但是均于术后 3个月后停止 ;全部患者的临床症状均得到显著改善 ,1例患者于术后 3个月时出现活动后胸闷 ,心脏超声与导管复查左心室流出道压力阶差回升到 >36mmHg ;3例患者术中出现一过性完全性房室传导阻滞 ,2例术后 1h内恢复到正常窦性心律 ;1例完全性房室传导阻滞于术后第 3天消失 ,因此无 1例需要安装永久起搏器。 4例 (2 2 %     

肥厚型梗阻性心肌病化学消融术后疗效观察

目的 探讨化学消融治疗肥厚型梗阻性心肌病(HOCM)的方法及疗效.方法 15例HOCM患者,经超声心动图及导管测压证实存在左室流出道压力阶差.选择靶间隔支注入无水乙醇消融后记录左室流出道压力阶差变化,出院时、出院后1个月及出院后3个月复查超声心动图.结果 15例中消融第一间隔支11例,消融第二间隔支2例,同时消融第一、二间隔支2例.1例术后4 h死亡,其余14例度过围术期并出院随访(其中1例术后5 d置入永久双腔起搏器).术后即刻导管测量左室流出道压差较术前明显下降[(55.90±31.08)mm Hg比(92.62±43.75)mm Hg,P＜0.01],出院时与术前相比,LVOTG和二尖瓣收缩期前移(SAM)幅度较术前明显改善[(45.83±27.92)mm Hg 比(84.02±35.59)mm Hg,(2.3±1.28)mm 比(4.2±1.35)mm,P＜0.01];出院后1个月、3个月超声测量LVOTG、左室流出道内径、室间隔厚度和SAM幅度较术前及出院时明显改善(P＜0.01).结论化学消融是治疗HOCM的有效方法,但属于破坏性手术,需严格进行手术风险控制,防止"过犹不及".     

Comparison of percutaneous transluminal septal myocardial ablation versus septal myectomy for the treatment of patients with hypertrophic obstructive cardiomyopathy--a meta analysis

BACKGROUND: The effects of percutaneous transluminal septal myocardial ablation (PTSMA) with septal myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM) are not thoroughly compared. METHODS: Three articles comparing the effects of PTSMA and septal myectomy treatment for HOCM were identified from a search in Pubmed, and a meta analysis was conducted. RESULTS: 177 patients (86 underwent PTSMA and 91 underwent septal myectomy) were included. Interventricular septum thickness was decreased from 22.1 to 15.1 mm (p<0.05) in PTSMA group and from 22.0 to 13.9 mm (p<0.05) in septal myectomy group; left ventricular end-diastolic dimension was increased from 41.8 to 45.2 mm (p<0.05) in PTSMA group and from 41.8 to 43.9 mm (p<0.05) in septal myectomy group; NYHA class was improved from 3.17 to 1.47 (p<0.05) in PTSMA group and from 2.97 to 1.36 (p<0.05) in septal myectomy group; there were no differences in the two groups. However, left ventricular outflow tract gradient was decreased from 76.0 to 15.7 mm Hg (p<0.05) in PTSMA group and from 74.7 to 9.4 mm Hg (p<0.05) in septal myectomy group and the effect of septal myectomy was better than PTSMA (p<0.05). CONCLUSIONS: The effects of septal myectomy treatment for HOCM are better with regard to relief of LVOT gradient, and lower risk of pacemaker requirement, compared to PTSMA. Large randomized clinical trials further comparing the two treatments are suggested.     

Percutaneous transluminal septal myocardial ablation in drug-resistant hypertrophic obstructive cardiomyopathy: 18-month follow-up results.

OBJECTIVE: Surgery has been the only therapeutic option in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are resistant to standard treatment. Percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced occlusion of the septal artery for the reduction of left ventricular outflow tract (LVOT) gradient is a novel method. However, long-term clinical follow-up is insufficient. This study reports the acute and mid-term results after PTSMA in symptomatic patients with HOCM. METHODS: Six patients (4 men and 2 women) with symptomatic HOCM and inadequate response to pharmacologic therapy had their major septal branches ablated with alcohol. Mean duration of follow-up was 1.5 years. RESULTS: There was reduction in LVOT gradient in all patients (100%) with a mean reduction of 50 mmHg. Two patients developed complete heart block (CHB) and 3 patients developed bifascicular block. CHB persisted in 1 patient. Two patients died within 8 days of the procedure; one due to cerebrovascular accident and 1 due to asystole. The patient who died of asystole had CHB but refused permanent pacemaker implantation. CHB reverted in 1 patient and bifascicular blocks persisted in 3 patients. Clinical and echocardiographic follow-up was achieved in the 4 surviving patients after 1.5 years. All surviving patients had LVOT gradient reduction and clinical improvement. CONCLUSION: PTSMA for HOCM is a non-surgical technique for reducing LVOT gradient. Heart blocks are one potential complication, and may require pacemaker implantation. Long-term follow-up and a larger series of patients are required to determine conclusive therapeutic significance.     

Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery

OBJECTIVES: This study was conducted to evaluate follow-up results in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent either percutaneous transluminal septal myocardial ablation (PTSMA) or septal myectomy. BACKGROUND: Controversy exists with regard to these two forms of treatment for patients with HOCM. METHODS: Of 51 patients with HOCM treated, 25 were treated by PTSMA and 26 patients via myectomy. Two-dimensional echocardiograms were performed before both procedures, immediately afterwards and at a three-month follow-up. The New York Heart Association (NYHA) functional class was obtained before the procedures and at follow-up. RESULTS: Interventricular septal thickness was significantly reduced at follow-up in both groups (2.3 +/- 0.4 cm vs. 1.9 +/- 0.4 cm for septal ablation and 2.4 +/- 0.6 cm vs. 1.7 +/- 0.2 cm for myectomy, both p < 0.001). Estimated by continuous-wave Doppler, the resting pressure gradient (PG) across the left ventricular outflow tract (LVOT) significantly decreased immediately after the procedures in both groups (64 +/- 39 mm Hg vs. 28 +/- 29 mm Hg for PTSMA, 62 +/- 43 mm Hg vs. 7 +/- 7 mm Hg for myectomy, both p < 0.0001). At three-month follow-up, the resting PG remained lower in the PTSMA and myectomy groups (24 +/- 19 mm Hg and 11 +/- 6 mm Hg, respectively, vs. those before procedures, both p < 0.0001). The NYHA functional class was also significantly improved in both groups (3.5 +/- 0.5 vs. 1.9 +/- 0.7 for PTSMA, 3.3 +/- 0.5 vs. 1.5 +/- 0.7 for myectomy, both p < 0.0001). CONCLUSIONS: Both myectomy and PTSMA reduce LVOT obstruction and significantly improve NYHA functional class in patients with HOCM. However, there are benefits and drawbacks for each therapeutic method that must be counterbalanced when deciding on treatment for LVOT obstruction.     

经皮室间隔心肌消融术治疗老年肥厚型梗阻性心肌病的临床分析

目的　探讨经皮室间隔心肌消融术治疗老年肥厚型梗阻性心肌病 (HOCM)的可行性 ,安全性和近期效果。方法　对 6 0岁以上的 6例老年HOCM患者施行心肌声学造影指导下的经皮室间隔心肌消融术治疗。结果　 6例患者的经皮室间隔心肌消融术均获成功 ,未出现严重的心脏并发症 ,术后即刻应用心导管测左室流出道压差由术前(10 4.33± 19.6 1)mmHg降至 (35± 2 5 .88)mmHg(P <0 .0 0 1)。术后对 6例患者进行了 1～ 18个月的随访 ,经超声心动图测左室流出道压差由术前 (91.83± 2 7.17)mmHg降至 (36 .0 8± 33.6 3)mmHg(P <0 .0 5 ) ,室间隔厚度由术前(2 1.83± 2 .79)mm降至 (16 .0 2± 3.86 )mm (P <0 .0 5 )。术后心功能由术前的 3.4± 0 .5级改善为 1.1± 0 .3级 (P <0 .0 0 1)。结论　经皮室间隔心肌消融术治疗老年HOCM患者的即刻和近期效果良好 ,并发症少 ,安全性高。     

Simultaneous percutaneous treatment in hypertrophic obstructive cardiomyopathy and coronary artery disease: A case report

Percutaneous transluminal coronary angioplasty (PTCA) is an established therapy for coronary artery disease (CAD), whereas percutaneous transluminal septal myocardial ablation (PTSMA) is becoming increasingly significant in the therapy of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). We report the first ever simultaneous treatment, in a 62-yr-old patient, of significant HOCM and a 75% LAD stenosis from which the septal branch to be occluded stemmed. Using a double wire technique, first the septal branch was occluded through a fractional injection of 4 ml absolute alcohol, thus ablating the hypertrophied septal myocardium with reduction of the left ventricular outflow tract (LVOT) gradient at rest from 80 to 9 mmHg. Following this, the LAD stenosis was dilated and stented. Complications, in particular a trifascicular block or ventricular dysrhythmia, did not occur during the hospital stay. To conclude, combined PTSMA and PTCA may be considered as a therapeutic alternative to a combined surgical intervention in individual cases of symptomatic HOCM and CAD, provided that the potential complications are taken into account. Cathet. Cardiovasc. Diagn. 44:65–69, 1998. © 1998 Wiley-Liss, Inc.     

Symptomatic hypertrophic obstructive cardiomyopathy: the role of dual-chamber pacing

BACKGROUND AND PURPOSE: The management of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) has traditionally consisted of beta blockers and calcium channel blockers. Surgical treatment has been employed for operable patients who became refractory to medical therapy. However, associated complications, mortality rate, and recurrence of functional limitations have shifted the focus toward alternative therapy modalities. Recently, permanent dual-chamber (DDD) pacemaker has been introduced as an alternative treatment option. PATIENTS AND METHODS: This study comprises clinical, angiographic, echocardiographic, and electrophysiologic data obtained at a single center on 10 symptomatic patients with HOCM who received a DDD pacemaker after medical therapy failed to relieve symptoms. Presenting symptoms were exertional dyspnea and chest pain (60%), syncope (20%), and presyncope (20%). These symptoms were documented for 8.9+/-7.1 years before pacemaker implantation. All patients were in New York Heart Association functional class III or IV before pacemaker therapy. RESULTS: Placement of a permanent DDD pacemaker decreased the left ventricular outflow tract gradient from 83+/-44 mm Hg (range: 35-180 mm Hg) to 47.1+/-25.3 mm Hg (range: 10-75 mm Hg) in these patients. Within 1 to 30 months, follow-up found that the functional status of eight out of the 10 patients had improved to New York Heart Association class 0 or I. CONCLUSION: In selected patients with symptomatic HOCM who fail to respond to medical therapy, DDD pacemaker may offer a nonsurgical alternative treatment option. Large-scale multicenter, prospective, randomized trials are needed to establish the role of this modality in the treatment of hypertrophic obstructive cardiomyopathy.     

经皮室间隔化学消融治疗肥厚型梗阻性心肌病疗效观察

<正>肥厚型梗阻性心肌病(hypertrophic obstructive car-diomyopathy,HOCM)是原发性心肌病的一种特殊类型,约占肥厚型心肌病患者的25%[1]。临床治疗的目的是使流出道变宽,狭窄减轻,从而达到缓解流出道梗阻,减轻症状,降低猝死率。目前治疗的方法有     

Role of myocardial contrast echocardiography during nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy

Objectives. This study was undertaken to evaluate the ability of myocardial contrast echocardiography (MCE) to guide the targeted delivery of ethanol during nonsurgical septal reduction therapy (NSRT) and to assess the relation between the MCE risk area and infarct size determined by enzymatic and radionuclide methods.Background. NSRT with intracoronary ethanol is a new promising treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM). Proper localization and quantification of the septal infarct before ethanol injection are highly desirable. MCE can provide accurate delineation of the vascular territory of the coronary arteries.Methods. Twenty-nine patients with HOCM and maximal medical therapy underwent NSRT. The left ventricular outflow tract (LVOT) gradient by Doppler echocardiography at baseline was 53 ± 16 mm Hg (mean ± SD). Before NSRT, MCE was performed in all patients with intracoronary sonicated albumin (Albunex). Diluted sonicated albumin (Albunex) was selectively injected into the septal perforator arteries during simultaneous transthoracic imaging. Immediately after MCE, ethanol was injected into the same vessel. Plasma total creatine kinase (CK), total CK-MB fraction and CK-MB fraction subforms were measured at baseline and serially for 36 h.Results. LVOT gradient decreased to 12 ± 6 mm Hg (p < 0.001) after NSRT. Accurate mapping of the vascular beds of the septal perforators was successfully attained in all patients by MCE. Furthermore, the MCE risk area correlated well with peak CK (r = 0.79, p < 0.001). Six weeks after NSRT, 23 patients underwent myocardial perfusion studies performed with single-photon emission computed tomography (SPECT). Mean SPECT septal perfusion defect size involved 9.5 ± 6% of the left ventricle and correlated well with MCE area (r = 0.7), with no statistically significant difference between the risk area estimated by MCE and that by SPECT.Conclusions. Estimation of the size of the septal vascular territory with MCE is accurate, safe and feasible in essentially all patients during NSRT. MCE can delineate the perfusion bed of the septal perforators and can predict the infarct size that follows ethanol injection.     

经皮室间隔化学消融术治疗肥厚梗阻型心肌病

目的评价室间隔化学消融术治疗肥厚梗阻型心肌病在急性期的效果。方法对52例确诊肥厚梗阻型心肌病患者进行经皮室间隔化学消融术治疗,并于术前、术后急性期进行超声心动观察。结果41例患者介入治疗成功,成功率为78.8%。术前超声观察室间隔平均厚度(22.96±5.15)mm,左室流出道压力阶差(LVOTPG)(92.64±38.69)mm Hg(1mm Hg=0.133kPa),术后急性期(4.8±3.2)d,室间隔平均厚度(21.27±4.64)mm,较术前比变薄,P<0.05;LVOTPG(51.79±38.99)mm Hg,较术前明显降低,P<0.001。结论经皮室间隔化学消融术治疗肥厚梗阻型心肌病,在急性期可使室间隔平均厚度降低,收缩期左室流出道压力阶差显著下降。     

Pressure-guided nonsurgical myocardial reduction induced by small septal infarctions in hypertrophic obstructive cardiomyopathy

OBJECTIVES: We sought to assess the safety and efficacy of pressure-guided nonsurgical myocardial reduction (NSMR) with the induction of small septal infarctions in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: Nonsurgical myocardial reduction has been shown to decrease left ventricular outflow tract (LVOT) obstruction and to improve symptoms in patients with HOCM. Infarct sizes differ considerably among studies published so far. METHODS: In 50 patients, the LVOT gradient was invasively determined at the time of the intervention, four to six months (n = 49) and 12 to 18 months (n = 25) after NSMR. New York Heart Association functional class and quality of life were assessed by using a standard questionnaire. Exercise capacity was tested by spiro-ergometry. Left ventricular (LV) mass was determined by electron beam computed tomography. RESULTS: Small septal infarctions (mean creatine kinase value 413 +/- 193 U/l) resulted in a sustained decrease in LVOT gradients, from 80 +/- 33 to 18 +/- 17 mm Hg after four to six months (p < 0.001, n = 49) and to 17 +/- 15 mm Hg (p < 0.001, n = 25) after 12 to 18 months. Nonsurgical myocardial reduction was followed by a decrease in LV hypertrophy, which was associated with a sustained increase in exercise capacity, as well as improvement in quality of life. CONCLUSIONS: Pressure-guided NSMR inducing small septal infarctions was sufficient to result in a sustained decrease in LVOT obstruction and to improve symptoms. The incidence of complications, such as complete heart block with necessary permanent pacemaker implantation (<10%), seems to be diminished by minimizing the infarct size.     

Early remodelling of left ventricle and improvement of myocardial performance in patients after percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy

BACKGROUND: Percutaneous transluminal septal myocardial ablation (PTSMA) reduces left ventricular outflow (LVOT) gradient in patients with hypertrophic obstructive cardiomyopathy (HOCM) and leads to symptomatic improvement. Effects of PTSMA on left ventricular performance are currently unknown. The purpose of this study was to evaluate changes in the left ventricular performance using Doppler index of myocardial performance (sum of isovolumic contractile and relaxation times divided by left ventricular ejection time) and left ventricular remodelling after PTSMA for HOCM. METHODS: Twenty-five patients with symptomatic HOCM underwent echocardiography-guided PTSMA procedure. Clinical and echocardiographic data were collected at baseline and 3 months after PTSMA. RESULTS: PTSMA procedures were uneventful, in one patient (4%), pacemaker implantation was needed for sustained complete heart block after the procedure. At 3-month follow-up, the maximal LVOT gradient decreased from 68+/-39 to 18.6+/-12 mmHg (P<0.001), the provoked maximal LVOT gradient decreased from 128.8+/-59 to 25+/-21.4 mmHg (P<0.001), and basal septal thickness decreased from 21.7+/-4 to 15.2+/-3 mm (P<0.001). The improvement of the index of myocardial performance (from 0.65+/-7 to 0.56+/-11; P<0.001) was associated with neither significant change in left ventricular ejection fraction nor left ventricular ejection time. There was no significant difference in the left ventricular dimension at baseline and at follow-up. All patients reported a significant improvement in symptoms at follow-up, the mean NYHA class decreased from 2.6+/-0.7 to 1.4+/-0.7 (P<0.001), and the number of patients suffering from episodes of syncope or attacks of dizziness decreased from 13 to two during the 3-month follow-up. CONCLUSIONS: PTSMA is a safe, effective and reproducible method in the treatment of highly symptomatic patients with HOCM. This procedure results in a significant relief of symptoms associated with decrease in LVOT gradient and thickness of basal interventricular septum. Positive changes in Doppler IMP suggest possible improvement of left ventricular function.     

超声心动图在肥厚型梗阻性心肌病中的应用

目的评价超声心动图在肥厚型梗阻性心肌病(HOCM)患者经皮室间隔化学消融术(PTSMA)治疗中的应用价值.方法应用超声心动图筛选HOCM患者17例,介入治疗术中引导及监测PTSMA,术后随访.结果术后即刻导管测量左心室流出道(LVOT)压差较术前减低,差异有统计学意义(P＜0.01).术后4周经胸超声心动图检查,LVOT压差、室间隔厚度和左心室射血分数均较术前明显减低,LVOT宽度均较术前明显增加,均差异有统计学意义(均P＜0.01).术前及术后超声心动图与导管测压所得参数具有良好的相关性(r=0.78;r=0.82,均P＜0.01).结论超声心动图技术可用于指导和监测HOCM患者的PTSMA治疗.     

Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy; The Chinese experience in 119 patients from a single center

BACKGROUND: Percutaneous transluminal septal myocardial ablation (PTSMA) has been introduced as an alternative treatment for hypertrophic obstructive cardiomyopathy (HOCM). We report on the acute, short- and long-term results of our experiences in 119 patients from a single center in China. METHODS AND RESULTS: PTSMA was performed in 119 patients with symptomatic HOCM (mean age 35.4+/-14.8 years, male 80, female 39). All patients had echocardiography performed prior to the procedure, 2-week post-PTSMA, and 6-month post-PTSMA, and 65 patients had echocardiography repeated at 2-year follow-up. The average left ventricular outflow tract (LVOT) gradient was 67.3+/-7.8 mm Hg before the procedure, and 15.9+/-6.8 mm Hg after the procedure (p<0.05). The thickness of interventricular septum (IVS) was 23.3+/-5.6 mm before the procedure, 18.6+/-4.8 mm 2-week post-PTSMA (p<0.05), and 16.8+/-3.4 mm 6-month post-PTSMA in all of the patients, and 15.6+/-3.1 mm 2-year post-PTSMA in 65 patients. The mean width of LVOT was 6.7+/-2.0 mm before the procedure, 8.2+/-3.4 mm 2-week post-PTSMA (p<0.05), 13.7+/-6.3 mm 6-month post-PTSMA and 15.1+/-2.4 mm 2-year post-PTSMA. The incidence of right bundle branch block development post-PTSMA was 52.9%, and three patients (2.5%) had complete heart block. There was no death. CONCLUSIONS: PTSMA is a promising non-surgical procedure for symptomatic patients with HOCM because of its low risk and its significant hemodynamic, echocardiographic and clinical improvement. The significant therapeutic remodeling period was up to 6 months rather than 2 years following the procedure.     

Percutaneous transluminal septal myocardial ablation for hypertrophic obstructive cardiomyopathy.

Percutaneous transluminal septal myocardial ablation (PTSMA) is a new therapeutic option for patients with hypertrophic obstructive cardiomyopathy (HOCM). In the present study, the acute and follow-up results of PTSMA were evaluated. From August 1997 to March 2003 27 medically refractory patients (New York Heart Association (NYHA) functional class 2.9+/-0.6) with HOCM underwent PTSMA. The target septal branch was determined by probationary ballooning in 3 and by myocardial contrast echocardiography in 24 patients. The mean resting left ventricular outflow tract pressure gradient (PG) was reduced from 70+/-44 to 24+/-22 mmHg (p<0.0001); the peak concentration of creatine kinase was 1545+/-686 IU/L. Although transient trifascicular block was observed in 14 patients, permanent pacemaker implantation was not required. There were no major adverse cardiac events during the hospital stay; the mean clinical follow-up was 2.2+/-1.7 years. Repeated PTSMA was needed in 1 patient; however, symptomatic improvement had been well preserved in all patients (NYHA class 1.2+/-0.4). Follow-up echocardiographic examination showed sustained improvement in PG, septal and left ventricular posterior wall thicknesses, and the grade of systolic anterior movement and regurgitation of the mitral valve. In conclusion, PTSMA is a safe and effective therapeutic option for medically refractory patients with HOCM.     

肥厚型梗阻性心肌病化学消融术后中长期疗效观察

目的评价经皮经腔间隔心肌化学消融术(PTSMA)治疗肥厚型梗阻性心肌病(HOCM)的中-长期疗效。方法选择2000年11月~2004年8月共11例HOCM的患者,成功地接受了PTSMA治疗,术后超声随访12~48个月以上,随访观察患者的室间隔厚度(IVS)、左心室流出道宽度(LVOT)、无创性左心室流出道压力阶差(LVOTPG)、心功能变化。结果11例患者均成功地实施了PTSMA,术后IVS、LVOTPG和NYHA较术前有显著改善,P<0.000 1,术后随访示IVS术后12个月、48个月较术后1周显著改善,P<0.05。结论PTSMA能显著降低室间隔厚度,改善心功能且稳定,中长期疗效肯定,随术后观察时间的延长疗效有进一步增加的趋势。     

Dual-chamber pacing in hypertrophic obstructive cardiomyopathy: a comparison of acute and chronic effects

This study describes the acute and chronic effects of dual-chamber (DDD) pacing in 14 consecutive patients with hypertrophic obstructive cardiomyopathy (HOCM), whose symptoms were refractory to drug therapy. Although left ventricular (LV) outflow tract pressure gradients diminished from 106+/-47 to 62+/-33 mm Hg (p<0.001) by temporary pacing, the residual pressure gradients were >30 mm Hg in the majority of those with concomitant reductions in cardiac output. The DDD pacing was judged as insufficient by the acute study in the majority of patients. A dual-chamber pacemaker was, however, implanted in 11 patients, and the chronic pacing effects were evaluated. All symptoms (syncope, fainting, palpitation and dyspnea) subsided within 1 month. Left ventricular outflow tract pressure gradients diminished from 99+/-56 to 21+/-13 mm Hg (p<0.004) at 1 week after, and to 17+/-12 mm Hg (p<0.002) at 1 year after the implantation, as measured by Doppler echocardiography. Echocardiogram showed disappearance of the systolic anterior motion of the mitral valve, and significant regression of the septal hypertrophy (from 18.5+/-4.3 to 15.7+/-4.1 mm, p<0.04). There was no significant correlation between the acute and chronic pacing effects in the reduction of the pressure gradients or symptomatic improvement. These results suggest that DDD pacemaker implantation is an effective treatment without any serious risks for patients with drug-refractory HOCM. The chronic-pacing effect in the reduction of the pressure gradient, the regression of hypertrophy and symptomatic improvement cannot be predicted by the assessment of temporary DDD pacing.