Complications of percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy

目的：评价非手术疗法,即经皮穿刺间隔心肌消融术治疗肥厚型梗阻性心肌病（HOCM）并发症。方法：72名有流出道梗阻症的病人,术前经心脏超声动图明确诊断。病人被施行导管手术,以无水酒精注入靶血管内。观察并发症并分析其可能的原因。结果：在主入酒精时,69名病人发生严重胸痛,在手术及术后围手术期间,19名病人有不同程度的心脏传导阻滞,其中一名病人呈现永久性完全房室传导阻滞,需植入永久性直搏器。束枝传导阻滞在本研究中非常常见,暂时性右束枝传导阻滞占50％,永久性右束枝传导阻滞占38.9％。6例（8.3％）发生急性下壁心肌梗死,一例（1.4％）发生急性前壁心肌梗死。在超过二年的长期随访组中,24例病人无一例死亡,至目前为止,该组病人的心功能没有进行性恶化。在本研究中,无论长期及近期观察,均无死亡发生。结论：心肌消融治疗肥厚型梗阻性心肌病最普遍的并发症是右束枝传导阻滞。最重要的并发症是心脏传导阻滞。心肌消融治疗方法是治疗HOCM的一种良好的非外科手术疗法。     

梗阻性肥厚型心肌病无水酒精室间隔消融术中的并发症及处理

目的：总结梗阻性肥厚型心肌病（ＨＯＣＭ）无水酒精室间隔消融术中并发症及处理，以提高对其术中并发症的认识及处理的水平。方法：对１３ 例ＨＯＣＭ 患者行无水酒精室间隔消融术，注射无水酒精量为１．５～５ ｍ ｌ。消融成功率达１００％ 。结果：术中并发症９／１３ 例次，发生率６９．２％ ，其中以术中注无水酒精时血压下降为最严重，心绞痛最多见。结论：无水酒精室间隔消融术，虽有很好的临床效果，但也会引起一些并发症，如处理不当，甚至会造成死亡，应引起重视     

经皮间隔心肌消融术治疗梗阻性肥厚型心肌病的近期疗效观察

目的:评价经皮间隔心肌消融术(PTSMA)治疗梗阻性肥厚型心肌病(HOCM)的近期疗效及安全性。方法:对我院自2000年7月以来收治的6例HOCM患者行PTSMA术,分别在术前、术后及3个月后行超声心动图,记录室间隔厚度及左室流出道压力阶差(LVOTG)。结果:6例PTSMA手术均获成功,术后自觉症状明显缓解,心功能恢复为Ⅰ~Ⅱ级。LVOTG术前平均(94.0±40.8)mmHg,术后即刻(33.7±18.7)mmHg,术后3个月(32.5±12.9)mmHg,差异有统计学意义(P<0.05)。室间隔厚度术前平均(25.6±7.3)mm,术后1周(19.7±3.8)mm,术后3个月(15.5±4.2)mm,术后3个月与术前比较,差异有统计学意义(P<0.05)。1例发生一过性Ⅲ°房室传导阻滞,2 h后恢复正常,2例发生完全性右束支传导阻滞。结论:PTSMA是HOCM的一种有效治疗方法,近期疗效好,但其远期疗效仍需进一步观察。     

经皮间隔心肌消融术治疗肥厚型梗阻性心肌病的长期随访结果

目的评价经皮间隔心肌消融术(PTSMA)治疗肥厚型梗阻性心肌病(HOCM)的长期疗效.方法对于药物治疗仍有症状、心功能(NYHA)Ⅲ-Ⅳ级、静息左室流出道压力阶差(LVOTG)≥30mmHg的HOCM患者施行心肌声学造影指导下的PTSMA,长期随访观察血流动力学、运动耐量及心脏形态学变化的情况.结果共入选23例患者,其中男性12例,女性11例,年龄48.0±14.5岁.本组无死亡病例,无非靶域心肌梗死.28.4±4.0个月(24～36月)后随访,NYHA心功能分级由3.4±0.5改善到1.3±0.5(P＜0.001).超声心动图检查示LVOTG 从81.6±25.6mmHg降到27.9±26.5mmHg(P＜0.001),73.9%(17/23)的病人LVOTG下降超过50%;室间隔厚度变薄,由术前的23.9±3.7mm降至16.1±3.0mm(P＜0.001);左室舒张末内径和收缩末内径分别从术前的39.6±6.4mm,21.8±6.9mm增加到44.3±4.4mm,27.8±4.6mm(P＜0.01);左房内径和左室后壁厚度无明显变化.2例(8.7%)因Ⅲ度房室传导阻滞持续不恢复而安装永久起搏器.结论 PTSMA能有效降低HOCM患者的LVOTG,改善活动耐量,安全性高.PTSMA可能导致房室传导阻滞而需安装永久起搏器,通过心肌声学造影指导和减缓乙醇注入速度可能会减少危险的发生.     

经皮间隔心肌消融术治疗3例肥厚型梗阻性心肌病

目的评价经皮经腔间隔心肌消融术(percutaneoustransluminal septal myocardial ablation,PTSMA)治疗肥厚型梗阻性心肌病(hypertrophic obstructive cardiomyopathy,HOCM)的即刻和近期疗效,并探讨相关并发症的防治.方法对3例药物治疗效果不佳的HOCM患者,进行经皮经腔间隔心肌消融术治疗,由压力监测判断即刻疗效,术后半年则由患者临床症状及超声心动图评价近期疗效.结果室性早搏激发的左室流出道压力阶差术前平均143 mmHg(70～180 mmHg),术后平均53 mmHg(30～80 mmHg),下降幅度平均78%(69%～85%).3例中有1例出现完全性房室传导阻滞伴交界性逸搏心律,另有1例出现完全性右束支传导阻滞.3例均于术后6个月随访,其心绞痛症状基本消失,心功能明显改善,室间隔肥厚和SAM现象明显减轻.结论对于药物治疗效果不佳的HOCM患者,可采用PTSMA,其近期疗效良好.     

经皮间隔心肌化学消融治疗7例肥厚梗阻型心肌病的近期疗效观察

目的　评价我院采用PTSMA治疗 7例HOCM的近期疗效。方法　男 4 ,女 3例 ,平均年龄 (36 .6± 11)岁 ,测定静息时左心室与主动脉压差≥ 6 6 7kPa或应激压差≥ 9 33kPa,用球囊堵塞靶间隔支后压差下降和 /或杂音减轻 ,确定为靶血管。第 1间隔支消融 4例 ,第 2间隔支 2例 ,第 1和第 2支间隔支同时消融 1例 ,平均注射无水乙醇 (2 .0± 0 .8)ml。术后随访 (73± 37)d。结果　术后 7例梗阻等症状减轻或消失 ,NYHA分级增加Ⅰ～Ⅱ级 ;心脏超声示室间隔厚度由 (30 .14± 3.85 )mm降至 (2 4 .86±4 .6 7)mm(P =0 .0 0 18) ,左室流出道宽度由 (9.5± 2 .0 5 )mm增至 (14 .34± 3.19)mm(P =0 .0 0 3) ,左室与主动脉压力阶差由(9 .2 5± 1.74 )kPa降至 (4.4 3± 0 .85 )kPa(P =0 .0 0 0 8)。术中及住院期间完全性右束支阻滞 2例 ,窦性心动过缓 2例 ,房室传导阻滞及频发室性早搏 3例。 7例术后心肌酶谱均明显升高 ,最高CK(12 6 6± 6 15 )U。 1例因间歇性Ⅱ度Ⅱ型房室传导阻滞伴晕厥 ,于术后第 7天植入双腔心脏起搏器 ,1例遗留完全性右束支阻滞。结论　PTSMA是一项治疗HOCM的新技术 ,其近期疗效可靠 ,远期疗效有待于进一步观察。     

肥厚型梗阻性心肌病室间隔心肌化学消融术的疗效探讨

目的探讨经导管室间隔心肌化学消融术(PTSMA)治疗肥厚型梗阻性心肌病(HOCM)的近期疗效.方法 5例重症HOCM患者施行了PTSMA术,随访3～12个月,观察临床症状,超声心动图测定左室流出道压力阶差(LVOTPG)、室间隔厚度(IVST)、左室舒张末直径(LVDD).结果临床症状明显缓解.LVOTPG显著降低,术前(13.8±1.4) kPa,术后即刻(4.7±1.2) kPa,术后3个月(2.9±0.9) kPa;IVST明显变薄,术前(22±2) mm,术后1周(20±3) mm,术后3个月(17±2) mm;LVDD有效扩大,术前(41±4) mm,术后1个月(46±3) mm,术后3个月(48±3) mm.未发生永久性Ⅲ度房室传导阻滞.结论 PTSMA是治疗HOCM的有效手段,其近期疗效良好.     

Midterm outcomes of percutaneous transluminal septal myocardial ablation in patients with hypertrophic obstructive cardiomyopathy refractory to medication

Hypertrophic obstructive cardiomyopathy （HOCM） is a genetic disorder characterized by severe asymmetric hypertrophy of the interventricular septum （IVS） in the absence of any other systemic or cardiac diseases. The predominant abnormal haemodynamics are caused by increased left ventricular outflow tract pressure gradient （LVOTG） and abnormal systolic anterior motion of mitral valve.     

室间隔化学消融术治疗肥厚型梗阻性心肌病的临床疗效分析

目的 评估室间隔化学消融术(alcohol septal ablation,ASA)治疗肥厚型梗阻性心肌病(hypertrophic obstructive cardiomyopathy,HOCM)患者的临床疗效和安全性.方法 2001年1月至2015年1月行ASA的成年(≥18周岁)HOCM患者44例.术中实时监测静息和激发状态下的左室流出道压力阶差(left ventricular outflow tract gradient,LVOTG),并于术后3d,1、3、6、12、24个月采用超声心动图检测室间隔厚度、左室射血分数、二尖瓣反流程度、左房和左室容积、估测静息状态下LVOTG值,以及心功能状态、并发症和死亡率情况.结果 44例HOCM患者ASA术后即刻,静息LVOTG由术前(79.9±37.9) mmHg下降至(33.8 ±30.2)mmHg (P ＜0.01),激发LVOTG由术前(112.4±43.8)mmHg下降至(36.8±30.0) mmHg(P＜0.01).术后常规给予β受体阻滞剂,术后6个月随访结果显示,舒张末期左房容积由术前(113.8 ±50.3)mL下降至(97.6±45.7)mL(P ＜0.01),收缩末期或舒张末期左室容积均有明显增加,左室各节段收缩同步性升高,NYHA心功能分级有明显改善,且未出现严重并发症.结论 室间隔化学消融术治疗HOCM的安全性高,疗效显著,结合药物治疗可使患者长期获益.     

Cardiac electromechanical mapping in analyzing the mechanism of left ventricular remodeling immediately after percutaneous transluminal septal ablation in patients with hypertrophic obstructive cardiomyopathy

Background Effect of percutaneous transluminal septal ablation (PTSA) with ethanol injection on electromechanical remodeling of left ventricule still remains unknown. This study was conducted to assess the potential significance of cardiac electromechanical mapping (CEMM) in analyzing the left ventricular remodeling before and immediately after percutaneous transseptal myocardial ablation (PTSMA) in patients with hypertrophic obstructive cardiomyopathy (HOCM).Methods Eight patients with drug-refractory HOCM and 6 patients with hypertrophic cardiopathy (HM) without increased left ventricular outtract gradien (LVOTG) were enrolled into the present study. CEMM was undergone in patients with HOCM before and immediately after PTSA procedure, and in patients with HM.Results PTSA was successful in all patients with HOCM, LVOTG significantly decreased from (62.87±21.16) mmHg to (12.73±3.05) mmHg immediately after ablation procedure. Value of UVP in septal-base segment in HM group was higher than that in HOCM group ［(22.79±2.34)mV vs (18.54±1.76)mV］.In patients with HOCM, lateral-middle and -base segments had lowest value of UVP ［(15.93±1.11) mV and (15.83±1.07)mV］ before PTSA. Value of UVP at posterior-middle segment decreased from (23.58±2.21)mV pre-PTSA to (18.89±1.91)mV post-procedure, PTSA led to significant increase of UVP at lateral-middle segment. Septal region in patients with HM and septal-middle, septal-base, posterior-base segments in HOCM had lower value of local linear shortening (LLS) among all patients in both HOCM and HM groups. PTSA resulted in significant reduction of LLS in anterior region and at septal-apex segment. Anterior-base and septal-middle segments in patients with HM had lowest value of local active time (LAT), and significantly differentiated from that in patients with HOCM ［(-8.57±0.68)ms vs (-18.61±1.02)ms, (-6.75±0.37)ms vs (-21.90±0.96)ms, respectively］.LAT at septal-middle and -base segments in patients with HOCM was decreased significantly ［(-21.90±0.96)ms vs (-13.80±1.04)ms, P&lt;0.002; and (-15.20±1.06)ms vs (-6.33±0.52)ms, respectively］ immediately after PTSA.Conclusions Posterior-lateral and anterior region probably played important roles in electromechanical remodeling. Significant electromechanical remodeling disassociation (uncoupling) was detected in most left ventricular regions, which would be important in differentiating of HOCM from HM, and in predicting the prognosis in patients with HOCM after PTSA procedure. Chin Med J 2005; 118(21):1779-1785     

Acute and mid-term results of pecutaneous transluminal septal myocardial ablation in patients with hypertrophic obstructive cardiomyopathy

Objective: To assess the acute and mid-term results of cardiac function improvements and left ventricular outflow tract gradient (LVOTG)changes in 30 patients displaying hypertrophic obstructive cardiomyopathy (HOCM) treated with percutaneous transluminal septal myocardial ablation (PTSMA). Methods: PTSMA was intended for 32 patients comprising of 13 women and 19men (average years being 54.1 ± 15.5) to be treated in accordance with the following inclusion criteria: The New York Heart As-sociation(NYHA) definition for cardiac functional class Ⅲ or Ⅳ , or class Ⅱ but for whom medical therapies were not tolerated or with syncope; intraventricular septal (IVS) and left ventricular posterior wall (LVPW) hypertrophy asymmetrically associated with ratio of IVS to LVPW≥1.3 and LVOTG≥50 mm Hg at rest or ≥100 mm Hg at provocation (Valsalva maneuver). The target vessels were determined by coronary arteriography that demonstrated more than one septal branch and probatory balloon occlusion produced greater than 50% decrease of LVOTG. Once the target vessel established, the alcohol was administrated into septal ventricular via over-the-wire balloon. LVOTG was assessed by means of echocardiography measurements immediately after procedure and 3 months. Simultaneously, cardiac function class was also evaluated. Results: Two patients were abandoned prior to intervention due to inappropriate septal target vessels and DDD Pacemakers were chosed. Immediately after the procedure, resting LVOTG was reduced from 73.8 ± 35.5 to 16.6 ± 7.8 mmHg, at provocation LVOTG from 149.3 ± 42.5 to 61.9 ± 43.0 mmHg(P ＜0.0001 each) by echocardiography measurements. After 3 months, the mean New York Heart Association class was reduced from 2.8 ± 0.6 to 1.1 ± 1.0(P ＜ 0.0001) and the LVOTG also remained decrease(28.5 ± 6.4 mmHg at rest and 75.3 ± 11.6 mmHg at provocation). Conclusion: PTSMA is a promising nonsurgical technique for relief of symptoms and reduction of LVOTG in hypertrophic obstructive cardiomyopathy.     

梗阻型肥厚性心肌病冠状动脉造影特点及其对经皮室间隔心肌化学消融的临床意义

目的评价冠状动脉造影的形态学特征对经皮室间隔心肌化学消融(PTSMA)术治疗肥厚型梗阻性心肌病(HOCM)的指导意义.方法选择32例药物疗效欠佳并行PTSMA手术的HOCM患者,研究其冠状动脉造影特点,并与30例年龄、性别相匹配的冠状动脉造影正常的患者(对照组)进行比较.根据定量冠状动脉造影(QCA)测定目标消融间隔支的直径,分为≤1.5mm(小间隔支组)和>1.5mm组(大间隔支组),比较两组PTSMA术前、术后心导管测量左心室流出道压差(LVOTG)的变化.结果冠状动脉造影显示HOCM组的左主干、左前降支、左回旋支及左间隔支内径均显著大于对照组(均P<0.05),HOCM组左前降支肌桥的发生率较对照组亦明显增加(P<0.05);23例消融成功,PTSMA术前、术后导管测量LVOTG分别为(85.8±31.1)、(37.25±31.9)mmHg(P<0.01),其中大间隔支组PTSMA成功率明显高于小间隔支组(P<0.05),大间隔支组LVOTG的下降程度明显大于小间隔支组(P<0.05),两组间无水乙醇用量差异无统计学意义(P>0.05).结论 HOCM患者的左前降支肌桥发生率增加,且左冠状动脉内径较粗大,尤其是左间隔支粗大;间隔支>1.5mm的HOCM患者是PTSMA手术成功的重要预测因素,这对PTSMA目标消融间隔支的选择具有重要指导意义.     

经皮经腔间隔心肌消融术与室间隔心肌部分切除术治疗肥厚型梗阻性心肌病的Meta分析

目的 客观评价经皮经腔间隔心肌消融术(PTSMA)与室间隔心肌部分切除术(SM)治疗肥厚型梗阻性心肌病的疗效,为指导临床实践提供可靠证据.方法 计算机检索Cochrane图书馆、PubMed、Web of Science、万方数据库、中国学术期刊网全文数据库(CNKI)从建库至2012年8月收录的PTSMA与SM治疗肥厚型梗阻性心肌病的临床对照试验,并对纳入的中英文文献采用RevMan5.0软件进行Meta分析.结果 5篇文献共286例患者纳入研究,其中行PTSMA治疗149例,SM治疗137例.肥厚型梗阻性患者经SM治疗后左心室流出道压差较PTSMA减低更明显,差异具有统计学意义(OR=9.07,95％ CI:0.96～17.18,P=0.030);行PTSMA和SM治疗患者的室间隔厚度(OR=1.15,95％ CI:-0.79～3.10,P=0.240)、左房内径(OR=1.95,95％CI:-0.16～4.07,P=0.070)、左室舒张末期(OR=0.70,95％ CI:-0.79～2.19,P=0.360)及收缩末期内径(OR=1.14,95％ CI:-1.65 ～ 3.93,P=0.420)、症状改善程度(胸痛:OR=1.07,95％ CI:0.35 ～ 3.23,P=0.910;晕厥:OR=0.32,95％CI:0.08 ～ 1.23,P=0.100)、术后病死率(OR=1.63,95％CI:0.46 ～5.76,P=0.450),差异无统计学意义;但PTMSA治疗后患者起搏器植入率(OR=5.91,95％ CI:2.04～17.11,P=0.00l)和再介入治疗率(OR =6.62,95％ CI:1.20～36.62,P=0.030)较SM治疗者偏高,差异具有统计学意义.结论 目前,PTSMA只能作为治疗肥厚型梗阻性心肌病的一种选择,现有的证据尚不能证明其可完全替代SM,但可根据左室流出道压差、症状、靶血管解剖形态等选择合适的治疗方案.     

经皮室间隔化学消融治疗肥厚型梗阻性心肌病

近年来国内外采用经皮室间隔化学消融术(ＰＴＳＭＡ)治疗肥厚型梗阻性心肌病(ＨＯＣＭ),取得很好的临床效果。我们采用该法治疗1例ＨＯＣＭ,疗效满意。资料与方法一、病例资料患者男,55岁,反复活动后胸闷、心悸20年,加重伴气急3月,黑朦1次。院外服用心得安40ｍｇ/ｄ,初期症状有所好转,近日心率减至50次/ｍｉｎ,症状未能控制而入院。其姐有反复晕厥史。患者入院时血压为14.89/10.37ｋＰａ(112/78ｍｍＨｇ),心界未扩大,胸骨左缘3～4肋间可闻及Ⅲ/6级收缩期吹风样杂音,杂音粗糙、局限、站或坐时无明显变化,肝、脾无肿大,两下肢不肿。心脏Ｂ超:…     

经导管室间隔心肌化学消融治疗肥厚梗阻型心肌病

目的：评价经导管室间隔心肌化学消融（PTSMA）治疗肥厚梗阻型心肌病（HOCM）的安全性和有效性。方法：观察6例HOCM病人用无水酒精进行PTSMA后的早期疗效和并发症。结果：PTSMA后左室流出道压力阶差显著下降，症状和心脏杂音减轻；但并发有酒精外溢，束支传导阻滞，房室传导阻滞和室性早搏。结论：PTSMA是一项相对安全和有效的治疗HOCM的新技术，春早期疗效令人满意。     

Transcoronary ablation of septal hypertrophy compared with surgery in the treatment of hypertrophic obstructive cardiomyopathy

Transcoronary ablation of septal hypertrophy (TASH) can lead to sustained improvement in both hemodynamics and symptoms in patients with hypertrophic obstructive cardiomyopathy ( HOCM ) . ^1-4 However, there have been few reports about its efficacy and safety compared with traditional surgical procedures. This study sought to compare TASH with surgery in the treatment of HOCM.     

Transcatherter chemical myocardial ablation for hypertrophic obstructive cardiomyopathy：short to mid term results

Objective:Hypertrophic obstructive cardiomyopathy is still a troublesome clinical problem,lack of good treatment method.We use transcatheter chemical myocardial ablation to treat hypertrophic obstructive cardiomyopathy and analysis 25 cases results,to search a novel technique for hypertrophic obstructive cardiomyopathy.Method:From Nov.1996 to Oct.2001 25 patients with symptomitical and drug resistents hypertrophic obstructive cardiomyopathy accepted a nonsurgical treatment,that is percutaneous transseptal myocardial ablation(PTSMA) in our department including 16 males and 9 females, with mean age 44.1 years All patients meet echocardiography diagnosis criterias of hypertrophic obstructive cardiomyopathy,With clinical symptoms of angiana pectors,sycope,short breath etc. No improvement to long term medical theraphy,rest pressure left ventricular outflow tract gradients over 30 mmHg,or over 50 mmHg during provocal test eigher by invasion or indirect measurement with Doppler echocardiography, 5 patients accepted treatment With Sigwart′s method as previous described,other 20 cases with pigtail catheter left ventricular Continuous curve to measure left ventricular outflow tract gradient,percutaneous insert 1.5mm to 2.0mm balloon catheter into first septal branch of left anterior descending coronary artery, via inflated balloon,inject 3-5ml absolute alcohol into the artery,keep inflating balloon for other 5 minutes continue monitoring pressure gradients and ECG, temporary pacemaker and defibrillator were stand by.Results:All patients,left ventricular outflowtract gradients were significantly reduced, more than 50%, 6 cases occurred serve bradycardia,hypotension need immediate administration,17 cases with trancient complete right branch block,and in five case,with permonant complete righ branck block,2 cases with transient complete AV block.In follow up,symptom and life quality of all patients were dramitically improved,in first month post procedure,septum thickness reduction,6 mm in average and,6.8mm reduction were achieved in 1.5 to 2 years.and 12 cases were follow ed up for more than 4 years,the longest one has been 6 years still in perfect condition.Anther 5 cases chemical myocardial ablation can not be oerformed for vessels anatormy reasons accepted dual chamber pacing,get compariale results with PTSMA.Conclusion:Our results shown that this technique is a safety and reliable,might be an alternative method to patients with hypertrophic obstructive cardiomyopathy and we although should mention,our anther 5 patients whese can not be performaed PTMSA received DDDR pacemaker, with symptom improvement and pressure gradients reduction for two years,as demonstrated by other experts,is althought a opitmal for HOCM.     

Myocardial condition after transcoronary ablation predicts the curative effect in patients with hypertrophic obstructive cardiomyopathy

Transcoronary ablation of septal hypertrophy （TASH） has been recommended as an option forpatients with drug-refractory hypertrophic obstructive cardiomyopathy （HOCM）. However, its outcome is varied, and some factors are attributed to the diversity results.1 Up to now, there is no study on the influence of the ablated myocardium＇s condition on the outcome. We retrospectively analyzed the myocardial perfusion imaging （MPI） obtained before and early after TASH in our patients to explore the relationship between the ablated myocardium＇s condition and the clinical outcome.