经皮室间隔心肌化学消融治疗肥厚梗阻性心肌病16例观察

目的探讨经皮室间隔心肌化学消融（胛SMA）方法治疗肥厚性心肌病（HOCM）的疗效。方法16例肥厚型梗阻性心肌病患者,男性12例,女性4例,平均年龄（35．8＋11,O）岁;均在术前接受过13受体阻滞剂和（或）钙拮抗剂治疗效果不佳。确定靶血管后,向球囊导管中心腔内注入无水乙醇,同时密切观察患者的心电图及LVOTG的变化。所有患者术后均复查超声心动图,随访观察6个月。结果16例患者中13例消融第一间隔支,3例消融第二间隔支,2例同时消融第一、二间隔支。无严重并发症（高度房室传导阻滞）发生。术后2例心脏杂音完全消失,9例心脏杂音减轻1～2级。术后超声心动图均提示原先肥厚的室间隔心肌变薄,搏动减弱,LVOTG下降,SAM现象消失。结论PTSMA是通过PTCA技术经导管向供应肥厚室间隔心肌的间隔支动脉内注入无水乙醇引起局灶性心肌梗死以达到缓解左室流出道梗阻的一种新技术,是一种治疗HOCM的有效方法。     

活动平板运动试验诱发冠心病心律失常

目的 探讨活动平板运动试验诱导冠心病（ＣＨＤ）心律失常的临床特点。方法 使用ＭａｒｑｕｔｔｅＣＡＳＥ１６系统按Ｂｒｕｃｅ方案对３４例ＣＨＤ患者进行活动平板运动试验,并分析心电图记录到的心律失常发生率,发生时间,类型及缺血范围,ＣＨＤ类例,射血分数与心律失常发生的关系。结果 活动平板运动试验诱发ＣＨＤ心律失常的发生率为８０％（２７／３４）,以室性过速性心律失常多见,心律失常的发生随运动负荷增加而增加     

梗阻性肥厚型心肌病室间隔心肌消融术后心电图变化

目的 :探讨梗阻性肥厚型心肌病经皮腔内室间隔消融术后心电图变化及临床意义。方法 :5例梗阻性肥厚型心肌病患者完成经皮腔内室间隔消融术 ,观察并比较术后不同时间记录的心电图和动态心电图。结果 :5例患者术中和术后均发生右束支传导阻滞 ;术中 3例出现一过性Ⅲ度房室传导阻滞 ,其中 1例发生心室颤动 ,1例出现频发室性期前收缩 ,1例出现Ⅰ度房室传导阻滞 ;术后未见新发Q波 ,QRS时限、QT和QTc间期明显延长 ,Sv1+Rv5显著降低 ,动态心电图随访未见室性心律失常增加。结论 :经皮腔内室间隔消融术致心律失常的发生率较高 ,但常为一过性。 12导联心电图和动态心电图监测是最为实用的诊断手段     

冠状动脉心肌桥患者平板运动试验结果分析

目的探讨平板运动试验在评估冠状动脉心肌桥患者临床治疗中的指导意义。方法回顾性分析77例冠状动脉心肌桥患者的平板运动试验结果,评估其与年龄、症状、运动耐量之间的关系。结果平板运动试验阴性73例（94.8％）,阳性4例（5．20％）。平均代谢当量（8．66±2．02）METs,并且随着年龄增长,运动耐量逐渐减低。结论平板运动试验检查有利于了解冠状动脉心肌桥患者的心肌供血情况,并结合患者年龄、运动耐量等情况综合评估。     

Exercise-induced quantitative microvolt T-wave alternans in hypertrophic cardiomyopathy

Background/Purpose

Patients with hypertrophic cardiomyopathy (HCM) have elevated risk for sudden cardiac death (SCD). Our study aimed to quantitatively characterize microvolt T-wave alternans (TWA), a potential arrhythmia risk stratification tool, in this HCM patient population.

Left ventricular endomyocardial biopsy findings in patients with essential hypertension and hypertrophic cardiomyopathy with special reference to the incidence of bizarre myocardial hypertrophy with disorganization and biopsy score

Summary To investigate whether bizarre myocardial hypertrophy with disorganization (BMHD) is characteristic of hypertrophic cardiomyopathy (HCM), the histopathology of the biopsied left ventricular myocardium in 18 patients with essential hypertension (HT) and 14 patients with HCM was studied. A biopsy score was devised for a more quantitative evaluation of the BMHD and a comparative study on the biopsy score of the left ventricular biopsied specimen was also performed. The patients with HT were judged to be in stages I or II of the WHO criteria and had a history of hypertension of more than 5 years. The BMHD was defined as myocardial cells showing hypertrophy, disorganization, and bizarre nuclei. Disorganization of myocardial cells was distinguished both by the terminology and histopathological characteristics from disarrangement of myocardial cells. The biopsy score employed four factors and was determined according to the following formula: Biopsy score = hypertrophy of myocardial cells + (disorganization of myocardial cells) ×2+ bizarre nuclei + whorling of muscle bundles. Both the hypertrophy and the disorganization of myocardial cells were regarded as essential conditions indicating the presence of BMHD. The BMHD was found in 2 of 18 patients with HT (11%) and in 10 of 14 patients with HCM (71%) in the left ventricular biopsied specimens (P<0.005). However, disarrangement of myocardial cells was found in 13 of 18 HT patients (72%) and in 10 of 14 HCM patients (71%) in the left ventricular biopsied specimens, showing no difference between the two groups. The biopsy score in HCM patients was larger than that found in HT patients. It was concluded that BMHD is highly specific (89%) for HCM but that disarrangement of myocardial cells is not specific or diagnostic for HCM. The biopsy score is, therefore, useful for diagnosing HCM histologically and for distinguishing HCM from HT.     

肥厚型梗阻性心肌病室间隔心肌消融术中国专家共识

型梗阻性心肌病（hypertrophic obstructive cardiomyopathy,HOCM）是肥厚型心肌病的一种,因肥厚室间隔造成心室梗阻而得名.目前尚无理想的治疗措施,药物治疗为首选.但部分ＨＯＣＭ患者药物治疗效果不佳或不能耐受,这部分患者需要借助非药物治疗方法.     

The distribution of left ventricular hypertrophy in hypertrophic cardiomyopathy: comparison to athletes and hypertensives

Cross-sectional echocardiogaphy was performed in 134 patientswith hypertrophic cardiomyopathy and 75 with secondary leftventricular hypertrophy (57 hypertensives and 18 athletes) todetermine the diagnostic sensitivity and specificity and predictivevalue of the pattern of left ventricular hypertrophy. Myocardialwall thickness was assessed in the anterior and posterior septum,free wall and posterior wall in both the upper and lower leftventricle. All patients had at least one region exceeding 2SD from normal (>l-4cm). Asymmetrical septal hypertrophy)septum to posterior wall ratio 1.5: 1 in the upper or lowerleft ventricle) was found in 75 patients with hypertrophic cardiomyopathy(56%), 11 hypertensives (18%) and 4 (22%) athletes. This patternwas more common in patients with primary compared to secondaryleft ventricular hypertrophy (P<0.01). Distal ventricularhypertrophy was only seen in patients with hypertrophic cardiomyopathy(10%). Symmetrical left ventricular hypertrophy was demonstratedin 45 patients with hypertrophic cardiomyopathy (34%), 50 hypertensives(82%) and 14 athletes (78%). This pattern was significantlymore common in patients with secondary left ventricular hypertrophy(P<0.01). Amongst those with symmetrical hypertrophy, patientswith hypertrophic cardiomyopathy had more severe hypertrophywhile the athletes had larger left ventricular cavity size.Asymmetrical septal hypertrophy was the most sensitive (56%)and distal ventricular (100%) the most specific pattern forthe diagnosis of hypertrophic cardiomyopathy with a predictivevalue of 83 and 100% respectively. Symmetrical left ventricularhypertrophy was 81% sensitive and 66% specific with a predictivevalue of 58% for the diagnosis of secondary hypertrophy. Inconclusion, the pattern of hypertrophy was of only moderatepredictive value in differentiating primary from secondary leftventricular hypertrophy.     

PCI术后患者平板运动试验与心肺运动试验比较研究

目的 探讨平板运动试验与心肺运动试验的相互关系及临床应用价值。方法 选取解放军总医院心血管内科38例行经皮冠状动脉介入治疗（PCI）的冠心病患者,随机交替进行心肺运动试验及平板运动试验检查,比较各项试验参数情况。结果 患者行心肺运动试验检查时静息血压及运动中最大血压均高于平板运动试验（P＜0.01）,平板运动试验中患者的运动耐量（MET）大于心肺运动试验（P＜0.01）,且两者存在相关关系。患者在平板运动试中自我感知运动强度评分量表（Borg评分）低于心肺运动试验,差异有统计学意义（P＜0.01）。心肺运动试验各参数中,男性与女性相比,运动时间、运动耐量、最大耗氧量表现出统计学差异（P＜0.05）。结论 平板运动试验与心肺运动试验同为负荷试验,两者不可互相替代,因根据患者不同情况进行不同的选择。对于PCI术后的患者而言,心肺运动试验可以提供更多运动能力评价的客观指标。     

老年梗阻性肥厚型心肌病患者经皮室间隔化学消融术有效性和安全性分析

目的评估经皮室间隔化学消融术(PTSMA)在老年药物难治性梗阻性肥厚型心肌病患者中的有效性和安全性。方法连续收录上海交通大学附属胸科医院2001年4月至2019年1月行PTSMA治疗的梗阻性肥厚型心肌病患者,按照年龄分成青年组(年龄<55岁)和老年组(年龄≥55岁)。通过查阅病历记录患者的一般资料、临床病史、手术情况及住院期间并发症发生情况,以及通过电话或门诊随访所记录患者的生命状态、临床表现和心功能情况,应用Kaplan-Meier法分析两组生存曲线。结果共111例患者纳入本研究,中位年龄为56.0(15.0,82.0)岁,女性共42例(37.8%),其中青年组中位年龄43.5(15.0,54.0)岁,老年组中位年龄为63.0(55.0,82.0)岁。总体消融成功率为68.5%,青年组、老年组分别为66.7%、70.0%。术中无水酒精中位注射量为2.0(1.0,5.0)ml,青年组和老年组分别为2.1(1.0,5.0)ml和2.0(1.0,5.0)ml,两组比较差异无统计学意义(P=0.728)。房室传导阻滞、室性心律失常、低血压为手术常见并发症,2例患者(均≥55岁)因持续高度房室传导阻滞需植入永久起搏器,1例患者(66岁)因术后心室颤动、心原性休克经抢救无效死亡。老年组患者围术期主要不良心血管事件(包括心原性死亡,高度房室传导阻滞需植入永久起搏器,由于心室颤动或室性心动过速引起的心搏骤停复苏等)发生率较青年组高(P=0.060)。111例患者除外1例围术期死亡,对其余110例患者进行了长期随访,随访时间为3~212(35.5±48.5)个月,随访率为86.4%(95/110),全因死亡11例,总死亡率为10.0%(11/110),除外1例因肺部感染死亡,其余10例为肥厚型心肌病相关死亡,包括6例心原性猝死,3例因心房颤动、急性脑梗死致死,1例心力衰竭致死。梗阻性肥厚型心肌病患者PTSMA后1年、5年和10年的总生存率分别为96.9%、93.4%和81.1%。青年组和老年组1年、5年、10年总生存率分别97.7%、97.7%、91.6%和96.2%、89.7%、66.4%(P=0.068)。结论老年梗阻性肥厚型心肌病患者PTSMA的效果与青年患者相当,但手术相关的主要不良心血管事件风险可能增加,术后长期总生存率略低于青年组患者。     

肥厚性心肌病的心室造影特点

目的分析梗阻型肥厚性心肌病(HOCM)患者心室造影结果及形态学特征。方法纳入1995~2005年收治入院并接受心室造影和超声检查的74例确诊为肥厚型心肌病的患者。以左心室流出道与左心室压力差≥30 mmHg为梗阻型,30 mmHg为非梗阻型,将患者分为2组。比较其形态学和造影结果。结果 (1)入选74例患者,梗阻型14例(18.9%),其中收缩期前向运动6例(42.9%),冠心病3例(21.4%);非梗阻型60例(81.1%),其中11例合并冠心病(18.3%)。(2)超声显示室间隔增厚至(11.4±2.5)mm,左室后壁厚度(9.8±1.7)mm,左心室舒张末内径(48±5)mm,左心房内径(36±5)mm。(3)左室造影显示左室舒张末容积为(123±31)ml,左室收缩末容积为(27±11)ml,左心室射血分数(EF)为(78±6)%。(4)左心室造影形态学特征为梗阻型心室结构14例,其中正常5例;非梗阻型左心室结构60例,正常27例。结论非梗阻型肥厚性心肌病与HOCM左室舒张末内径、左室舒张末容积及左室收缩末容积、EF值,以及呈现正常形态的病例数等均无差异。     

肥厚型梗阻性心肌病合并心肌桥的外科治疗策略和临床结果

目的：总结肥厚型梗阻性心肌病（HOCM）合并心肌桥的患者行改良扩大Morrow术时同期心肌桥松解术的处理策略及早期结果。方法：回顾性分析 2015年6月至2018年6月阜外医院第二住院部实施手术治疗的HOCM合并心肌桥的患者36例,男性30例（30/36,83.3%）,女性6例（6/36,16.7%）,年龄12-57（37.4±13.2）岁。手术前后及随访期常规行心脏超声心动图、心电图及胸部 X 线片、核磁共振检查,评价心功能、左室流出道及二尖瓣的结构和功能变化。结果：术前出现胸闷症状者27例,胸痛症状者5例,晕厥史13例。术前左室流出道峰值压差（LVOTG）为51-120（73.1±18.6）mmHg（1mmHg=0.133kPa）。全部患者均接受改良扩大 Morrow术联合肌桥松解术,同期行冠脉旁路移植术2例,二尖瓣置换术1例,二尖瓣成形术3例,房间隔缺损修补术1例,改良迷宫手术1例。全组无术中死亡及术后30天内死亡。心肌桥的位置为前降支的患者共34例,心肌桥的位置为后降支的患者为2例,心肌桥的长度范围7-50mm,平均长度为21.8±15.5mm。术后ICU时间1-5（2.6±1.4）天,术后住院时间7-13（7.9±2.6）天,术后未见严重并发症,术后完全性左束支传导阻滞9例,术后完全性右束支传导阻滞1例。术后左室流出道峰值压差（73.1±18.6 mmHg vs 11.2±5.5 mmHg,P=0.00）,室间隔厚度（19.2±4.2 mm vs 14.8±4.3mm,P=0.00）与术前比较均明显降低。术后二尖瓣反流程度较术前明显减轻（P<0.001）,二尖瓣前向运动（SAM征）基本消失。本组术后随访3-52个月,平均(24.6±12.5)个月,随访患者症状均消失,心动能NYHA分级级别较术前降低I～II级,无远期死亡、并发症或再次手术。结论 对于肥厚型梗阻性心肌病合并严重心肌桥的患者行改良扩大Morrow术时同时行心肌桥松解术是安全的。可明显改善患者的生存率及症状,起到协同作用,不增加患者的手术并发症。     

Quantitative analysis of intraprocedural myocardial contrast echocardiography during percutaneous septal ablation for hypertrophic obstructive cardiomyopathy.

AIMS: We tested whether procedural success of percutaneous septal ablation for hypertrophic obstructive cardiomyopathy is related to quantitative measurements of intraprocedural myocardial contrast echocardiography. METHODS AND RESULTS: In a study group of 34 patients, the mean area of the contrast depot was 8.5+/-2.5 cm2, its length along the left ventricular endocardial border 3.0+/-0.7 cm and its proximal edge 2.0+/-0.6 cm upstream the point of mitral-septal contact. Clinical and hemodynamic success was achieved in all but one patient 3 months following percutaneous septal ablation. The proximal edge of the ablation lesion correlated weakly (r=0.5) with the proximal edge of the contrast depot with respect to their distance from the mitral valve leaflet tips. No other correlations were found between the efficacy of percutaneous septal ablation and various quantitative measurements of intraprocedural contrast echocardiography. CONCLUSIONS: The localization of the ablation lesion 3 months after percutaneous septal ablation is predicted by the localization of the contrast depot with respect to the point of mitral-septal contact. The final hemodynamic effect of the ablation lesion, however, does not correlate with quantitative parameters of intraprocedural contrast echocardiography, but appears to be the result of an individual remodeling process.     

肥厚性心肌病和高血压病左室肥厚患者QT离散度的对比观察

目的：对比观察原发性肥厚性心肌病与高血压病左室肥厚患者的QT离散度。方法：以体表心电图描测15例肥厚性心肌病及42例高血压病左室肥厚患者的QT离散度（QTd）和经校正的QTd（QTCd），并与高血压无左室肥厚者及正常对照组进行比较。结果：（1）两组心室肥厚患者的QTd和QTcd均明显高于高血压元左室肥厚者及正常对照组（P＜0.01）；（2）两组心室肥厚者间以上诸指标无明显统计学差异；（3）QTd＞60ms的患者中，两组心室肥厚患者的复杂室性心律失常（≥LownⅢ级）发生率间无明显差异，但均高于高血压病无左室肥厚者。结论：无论是原发性或继发性左室肥厚均与QT离散度的增加相关，并可能为复杂室性心律失常潜在病理基础之一。     

Delayed electrocardiographic changes after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy

Objectives

This work aimed to study the delayed electrocardiographic changes, including Q-T interval, corrected Q-T dispersion, and heart rate variability (HRV) 3 years after percutaneous transluminal septal myocardial ablation (PTSMA), in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM).

Methods

In 26 patients (11 women, 15 men; average age, 37.4 ± 11.2 years) with symptomatic and medically refractory HOCM, 1.4 ± 0.5 septal branches were occluded with an injection of 3.8 ± 1.3 mL of alcohol (95%) to ablate the hypertrophied interventricular septum. Baseline and 3 days and 3 years postprocedure 24-hour Holter electrocardiographic findings were determined.

Results

One patient developed complete atrioventricular block requiring permanent pacing. The PR interval was significantly prolonged 3 days after ablation, but recovered 3 years postprocedure. Three days after the procedure, all patients developed right bundle branch block, which was present in 24 patients after 3 years. The QRS duration was significantly prolonged 3 days after ablation and during 3 years of follow-up. There was significant and persistent prolongation of QT interval and transient prolongation of corrected QT dispersion 3 days after ablation and returned to preablation values 3 years postprocedure, but JT interval and corrected JT dispersion were not significantly changed after PTSMA. Heart rate variability data (time domain and frequency domain) 3 days and 3 years after PTSMA, including low frequency, high frequency, root mean squared successive difference interval, and the percent of sinus cycles differing from the preceding cycle by more than 50 milliseconds, significantly increased compared to that before the procedure. Low frequency/high frequency, SD of all normal-to-normal intervals, and SD of 5-minute average normal-to-normal intervals were not significantly changed after PTSMA.

Conclusions

Percutaneous transluminal septal myocardial ablation for HOCM induces significant delayed electrocardiographic changes in most patients. The changes include QRS prolongation, new right bundle branch block, persistent QT prolongation, transient QT dispersion and PR prolongation, and changes in HRV data. Electrocardiographic long-term follow-up of a larger series of patients is required to determine the conclusive therapeutic significance.     

活动平板试验对评估冠状动脉狭窄程度的预测价值

目的 为了明确活动平板试验与冠状动脉狭窄程度的关系。方法 选取冠状动脉造影阳性且造影1周前后作活动平板试验115例,冠状动脉造 通用直径法确定冠状动脉狭窄程度并与活动平板试验中心电活动改变对比观察。结果 平板运动中ST下移出现越早,ST段下移程度越大,持续时间越长冠状动脉狭窄越重,相反ST段下移出现晚,下移程度小,提示冠状动脉病变程度轻。冠状动脉造影阳性而平板运动试验阴性者,多为单支或轻度病变。结论 活动平板运动试验可估测冠状动脉狭窄程度。     

“室间隔隧道心肌化学消融”治疗肥厚梗阻型心肌病临床疗效观察

目的探索经皮“室间隔隧道心肌化学消融术（PTSTMA）”治疗肥厚梗阻型心肌病（HOCM）的方法及疗效。方法观察PTMTMA和传统心肌化学消融术两种方法无水乙醇注入剂量、术后即刻静息左室流出道压力阶差（LVOTPG）下降程度、3个月心脏超声参数改变以及临床随访中主要临床症状的转归变化,比较两种方法的临床疗效。结果26例患者LVOTPG均下降≥50％;3个月心脏超声室间隔厚度、左房内径、压力阶差均较术前明显改善;随访胸痛、胸闷症状明显减轻,“室早”明显减少,心功能分级明显改善;两组无水乙醇注入量无明显差别,临床疗效也无差别。结论PTSTMA是HOCM心肌化学消融术的一种补充方法,近中期安全有效。     

活动平板运动试验致晕厥12例分析

活动平板运动试验已广泛应用于冠心病的诊断、预后及劳动耐量的评价,但也可并发晕厥等严重的急性事件。我院自2004年1月启用Marauette Series 2000型活动平板机至今已检查1300余例患者,其中发生活动平板运动试验晕厥12例,应引起临床高度重视。     

Diastolic intraventricular gradient in hypertrophic cardiomyopathy with apical hypertrophy

Patients with hypertrophic cardiomyopathy and additional diastolicflow abnormalities are relatively rare. This report describesa case of apical ventricular hypertrophy with complete systolicobstruction and holodiastolic intraventricular pressure gradient.     

急性心肌梗死恢复期患者平板运动试验Q-T间期离散度的价值研究

目的 探讨急性心肌梗死恢复期患者运动试验后Q-T间期离散度（Q-Td）的变化.方法 观察51例急性心肌梗死恢复期患者（观察组）平板运动试验的Q-Td的变化,并观察运动后出现严重室性心律失常、胸痛、血压下降与Q-Td变化的关系.结果 患者峰心率时Q-Td（64.3±20.5ms）较运动前（51.2±23.5ms）增大,差异有显著统计学意义（P＜0.01）.运动中出现严重室性心律失常或明显胸痛、血压下降者15例（A亚组）与36例未出现者（B亚组）比较,运动前Q-Td差异无统计学意义（59.1±17.5ms和16.3±19.2ms,P ＞0.05）,峰心率时A亚组Q-Td（76.8±15.5ms）较B亚组（60.1±16.1ms）延长,差异有显著统计学意义（P＜0.01）.两亚组Q-Td多壁梗死均比单壁梗死延长,A亚组多壁梗死比B亚组延长,差异均有统计学意义（P ＜0.05）.结论 急性心肌梗死患者运动后Q-Td进一步增大,出现严重室性心律失常的危险性增大.平板运动试验可作为筛选急性心肌梗死高危人群的手段之一.