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。     

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.     

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.     

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     

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.     

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.     

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.     

Percutaneous transluminal septal myocardial ablation in patients with hypert rophic obstructive cardiomyopathy

Objective To evaluate theimmediate and follow-up results of percutaneous transluminal s eptal myocardial ablation (PTSMA) in patients with hypertrophic obstructive cardiomyo pathy (HOCM). Methods Fifteen symptomatic, drug-refractory patients with HOCM underwent PTSMA procedu res with application of a myocardial contrast echocardiography (MCE) intra-proc edure. Before and after the procedure, clinical evaluations were obtained in al l patients, who were followed up for a mean period of 8. 6±3. 8 (6-20) months. Results Immediate left ventricular outflow tract gradient (LVOTG) reduction was achie ved (77. 93±22 mm Hg vs 14. 8±15 mm Hg, P&lt;0. 0001) after the procedure with a mean decrease of5. 75±2. 87 mm Hg of left ventricular end diastolic pressure (P&lt;0. 001). Follow up results revealed that ventricular remodelli ng occurred mainly 1-3 months after the procedure, but without evidence of ventr icular dilation and contract dysfunction. Heart function (NYHA) was greatly imp roved （3. 4±0. 5 vs 1. 1±0. 4, P&lt;0. 001) and exercise endurance increased . A renewed increase of LVOTG was found in 2 patients during follow-up. Conclusions LVOTG was greatly decreased in HOCM patients undergoing a PTSMA procedure, and t heir symptoms were greatly improved without cardiac complications during follow -up. Sub-selection and re-opening of target vesselswere the causes of rene wed increase of LVOTG, and this can be avoided with the accumulation ofexperie nce. This is a promising method for the treatment of symptomatic patients with HOCM.     

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.     

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.     

“一站式”经导管主动脉瓣置换联合经皮腔内室间隔心肌消融手术1例

 经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）是治疗主动脉瓣狭窄（aortic valve stenosis,AS）的一种成熟手段。AS患者几乎均合并心肌肥厚,目前对于合并梗阻性肥厚型心肌病（hypertrophic obstructive cardiomyopathy,HOCM）的AS患者首先考虑外科手术而非TAVR。但高龄、高危患者常不能耐受外科手术,介入手段能否安全有效治疗此类患者尚存疑问。本文报道1例77岁女性患者,重度AS合并HOCM,经评估后行“一站式”TAVR联合经皮腔内室间隔心肌消融术（percutaneous transluminal septal myocardial ablation,PTSMA）,术后患者恢复良好。本病例为国内开展的首例“一站式”TAVR+PTSMA,为TAVR术中紧急处理并发症和拓宽适应证提供新的依据。     

Left ventricular endocardial pacing predicts the reduction of left ventricular outflow tract pressure gradient immediately after percutaneous transseptal myocardial ablation in patients with hypertrophic obstructive cardiomyopathy refractory to medication

Background  Hypertrophic obstructive cardiomyopathy (HOCM) carries an increased risk for sudden cardiac death. No data regarding the percutaneous transseptal myocardial ablation (PTSMA) and epicardial left ventricular pacing (LVP) were reported.
Methods  Seven patients with recurrent symptoms and increased resting left ventricular outflow tract pressure gradient (LVOTG) after PTSMA and another 14 patients with HOCM without history of PTSMA were studied. Both resting and dobutamine stress echocardiography, PTSMA and LVP were routinely performed.
Results  In patients without previous PTSMA procedure, mild reduction of resting LVOTG was detected at 5 minutes after left ventricular pacing, and this reduction became significant at 10 minutes. All patients were divided into successful and unsuccessful groups according to their response to LVP. In contrary to patients in unsuccessful group, resting and R-S2 stimuli-induced LVOTG during PTSMA procedure were decreased dramatically ((9±5) mmHg vs (58±12) mmHg, (12±2) mmHg vs (113±27) mmHg, P<0.001). Analysis of Logistic regression demonstrated that only LVOTG level during left ventricular pacing was an independent factor predicting the reduction of LVOTG immediately after PTSMA (odds ratio (OR), 0.59; 95% CI 2.67 to 5.82; P=0.0002).   
Conclusion  Left ventricular endocardial temporary pacing plays a critical role in predicting acute effect on the reduction of LVOTG immediately after PTSMA procedure.

     

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.     

肥厚梗阻型心肌病化学消融术酒精用量对术后早期血流动力学和心脏重构的影响

目的:探讨经皮室间隔心肌化学消融术(PTSMA)最适酒精使用剂量?方法:连续选择2007年1月~2010年12月在本院接受低剂量酒精(≤ 2.0 ml)消融的肥厚梗阻型心肌病(HOCM)患者10例;按1∶2配比的病例对照研究,选择2000年1月~2006年12月接受较大剂量酒精(> 2.0 ml)消融治疗的患者20例作为历史对照组,分别评估两种治疗方案对术后早期血流动力学和心脏重构的影响?结果:低剂量和对照组术后即刻[(28.0 ± 8.8) mmHg和(27.5 ± 7.2) mmHg]?术后3个月[(29.5 ± 6.6) mmHg和(28.1 ± 5.0) mmHg]的左心室流出道压力阶差(LVOTPG)均较基线时[(69.9 ± 13.1) mmHg和(70.6 ± 13.4) mmHg]显著性下降(P < 0.01),术后室间隔厚度明显减小(P < 0.01),左心室舒张末内径无变化;而两组间术后即刻?术后3个月LVOTPG水平及下降幅度均无差异(P > 0.05);相关分析显示,酒精用量分别与术后即刻LVOTPG以及术后3个月LVOTPG?室间隔厚度和左室舒张末内径等变化无相关性(P > 0.05)?结论:小剂量酒精消融同样导致术后早期血流动力学和心脏结构的改善?     

经皮室间隔心肌化学消融术治疗肥厚型梗阻性心肌病疗效评价

目的 评价经皮室间隔心肌化学消融术 (PTSMA)治疗肥厚型梗阻性心肌病 (HOCM)近期疗效 ,并探讨其方法学。方法 31名HOCM患者接受PTSMA治疗 ,6例采用心肌声学造影监测判断消融靶血管。结果 31例患者均成功实施PTSMA治疗 ,患者术前平均跨左心室流出道压力阶差 (71.6±25.7)mmHg,术中球囊充盈15min后为 (29.1±15.6)mmHg,消融术毕为 (21.6±7.7)mmHg,与术前比较均有显著下降 (均P<0.05) ;临床状况显著改善18例 ,明显改善9例 ,改善不显著4例 ;1例患者发生迟发性高度房室传导阻滞 ,经积极药物处理后传导阻滞消失 ,无死亡和需行永久性起搏治疗者。 结论 PTSMA手术是HOCM患者一项有效、相对安全的治疗方法。     

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。