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.     

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.     

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     

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<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     

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。     

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.     

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.     

定量组织速度成像技术评价肥厚型心肌病患者的左室收缩及舒张功能

目的探讨定量组织速度成像技术(QTVI)评价肥厚型心肌病(HCM)左心室整体及节段性心肌功能的临床价值。方法应用QTVI技术检测36例HCM患者和40例正常对照者的心肌,测量收缩期峰值速度(Vs)、舒张早期峰值速度(Ve)、舒张晚期峰值速度(Va),并计算Ve/Va,心尖双平面Simpson法测量左心室射血分数。结果HCM组Vs、Ve、Ve/Va均明显小于正常组(P<0.01),而Va与正常组的差异无显著性(P>0.05);HCM组左室射血分数呈高动力状态,与正常组比较差异有统计学意义(P<0.05)。结论HCM患者左心室长轴方向上收缩功能及主动松弛功能均较对照组减低。QTVI技术能定量评价HCM患者左室局部收缩功能。     

应变和应变率成像评价肥厚型心肌病左室局部心肌收缩和舒张功能的研究

目的：应用应变成像（SI）和应变率成像（SRI）评价肥厚型心肌病（HCM）患者左心室局部心肌收缩和舒张功能。方法：应用SI和SRI技术对34例HCM患者和24例正常人进行检测，获取左室各壁长轴方向基底段、中间段心肌应变和应变率曲线，测量各节段收缩期峰值应变（S）、收缩期峰值应变率（SRs）、舒张早期应变率（SRe）、舒张晚期应变率（SRa）。结果：与正常对照组比较，HCM组左室各节段收缩期峰值应变（S）、收缩期峰值应变率（SRs）、舒张早期应变率（SRe）均明显降低（P〈0．05），左室大部分节段舒张晚期应变率SRa差异无显著性（P〉0.05）。正常对照组约20％节段出现收缩期后缩短（PSS），HCM组约43％节段出现PSS，差异有显著性（P〈0．05）。结论：SI和SRI可敏感地检出HCM患者左室局部心肌收缩和舒张功能的异常，是准确定量评价局部心肌收缩和舒张功能的一种新方法。     

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.