肥厚型梗阻性心肌病的外科治疗及围术期治疗策略

目的 总结肥厚型梗阻性心肌病（Hypertrophicobstructivecardiomyopathy，HOCM）的外科治疗效果，探讨围术期治疗策略。方法 回顾性分析2012年6月至2013年10月我院由单一术扦实施外科手术治疗的HOCM忠并75例，刃性47例（47／75，63％），女性28例（28／75，37%）．年龄10—66（42．92±15．07）岁，术前左室流出道峰值压差（LVOTGP）为50—270（86．98±42．69）mmHg（1mmHg=0．133kPa）、令=部患行均接受室间隔心肌切除术（改良扩大Morrow术）．同期行冠状动脉旁路移植术6例，室壁确切除术1例，二尖瓣置换术4．二尖瓣成形术9，主动脉瓣置换术2，三尖瓣成形术3，先心病2例．围术期常规行心脏超声心动图、心电图及胸部X线片检查，评价超声心动图检查指标、二尖瓣的结构和功能改变。结果 全组无围术期或远期死亡。全组体外循环时间66—258（J33．00±39．83）分钟，升主动脉阻断时间45—157（84．71±25．85）分钟，机械通气时间8-396（2447±44．78）小时，术后住ICU时间1-27（299±3．23）天，术后住院时间6—35（10．20±5．31）天，术后胸腔积液12例，二次插管1例，气管切外1例，床旁血液滤过治疗1例，主动脉内球囊反搏1例，无气胸、无二次开胸探查及二次手术.术后片心房内径（37.31±4．34mm vs43．50±5．89mm，P=O．000），左室流出道峰值压差（12．31±7.00mmHg vs 86．98±42．69mmHg，P=0．000），室间隔厚度（15．41±5．00mmvs22．34±6．20mm．P=O．000）与术前比较均减小或降低。二尖瓣关闭好或仅有轻度反流，二尖瓣前向运动（SAM征）基本消失。术后发生的主要心律失常包括完全性左束支传导阻滞、室内传导阻滞、完全性房室传导阻滞和心房颤动等。远期随访患者症状消失或仅有轻度症状，生活质量明显改善，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。结论外科室间隔心肌切除术治疗肥厚型梗阻性心肌病具有良好的手术效果，能够安全有效地解除左室流出道的梗阻，消除二尖瓣SAM征，改善临床症状。术后并发症主要为心律失常表现为传导束传导异常和心房颤动．具有较好的近远期生存率。

Evaluation of Surgical Treatment and the Treatment Strategies during Perioperative Period for Hypertrophic Obstructive Cardiomyopathy

Objective To summary the surgical treatmeot in patients with hypertrophic obstructive cardiomyopathy （HOCM） and investigate the treatment strategies during per~operative period. Methods We retrospectively summarized 75 consecutive HOCM patients who underwent surgical treatment by one surgeon in our hospital from June 2012 to October 2013. There were 47 （47/75, 63%） male and 28 （28/75, 37%） female, aged 10-66 years with mean （42.92±15.07） years. The left vcntricular outflow tract gradient （LVOTPG） were 50-270 with mean （86.98±42.69） mmHg （lmmHg 0.133kPa）. The ventricular scptal myotomy-myectomy operation （extended Morrow procedure） was performed for all patients. The concomitant operations included coronary artery bypass grafting （6 cases）, aneurysmectomy （1 case）, mitral valve replacement （4 cases）, mitral valve plasty （9 cases）, aortic valve replacement （2 cases）, tricuspid valve plasty （3 cases）, and congenital heart disease （2 cases）. During the peroperative period, the patients were examined by echocardiography, electrocardiogram or dynamic echocardiogram and chest radiography. Left atrial diameter, Icfl ventricular end-diastolic diameter, left ventricular outflow tract （LVOT） pressure gradient, interventricular septal thickness, ejection fraction （EF）, the changes of mitral valve construction and function were evaluated. Results No operative or late deaths occurred. The time of CPB and aortic occlusion wcrc 66-258 （133.00±39.83） min and 45-157 （84.71±25.85） min, respectively. Mechanical ventilation time were 8-396 （24.47±44.78） hrs. The postoperative intensive care unit （ICU） stay were 1-27 （2.99±3.23） days and the postoperative hospital stay were 6-35 （10.20±5.31） days. Postoperative complicatio,as included pleural effusion （12 cases）, secondary intubation （1 case）, tracheotomy （1 case）, hemofiltration （1 case）, intra- aortic balloon pump （1 case）. There was no pncumothorax, secondary thoracotomy and second surgery. Postoperative left atrial diameter （37.31±4.34 mm vs 43.50±5.89 mm, P-0.000）, LVOTGP （12.31±7.00 mmHg vs 86.98±42.69 mmHg, P=0.000） and intervent ricular septal thickness （15.4 1±5.00 mm vs 22.34±6.20 mm, P-0.000） decreased significantly compared with those before operation. There was no mitral valve regurgitation, or only mild mitral valve regurgitation. No systolic anterior motion （SAM） was found. The main postoperative arrhythmias included complete left bundle branch block, intraventricular block, complete atrioventricular block and atrial fibrillation. All patients were asymptomatic or only mildly symptomatic.The quality of life improved significantly. NYHA classification decreased than that before the operation （class I and class II）. During fbllow-up, no myectomy related complication, reintervention or death was observed. Conclusions Septal myectomy may eliminate left ventricular outflow tract obstruction, relief the symptom and make better living quality in HOCM patients, with high near-term and long-term survival rate. The main arrhythmias after operation are bundle branch block and atrial fibrillation.