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。

Result of surgical treatment of obstructive hypertrophic cardiomyopathy with myocardial bridging

Objective The purpose of this study was to to summarize the perioperative management strategies and early results of modified Morrow operation and myocardial unroofing in patients with obstructive hypertrophic cardiomyopathy (HOCM) and myocardial bridging. Methods Between June 2015 and June 2018, in second inpatient department of Fu Wai Hospital, 36 patients (30 female and 6 male) underwent modified Morrow operation and myocardial unroofing. The median age at procedure was 37.4±13.2 years (interquartile range 12 to 57 years). Cardiac echocardiography, electrocardiogram, chest X-ray, MRI were performed routinely after operation and follow-up to analyze structure and function of heart and mitral valve. Results Preoperative chest distress symptoms in 27 cases, chest pain symptoms in 5 cases, history of syncope in 13 cases. The preoperative left ventricular outflow tract peak pressure gradient (LVOTG) was 73.1±18.6 (interquartile range 51 to 120 ) mmHg (1mmHg=0.133kPa). All patients underwent modified and expanded Morrow combined with myocardial unroofing. 2 patients underwent CABG in the same period, mitral valve replacement in 1 patient, mitral valve angioplasty in 2 patients, Maze operation in 1 patient and repair of atrial septal defect in 1 patient. There was no hospital mortality. The location of myocardial bridge of Left anterior descending branch in 34 patients, posterior descending branch in 2 cases. The average length of myocardial bridge was 21.8±15.5mm (interquartile range 7 to 50mm). The postoperative ICU time ranged from 1 to 5 days (2.6 ± 1.4 days) and postoperative hospital stay ranged from 7 to 13 (7.9 ± 2.6 days). No severe postoperative complications were found and the postoperative new arrhythmia including left bundle branch block in 9 cases, right bundle branch block in 1 case. Compared with the preoperative values, Postoperative left ventricular outflow tract peak pressure (73.1±18.6 mmHg vs 11.2±5.5mmHg, P = 0.00), interventricular septum thickness (19.2±4.2 mm vs 14.8±4.3mm, P = 0.00) were decreased obviously. Mitral valve closure is good or only mild reflux, mitral valve forward movement (SAM sign) disappeared. The patients were followed up for 3-52 months, with an average of (24.6±12.5) months. All patients were followed up with symptoms disappeared or only mild symptoms. NYHA classification decreased I to II grade after surgery, without long-term mortality, complications or reoperation. Conclusions For patients with obstructive hypertrophic cardiomyopathy with myocardial bridging, the application of improved expand morrow operation at the same time undergoing myocardial unroofing is safe. This can significantly improve patient survival and reduce symptoms, play a synergistic effect, and does not increase the patient''s surgical complications.