扩大室间隔切除治疗肥厚型梗阻性心肌病的临床研究

目的总结扩大室间隔切除治疗肥厚型梗阻性心肌病（HOCM）的临床经验。方法2009年2月至2011年12月我院外科治疗肥厚型梗阻性心肌病42例，其中男性23例，女性19例，年龄13～66（38±6）岁，体重45±85（62．4±14．7）kg。手术在全身麻醉低温体外循环下完成，按常规经主动脉切13行室间隔心肌切除术（改良Morrow技术），同期完成二尖瓣机械瓣膜置换术2例、冠状动脉旁路移植术5例、主动脉瓣置换术3例。围术期及术后随访心脏超声心动图（UCG）或食管超声心动图（TEE）评价左心房（LA）、左心室（LV）、左室流出道流速及压差（LVOT）、左室射血分数（LVEF）、二尖瓣结构和功能。结果全组患者手术均获得成功，无停机困难，体外循环（84．7±13．8）min，主动脉阻断（60．3±18．4）min。术后所有患者症状均明显改善或消失。超声心动图显示室间隔厚度较术前明显减小，左心室流出道内径较术前明显增宽，左心室流出道压差下降。SAM患者术后超声心动图示SAM消失。二次转机行二尖瓣置换术2例。住院时间11～23d，平均12d。34例获得6～26（14±3）个月随访，随访中进行超声心动图检查。术后10d．6个月及1年的超声心动图均提示LVOTG和室间隔厚度（IVST）较术前显著下降（P〈0．05）；除术前外，其他各时间点的LVOTG和IVST间差异无统计学意义。术后1年心功能（NYHA分级）：I级30例、Ⅱ级3例、Ⅲ级1例。结论扩大室间隔心肌切除术可避免行二尖瓣置换术治疗肥厚型梗阻性心肌病，左心室舒张功能改善，有利于左心室的重塑。患者症状及心功能改善，治疗结果满意。

Clinical study of the expansion ventricular septal resection in patients with hypertrophic obstructive cardiomyopathy

Objective To summarize the clinical experience of expanded resection of the ventricular sep- tal myocardium in patients with hypertrophic obstructive cardiomyopathy （HOCM）. Methods From February 2009 to December 2011, 42 patients with hypertrophic obstructive cardiomyopathy undertaken surgical treatment were included, 23 males and 19 females, aged 13-66 （38±16）years and weighing 45-85 （62.4±14.7）kg. Surgery was performed by general anesthesia and hypothermic cardiopulmonary bypass. Myoeardium was resected from the ven- tricular septum by conventional aortic incision （modified Morrow technique）. Associated surgery were undertaken including mitral valve replacement in two cases, coronary artery bypass grafting in five cases, aortic valve replacement in 3 cases. Transthoracic echocardiography（UCG） or transesophageal eehocardiography （TEE） were examined postoperative and during followed-up periods after discharge to evaluate the volume of left atrium （LA） and leftventricular（LV）, the flow and the pressure gradient through left ventricular outflow tract（LVOT）, left v（entricular eject fraction（EF）, structure and function of mitral valve. Results Operations were successful in the whole group. Cardiopulmonary bypass was withdrawn smoothly in all patients during the operation, with CPB time（84.7±13.8）min and aortic cross clamp time （60.3±18.g）min. Symptoms were relieved significantly in all cases. Echocardiography showed septal thickness reduced distinctly, diameter of the left ventricular outflow tract enlarged obviously and pressure gradients through left ventricular outflow tract decreased significantly compared with preoperative condition. SAM sign disappeared postoperatively. CPB were performed again and MVR were undertaken in 2 cases. Postopera- tive stay averaged 12 days （11-23 days）. 34 patients were followed-up for 6-26 months with average （14±3） months. Echocardiography were examined at 10 d, 6 months and 1 year after surgery, showing LVOTG and IVST decreased significantly （P〈0.05） compared with preoperative condition, but no statistical significant difference were found from these data among different postoperative time points. Cardiac function at 1 year after surgery （NY- HA functional class） was： 30 cases class Ⅰ , 3 cases of class Ⅱ , 1 case of class III. Conclusion Expanded septal myocardial resection can avoid mitral valve replacement in treating hypertrophic obstructive cardiomyopathy, improve left ventricular diastolic function and benefit for left ventricular remodeling. Symptoms are relieved and car- diac function is improved. Treatment is with satisfactory results.