肥厚型梗阻性心肌病外科治疗术后并发完全性房室传导阻滞的探讨  

Clinical features and management of complete heart block after transaortic extended septal myectomy in patients with hypertrophic obstructive cardiomyopathy

作　　者：罗明尧[1] 王水云[1] 孙宏涛[1] 尹朝华[1] 孙欣[2] 宋云虎[1] 胡盛寿[1] 

机构地区：[1]中国医学科学院北京协和医学院阜外心血管病医院心外科,100037 [2]中国医学科学院北京协和医学院超声科,100037

出　　处：《中华心血管病杂志》2013年第7期598-601,共4页Chinese Journal of Cardiology

基　　金：基金项目：首都临床特色应用研究项目（Z121107001012017）;首都卫生发展科研专项项目（首发2011-4003-05）

摘　　要：目的评价扩大室间隔肥厚心肌切除术（扩大Morrow术）治疗肥厚型梗阻性心肌病后，并发完全性房室传导阻滞的病例特点及其预防和处理。方法回顾性分析1996年10月至2011年12月，阜外心血管病医院手术治疗的160例肥厚型梗阻性心肌病患者中并发完全性房室传导阻滞的10例患者的临床资料。其中男6例，女4例，年龄13—60（45．4±15．8）岁，左心室流出道（1eft ventricular outflow tract，LVOT）峰值压差为68～149（105．1±25．9）mmHg（1mmHg=0．133kPa），术前心电图示5例合并右束支传导阻滞，5例合并其他异常，如房性早搏、心房颤动、室性早搏、ST—T段波形改变、异常Q波等。全组均在全麻低温体外循环下经主动脉切口行扩大Morrow术，同期行二尖瓣置换术2例，二尖瓣置换＋冠状动脉旁路术2例。分析患者手术前后的心电图、超声心动图，出院后门诊复查和电话随访结果。结果10例患者术后均发生完全性房室传导阻滞，围术期死亡2例，死因均为完全性房室传导阻滞合并低心排血量综合征、多器官功能衰竭。存活的8例中，4例行二尖瓣行换瓣术，其余4例的二尖瓣为无反流（2例）、微少量反流（2例），SAM征均消失，术后LVOT压差为0～31（13．6±9．7）mmHg。该8例患者于扩大Morrow术后6d～7个月置人永久起搏器，未合并其他并发症。随访4～72（19．4±22．1）个月，1例于术后71个月因起搏器电压低，返院更换起搏器。患者生活质量改善，心功能I一Ⅱ级，无远期死亡。结论完全性房室传导阻滞是扩大Morrow术后的主要并发症，须重视术前心电图异常改变，尤其是右束支传导阻滞。完全性房室传导阻滞一旦发生，应及时安装永久起搏器。Objective To analyze the clinical features, precaution and management of complete heart block （CHB） after transaortic extended septal myectomy operation （ extended Morrow procedure） in patients with hypertrophic obstructive cardiomyopathy （HOCM）. Methods From October 1996 to December 2011, 1016 men; mean age （45.4 ± 15.8） years, range 13 -60 years] out of 160 consecutive HOCM patients underwent extended Morrow procedure developed CHB postoperatively. Their clinical data were retrospectively analyzed. Baseline transthoracic echocardiography showed that the left ventricular outflow tract （LVOT） gradients was from 68 to 149 （105. 1 ±25.9） mm Hg （1 mm Hg = 0. 133 kPa）, ECG showed right bundle branch block in 5 patients and atrial fibrillation, atrial premature beats or ST-T segment changes in other 5 patients. Besides extended Morrow procedure, concomitant surgical procedures included mitral valve replacement （MVR） in 2 （2/10） and MVR plus coronary artery bypass grafting in another 2 （2/10） patients. Follow-up data were obtained by subsequent clinic visits in outpatient department and telephone interviews. Results The in-hospital mortality was 20% （these two patients died of low cardiac output syndrome and multiple organs failure）. Four patients underwent MVR simultaneously survived theoperation. Postoperative echocardiography demonstrated a reduced LVOT gradient [ （ 13.6 ± 9.7） mm Hg, P 〈0. 001 ]. Permanent pacemakers were implanted in all 8 survived patients at 6 days to 7 months after operation. No other severe complications were observed. During follow-up [ from 4 to 72 （ 19.4 ± 22. 1 ） months], there was no death, 1 patient readmitted to our center at 71 months post operation to change the pacemaker because of low voltage of previously implanted pacemaker. Physical capacity and quality of life improved significantly post operation in these 8 patients. The NYHA functional class remained at I - II post operation and during follow up. Conclusions CHB is a se

关 键 词：心肌病 肥厚性 心脏外科手术 心脏传导阻滞 

分 类 号：R654.2[医药卫生—外科学]