外科治疗肥厚型梗阻性心肌病合并冠心病的处理策略及早中期结果  

Result of surgical treatment of hypertrophic obstructive cardiomyopathy with coronary heart disease

作　　者：蒙延海[1] 王水云[1] 张燕搏[1] 于钦军[1] MENG Yanhai;WANG Shuiyun;ZHANG Yanbo;YU Qinjun(Department of Cardiovascular Surgery,State Key Laboratory of Cardiovascular Disease,Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing,100037,P.R.China)

机构地区：[1]中国医学科学院北京协和医学院国家心血管病中心阜外医院心血管疾病国家重点实验室,北京100037

出　　处：《中国胸心血管外科临床杂志》2019年第2期142-147,共6页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

基　　金：国家自然科学基金(81570276);首都卫生发展科研专项基金(2011-4003-05);首都特色医疗专项基金(Z121107001012017)

摘　　要：目的总结肥厚型梗阻性心肌病(HOCM)合并冠状动脉粥样硬化性心脏病(冠心病)的患者行改良扩大Morrow术时同期冠状动脉旁路移植术(CABG)的围术期处理策略及早期结果。方法回顾性分析2012年1月至2017年12月阜外医院住院二部实施手术治疗的HOCM合并冠心病32例患者的临床资料,男20例、女12例,年龄37～67(53.7±8.7)岁;术前出现胸闷症状者24例,胸痛症状者14例,晕厥史6例。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。结果全部患者均接受改良扩大Morrow术联合CABG,术前左室流出道峰值压差(LVOTG)为40～152(79.6±28.7)mm Hg,同期行心肌桥松解术4例,二尖瓣置换术2例,二尖瓣成形术3例,三尖瓣成形术3例,改良迷宫手术2例。全组无术中死亡及术后30 d内死亡。患者合并行CABG的分支包括前降支26例,对角支16例,回旋支8例,右冠状动脉11例。合并行CABG搭桥1支的患者15例,合并行CABG搭桥2支的患者5例,合并行CABG搭桥3支的患者12例,平均CABG支数(1.9±0.6)支。术后住ICU时间1～13(4.1±2.8)d,术后住院时间6～30(12.6±5.5)d,术后未见严重并发症,术后切口愈合不良1例,术后新发左束支传导阻滞6例。术后左室流出道峰值压差[(79.6±28.7) mm Hg vs.(10.8±5.9)mm Hg,P<0.001],室间隔厚度[(1.9±0.4)cm vs.(1.3±0.5)cm,P<0.001]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6～68 (38.8±20.6)个月,随访患者症状均消失,心功能(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HOCM合并冠心病的患者行改良扩大Morrow术时同时行CABG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。Objective To summarize the perioperative management strategies and early results of modified Morrow expanded operation and coronary artery bypass grafting(CABG) in patients with hypertrophic obstructive cardiomyopathy(HOCM) and coronary atherosclerotic heart disease. Methods Between January 2012 and December 2017, in the Second Inpatient Department of Fuwai Hospital, 32 patients(20 females and 12 males) underwent modified expanded Morrow operation and CABG. The median age was 53.7±8.7 years(interquartile range 37 to 67 years).Preoperative chest distress symptom was found in 24 patients, chest pain symptom was found in 14 patients, history of syncope in 6 patients. Cardiac echocardiography, electrocardiogram, chest X-ray, magnectic resonance imaging(MRI)were performed routinely after operation and follow-up to analyze structure and function of heart and mitral valve.Results All patients underwent modified and expanded Morrow combined with CABG. The preoperative left ventricular outflow tract peak pressure difference(LVOTG) was 40 to 152(79.6±28.7) mm Hg. Four patients underwent myocardial bridge releasing in the same period, mitral valve replacement in 2 patients, mitral valve angioplasty in 3 patients, Maze operation in 2 patients and tricuspid valveoplasty in 3 patients. There was no hospital mortality. CABG surgery in patients with branches included anterior descending artery in 26 patients, diagonal branch in 16 patients, left circumflex in 8 patients, right coronary artery in 11 patients. There were 15 patients with one coronary artery(CA) bypass graft, 5 patients with two CA bypass grafts, and 12 patients with 3 CA bypass grafts. The average of CA bypass grafts was 1.9±0.6. The postoperative ICU time ranged from 1–13(4.1±2.8) days and postoperative hospital stay ranged from 7 to 30(12.6±5.5)days. No severe postoperative complications were found and 1 patient had postoperative incision healing. The postoperative new arrhythmia included left bundle branch block in 6 patients. Compared with the preoperat

关 键 词：肥厚型梗阻性心肌病 冠状动脉粥样硬化性心脏病 外科手术 

分 类 号：R654.2[医药卫生—外科学]