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  

Result of surgical treatment of hypertrophic obstructive cardiomyopathy with myocardial bridging

作　　者：蒙延海[1] 王水云[1] 张燕搏[1] 于钦军[1] MENG Yan-Hai;WANG Shui-Yun;ZHANG Yan-Bo;YU Qin-jun(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,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成人术后恢复中心2区,北京市100037

出　　处：《中国心血管病研究》2019年第1期35-39,共5页Chinese Journal of Cardiovascular Research

基　　金：国家自然科学基金(81570276);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岁,平均(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、左心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。术前左心室流出道峰值压差(LVOTG)为51~120mm Hg,平均(73.1±18.6)mm Hg。全部患者均接受改良扩大Morrow术联合肌桥松解术,同期行冠状动脉旁路移植术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 d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±15.5)mm。术后ICU时间1~5 d,平均(2.6±1.4)d,术后住院时间7~13 d,平均(7.9±2.6)d,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。术后左心室流出道峰值压差[(73.1±18.6)mmHg比(11.2±5.5)mmHg,P=0.00]、室间隔厚度[(19.2±4.2)mm比(14.8±4.3)mm,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。Objective To summarize the perioperative management strategies and early results of modified Morrow operation and myocardial unroofing in patients with hypertrophic obstructive cardiomyopathy (HOCM)and myocardial bridging.Methods Between June 2015 and June 2018,in second inpatient department of Fuwai Hospital,36 patients underwent modified Morrow operation and myocardial unroofing. There were 30 males (30/36,83.3%)and 6 females (6/36,16.7%).The median age at procedure was (37.4±13.2)years (ranged from 12 to 57 years).Cardiac echocardiography,electrocardiogram,chest X-ray,MRI were performed routinely after perioperation and follow-up to analyze the cardiac function,left ventricular outflow tract,mitral valve structure and function.Results There were 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)nun Hg (ranged from 51 to 120 mm Hg).All patients underwent modified Morrow operation combined with myocardial unroofing.2 patients underwent coronary artery bypass grafting;1 patient underwent mitral valve replacement;2 patients underwent mitral valve angioplasty;1 patient underwent Maze operation and 1 patient underwent repair of atrial septal defect at same time.There was no hospital mortality.The location of myocardial bridge were at left anterior descending branch in 34 patients and at posterior descending branch in 2 cases.The average length of myocardial bridge was (21.8±15.5)mm (ranged from 7 to 50 ram).The postoperative ICU time was (2.6±1.4)days(ranged from 1 to 5 days)and postoperative hospital stay was (7.9±2.6)days (ranged from 7 to 13 days).No severe postoperative complications were found. There were the postoperative new arrhythmia including left bundle branch block in 9 cases and right bundle branch block in 1 case.Compared with the preoperative values,postoperative left ventricular outflow tract peak pressure [(73.1±18.6 )mm Hg vs.(11.2±5.5 )mm

关 键 词：肥厚型梗阻性心肌病 心肌桥 外科手术 

分 类 号：R654.2[医药卫生—外科学]