扩大心肌切除术对消除肥厚型梗阻性心肌病二尖瓣反流的效果分析  

Efficacy of Extended Myectomy on Reducing Mitral Regurgitation in Patients With Hypertrophic Obstructive Cardiomyopathy

作　　者：唐亚捷 宋云虎[1] 邓隆 段福建[1] 刘赟[2] 然鋆[1] 高歌[1] 李源[1] 李琦[1] TANG Ya-jie;SONG Yun-hu;DENG Long;DUAN Fu-jian;LIU Yun;RAN Jun;GAO Ge;LI Yuan;LI Qi(Department of Cardiac Surgery, National Center for Cardiovascular Diseases and Fuwai Hospital, CAMS and PUMC, 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成人外科中心,北京市100037 [2]上海交通大学医学院附属瑞金医院

出　　处：《中国循环杂志》2018年第6期585-590,共6页Chinese Circulation Journal

摘　　要：目的:分析扩大心肌切除术对消除肥厚型梗阻性心肌病(HOCM)二尖瓣反流的效果。方法:回顾2002-11至2017-07我院单一术者手术治疗的480例HOCM患者,患者均接受扩大心肌切除、离断二尖瓣装置与室间隔的异常连接及修剪乳头肌等操作,术后利用超声心动图结果评估手术对左心室流出道(LVOT)梗阻及二尖瓣反流的改善效果。结果:480例患者中22例(4.6%)因二尖瓣器质性病变而行二尖瓣成形或置换,其余458例(95.4%)未行二尖瓣处理的患者中,1例(0.2%)术后第5天死于感染性休克,4例失访(0.9%),中位随访时间为6个月(3,12)。随访超声心动图结果显示:患者LVOT压差较术前显著减小[(12.8±11.6)mm Hg vs(89.1±30.6)mm Hg,1 mm Hg=0.133 k Pa,P<0.001];合并二尖瓣前向运动(SAM)的患者由术前451例(98.5%)下降至随访时42例(9.3%)(P<0.001);二尖瓣中量以上反流患者由术前的297例(64.8%),下降至随访期间的14例(3.1%)(P<0.001)。多因素回归分析显示:随访期间残余SAM现象的患者二尖瓣中量以上反流的发生率较高(OR=30.334,95%CI:5.619~163.739,P<0.001)。结论:扩大心肌切除术可消除绝大部分患者的LVOT梗阻及SAM相关二尖瓣反流。在不合并二尖瓣器质性病变时,HOCM患者极少需要同期处理二尖瓣。Objectives：To analyze the impact of extended myectomy on reducing mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy（HOCM）.Methods： We retrospectively analyzed 480 consecutive HOCM patients who underwent surgical treatment by the same surgeon in our institution from October 2002 to July 2017. The efficacy of extended myectomy for reducing mitral regurgitation and left ventricular outflow tract（LVOT） obstruction were evaluated by echocardiography after surgery.Results： Among the 480 patients, 22（4.6%） received concomitant mitral repair or replacement because of their intrinsic mitral diseases. In the remaining 458（95.4%） patients without concomitant mitral valve surgery, 1（0.2%） died at the 5 th day after surgery because of infective shock, and another 4（0.9%） lost to follow-up, a total of 453（98.9%） patients underwent echocardiographic follow-up（median follow-up time： 6 months [3, 12]）. During follow-up, left ventricular out flow tract gradient was significantly decreased from（89.1±30.6） to（12.8±11.6） mm Hg（P〈0.001）; the number of patients with systolic anterior motion（SAM） of mitral leaflets decreased from 451（98.5%） to 42（9.3%）（P〈0.001）; 297（64.8%） patients presented with moderate or severe mitral regurgitation before surgery, which decreased to 14（3.1%） at follow-up（P〈0.001）; the multivariate regression analysis showed that patients with residual SAM were significantly associated with a higher incidence of moderate to severe mitral regurgitation during follow-up（odds ratio 30.334, 95% confidence interval： 5.619-163.739, P〈0.001）. Conclusions： Extended myectomy, combined with dividing the anomalous links between mitral apparatus and septum, andtrimming papillary muscles, yields satisfactory outcomes of relieving LVOT obstruction and reducing mitral regurgitation in most of patients with HOCM. Concomitant mitral valve surgery is rarely required unless the patient have intrinsic mitral valv

关 键 词：心肌病 肥厚型 扩大心肌切除 二尖瓣反流 

分 类 号：R541[医药卫生—心血管疾病]