梗阻性肥厚型心肌病的外科治疗:单中心5年421例经验总结  

Surgical treatment for obstructive hypertrophic cardiomyopathy: a five-year single-center experience of 421 cases

作　　者：刘方钰 季强 王毓琳[1] 陈金淼[1] 董丽莉[2] 丁文军[1] 赖颢[1] 王春生[1] Liu Fangyu;Ji Qiang;Wang Yulin;Chen Jinmiao;Dong Lili;Ding Wenjun;Lai Hao;Wang Chunsheng(Department of Cardiac Surgery,Zhongshan Hospital,Fudan University,Shanghai Municipal Institute for Cardiovascular Diseases,Shanghai 200032,China;Department of Cardiac Ultrasound Diagnosis,Zhongshan Hospital,Fudan University,Shanghai 200032,China)

机构地区：[1]复旦大学附属中山医院心脏外科、上海市心血管疾病研究所,上海200032 [2]复旦大学附属中山医院心超诊断科,上海200032

出　　处：《中华外科杂志》2023年第3期201-208,共8页Chinese Journal of Surgery

摘　　要：目的探讨外科治疗梗阻性肥厚型心肌病(HCM)的早中期效果并总结经验。方法回顾性收集2017年1月至2021年12月在复旦大学附属中山医院心脏外科接受手术治疗的421例梗阻性HCM患者的围手术期资料和术后随访结果。男性207例,女性214例,年龄(56.5±11.7)岁(范围:19~78岁)。术前心功能纽约心脏病学会分级Ⅱ级45例,Ⅲ级328例,Ⅳ级48例。58例为隐匿梗阻性HCM,占13.8%(58/421)。257例合并中度及以上二尖瓣反流,56例存在二尖瓣器质性病变。手术由多学科团队共同完成,心脏超声医师参与术前规划和术中监测,确定合理的二尖瓣处理策略。338例患者接受单纯室间隔心肌切除术,59例同期接受二尖瓣手术。355例为单一经主动脉切口入路,51例经右心房-房间隔/房间沟入路。术中选用长柄微创手术器械,识别并处理二尖瓣瓣下异常结构。手术前后数据的比较采用配对t检验、配对秩和检验、χ^(2)检验或Fisher确切概率法。结果单纯室间隔心肌切除术的主动脉阻断时间为(34.3±8.5)min(范围:21~94 min)。18例患者术中发生不良事件并即刻再次手术,包括残余梗阻10例、左心室游离壁破裂4例、室间隔穿孔3例、主动脉瓣穿孔1例。院内死亡4例,术后发生完全性房室传导阻滞11例。随访率为92.1%(384/421),中位随访时间9个月,患者均存活。心功能分级Ⅰ级216例,Ⅱ级168例,较术前有所改善(χ^(2)=662.73,P<0.01)。术后6个月随访超声心动图,室间隔厚度[(13.6±2.5)mm比(18.2±3.0)mm,t=23.51,P<0.01]和左心室流出道压差峰值[(12.0±6.3)mmHg比(93.4±19.8)mmHg,1 mmHg=0.133 kPa,t=78.29,P<0.01]均较术前降低。结论手术团队(尤其是心脏超声医师)的建设、合理的二尖瓣处理策略、二尖瓣瓣下异常结构的识别和处理、长柄微创手术器械的选用有助于室间隔心肌切除术取得满意的早中期结果。Objectives To examine the short-term and mid-term effects of surgical treatment of obstructive hypertrophic cardiomyopathy(HCM)in one center.Methods The perioperative data and short-term follow-up outcomes of 421 patients with obstructive HCM who received surgical treatment at Department of Cardiac Surgery,Zhongshan Hospital,Fudan University from January 2017 to December 2021 were analyzed retrospectively.There were 207 males and 214 females,aged(56.5±11.7)years(range:19 to 78 years).Preoperative New York Heart Association(NYHA)classification included 45 cases of classⅡ,328 cases in classⅢ,and 48 cases in classⅣ.Fifty-eight patients were diagnosed with latent obstructive HCM and 257 patients had moderate or more mitral regurgitation with 56 patients suffering from intrinsic mitral valve diseases.All procedures were completed by a multidisciplinary team,including professional echocardiologists involving in preoperative planning for proper mitral valve management strategies and intraoperative monitoring.A total of 338 patients underwent septal myectomy alone,and 59 patients underwent mitral valve surgery along with myectomy.A single transaortic approach was used in 355 patients,and a right atrial-atrial septal/atrial sulcus approach was used in 51 other patients.Long-handled minimally invasive surgical instruments were used for the procedures.Student t test,Wilcoxon rank sum test,χ^(2) test or Fisher exact test were used to compare the data before and after surgery.Results The aortic cross-clamping time of septal myectomy alone was(34.3±8.5)minutes(range:21 to 94 minutes).Eighteen patients had intraoperative adverse events and underwent immediate reoperation,including residual obstruction(10 patients),left ventricular free wall rupture(4 patients),ventricular septal perforation(3 patients),and aortic valve perforation(1 patient).Four patients died during hospitalization,and 11 patients developed complete atrioventricular block requiring permanent pacemaker implantation.After discharge,384(92.1%)patients re

关 键 词：心肌病 肥厚性 心肌切除术 二尖瓣器质性病变 二尖瓣瓣下结构异常 隐匿梗阻性肥厚型心肌病 

分 类 号：R654.2[医药卫生—外科学]