全胸腔镜经二尖瓣行室间隔心肌切除术治疗室间隔酒精消融术后复发左室流出道梗阻  

Totally endoscopic transmitral septal myectomy for the treatment of recurrent left ventricular outflow tract obstruction after alcohol septal ablation

作　　者：魏培坚 吴宏祥 谭桐 邱海龙 徐小维 朱伟 鹿冠玉 庄建[1,3] 刘健 郭惠明[1,3] WEI Peijian;WU Hongxiang;TAN Tong;QIU Hailong;XU Xiaowei;ZHU Wei;LU Guanyu;ZHUANG Jian;LIU Jian;GUO Huiming(Department of Cardiac Surgery,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangdong Cardiovascular Institute,Guangzhou,510080,P.R.China;Shantou University Medical College,Shantou,515041,Guangdong,P.R.China;Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases,Guangdong Provincial Key Laboratory of South China Structural Heart Disease,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangzhou,510080,P.R.China;Department of Adult Cardiac Ultrasound Medicine,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangdong Cardiovascular Institute,Guangzhou,510080,P.R.China;Department of Radiology,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangzhou,510080,P.R.China)

机构地区：[1]广东省人民医院广东省医学科学院,广东省心血管病研究所心外科,广州510080 [2]汕头大学医学院,广东汕头515041 [3]广东省人民医院广东省医学科学院,广东省华南结构性心脏病重点实验室,心血管人工智能与三维技术实验室,广州510080 [4]广东省人民医院广东省医学科学院,广东省心血管病研究所成人超声科,广州510080 [5]广东省人民医院广东省医学科学院影像科,广州510080

出　　处：《中国胸心血管外科临床杂志》2023年第8期1102-1111,共10页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

基　　金：广东省登峰计划项目(DFJH2019,DFJH201802);广东省科技计划项目(2019B020230003,2018B090944002);广东省人民医院心血管专项(2020XXG010)。

摘　　要：目的初步探讨全胸腔镜经二尖瓣室间隔心肌切除术治疗室间隔酒精消融术后复发左室流出道梗阻的手术策略及临床疗效。方法回顾性分析广东省人民医院心外科2020年7月—2021年7月因室间隔酒精消融后复发左室流出道梗阻患者的临床资料。术前患者均进行心脏超声、心脏磁共振成像、心脏CT、3D建模与打印技术的评估,并根据多模态影像学评估制定个性化手术策略,于数字模型上进行可视化探查并在打印模型上进行模拟手术切除,再行全胸腔镜经二尖瓣室间隔心肌切除术。结果共纳入2例患者,均为女性,年龄分别为62岁和64岁。2例患者均成功接受全胸腔镜经二尖瓣室间隔心肌切除术,主动脉阻断时间分别为96 min和85 min,术后左室流出道梗阻即刻解除(左室流出道峰值压差分别由100 mm Hg降至4 mm Hg和由84 mm Hg降至6 mm Hg),二尖瓣反流明显改善。2例患者均未出现Ⅲ度房室传导阻滞,无需植入永久起搏器,且顺利出院,无术后并发症发生。结论对室间隔酒精消融术后复发左室流出道梗阻的患者,结合多模态影像学评估及3D建模与打印技术的个性化全胸腔镜经二尖瓣室间隔心肌切除术临床效果良好,能准确切除肥厚室间隔心肌,同时避免如室间隔穿孔或Ⅲ度房室传导阻滞等严重并发症。Objective To investigate the surgical strategies and clinical efficacy of transmitral septal myectomy in the treatment of recurrent left ventricular outflow tract obstruction(LVOTO)after alcohol septal ablation.Methods The clinical data of patients with recurrent LVOTO after alcohol septal ablation from July 2020 to July 2021 in the Department of Cardiac Surgery,Guangdong Provincial People's Hospital were retrospectively analyzed.Patients were preoperatively evaluated by echocardiography,cardiac magnetic resonance imaging,cardiac computed tomography,3D modeling and printing technology.A personalized surgical strategy was preoperatively developed according to multimodality imaging assessment,while visual exploration was performed on the digital model and simulated surgical resection was performed on the printed model.Results Two female patients were enrolled,aged 62 years and 64 years,respectively.Totally endoscopic transmitral extended myectomy was successfully performed on both patients with aortic cross-clamping time of 96 min and 85 min,respectively.LVOTO was relieved immediately(subaortic peak pressure gradient decreased from100 mm Hg to 4 mm Hg and from 84 mm Hg to 6 mm Hg,respectively)and the mitral regurgitation significantly improved after the procedure.No patient had complete atrioventricular block or required permanent pacemaker implantation.The patients were discharged uneventfully without postoperative complications.Conclusion Personalized totally endoscopic transmitral extended myectomy combined with multimodality imaging assessment and 3D modeling and printing has an acceptable clinical effect in patients with recurrent LVOTO after alcohol septal ablation.The procedure can precisely resect the hypertrophic septal myocardium while avoiding serious complications such as septal perforation or complete atrioventricular block.

关 键 词：全胸腔镜 室间隔心肌切除术 室间隔酒精消融术 左室流出道残余梗阻 3D打印 

分 类 号：R654.2[医药卫生—外科学]