118例肥厚型梗阻性心肌病的外科治疗经验

Surgical treatment for hypertrophic obstructive cardiomyopathy： a report of 118 cases

目的总结外科手术治疗118例肥厚型梗阻性心肌病（HOCM）的早中期疗效。方法回顾性分析2009年10月至2012年4月阜外心血管病医院手术治疗的118例HOCM患者，其中男69例，女49例，平均年龄（464-13）岁，全组均在全麻低温体外循环下行扩大Morrow手术，术前、术后常规行经胸超声心动图检查，术中常规行经食管超声心动图检查。根据术前查明的心脏合并疾病，必要时同期施行相应的手术治疗。结果本组患者术前室间隔最大厚度为（254-7）mm，二尖瓣收缩期前向运动（SAM）现象阳性率100％。全组无术中死亡，术后30d病死率0．8％（1／118），死亡原因为术后低心排综合征导致的多器官功能衰竭。手术前后LVOT峰值压差平均为（924-22）和（134-10）mmHg（1mmHg=0．133kPa，P=0．000），心功能NYHA分级分别为2．9±0．6和1．24-0．4（P=0．000）。术后除1例患者仍存在轻度SAM现象外，余均消失；二尖瓣均为无反流、微量或者少量反流。同期进行其他心脏手术45例（38．1％）。术后主要并发症包括完全性房室传导阻滞3例，一度房室传导阻滞6例，完全性左束支传导阻滞51例，室内阻滞或左前分支阻滞26例，二次开胸止血3例，一过性急性肾功能衰竭2例，需主动脉球囊反搏支持2例。本组术后随访1～27个月，平均（74-6）个月，患者生活质量改善，心功能均为I～Ⅱ级，无死亡或再次手术。结论外科手术治疗HOCM安全有效。根据其解剖特点，严格实施各部位的外科操作，能够有效地解除左心室流出道梗阻，可重复性好。

Objective To assess the clinical outcomes of transaortic extended septal myectomy on early and midterm survival of patients with hypertrophic obstructive cardiomyopathy （ HOCM）. Methods From October 2009 to April 2012, 118 consecutive patients underwent extended Morrow＇s procedure for HOCM. There were 69 males and 49 females with an average age of （46 ±13 ） years. Their clinical data were analyzed retrospectively. Preoperative transthoracic, intraoperative transoesophageal and postoperative transthoracic echocardiography was performed to assess septal thickness, left ventricular outflow tract （LVOT） gradient, mitral valve function and systolic anterior motion （SAM） of anterior mitral valve leaflet, etc. Concomitant surgical procedures were performed if other cardiac diseases required surgical interventions. Follow-up study was carried out during subsequent clinic visits at outpatient department and through telephone interviews with patients and their relatives. Results The septal thickness was （25 ± 7） ram. SAM was detected in all. The in-hospital mortality was 0. 8% （1/118） since one patient died of multiple organs failure one week later. Postoperative echocardiography demonstrated marked reduction in LVOT gradient （92 ±22 vs 13 ± 10 mm Hg （1 mm Hg =0. 133 kPa）, P =0.000）, New York Heart Association （NYHA） class （2. 9 ± 0. 6 vs 1.2 ± 0. 4, P = 0. 000） and significant improvement in mitral regurgitation. Concomitant surgical procedures were performed in 45 cases （38. 1% , all for preexisting conditions）. Complications included complete atrioventricular block （n = 3 ）, first degree atrioventricularblock （ n = 6）, complete left bundle branch block （ n = 51 ） , intraventricular conduction delay or left anterior division block （ n = 26）, transient renal dysfunction （ l= 2） and intra-aortic-balloon-pumping （ n = 2）. No other severe complication was observed. During a follow-up period of 1 -27 （7 ± 6） months, there was no readmission or death. All patients reported significant increase in physical ability and obvious decrease in limiting symptoms. At the latest follow-up, the NYHA functional class maintained grade I - Ⅱin all. And mitral regurgitation remained absent or mild. Conclusion Surgical procedure for HOCM patients is both safe and efficacious. It provides an excellent relief of LVOT obstruetion.