经皮腔内间隔心肌化学消融术治疗肥厚性梗阻性心肌病临床分析

Percutaneous Transluminal Septal Alcoholization for the Treatment of Hypertrophic Obstructive Cardiomyopathy

目的分析经皮腔内间隔心肌化学消融术(PTSMA)治疗药物难治的肥厚性梗阻性心肌病(HOCM)术中术后左室流出道压差(LVOTG)、心律失常、心肌酶谱的变化和机制。方法15例经心脏彩色多普勒诊断为HOCM的药物治疗无效的病人拟行PTSMA治疗,13例病人(男7例,女6例)接受了PTSMA治疗。无水酒精消融前后导管测量LVOTG,术后心电监护72小时,6-8小时检查一次心肌酶谱,术后一周复查心脏彩色多普勒。结果13例病人中,3例(23.1%)术后即刻LVOTG消失,6例(46.2%)术后即刻LVOTG<30mmHg,2例(15.4%)术后即刻LVOTG下降>50%,1例(7.7%)LVOTG下降<50%。手术前后平均静息LVOTG77.0±38.8mmHgVS21.4±16.3mmHg,P<0.001。CRBBB发生率为46.2%,消融第一间隔支者CRBBB发生率为57.1%,第二间隔支者为33.3%,前者CRBBB的发生率略高,但无显著差异(P=0.645);心肌酶谱CK-MB峰值与术后即刻LVOTG下降幅度无相关性(P>0.05)。结论PTSMA治疗HOCM病人近期疗效显著且并发症少,是一个很有前景的治疗手段。

Objective To observe the changes of the left ventricular outflow tract gradients （LVOTG）, arrhythmias and CK - MB enzymatic fraction after percutancous transluminal septal alcoholization （PTSMA） in treating refractory obstructive hypertrophic cardiomyopathy （HOCM）. Methods 15 patients were diagnosed as HOCM by Doppler echocardiography and were treated with PTSMA. Among them, 13 patients （male 7, female 6, moan age of 53.4 ±10.1） with heart function class Ⅱ - Ⅲ underwent PTSMA. LVOTG were measured prior to and after the injection of absolute alcohol. After PTSMA, the electrocardiogram were monitored for 72h. CK - MB enymatic fraction was ~ured once every 6 - 8h. Doppler echoeardiography was performed one week after the operation. Results Of 13 patients completed alcoholization, complete abolition of the pressure gradiem was observed in 3patients （23.1%）, a basal residual gradient 〈 30mmHg was observed in 6 patients （46.2%）, It was found that LVOTG decreased more than 50% in 2 cases （ 15.4% ） soon after the injection, but one week later LVOTG was increased. A reduction in LVOTG less than fifty percent of the baseline was observed in 1 case （7.7%）. After alcoholization the moan rest LVOTG decreased from 77.0 ± 38.8 mHg to 21.4 ± 16.3mmHg, P 〈 0.001. Complete right bundle- branch block （CRBBB） was observed in 46.2% of the patients. The incidence rate of CRBBB for absolute alcohol injection in the first septal branch of the anterior descending artery was higher （57.1% ） than in the second septal branch （33.3%）, but the difference was not significant （P= 0.645）. We found no relationship among the peak CK- MB enzymatic fraction, the reduction of LOVTG, and the amount of alcohol （P 〉 0.05）. Conduslons PTSMA is effective and safe in the treatment of HOCM, and has been propesed as the most promising alternative to surgery.