超声心动图在肥厚型梗阻性心肌病经皮间隔化学消融术中的应用

Effect of echocardiography in percutaneous transluminal septal myocardial ablation in patients with hypertrophic obstructive cardiomyopathy

目的评价超声心动图在肥厚型梗阻性心肌病(HOCM)经皮经冠状动脉心肌化学消融术(PTSMA)中的应用价值。方法20例经超声心动图诊断为梗阻性肥厚型心肌病的患者,术前确定左室流出道梗阻部位(靶区)及左室流出道压力阶差(LVOTPG)后,进行PTSMA治疗,术中先行冠状动脉造影,球囊试验性阻断间隔支动脉(靶血管),如果LVOTPG下降,则提示靶血管选择正确,注入无水乙醇行PTSMA治疗,术中超声心动图随乙醇注人实时监测室间隔显影部位、形态,消融心肌的面积、回声及LVOTPG的变化。结果注入无水乙醇后,17例患者心肌显影的部位与术前靶区吻合,3例心肌显影部位与术前靶区不符:室间隔右室面显影1例,室间隔左室广泛心内膜面下显影1例,左室侧壁基底段显影1例,该3例在超声提示下更换或增加靶血管后,也成功完成了PTSMA。本组20例患者术后获得良好的血流动力学效果,LVOTPG较术前下降达50%以上或降至正常水平。结论应用超声心动图监测PTSMA,能确定消融部位及面积是否与术前靶区相符,可减少因盲目消融所导致的心肌损伤及各种并发症,并能即时监测LVOTPG变化情况,即时评价治疗效果。

Objective To evaluate the value of echocardiography in percutaneous transluminal septal myocardial ablation（PTSMA） in patients with hypertrophic obstructive cardiomyopathy（HOCM）. Methods Twenty patients with HOCM were enrolled. Echocardiography was used to confirm the target area and left ventricular outflow tract pressure gradient（LVOTPG） before PTSMA. After coronary angiography（CAG）, the target blood vessels were tested by obstructing them with balloon. If LVOTPG decreased, it indicated that the septal brance was the right one. Then pure alcohol was injected to the target vessel. Echocardiography was used to supervise the enhanced region, ablative myocardial area and LVOTPG during the operation. Results The enhanced region was consistent with the area confirmed before operation in 17 patients and was not consistent with the area in 3 patients （1 in interventriseptum near right ventricle, 1 in left ventricle subendocardium near interventriseptum and 1 in the basis of lateral）. PTSMA succeeded after the target vessels were changed or more target vessels were included. Twenty patients showed good hemodynamic effect. These patients＇ pressure gradient of left ventricle dropped over 50 percent or to normal. Conclusion Echocardiography was very helpful in both selecting target vessel and finding scope in PTSMA so as to avoid myocardial injury and complication. The effect of the operation can be evaluated timely from supervising the change of LVOTPG during operation from echocardiography.