老年肥厚型梗阻性心肌病消融和起搏器治疗的对照观察

Trancoronary ablation of septal hypertrophy versus dual-chamber cardiac pacing for the treatment of aged patients with hypertrophic obstructive cardiomyopathy

目的比较老年肥厚型梗阻性心肌病患者接受经冠状动脉消融肥厚心肌(TASH)或起搏器治疗的有效性和安全性。方法 23例充分药物治疗不满意,心功能Ⅲ级(NYHA)以上的老年肥厚型梗阻性心肌病患者随机接受心肌声学造影指导下的 TASH 或根据血压优化 PR 间期的右心双腔起搏器治疗。其中2例接受 TASH 治疗者并发永久起搏器依赖而安装永久起搏器。对单纯接受TASH(13例)或起搏器(8例)治疗者进行了平均24个月的随访。结果接受两种治疗方法的患者心功能和主观症状积分均得到显著的改善。TASH 组心功能由3.2±0.7级改善到1.5±0.5级,综合症状积分由5.9±1.6下降到1.8±0.7,P 均<0.001。起搏器治疗组心功能也由3.0±0.1改善到1.9±0.6级,综合症状积分也由4.5±1.3下降到2.3±1.6,P 均<0.01。综合症状改善程度 TASH组明显优于起搏器治疗(4.2±1.5比2.3±1.3,P=0.007)。左心室流出道压力阶差 TASH 组平均下降了(79.9±35.5)mm Hg(1 mm Hg=0.133 kPa,P<0.001),起搏器治疗组平均下降了(49.3±37.7)mm Hg(P<0.05),平均下降率分别为84%和53%。左心室流出道压力阶差下降率>75%和<50%TASH 组分别有10例和1例,起搏器治疗组分别有4例和3例。TASH 组治疗后室间隔厚度、左室舒张末径、收缩末径与术前比较变化显著[分别为(22.2±4.1)mm 比(17.1±3.2)mm,(41.5±5.3)mm比(44.7±4.6)mm,(23.5±4.4)mm 比(28.3±3.6)mm,P 均<0.05],但没有左室收缩功能异常。随访中,TASH 组3例阵发性心房颤动中有2例转为慢性心房颤动,起搏器治疗组中2例阵发性心房颤动中1例发展成慢性心房颤动。结论 TASH 和起搏器治疗两种方法均能使老年肥厚型梗阻性心肌病患者心功能和综合症状得到显著改善,综合症状改善 TASH 优于起搏器治疗。TASH 显著降低左心室流出道压力阶差,起搏器治疗中等程度降低心室流出道压力阶差。TASH 导致的左心室流出道重构不会导致老年肥厚型梗阻性心肌病患者收缩功能的异常和左心室的扩张,但同样存在并发症,甚至严重并发症发生的可能。

Objective To compare the safety and efficacy of trancoronary ablation of septal hypertrophy （TASH） versus dual-chamber cardiac pacing （PM） for the treatment of aged （ 〉60 years old） patients with hypertrophic obstructive cardiomyopathy （HOCM）. Methods Medically uncontrolled symptomatic aged patients with hypertrophic obstructive cardiomyoapthy （HOCM, n = 23） were treated by transcoronary ablation of septal hypertrophy （ TASH, n = 15 ） or dual-chamber cardiac pacing （ PM, n = 8 ） and followed up for 24 months. Two patients needed permanent pacemaker after TASH were excluded from the analysis. Results NYHA class improved from 3.2 ±0.7 to 1.5±0.5 and from 3.0 ± 0. 1 to 1.9 ± 0. 6 and general symptomatic score decreased from 5.9 ± 1.6 to 1.8 ± 0.7 and from 4. 5 ± 1.3 to 2. 3 ± 1.6 post TASH or PM treatments, respectively （all P 〈0. 01 vs. baseline）. The decrease of left ventricular outflow pressure gradient （PG） was （80. 0 ±35.5） mm Hg （ 1 mmHg =0. 133kPa）and （49. 3 ±37.7） mmHg post TASH and PM treatments respectively （all P 〈0. 05 vs. baseline） and the PG decrease was more significant in TASH group compared to PM group （ P 〈 0. 01 ）. Interventricular septal thickness was significantly reduced post TASH [ （22±4）mm vs. （17 ± 3） mm, P 〈 0. 05] and remained unchanged in PM group. Three patients with paroxysmal atrial fibrillation （2 patients in TASH group and 1 in PM group） developed chronic atrial fibrillation during the follow-up. Conclusions Both therapeutic approaches-TASH and PM implantation, significantly reduced PG and significantly improved NYHA class and general symptomatic score in aged symptomatic patients with HOCM. TASH was superior to PM in terms of PG decrease and general symptomatic score improvement.