肥厚型心肌病并发冠状动脉肌桥的临床特征及治疗

Clinical characteristics and therapies of hypertrophic cardiomyopathy combined with myocardial bridging

目的:总结肥厚型心肌病并发冠状动脉肌桥的临床特征及治疗方法。方法:回顾性分析我院2000年1月～2009年5月经心脏超声或左室造影证实的肥厚型心肌病并经冠脉造影证实并发冠状动脉肌桥患者的临床特征及治疗。结果:612例肥厚型心肌病患者中73例(11.9%)并发冠状动脉肌桥78处。临床症状表现为胸闷、气短31例,心前区疼痛22例,心悸8例,晕厥及晕厥前驱症状8例,乏力2例,发现心电图异常前来就诊2例。肥厚性非梗阻型心肌病患者28例,肥厚性梗阻型心肌病19例,心尖肥厚型心肌病26例。肌桥长度(10±4)mm。肌桥位于前降支中段49处(63%),前降支近中段2处(3%),中远段11处(14%),近段1处(1%),远段12处(15%),间隔支2处(3%),后降支1处(1%)。收缩期管腔直径压缩<50%者31处(40%),50%～75%者21处(27%),>75%者26处(33%)。68例患者服用β-受体阻滞剂,5例患者因不能耐受β-受体阻滞剂或有禁忌证而服用钙离子拮抗剂,临床随访3～20(13±4)个月,临床症状缓解率75%,不同药物间无统计学差异(76%vs.60%)。诊断冠心病或冠状动脉粥样硬化症患者均嘱其长期服用阿司匹林抗血小板治疗。经冠脉造影诊断冠心病4例,植入支架4枚,靶血管均为非肌桥段血管。6例药物治疗效果不佳的肥厚性梗阻型心肌病患者接受了经皮经腔间隔心肌消融术,术后住院期间自觉症状均缓解。出院后随访3～12(7±3)个月均存活,临床症状均明显缓解。无患者因肌桥接受支架植入术或外科手术。结论:β-受体阻滞剂和钙离子拮抗剂均适用于治疗肥厚型心肌病和肌桥。对于药物治疗效果不佳的肥厚性梗阻型心肌病可选择经皮间隔心肌消融术,可明显缓解临床症状。

AIM： To summarize the clinical characteristics and therapies of hypertrophic cardiomyopathy （HCM） combined with myocardial bridging （MB）. METHODS： The clinical characteristics and thera- pies were analyzed retrospectively in HCM patients combined with MB identified by echocardiographic or left ventriculography and coronary angiography. RESULTS： Seventy-eight MBs were found in 73 cases （ 11.9% ） among the 612 HCM patients. Clinical presentations included chest distress and dyspnea in 31 patients, angina in 22 patients, cardiopalmus in eight patients, syncope and presyncope in eight patients and debilitation in two patients. Two patients were seen because of electrocardiographic abnormality. Among the patients were 28 nonobstructive HCM, 19 obstructive HCM and 26 apical HCM. The average length of MB was （9. 8 ± 4.5 ） ram. MB was located at the middle segment of the left anterior descending artery in 49 （62.8%） sites, at proximal-middle segment in two （2. 6% ） sites, at middle-distal segment in 11（ 14. 1% ） sites, at proximal segment in one （1.3%） site and at distal segment in 12 （15.4%） sites. Two （2.6%） MBs were found at the septal branch and one （ 1.3% ） at the posterior descending branch. The degrees of compressed systolic narrowing were 〈50% at 31 （39.7%） MBs, 50%-75% at 21 （26.9%） bridges and 〉 75% at 26 （33.3%） bridges. Sixty-eight patients were treated with [3- receptor blockers and five patients with calcium antagonists because of intolerance or contraindication to F-receptor blockers. The clinical follow-up periods were 3 - 20 （ 12. 7 ± 4. 1 ） months and the rate of symptomatic relief was 75.3%. No statistical difference was observed between the therapeutic effects of the two drugs （76.5% vs. 60.0% ）. Patients with coronary artery disease （CAD） or atherosclerosis underwent long-term antiplatelet therapy with aspirin. Four cases of CAD were diagnosed by coronary angiography in whom four stents were implanted and all the target vessels were unrelated to MB. Six obstructive HCM patients with poor results from drug therapy were treated with percutaneous transluminal septal myocardial ablation. Clinical symptoms improved significantly after myocardial ablation and patients were alive during the 3- to 12-month （7.0 ± 3.2） months follow-up. No patients underwent stent implantation or surgery because of MB. CONCLUSION： Both -receptor blockers and calcium antago- nists are optimal for HCM and MB. Obstructive HCM patients with poor results from drug therapy should be treated with percutaneous transluminal septal myocardial ablation. Stent implantation and lysis of MB are not recommended for isolated MB.