肥厚梗阻型心肌病患者经皮腔内室间隔心肌消融术围术期心电图变化

Analysis of the electrocardiographic characteristics of hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation during perioperative period

目的探讨肥厚梗阻型心肌病(HOCM)患者经皮腔内室间隔心肌消融术(PTSMA)前后心电图变化的特点及其临床意义。方法 48例HOCM患者行PTSMA,手术前后记录常规心电图和24 h动态心电图,观察QRS波群、ST-T、心律失常和心率变异性等变化特点,分析心电图改变的特征及与心肌肥厚部位、程度和左心室流出道压力阶差的关系。结果 (1)HOCM患者的术前QRS形态可归纳为4种类型。(2)与术前相比,术后QRS时限延长[(0.15±0.20)s比(0.10±0.10)s,P<0.05],但排除束支传导阻滞病例后,QRS时限差异无统计学意义[(0.09±0.14)s比(0.09±0.10)s,P>0.05]。(3)术后ST_V_1抬高幅度增加[(0.25±0.12)mV比(0.11±0.06)mV,P<0.05]。(4)术后右束支传导阻滞增加[47%(23/48)比4%(2/48),P<0.05],室性期前收缩数量增加[103(0～5819)个比56(0～4623)个,P<0.05],加速性室性心律增加[41%(20/48)比0(0/48),P<0.05],术中一过性三度房室阻滞19例(39%)。(5)术后心率变异性(HRV)时域指标(SDNN)降低(108.6±36.3比118.3±27.1,P<0.05),24 h平均心率增加[(72.3±9.4)次/min比(68.8±8.2)次/min,P<0.05]。结论 HOCM患者具有独特的心电图特征,行PTSMA术后,会引起心电图变化,包括新出现异常Q波、右束支传导阻滞、V_1导联ST抬高、SDNN减低及24h平均心率增加等,但这些变化对PTSMA的临床疗效无明显影响。

Objective To investigate electrocardiographic changes in patients with hypertrophic obstructive cardiomyopathy （HOCM） after pereutaneous transluminal septal myocardial ablation （PTSMA） during perioperative period. Methods The PTSMA was performed on 48 patients with confirmed HOCM. Resting electrocardiogram and Holter were recorded to compare the QRS duration, the abnormal Q Wave, the ST-T alteration, the arrhythmias and heart rate variability before and after the PTSMA, and to correlate the electrocardiographic variables with hypertrophic degree or the left ventricular outflow tract pressure gradient. Results （ 1 ） ECG was classified as 4 types based on QRS morpholopy before PTSMA. （2） After PTSMA, QRS duration was significantly increased [ （0. 15 ±0. 20） s vs. （0. 10 ±0. 10） s, P 〈 0. 05 ] , but no significant changes on the QRS duration after excluding the influenting of bundle branch block [ （0. 09 ＋ 0. 14）s vs. （0. 09±0. 10）s, P 〉0. 05]. （3） The elevation of STV1 was （0. 11 ±0. 06） mV vs. （0. 25 ±0. 12） mV （P 〈 0. 05 ） before and after the PTSMA. The decline of ST was （0. 04 ±0. 05 ） mV vs. （0. 11 ±0. 05 ） mV （ P 〈 0. 05 ） before and after the PTSMA. （4） The incidences of right- bundle branch block before and after PTSMA was 4% （2/48） vs. 47% （23/48） （P 〈 0.05） ; The incidences of VE [ 103 （0 - 5819） vs. 56 （0 - 4623）, P 〈 0.05] and accelerated idioventricular rhythm 0% （0/48） vs. 41% （20/48） （P 〈0. 05） were increased. Transient third degree AVB was 19 cases （39%） during procedure. （5）Before and after the PTSMA , heart rate variability （HRV） time domain index （SDNN） was 108.6 ±35.3 vs. 118.3 ±27. 1 （P 〈 0. 05 ）, the average heart rate during the 24 hour Holter was 72. 3 ± 9. 4 bpm vs. 68.8± 8.2 bpm （P 〈 0.05 ）. Conclusions PTSMA for HOCM can result in significant changes on the resting ECG and Holter. No correlation is found between electrocardiographic changes and the left ventricular outflow tract pressure gradient which suggest that electrocardiographic changes can＇t predict the efficacy of PTSMA.