右室起搏对肥厚梗阻型心肌病临床、血流动力学及形态学影响的随访研究

Follow-up study on clinic, hemodynamics and morphology of hypertrophic obstructive cardiomyopathy during right ventricular pacing

目的：观察肥厚梗阻型心肌病（ＨＯＣＭ）患者右室起搏治疗的远期临床、血流动力学及形态学变化，以确定右室起搏对患者的治疗效果及预后。方法：采用有创血流动力学监测技术及超声多普勒检查方法观察右室起搏前、后（２ ｈ、１２周、４年）患者的血流动力学及形态学变化。结果：右室起搏治疗４年后，患者临床症状、心功能、多数血流动力学及形态学指标均有不同程度改善；尤其是左室舒张期末压力（ＬＶＥＤＰ）、左室流出道（ＬＶＯＴ）压力阶差（ＬＶＯＴＧ），ＬＶＯＴ内径、ＬＶＯＴ血流速度、二尖瓣前向运动（ＳＡＭ）评级等均较起搏前显著降低或减少（Ｐ＜０． ０１），其中 ＬＶＯＴＧ，ＬＶＯＴ血流速度及 ＳＡＭ评级又较起搏１２周时显著改善（Ｐ＜０．０５）；心排血量（ＣＯ）及心排血指数（ＣＩ）较起搏治疗前明显增加，肥厚的室间隔较起搏前及起搏１２周时均明显变薄（Ｐ＜０．０５）。结论：右室起搏能显著地改善患者的临床症状、心功能及血流动力学指标，并能逆转肥厚的室间隔及左室游离壁，改善ＬＶＯＴ梗阻，其远期疗效显著；对药物治疗无效或疗效不满意的ＨＯＣＭ患者起搏治疗可能成为较为理想的治疗措施。

Objective: To observe the changes of long-term clinical effect, hemodynamics, ultrasonic morphology and prognosis of right ventricular pacing (RVP) on hypertrophic obstructive cardiomyopathy (HOCM). Methods: Sixty patients with HOCM before RVP and 2 hours, 12 weeks, 4 years after RVP were observed by invasive hemodynamic surveillance and ultrasonic morphology. Results: After patients treated with RVP for 2 hours, 12 weeks and 4 years,it was found that clinical symptoms, cardiac function, systolic anterior motion (SAM)of the mitral valve leaflet,left ventricular outflow tract (LVOT) blood velocity, LVOT pressure gradient, left ventricular end-diastolic pressure(LVEDP),cardiac output (CO) and index(CI) were all improved significantly (P<0. 01). Although ventricular septum(VS) hypertrophy had been considered to be a primary feature of HOCM, pacing appeared to reverse VS thickness after 4 years (P<O. 05). The changes were even more obvious with prolongation of follow-up time. Conclusion: RVP may be an effective and ideal alternative treatment for the patients with HOCM whose symptoms are not relieved by drugs.