经食管超声心动图在梗阻性肥厚型心肌病扩大室间隔切除术中的应用

Application of Intro-operative Transesophageal Echocardiography for Extended Septal Myectomy in Patients With Obstructive Hypertrophic Cardiomyophathy

目的：总结分析经食管超声心动图在梗阻性肥厚型心肌病（HCM）扩大室间隔切除术中的应用价值。 方法：回顾性分析2012-01至2012-12因梗阻性HCM行扩大室间隔切除术56例患者术前经胸超声心动图，术中经食管超声心动图及术后经胸超声心动图结果。 结果：56例患者中男性36例，女性20例，年龄（46.1±11.3）13~67岁,术前室间隔厚度（26.1±6.9）15~46 mm，左心室流出道峰值压差（87.5±12.5）27~163 mmHg（1 mmHg=0.133 kPa），所有患者均成功完成外科手术，无住院死亡，无经食管超声心动图相关并发症，其室间隔切除厚度为（10.7±2.1）6~16 mm，长度为39.1±5.5（35~55）mm。与术前经胸超声心动图对比，经食管超声心动图显示术后即刻左心室流出道峰值流速[（1.68±0.46）m/s vs（4.57±0.99）m/s]、左心室流出道峰值压差[（11.3±7.0）mmHg vs（87.5±34.4）mmHg]均明显减低，二尖瓣反流及收缩期二尖瓣前向运动现象明显较少，差异均具有统计学意义（P均〈0.001）。与术后经胸超声心动图结果对比，经食管超声心动图术后即刻左心室流出道峰值流速及峰值压差差异也具有统计学意义（P〈0.001）,术中左心室流出道峰值流速（r=0.63）及左心室流出道峰值压差（r=0.48）与术后相关性良好。术后经食管超声心动图发现2例患者出现新发室间隔缺损，1例予以外科修补。 结论：经食管超声心动图可以安全用于HCM患者改良扩大室间隔切除术中监测，术前定性二尖瓣反流病因及程度，术后即刻评估左心室流出道梗阻缓解程度、二尖瓣反流程度并及时发现外科相关并发症以指导外科医生进行相应补救。

Objective： To evaluate the intro-operative transesophageal echocardiography （TEE） for extended septal myectomy in patients with obstructive hypertrophic cardiomyophathy （HCM）. Methods： A total of 56 obstructive HCM patients with extended septal myectomy in our hospital from 2012-01 to 2012-12 were retrospectively studied. The results of pre-operative transthoracic echocardiography, intro-operative TEE and post-operative transthoracic echocardiography were analyzed and compared. Results： There were 36 male and 20 female patients with the average age of （46.1 ± 11.3） years. The pre-operative width of inter ventricular septal was （26.1 ± 6.9） mm, left ventricular outlfow tract （LVOT） pressure gradient was （87.5 ± 12.5） mmHg. All patients received successful operation, no in-hospital death, no TEE related complication. The removed ventricular septal thickness was at （10.7 ± 2.1） mm, length at （39.1±5.5） mm. Compared with pre-operative transthoracic echocardiography, TEE indicated the immediate drop of post-operative LVOT peak velocity （4.57 ± 0.99）m/s vs （1.68±0.46）m/s and LVOT peak gradient （87.5 ± 34.4） vs （11.3 ± 7.0） mmHg, both P〈0.001;signiifcant reduce of mitral regurgitation （MR） and mitral valve systotic onterior motion, both P〈0.001. TEE showed that intra-operative LVOT peak velocity （r=0.63） and LVOT peak gradient （r=0.48） well related to post-operative transthoracic echocardiography. Post-operative TEE found that 2 patients had ventricular septal defect and 1 received surgical repair. Conclusion： TEE is safe for extended septal myectomy in obstructive HCM patients. It may pre-operatively identify the cause and degree of MR, evaluate the post-operative improvement of LVOT obstruction and MR. Meanwhile, TEE may ifnd the surgical complication for in time correction in relevant patients.