超声心动图在肥厚性梗阻型心肌病外科治疗中的作用

Echocardiography in the surgical treatment of hypertrophic obstructive cardiomyopathy

目的总结超声心动图在肥厚性梗阻型心肌病（HOCM）外科治疗中的应用经验。方法自2003年6月至2014年6月共收治HOCM患者56例。其中男性38例,女性18例;年龄18～65岁,平均（39.4±14.1）岁。术前均常规行超声心动图确诊。所有患者采用改良Morrow手术,行肥厚室间隔心肌的彻底切除,疏通左室流出道,术中经食管超声心动图（TEE）监测评估手术解除梗阻效果,术后1～2周内再次经胸超声心动图复查手术效果。随访时复查超声心动图。结果所有56例患者术前经胸超声心动图（TTE）检查均见室间隔不对称肥厚,室间隔厚度平均（28.6±7.9）mm,左心室流出道压差平均（89.7±27.9）mm Hg。所有患者均可见中、重度二尖瓣收缩期前向运动（SAM征）,42例患者伴有不同程度的二尖瓣关闭不全。所有患者均成功接收改良Morrow手术,无室间隔穿孔及高度房室传导阻滞等严重并发症。术中食道超声测量左室流出道压差（LVOTG）14.5±9.6 mm Hg,较术前[（94.7±32.4）mm Hg]明显降低（P=0.00001）。手术前后经胸心脏超声数据统计比较表明,术后室间隔厚度[（12.0±3.8）mm]较术前[（28.6±7.9）mm]明显变薄（P=0.0000）,左室流出道压差[（16.8±11.5）mm Hg[较术前[（89.8±27.9）mm Hg]明显降低（P=0.0000）。二尖瓣关闭不全程度及SAM现象明显改善或消失。术后平均随访60个月,患者术前症状均明显减轻或消失,恢复正常生活,超声心动图检查左心室流出道压力阶差保持术后水平或稍有降低。结论超声心动图在HOCM外科治疗中起重要作用,可用于术前诊断、术中指导手术、术后评估手术效果及随访。

Objective To summarize the role of echocardiography in the surgical management of hypertrophic obstructive cardiomyopathy（ HOCM）. Methods From June 2003 to June 2014,56 patients（ 38 males and 18 females） with HOCM underwent modified Morrow procedure. The mean age was 39. 4 years（ range,18 to 65 years）. The diagnosis was made by echocardiography.Transesophageal echocardiography（ TEE） was used intraoperatively to monitor and evaluate the results of the surgical procedures. After1-2 weeks of operation,transthoracic echocardiography（ TTE） was performed to evaluate the effect of operation. All patients were followed up with TTE after operation. Results Preoperative TTE examination showed all 56 patients had the characteristic of marked left ventricular asymmetric hypertrophy. Echocardiographic assessment revealed that the mean thickness of the ventricular septum was 28. 6±7. 9 mm and the mean preoperational peak gradient between the LV and the aorta was 89. 7 ± 27. 9 mm Hg. There was moderate or severe systolic anterior motion（ SAM） in 56 cases and mitral regurgitation in 42 cases. Ventricular septal myectomy with modified Morrow procedure was successfully performed in all 56 cases without complications. Intraoperative TEE showed that the mean systolic gradient between the left ventricle and the aorta decreased from 94. 7±32. 4 mm Hg pre-operatively to 14. 5±9. 6 mm Hg（ P = 0. 0000） after operation,and the thickness of ventricular septum decreased from 28. 6±7. 9 mm Hg to 12. 0 ±3. 8 mm（ P = 0. 0000）. TTE showed that the mean systolic gradient between the left ventricle and the aorta was decreased from 89. 8±27. 9 mm Hg pre-operatively to 16. 8±11. 5 mm Hg（ P = 0. 0000） at 1- to 2- week after operation. Mitral regurgitation and SAM were significantly improved or disappeared. During the follow-up,all patients were asymptomatic or mild dyspneic on exertion. No syncope was noted. TTE showed that the pressure gradient maintained on the post-operative level or slightly decreased. Conclusion Echocardiography plays an important role in the surgical management of HOCM. It is a useful tool for preoperative diagnosis,intraoperative guidance to the site and extent of septal myectomy,post-operative evaluating the surgical effects and follow-up.