室间隔部分切除联合二尖瓣置换治疗肥厚型梗阻性心肌病合并二尖瓣反流

Combined mitral valve replacement and partial septal myectomy in patients with hypertrophic obstructive cardiomyopathy and mitral regurgitation

目的分析室间隔部分切除联合二尖瓣置换治疗肥厚型梗阻性心肌病(HOCM)合并二尖瓣反流的临床疗效。方法 24例(男性13例,女性11例)HOCM合并二尖瓣反流患者行部分肥厚室间隔切除联合二尖瓣置换术。经主动脉切口操作解除梗阻9例,经房室环者15例。术中食管超声(TEE)评估解除梗阻效果及瓣膜反流情况,术后随访复查经胸心脏超声。结果术后左心室流出道压差从(103.79±16.69)mmHg降至(19.46±4.5)mmHg(t=1.45,P<0.05),室间隔厚度从(20.17±1.86)mm降至(10.5±1.12)mm(t=1.97,P<0.05);随访(21.4±9.7)个月后,上述参数保持稳定,左心室舒张末内径较术前增大[(48.72±3.90)mm vs(41.23±3.72)mm,t=2.145,P<0.05],纽约心脏协会心功能分级明显改善(1.58±0.48、vs 3.25±0.37,t=1.71.P<0.05)。2例并发轻中度二尖瓣瓣周漏,无室间隔穿孔、三度房室传导阻滞及死亡发生。结论室间隔部分切除联合二尖瓣置换术治疗HOCM合并二尖瓣反流安全有效,创伤小,并发症少。

Objective To analyze efficacy of septal myectomy combined with mitral valve replacement （MVR） in patients with hypertrophic obstructive cardiomyopathy（HOCM） and mitral regurgitation（MR）, Methods Septal myectomy combined with MVR were performed in 24 patients with HOCM and MR. Septal myectomy was done through aortic incision in 9 cases and through left atrioventricular orifice in 15 cases. Trans-oesophagus echocardiograpy was used to evaluate improvement of outflow tract obstruction and MR during operation, Transthorax echocardiograpy was performed during follow-up. Results The left ventricular outflow tract gradient decreased from 103.79 ± 16.69 mmHg to 19.46 ± 4.5mmHg（t=1.45, P〈0.05） and the ventricular septal thickness decreased from 20.17 ±1.86mm to 10.5 ± 1.12mm （t=1.97, P〈0.05 ） after operation, During follow-up of （21.4 ± 9.7）months, these changes were maintained, the left ventricular end diastolic dimension increased from 41.23 ± 3.72mm to 48.72 ± 3.9mm, and cardiac function improved from NYHA class 3.25 ±0.37 to 1.58 ±0.48 （t=1.71, P〈0.05）. Two cases had mild to moderate mitral paravalvular leak. There was no ventricular septal perforation, Ⅲ degree atrioventricular block and death. Conclusion Septal myectomy combined MVR is a safe and effective therapy with less injury and complication for HOCM with MR.