改良扩大Morrow手术治疗主动脉瓣下梗阻合并左心室中部梗阻的肥厚型梗阻性心肌病中期效果分析

Mid-term Outcomes of Surgical Effect in 34 Patients With Hypertrophic Obstructive Cardiomyopathy Combining Mid Left Ventricular Obstruction

目的:总结改良扩大Morrow手术(室间隔心肌切除术)治疗34例主动脉瓣下梗阻合并左心室中部梗阻的肥厚型梗阻性心肌病(HOCM)患者的中期效果。方法:纳入1996-11至2015-01在阜外医院行手术治疗的34例主动脉瓣下合并左心室中部梗阻的HOCM患者。所有患者均在全麻低温体外循环下行改良扩大Morrow手术,比较术前、术后及随访时的经胸超声心动图指标,以评估左心室中部、主动脉瓣下压差变化及心脏瓣膜功能。结果:术后平均随访时间(25.7±14.9)个月,无死亡病例,失访2例;随访时超声心动图检查显示,患者左心室中部压差[(21.0±19.8)mm Hg(1 mm Hg=0.133 k Pa)vs(60.3±29.4)mm Hg]、主动脉瓣下压差[(11.1±6.5)mm Hg vs(77.9±26.2)mm Hg]、最大室间隔厚度([17.9±7.2)mm vs(25.2±4.9)mm]、左心房直径([37.6±6.4)mm vs(41.1±7.8)mm]均较术前明显降低,左心室舒张末期内径[(42.2±4.3)mm vs(39.8±5.1)mm]较术前明显增加,差异均有统计学意义(P均<0.05);5例患者因切除范围不够导致术后左心室中部压差缓解不明显。随访时患者纽约心脏协会心功能分级明显改善(P<0.01),二尖瓣反流程度减低(P<0.01),二尖瓣收缩期前向运动现象消失。术后并发症包括:三度房室阻滞3例(8.8%),胸骨愈合不良并肺部感染二次入院1例(2.9%)。结论:改良扩大Morrow术可以减轻主动脉瓣下梗阻及左心室中部梗阻,能改善患者中期预后,有可能改善患者的左心室舒张功能。

Objective： To summarize the mid-term effect of modified extended Morrow procedure in patients with hypertrophic obstructive cardiomyopathy （HOCM） combining sub aortic valve obstruction and mid left ventricular obstruction. Methods： We studied 34 consecutive HOCM patients with sub aortic and midventricular obstruction who received modified extended Morrow procedure with extracorporeal circulation in our hospital from 1996-11 to 2015-01. Transthoracic echocardiography was conducted at pre-, post-operation and follow-up period to evaluate the changes of mid-ventricular gradient, subarctic gradient and each heart valve function. Results： The average follow-up time was （25.7± 14.9） months, 2 patients lost contact and no death occurred. In rest 32 patients, the mid ventricular gradient decreased from （60.3 ± 29.4） mmHg to （21.0 ± 19.8） mmHg, subaortic valve gradient decreased from （77.9± 26.2） mmHg to （11.6 ± 6.5） mmHg, the maximum ventricular septal thickness dropped from （25.2± 4.9） mm to （17.9± 7.2） mm, left atrial diameter reduced from （41.1 ± 7.8） mm to （37.6 ±6.4） mm, left ventricular end-diastolicdiameter increased from （39.8 ± 5.1） mm to （42.2± 4.3） mm, all P〈0.05; there were 5 patients without obviously improved mid ventricular gradient because of insufficient resection of septal myocardium in mid-ventricle. The post-operative NYHA classification was improved, P〈0.01, mitral valve regurgitation degree was decreased, P〈0.01 and SAM phenomenon was disappeared. Complications included 3 （8.8%） patients of III atrio-ventricular block, 1 （2.9%） patient of re-admission due to poorly healed sternum combining pneumonia Conclusion： Modified extended Morrow procedure may relieve sub aortic valve and mid ventricular obstruction, therefore improve left ventricular diastolic function and prognosis in relevant patients.