肥厚梗阻型心肌病合并重度二尖瓣反流的外科治疗策略

Surgical Strategies for Hypertrophic Obstructive Cardiomyopathy(HOCM) with Severe Mitral Valve Regurgitation

目的 总结肥厚梗阻型心肌病（HOCM）合并重度二尖瓣反流的外科治疗策略和远期效果。方法回顾性分析2004年1月至2014年1月,我科共收治肥厚梗阻性心肌病合并重度二尖瓣反流23例的临床资料,其男14例、女9例,年龄15～71（50.2±15.4）岁。本组患者术前左心室流出道峰值压差（LVOTGP）为75～161（98.1±19.3）mm Hg,室间隔厚度为（25.8±2.8）mm,23例均有收缩期二尖瓣前向运动（SAM）现象及重度的二尖瓣反流。全组均在全身麻醉低温体外循环下行室间隔心肌切除术加二尖瓣修复术,同期4例合并房颤者行左房消融术并切除左心耳手术。结果 全组均顺利完成手术,停体外循环时,经食管超声心动图（TEE）监测左心室流出道压力阶差为16～39（26.9±4.9）mm Hg,SAM现象完全消除,除2例二尖瓣有微量反流,1例有轻度反流外,余20例二尖瓣反流均得以完全纠正。术后早期无死亡,1例发生一过性Ⅲ度房室传导阻滞,后恢复正常窦性心律。术后长期随访6～126（53.1±34.9）个月,无晚期死亡。无二尖瓣反流需再次手术,2例有轻度反流,4例微量反流。左心室流出道最大压力阶差不超过42 mm Hg,室间隔厚度从术前的（25.8±2.8）mm降至术后（14.1±1.3）mm（P〈0.001）。3例房颤未再复发,1例仍有阵发性房颤。远期随访患者症状消失或仅有轻度症状,生活质量明显改善,无远期死亡、并发症或再次手术。结论 室间隔肥厚肌肉的广泛切除术可彻底疏通左心室流出道狭窄,可消除SAM现象,二尖瓣修复术可纠正二尖瓣反流,上述综合性外科处理策略可获得良好的长期治疗效果。

Objective To summarize the surgical treatment strategies and the clinical outcomes of hypertrophic obstructive cardiomyopathy（HOCM） with severe mitral regurgitation. Methods We retrospectively analyzed the clinical data of 23 patients of HOCM with severe mitral regurgitation in our hospital from January 2004 through January 2014 year.There were 14 males and 9 females, aged from 15-71（50.2±15.4） years. The preoperative left ventricular outflow tract gradient（LVOTPG） of these patients was 75-161（98.1±19.3） mm Hg. And the septal thickness was 25.8±2.8 mm. All 23 patients had at least moderate mitral regurgitation and systolic anterior motion（SAM）. All of them had extend septal myectomy（extend Marrow procedure） and mitral valve repair（MVP）,while 4 patients with atrial fibrillation had left atrial ablation and left atrial appendage operation. Results All patients were successfully operated. The left ventricular outflow tract pressure gradient was 16-39（26.9±4.9） mm Hg when the cardiopulmonary bypass stopped and SAM phenomenon was completely eliminated. Except for 2 mitral valve patients with trace amounts of regurgitation, 1 patient with mild regurgitation, the other 20 patients of mitral regurgitation were completely corrected. All patients survived after operation and only 1 patient suffered from transient complete atrioventricular block and then back to normal sinus rhythm. A longterm follow-up from 6 months to 126 months with an average of 53.1±34.9 months showed no late postoperative death. No mitral regurgitation need reoperation. Two patients had mild reflux. Four patients were of trace reflux. The left ventricular outflow tract the maximum pressure gradient was less than 42 mm Hg. The thickness of interventricular septum dropped from preoperative 25.8±2.8 mm to postoperative 14.1±1.3 mm（P〈0.001）. No recurrence was noted in the 3 patients with atrial fibrillation. And one patient still had paroxysmal atrial fibrillation. Long term follow-up of the patients＇ symptoms disappeared or with only mild symptoms. And quality of their life improved significantly. And there was no long-term complication, reoperation, or death. Conclusions The extensive septal myectomy can completely dredge left ventricular outflow tract stenosis and eliminate SAM phenomenon. The mitral valve repair can correct mitral regurgitation. The comprehensive surgical treatment strategy can achieve a good long-term therapeutic effect.