心肌间隔消融术和肌切除术治疗药物难治性肥厚型梗阻性心肌病的单中心对比研究

A single-center comparative study of alcohol septal ablation(SA) and surgery myectomy(SM) for refractory hypertrophic obstructive cardiomyopathy(HOCM)

目的探讨间隔心肌消融(SA)术和肌切除(SM)术治疗药物治疗不佳的肥厚型梗阻性心肌病(HOCM)的有效性和安全性。方法回顾性收集2002年9月至2014年9月260例行SA术和SM术治疗和随访的HOCM患者资料,其中男172例,女88例;年龄(48.5±12.4)岁。根据治疗方式将患者分成SA组(184例)和SM组(76例),有2次以上侵入性治疗者依据末次治疗方式入组。记录患者临床资料,计量资料采用t检验,计数资料采用χ^2检验,单因素生存分析采用Kaplan-Meier法,多因素生存分析采用Cox回归模型进行多因素生存分析。比较两组间全因死亡、心源性死亡(包括围手术期)发生比例,心功能改善、手术相关并发症和起搏器安装情况。结果与SM组患者比较,SA组心功能更差(NYHA分级2.97±0.29对2.50±0.56,P=0.01)、房颤患者更多(15.14%对6.80%,P<0.05)、随访期更长[(5.4±3.8)年对(2.5±2.2)年,P=0.01]。SA组和SM组的全因累积病死率分别是6例(3.3%)和11例(14.5%),P=0.001;心源性死亡发生比例分别是3例(1.63%)和10例(13.16%),P<0.001。心脏骤停是SA和SM治疗后主要的心源性死亡原因,收缩性心衰死亡主要见于SM组。SA组和SM组术后心功能改善值分别为1.23±0.61和0.88±0.64,组内比较P值均<0.01。SA组相关起搏器依赖发生率低(1.63%对4.20%,P<0.05)。结论SA术具有生存优势和较低的起搏器依赖发生,心功能改善程度与SM术相似。

Objective Septal reduction therapies were recommended for drug-refractory patients with hypertrophic obstructive cardiomyopathy(HOCM). To explore and compare the effectiveness and safety in patients with hypertrophic obstructive cardiomyopathy(HOCM) treated with surgery myectomy(SM) and alcohol septal ablation(SA). Methods The clinical data of 260 patients performed SA(n=184) or SM(n=76)between September 2002 and September 2014 in our institute were retrospectively reviewed. The t-test, rank sum test and chi-square test were used to compare the differences between the two groups, and the Cox regression model was used for multivariate survival analysis. All-cause mortality, cardiac cause death(perioperative death were included), heart function improvement, procedure-related complications and permanent pacemaker dependence(PPM) constituted the main contents of this study. Results Compared with patients treated with SM, patients undergone SA were poor heart function status(2.97±0.29 vs 2.50±0.56, P=0.01), more prevalence of atrial fibrillation( 15.14% vs 6.80%, P=0.046) and longer follow-up period[(5.4±3.8) years vs(2.5±2.2) years, P=0.01)]. All-cause mortality for SA and SM were 3.3% and 14.5% respectively(P=0.001). The fatal cardiac events of SA and SM were 1.63% and 13.16% respectively(P<0.001). Sudden cardiac arrest were the main cardiac cause death for both patients treated with SA and SM. The cardiac death of left ventricular systolic dysfunction was main found in patients treated with SM. Heart function improvement(NYHA) after SA and SM were 1.23±0.61 and 0.88±0.64 respectively(all P<0.01). And SA had a lower procedure-related PPM implantation(1.63% vs 4.20%, P<0.05). Conclusion Our results shown that SA have survival advantage, lower PPM and similar heart function improvement compared with SM for refractory patients with HOCM.