室间隔部分切除术和经皮室间隔心肌消融术治疗肥厚型梗阻性心肌病患者的中远期效果比较

Comparison on the Medium-and Long-term Clinical Effects of Surgical and Interventional Septal Reduction Treatment for Patients With Hypertrophic Obstructive Cardiomyopathy

目的:探讨室间隔减容治疗即室间隔部分切除术和经皮室间隔心肌消融术治疗肥厚型梗阻性心肌病(HOCM)患者的中远期效果。方法:回顾性选择2010年1月1日至2016年12月31日在首都医科大学附属北京安贞医院进行室间隔部分切除(手术组125例)或经皮室间隔心肌消融(介入组41例)的HOCM患者,并在手术前、术后对入组患者进行随访,中位随访时间为386天(136～1 617天),获取患者术前及术后半年以上的超声心动图指标评价室间隔厚度及左心室流出道压差变化。结果:手术组患者125例,年龄中位数48岁,男性70例(56.0%);介入组患者41例,年龄中位数50岁,男性28例(68.3%)。两组患者临床资料比较差异无统计学意义(P>0.05)。中位随访386天,失访26例患者(15.6%),手术组和介入组分别失访18例和8例。与术前相比,术后手术组室间隔厚度(16.0 mm vs 21.0 mm,P<0.05)、左心室流出道压差(8 mmHg vs 73 mmHg,1 mmHg=0.133 kPa,P<0.05)均下降;介入组室间隔厚度(15.0 mm vs 20.0 mm,P<0.05)、左心室流出道压差(11 mmHg vs 66 mmHg,P<0.05)均下降,以手术组残余压差更低(P<0.05)。随访过程中手术组1例患者死亡,两组均有1例患者手术前后左心室流出道压差无明显改善。结论:两种室间隔减容治疗均可有效降低远期左心室流出道梗阻的情况,室间隔切除术患者术后残余左心室流出道压差更低。

Objectives: To compare the medium-and long-term clinical efficacy of septal reduction therapy [myectomy versus percutaneous transluminal septal myocardial ablation(PTMSA)] for patients with hypertrophic obstructive cardiomyopathy(HOCM). Methods: A total of 166 patients with HOCM underwent myectomy(n=125) and PTMSA(n=41) between January 1, 2010 and December 31, 2016 in our hospital were included in this study. Echocardiography was performed before and post(> 6 months) operation. Patients were followed up for a mean of 386 days(136~1617 days). Changes on left ventricular septal thickness and left ventricular outflow tract gradient were compared before and post operation and between the two groups at baseline and post operation.Results: The median age was 48 years old(70 males, 56.0%) in surgery group, and 50 years old(28 males, 68.3%) in PTMSA group. There was no significant difference in age, gender, the time of diagnosis, syncope, family history and atrial fibrillation between two groups(all P>0.05). The rate of lost to follow up was 15.6%(n=26, 18 in surgery group and 8 in PTMSA group). Baseline left ventricular outflow tract(LVOT) gradient was comparable between the two groups(73 mmHg in surgery group vs. 66 mmHg in PTMSA group, P>0.05). The mean LVOT gradient after septal reduction therapy was 8 mmHg in surgery group and 11 mmHg in PTMSA group(P<0.05), both significantly reduced compared to baseline level(P<0.01). Left ventricular septal thickness was reduced from 21 mm to 16 mm in surgery group(P<0.05), reduced from 20 mm to 15 mm(P<0.05) in PTMSA group during follow up. One death was reported in surgery group during the follow up. There was one case with non-significant improvement of LVOT gradient after treatment in both groups. Conclusions: Both surgical and interventional septal reduction strategies can significantly improve the LVOT obstruction in HOCM patients, LVOT gradient reduction is more significant in surgery group as compared to PTMSA group.