在心内三维超声指导下经皮心内膜室间隔射频消融术治疗肥厚型梗阻性心肌病合并晕厥的临床应用研究

Safety and Efficacy of Percutaneous Endocardial Septal Radiofrequency Ablation of Ventricular Septum Guided by 3D Intracardiac Echocardiography in Hypertrophic Obstructive Cardiomyopathy Patients Complicating With Syncope

目的:探讨在心内超声联合三维电解剖标测系统指导下经皮心内膜室间隔射频消融术治疗肥厚型梗阻性心肌病合并晕厥患者的安全性与有效性。方法:12例肥厚型梗阻性心肌病合并晕厥发作患者在局麻下完成在心内三维超声指导下的经皮左心室心内膜室间隔射频消融治疗。术中记录消融相关参数与病损参数。术前、术后住院期间与术后3个月随访期分别进行超声心动图和心电图检查。结果:患者平均年龄(57±15)岁,男性6例,5例合并高血压,4例合并糖尿病,4例合并心房颤动,1例曾行冠状动脉间隔支酒精消融。肥厚心室肌累及范围:6例单纯累及室间隔,1例累及室间隔和前壁,1例累及室间隔和后乳头肌肥大、4例累及室间隔+前壁+下壁。7例经主动脉逆行途径消融成功(其中2例经房间隔途径失败),5例经房间隔穿刺途径消融成功(其中3例经主动脉途径失败)。平均消融功率(37±3)W,平均消融累计时间(916±728)s,平均消融表面积(1.14±1.16)cm^2,平均消融深度(4.5±3.7)mm。1例患者消融术中发生心肌组织气爆现象,1例患者发生股动脉穿刺并发症。超声心动图检查显示,患者术后住院期间平均左心室流出道压差下降(中位数)23.5(第5和第95百分位数:1.0,84.0)mmHg(1 mmHg=0.133 kPa),术后3个月继续下降14(1,59)mmHg,较入院时总体下降37(2,78)mmHg,平均降幅36.4%(2.8%,80.4%)。随访期间11例患者无晕厥发作,1例患者出现心力衰竭发作;所有患者均无心脏传导系统受损的心电图表现。结论:在心内超声联合三维电标测系统指导下进行经皮心内膜室间隔射频消融术治疗肥厚型梗阻性心肌病合并晕厥患者是安全、有效的。

Objectives:To investigate the safety and efficacy of percutaneous endocardial septal radiofrequency ablation(PESA)in hypertrophic obstructive cardiomyopathy(HOCM)patients complicating with syncope under the guidance of intracardiac echocardiography combined with the three-dimensional electroanatomical mapping system.Methods:PESA were performed in 12 HOCM patients with syncope attacks under the guidance of intracardiac echocardiography combined with the three-dimensional electroanatomical mapping system.Intraoperative ablation parameters and lesion parameters were recorded.Echocardiography and electrocardiogram were performed before,during hospitalization and at 3 months post-operation.Results:The mean age of patients were(57±15)years,there were 6 males,5 patients with hypertension,4 patients with diabetes mellitus,4 patients with atrial fibrillation,1 patient with failure treatment of coronary artery alcohol ablation.The range of involvement of hypertrophic ventricular muscles was as follows:isolated interventricular septum involvement in 6 patients,combined involvement of interventricular septum and anterior wall in 1 patient,interventricular septum involvement and extensive hypertrophic postpapillary muscles in 1 patient,and interventricular septum,anterior wall and the inferior wall involvement in 4 patients.PESA was successful in 7 patients through retrograde aortic ablation(including 2 patients with failed transseptal access)and in 5 patients through atrial transseptal access(including 3 patients with failed retrograde aortic ablation).The mean power used was(37±3)W,the mean total ablation time was(916±728)s,the mean ablation area was(1.14±1.16)cm2,the mean deep of ablation was(4.5±3.7)mm.During the operation,1 patient experienced the tissue gas explosion during the ablation,and 1 patient suffered from femoral artery puncture complications.The average left ventricular outflow tract pressure gradients were decreased by 23.5(1.0,84.0)mmHg(1 mmHg=0.133 kPa)post-operation during hospitalization period,and further decreased by 14(1,59)mmHg on the follow up examination at 3 months post operation,37(2,78)mmHg reduction(36.4%[2.8%,80.4%]reduction)was achieved when compared with the gradient on admission.The clinical follow-up results showed that 11 patients had no syncope recurrence,1 patient had a heart failure attack,and none had manifestations of damage of the heart conduction system on electrocardiogram.Conclusions:PESA is safe and effective for HOCM patients with syncope under the guidance of intracardiac echocardiography combined with the three-dimensional electrical mapping system.