不同术式治疗室间隔厚度较小的肥厚型梗阻性心肌病患者的疗效比较

Comparison of curative effect of different surgical strategies for patients with hypertrophic obstructive cardiomyopathy with a relatively thin interventricular septum

目的总结分析不同术式治疗室间隔厚度较小(≤18 mm)的肥厚型梗阻性心肌病(hypertrophic obstructive cardiomyopathy,HOCM)患者的手术效果。方法纳入2014年1月至2018年10月于上海交通大学医学院附属瑞金医院心脏外科行外科手术的室间隔厚度≤18 mm的HOCM患者84例。根据是否合并二尖瓣手术,分为二尖瓣处理组(n=41)与非二尖瓣处理组(n=43)。收集患者术前、术后1周内以及随访时心脏超声资料和围术期并发症情况,评价手术疗效。结果与术前比较,二尖瓣处理组与非二尖瓣处理组患者术后左心室流出道压差显著降低,二尖瓣收缩期前移显著改善,二尖瓣反流程度显著减轻,差异均有统计学意义(P<0.05)。二尖瓣处理组患者术后30 d死亡2例(4.9%),其病死率显著高于非二尖瓣处理组(0),差异有统计学意义(P<0.05);同时围术期输血率也显著高于非二尖瓣处理组,差异有统计学意义(43.9%vs.23.3%,P=0.041)。出院后80例患者获随访,症状均消失,左心室流出道压差仍保持较低水平,与术后比较,差异无统计学意义(P>0.05)。结论单纯改良Morrow术治疗室间隔厚度较小(≤18 mm)的HOCM患者疗效确切,并发症较少,但需要经验积累。这一策略可以尽量避免不必要的二尖瓣手术,其近中期疗效满意,远期疗效有待进一步随访。

Objectives To summarize and analyze the surgical effects of different surgical strategies for patients with hypertrophic obstructive cardiomyopathy(HOCM)with a relatively thin interventricular septum(≤18 mm).Methods Eighty-four patients with interventricular septal thickness≤18 mm who underwent surgery in Department of Cardiovas⁃cular Surgery of Ruijin Hospital from January 2014 to October 2018 were included.These patients were divided into mitral valve treatment group(n=41)and non-mitral valve treatment group(n=43)according to whether they received mitral valve surgery or not.Cardiac ultrasound data and perioperative complications were collected to evaluate the efficacy of surgery.Results Left ventricular outflow tract pressure gradient significantly decreased,systolic anterior motion(SAM)of the mitral valve eliminated and the degree of mitral valve regurgitation reduced in patients of both groups after procedure(P<0.05).Two patients(4.9%)died in 30 days after operation in mitral valve treatment group,which was significantly higher than that in non-mitral valve treatment group(0)(P<0.05).After operation,the perioperative blood transfusion rate of mitral valve treatment group was also significantly higher than that in non-mitral valve treat⁃ment group(43.9%vs.23.3%,P=0.041).After discharge,80 patients were followed-up.The left ventricular outflow tract pressure gradient of all the patients remained low,with no significant difference from that after surgery(P>0.05).Conclusions The modified Morrow procedure in the treatment of HOCM patients with interventricular septal thickness≤18 mm is safe and effective,but learning curve is needed.This strategy could avoid the unnecessary mitral valve surgery,of which the mid-term efficacy is satisfactory,and further follow-up should be warranted to evaluate the effectiveness.