梗阻性肥厚型心肌病患者酒精室间隔消融术的预后与室间隔厚度的相关性研究

Study on the relationship between the prognosis of alcohol chemical ablation and the thickness of interventricular septum in patients with hypertrophic obstructive cardiomyopathy

目的探讨室间隔厚度(IVST)与梗阻性肥厚型心肌病(HOCM)患者酒精室间隔消融术(ASA)预后的相关性。方法回顾性连续入选2010年8月至2021年8月在安徽医科大学附属省立医院、安徽医科大学第一附属医院、安徽医科大学第二附属医院、安徽医科大学第四附属医院的心血管内科经ASA治疗的HOCM患者149例。根据患者术前的IVST,采用二分位法分为IVST≤21 mm组和IVST>21 mm组。收集HOCM患者的一般临床资料、手术资料及住院期间并发症资料,并通过电话随访患者的心功能改善情况、生存情况等。将可能影响ASA术后患者生存率的因素纳入多因素Cox回归模型,分析确定全因死亡的独立危险因素。两组患者的生存分析采用Kaplan-Meier法,同时使用Log-rank法进行组间比较。结果IVST≤21 mm组有88例(59.1%)患者,IVST>21 mm组有61例(40.9%)。所有患者的术后平均左心室流出道压力阶差(LVOTG)、平均IVST均较术前明显下降(P<0.001)。ASA术后超声心动图提示,IVST≤21 mm组与IVST>21 mm组相比,LVOTG的降低更为明显(P<0.05)。术后IVST≤21 mm组的纽约心脏病协会(NYHA)心功能分级更好(P=0.033),但是有更多的围术期并发症发生(P=0.015)。所有患者平均随访时间为(4.1±2.2)年,IVST≤21 mm组中有4例(4.5%)患者死亡,IVST>21 mm组9例(15.0%)死亡。IVST≤21 mm组的永久性起搏器植入率有多于IVST>21 mm组的趋势,但差异无统计学意义(P>0.05)。长期随访IVST≤21 mm组的NYHA心功能分级优于IVST>21 mm组(P=0.039)。多因素Cox回归分析结果表明,全因死亡率的独立危险因素是IVST(HR 1.163,95%CI 1.018~1.329,P=0.026)。Kaplan-Meier生存分析结果表明,ASA术后IVST≤21 mm组的无全因死亡生存率高于IVST>21 mm组(P=0.014)。结论ASA能够有效减小HOCM患者的IVST,并降低LVOTG,进而不同程度地改善患者的心功能和临床症状。IVST≤21 mm组与IVST>21 mm组相比,术后并发症发生率更高,但远期预后较好。IVST与HOCM患者ASA的预后相关。

Objective To investigate the correlation between the interventricular septum thickness(IVST)and the prognosis of alcohol septal ablation(ASA)in patients with hypertrophic obstructive cardiomyopathy(HOCM).Methods A total of 149 patients with HOCM treated by alcohol chemical ablation in 4 hospitals of gradeⅢclass A in Anhui Province from August 2010 to August 2021 were retrospectively included.According to the preoperative IVST,the patients were divided into two groups:IVST≤21 mm group and IVST>21 mm group.The general clinical data,surgical data and complications during hospitalization of patients with ASA were collected,and the improvement of cardiac function and survival were followed up by telephone.The factors that may affect the survival rate of patients after ASA were included in the multivariate Cox regression model to analyze and determine the independent risk factors of all-cause death.Kaplan-Meier method was used to analyze the survival of the two groups,and Log-rank method was used to compare the two groups.Results There were 88 patients(59.1%)in IVST≤21 mm group and 61 patients(40.9%)in IVST>21 mm group.The mean left ventricular outflow tract gradient(LVOTG)and mean IVST(both P<0.001)of all patients after operation were significantly lower than those before operation.Echocardiography after ASA showed that compared with IVST>21 mm group,LVOTG decreased more significantly in IVST≤21 mm group(P<0.05).The New York Heart Association(NYHA)functional class was better in the postoperative IVST≤21 mm group(P=0.033),but there were more perioperative complications(P=0.015).The average followup time of all patients was(4.1±2.2)years,4 patients(4.5%)died in IVST≤21 mm group and 9 patients(15.0%)died in IVST>21 mm group.The rate of permanent pacemaker implantation and the number of re-admitted interventricular septal myectomy in IVST≤21 mm group were more than those in IVST group>21 mm group,but there was no significant difference(P>0.05).The NYHA cardiac function grade of IVST≤21 mm group was better than that of IVST>21mm group(P=0.039).Multivariate Cox regression analysis showed that IVST was the only predictor of all-cause mortality(HR 1.163,95%CI 1.018–1.329,P=0.026).Kaplan-Meier survival analysis showed that the survival rate of all-cause death in IVST≤21 mm group was higher than that in IVST>21 mm group(P=0.014).Conclusions ASA can effectively reduce IVST and LVOTG in patients with HOCM,thus improving cardiac function and relieving clinical symptoms in varying degrees.Compared with IVST>21 mm group,IVST≤21 mm group had more postoperative complications,but the long-term prognosis was better.IVST is associated with the prognosis of ASA in patients with HOCM.