室间隔消融术治疗症状轻微和严重的梗阻性肥厚型心肌病患者的预后对比研究

Efficacy of alcohol septal ablation in mildly symptomatic or severely symptomatic patients with hypertrophic obstructive cardiomyopathy

目的比较室间隔消融术(ASA)治疗症状轻微和症状严重的梗阻性肥厚型心肌病(OHCM)患者的预后。方法该回顾性队列研究纳入了2001年3月至2021年8月在首都医科大学附属北京安贞医院接受诊断、评估及ASA治疗的OHCM患者,根据症状严重程度分为症状轻微组和症状严重组。并进行长期随访,收集以下数据:随访时间、术后治疗方式、纽约心脏协会(NYHA)心功能分级、心律失常事件和起搏器置入、超声心动图参数以及死亡原因。比较2组患者的总体生存率、去除肥厚型心肌病(HCM)相关死亡的累计生存率,并评估患者临床症状、静息左心室流出道梗阻(LVOTO)的改善情况和新发心房颤动的发生率。采用Kaplan-Meier法和log-rank检验确定和比较不同组的累计生存率。采用Cox回归分析模型确定临床事件的预测因素。结果本研究共纳入189例OHCM患者,其中症状轻微组68例,症状严重组121例。随访时间中位数为6.0(2.7,10.6)年。症状轻微组的总体生存率(5年和10年总体生存率分别为97.0%和94.4%)与症状严重组(5年和10年总体生存率分别为94.2%和83.9%)相比,差异无统计学意义(P=0.405);症状轻微组中去除HCM相关死亡的累计生存率(5年和10年分别为97.0%和94.4%)与症状严重组(5年和10年去除HCM相关死亡的累计生存率分别为95.2%和92.6%)相比,差异也无统计学意义(P=0.846)。和术前相比,术后症状轻微组NYHA心功能分级改善(P<0.001),其中NYHA心功能分级Ⅰ级的患者37例(54.4%),静息左心室流出道压差(LVOTG)由67.6(42.7,90.1)mmHg(1 mmHg=0.133 kPa)降至24.4(11.7,35.6)mmHg(P<0.001)。与术前相比,术后症状严重组NYHA心功能分级改善(P<0.001),其中NYHA心功能分级改善≥Ⅰ级的患者96例(79.3%),静息LVOTG由69.6(38.4,96.1)mmHg降至19.0(10.6,39.8)mmHg(P<0.001)。症状轻微组和症状严重组新发心房颤动的风险相似(10.2%比13.3%,P=0.565)。Cox多因素回归分析结果显示年龄为OHCM患者全因死亡的独立预测因素(HR=1.068,95%CI 1.002~1.139,P=0.042)。结论在接受ASA治疗的OHCM患者中,与症状严重组相比,症状轻微组的总体生存率、去除HCM相关死亡的累计生存率相似。无论对于症状轻微还是症状严重的OHCM患者,ASA治疗都能显著缓解静息LVOTO和改善临床症状。年龄是OHCM患者全因死亡的独立预测因素。

Objective To compare the prognosis of mildly or severely symptomatic patients with obstructive hypertrophic cardiomyopathy(OHCM)who underwent alcohol septal ablation(ASA).Methods This retrospective study cohort consisted of patients with OHCM who received ASA treatment in Beijing Anzhen Hospital,Capital Medical University from March 2001 to August 2021.These patients were divided into mildly and severely symptomatic groups according to the severity of clinical symptoms.Long-term follow-up was conducted,and the following data were collected:duration of follow-up,postoperatire treatment,New York Heart Association(NYHA)classification,arrhythmia events and pacemaker implantation,echocardiographic parameters,and cause of death.Overall survival and survival free from OHCM-related death were observed,and the improvement of clinical symptoms and resting left ventricular outflow tract gradient(LVOTG)and the incidence of new-onset atrial fibrillation were evaluated.The Kaplan-Meier method and log-rank test were used to determine and compare the cumulative survival rates of the different groups.Cox regression analysis models were used to determine predictors of clinical events.Results A total of 189 OHCM patients were included in this study,including 68 in the mildly symptomatic group and 121 in the severely symptomatic group.The median follow-up of the study was 6.0(2.7,10.6)years.There was no statistical difference in overall survival between the mildly symptomatic group(5-year and 10-year overall survival were 97.0%and 94.4%,respectively)and the severely symptomatic group(5-year and 10-year overall survival were 94.2%and 83.9%,respectively,P=0.405);there was also no statistical difference in survival free from OHCM-related death between the mildly symptomatic group(5-year and 10-year survival free from HCM-related death were 97.0%and 94.4%,respectively)and the severely symptomatic group(5-year and 10-year survival free from HCM-related death were 95.2%and 92.6%,respectively,P=0.846).In the mildly symptomatic group,NYHA classification was improved after ASA(P<0.001),among which 37 patients(54.4%)were in NYHA classⅠ,and the resting left ventricular outflow tract gradient(LVOTG)decreased from 67.6(42.7,90.1)mmHg(1 mmHg=0.133 kPa)to 24.4(11.7,35.6)mmHg(P<0.001).In severely symptomatic group,NYHA classification was also improved post ASA(P<0.001),among which 96 patients(79.3%)improved by at least one NYHA classification,and the resting LVOTG decreased from 69.6(38.4,96.1)mmHg to 19.0(10.6,39.8)mmHg(P<0.001).The incidence of new-onset atrial fibrillation was similar between the mildly and severely symptomatic groups(10.2%vs.13.3%,P=0.565).Cox multivariate regression analysis showed that age was an independent predictor of all-cause mortality in OHCM patients post ASA(HR=1.068,95%CI 1.002-1.139,P=0.042).Conclusions Among patients with OHCM treated with ASA,overall survival and survival free from HCM-related death were similar between mildly symptomatic group and severely symptomatic group.ASA therapy can effectively relieve resting LVOTG and improve clinical symptoms in mildly or severely symptomatic patients with OHCM.Age was an independent predictor of all-cause mortality in OHCM patients post ASA.