全胸腔镜经二尖瓣行室间隔心肌切除术治疗室间隔酒精消融术后复发左室流出道梗阻

Totally endoscopic transmitral septal myectomy for the treatment of recurrent left ventricular outflow tract obstruction after alcohol septal ablation

目的初步探讨全胸腔镜经二尖瓣室间隔心肌切除术治疗室间隔酒精消融术后复发左室流出道梗阻的手术策略及临床疗效。方法回顾性分析广东省人民医院心外科2020年7月—2021年7月因室间隔酒精消融后复发左室流出道梗阻患者的临床资料。术前患者均进行心脏超声、心脏磁共振成像、心脏CT、3D建模与打印技术的评估,并根据多模态影像学评估制定个性化手术策略,于数字模型上进行可视化探查并在打印模型上进行模拟手术切除,再行全胸腔镜经二尖瓣室间隔心肌切除术。结果共纳入2例患者,均为女性,年龄分别为62岁和64岁。2例患者均成功接受全胸腔镜经二尖瓣室间隔心肌切除术,主动脉阻断时间分别为96 min和85 min,术后左室流出道梗阻即刻解除(左室流出道峰值压差分别由100 mm Hg降至4 mm Hg和由84 mm Hg降至6 mm Hg),二尖瓣反流明显改善。2例患者均未出现Ⅲ度房室传导阻滞,无需植入永久起搏器,且顺利出院,无术后并发症发生。结论对室间隔酒精消融术后复发左室流出道梗阻的患者,结合多模态影像学评估及3D建模与打印技术的个性化全胸腔镜经二尖瓣室间隔心肌切除术临床效果良好,能准确切除肥厚室间隔心肌,同时避免如室间隔穿孔或Ⅲ度房室传导阻滞等严重并发症。

Objective To investigate the surgical strategies and clinical efficacy of transmitral septal myectomy in the treatment of recurrent left ventricular outflow tract obstruction(LVOTO)after alcohol septal ablation.Methods The clinical data of patients with recurrent LVOTO after alcohol septal ablation from July 2020 to July 2021 in the Department of Cardiac Surgery,Guangdong Provincial People's Hospital were retrospectively analyzed.Patients were preoperatively evaluated by echocardiography,cardiac magnetic resonance imaging,cardiac computed tomography,3D modeling and printing technology.A personalized surgical strategy was preoperatively developed according to multimodality imaging assessment,while visual exploration was performed on the digital model and simulated surgical resection was performed on the printed model.Results Two female patients were enrolled,aged 62 years and 64 years,respectively.Totally endoscopic transmitral extended myectomy was successfully performed on both patients with aortic cross-clamping time of 96 min and 85 min,respectively.LVOTO was relieved immediately(subaortic peak pressure gradient decreased from100 mm Hg to 4 mm Hg and from 84 mm Hg to 6 mm Hg,respectively)and the mitral regurgitation significantly improved after the procedure.No patient had complete atrioventricular block or required permanent pacemaker implantation.The patients were discharged uneventfully without postoperative complications.Conclusion Personalized totally endoscopic transmitral extended myectomy combined with multimodality imaging assessment and 3D modeling and printing has an acceptable clinical effect in patients with recurrent LVOTO after alcohol septal ablation.The procedure can precisely resect the hypertrophic septal myocardium while avoiding serious complications such as septal perforation or complete atrioventricular block.