三维测量指导左室流出道疏通手术治疗肥厚型梗阻性心肌病及长期疗效

Three-dimensional echocardiographic measurement to guide the dredging of left ventricular outflow tract in the treatment of hypertrophic obstructive cardiomyopathy with long-term follow-up

目的探索术前超声心动图三维测量指导肥厚型梗阻性心肌病(hypertrophic obstructive cardiomyopathy,HOCM)外科手术切除的方法及其长期随访效果。方法中山大学附属第一医院2014—2022年术前对每例患者进行经胸超声心动图测量心脏舒张期肥厚室间隔在长轴、短轴、四腔心切面的长度、宽度、厚度,建立心肌肥厚三维测量数据,量化预估需要切除心肌的部位、深度和范围。手术中根据量化的数据切除室间隔肥厚心肌以疏通左室流出道。结果共纳入43例患者,男22例、女21例,年龄18~78(49.2±15.1)岁,同期行二尖瓣手术18例。全组患者左室流出道梗阻解除满意,术后经食管超声心动图证明左室流出道压力阶差明显下降[(94.2±28.1)mm Hg vs.(6.7±4.7)mm Hg,P<0.05]。手术中没有发生室间隔穿孔和完全性房室传导阻滞,无需二次阻断主动脉进行再次疏通手术。术后超声心动图复查提示二尖瓣关闭良好或仅有轻度反流,二尖瓣收缩期前向运动征基本消失。随访1.0~8.5年,患者左室流出道平均压力阶差维持在10 mm Hg以下,临床症状消失或明显改善。结论术前超声心动图三维测量量化预估切除肥厚心肌范围可以比较精准地指导HOCM外科手术范围,避免术中多次阻断主动脉,最大程度解除左室流出道梗阻,获得更好的长期效果。

Objective To introduce a method of preoperative three-dimensional measurement by echocardiography to guide the surgical resection of hypertrophic obstructive cardiomyopathy(HOCM)and its long-term follow-up effect.Methods Before operation,each patient underwent transthoracic echocardiography to measure the length,width and thickness of diastolic ventricular septum hypertrophy on the long axis,short axis and four chamber sections,in order to establish three-dimensional measurement data of myocardial hypertrophy,and quantitatively estimate the location,depth and range of myocardium to be removed between 2014 and 2022 in our hospital.According to the quantitative data during operation,the hypertrophic myocardium of ventricular septum was resected to dredge the left ventricular outflow tract.Results Forty-three patients were recruited,including 22 males and 21 females,aged 18-78(49.2±5.1)years.Eighteen patietns underwent mitral valve surgery at the same time.All patients were satisfied with the relief of left ventricular outflow tract obstruction.Postoperative transesophageal echocardiography showed that the left ventricular outflow tract pressure gradient decreased significantly(94.2±28.1 mm Hg vs.6.7±4.7 mm Hg,P<0.05).There was no ventricular septal perforation or complete atrioventricular block during the operation,and no one needed a secondary aorta-clamp for re-operation to remove hypertrophic myocardium again.Postoperative echocardiography showed that the mitral valve closed well or only had mild regurgitation,and the mitral systolic anterior motion sign basically disappeared.After 1.0-8.5 years of follow-up,the average pressure difference of left ventricular outflow tract remained below 10 mm Hg,and the clinical symptoms disappeared or improved significantly.Conclusion The quantitative prediction of the resection range of hypertrophic myocardium by three-dimensional measurement of preoperative echocardiography can accurately guide the surgical range of HOCM,avoid multiple blocking of aorta during operation,relieve left ventricular outflow tract obstruction to the greatest extent,and obtain better long-term results.