肥厚梗阻性心肌病的外科治疗

目的：总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法：2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均（42.7±13.6）岁;左室流出道压差（LVOTGP）70～120 mmHg（1 mmHg=0.133Kpa）,平均（95.0±22.6）mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术（MVR）7例,二尖瓣成形术（MVP）7例,二尖瓣、主动脉瓣成形术（MVP＋AVP）5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术（MVP＋AVP＋CABG）2例。分析比较病人术前超声心动图（UCG）,术中经食管心脏超声（TEE）,以及术后1周、3月、6月、1年超声心动图结果。结果：手术死亡1例（3.0%,1/33例）,主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例（3.0%,1/33例）。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象（SAM征）消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论：外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。

Surgical Treatment of Hypertrophic Obstructive Cardiomyopathy

Objective：To summarize the results of hypertrophic ventricular septum myectomy for hypertrophic obstructive car-diomyopathy（HOCM）,and investigate surgical treatment strategies.Methods：From March 2002 to October 2010,33 patients of HOCM underwent surgical treatment.There were 16 males and 17 female patients.The age ranged from 13 to 59 years old with a mean of（42.7±13.6） years old.The left ventricular out tract gradient pressure（LVOTGP） was 70 ~ 120 mmHg（1 mmHg=0.133Kpa）,with a mean of（95.0±22.6） mmHg.24 patients combine mitral valve regurgitation,7 patients combine aortic valve insufficiency,and 3 patients with ascending aortic widened 2 patients with coronary heart disease.Surgical operations accomplished under hypothermic cardiopul-monary bypass with general anesthesia,and ventricular septum myectomy carried through conventional aortic incision.There were 7 pa-tients with mitral valve replacement（MVR）,7 patients with mitral valvuloplasty（MVP）,5 patients with mitral valve aortic valvuloplasty（MVP ＋ AVP）,3 patients with mitral ascending aorta valvuloplasty,and 2 patients with mitral valve aortic valvuloplasty,coronary artery bypass grafting over the same period（MVP ＋ AVP ＋ CABG）.The manifestation of pre-operative UCG,intro-operative transesophageal echocardiography（TEE） and post-operative UCG in 1 week,3 months,6 months,1 year were compared and analyzed.Results：1 patient（3.0%,1 / 33） died in hospital due to severe low cardiac output syndrome and multiple organ failure.1 patient（3.0%,1 / 33） carried Second thoracotomy to stop bleeding.Intro-operative TEE showed systolic anterior mitral leaflet in all patients prior to movement phe-nomena（SAM sign） disappear.Survival of patients with good effect of surgery,anatomical narrow lift,lower peak pressure,SAM phe-nomenon disappeared.Long-term survival of the patients were followed up for symptoms,quality of life significantly improved cardiac function in I ~ II class,no late death,complications or reoperation.Conclusion：Surgical treatment of hypertrophic obstructive cardiomy-opathy is safe and efficient.Understand the pathophysiological process,careful exploratory surgery,radical surgery is the key to success-ful operation.