摘要
目的评估行经皮室间隔化学消融术(PTSMA)术后梗阻性肥厚型心肌病(HOCM)患者的长期生存情况。方法回顾性连续入选2001年4月至2019年2月在上海交通大学附属胸科医院接受PTSMA和外科室间隔心肌切除术的HOCM患者,根据不同的手术方案分为PTSMA组和室间隔心肌切除术组,另根据是否发生死亡事件将PTSMA患者进一步分为HOCM-PTSMA死亡组和HOCM-PTSMA存活组。入选的患者均为药物难治性HOCM患者。通过查阅病案记录患者的一般临床资料、手术资料及住院期间并发症,通过电话和门诊随访患者的生存情况、临床症状等。采用Kaplan-Meier生存曲线分析HOCM患者接受PTSMA术和外科室间隔心肌切除术后的生存率,并采用Log rank法进行组间比较。将HOCM-PTSMA存活组与死亡组比较P<0.05的因素及可能影响PTSMA术后HOCM患者生存率的因素纳入多因素Cox回归模型,分析PTSMA术后HOCM患者全因死亡的独立危险因素。结果共入选行PTSMA的HOCM患者104例,年龄(54±15)岁,其中女性41例(38.7%)。随访时间为37.5(14.3,76.8)个月,末次随访时共12例患者死亡(HOCM-PTSMA死亡组),生存者92例(HOCM-PTSMA存活组)。HOCM-PTSMA死亡组患者纽约心脏协会(NYHA)心功能Ⅲ/Ⅳ级者所占比例高于HOCM-PTSMA存活组(P=0.036),左心室后壁厚度大于PTSMA-HOCM存活组(P=0.006)。入选的HOCM患者PTSMA即刻成功率为66%(70/104),HOCM-PTSMA死亡组患者术中无水酒精用量为(2.9±0.8)ml,有多于HOCM-PTSMA存活组[(2.4±1.0)ml]的趋势,但差异无统计学意义(P=0.056)。Kaplan-Meier生存曲线分析结果显示,行PTSMA的HOCM患者术后5、10、15年无全因死亡生存率分别为90.1%、78.3%、56.9%,无HOCM相关死亡生存率分别为91.3%、79.4%、57.7%。多因素Cox回归分析结果显示年龄≥65岁是HOCM患者PTSMA术后全因死亡的独立危险因素(HR=2.697,95%CI 1.292~18.977,P=0.020)。室间隔心肌切除术组患者共32例,其NYHA心功能Ⅲ/Ⅳ级患者的比例高于PTSMA组(P<0.001),年龄、性别、合并症(心房颤动、冠心病、高血压、糖尿病)、左心房内径等两组间差异均无统计学意义(P均>0.05)。室间隔心肌切除术组患者随访时间为38.0(17.6,64.2)个月,随访期间未发生死亡事件。Kaplan-Meier生存曲线分析结果显示,室间隔心肌切除术组和PTSMA组患者无全因死亡和无HOCM相关死亡生存率差异均无统计学意义,P值分别为0.089和0.110。结论PTSMA治疗药物难治性HOCM患者在一定程度上是安全、有效的,且与接受室间隔心肌切除术比较PTSMA术后患者长期生存率并不低。
Objective To evaluate the long-term outcome of patients with hypertrophic obstructive cardiomyopathy(HOCM)after percutaneous transluminal septal ablation(PTSMA).Methods HOCM patients who underwent PTSMA and surgical myectomy at the Chest Hospital of Shanghai Jiao Tong University from April 2001 to February 2019 were included in this retrospective analysis.Patients were divided into PTSMA group and surgical myectomy group.In addition,patients undergoing PTSMA were further divided into HOCM-PTSMA non-survivor group and HOCM-PTSMA survivor group.The general clinical information,procedural/surgical information and complications during hospitalization were compared between groups.Multivariate Cox regression model was used to analyze the independent risk factors for all-cause death in HOCM patients after PTSMA.Results A total of 104 patients with HOCM who underwent PTSMA were enrolled.Mean age of the patients was(54±15)years old,including 41 females(38.7%).The follow-up time was 37.5(14.3,76.8)months.At the last follow-up,12 patients died(HOCM-PTSMA non-survivor group)and 92 were alive(HOCM-PTSMA survivor group).The proportion of patients with NYHA function classⅢ/Ⅳwas higher(P=0.036),and the posterior wall of the left ventricle was thicker(P=0.006)in the HOCM-PTSMA non-survivor group than in the HOCM-PTSMA survivor group.The immediate success rate of PTSMA in this cohort was 66%(70/104).The amount of absolute alcohol during the operation in the HOCM-PTSMA non-survivor group was(2.9±0.8)ml,which tended to be higher as compared to that in the HOCM-PTSMA survivor group((2.4±1.0)ml,P=0.056).Kaplan-Meier survival curve analysis showed that patients with HOCM who underwent PTSMA had an all-cause mortality-free survival rate of 90.1%,78.3%,and 56.9%at 5,10 and 15 years,and a HOCM-free survival rate of 91.3%,79.4%and 57.7%at 5,10 and 15 years,respectively.Multivariate Cox regression analysis showed that age≥65 years was an independent risk factor for all-cause death after PTSMA in patients with HOCM(HR=2.697,95%CI 1.292-18.977,P=0.020).There were 32 patients in the surgical myectomy group.The proportion of patients with NYHA function classⅢ/Ⅳwas higher than that in the PTSMA group(P<0.001),while age,gender,and major comorbidities(atrial fibrillation,coronary heart disease,hypertension,and diabetes)as well as the left atrium dimension were all similar between the two groups(all P>0.05).Patients in the surgical myectomy group were followed up for 38.0(17.6,64.2)months,and no deaths occurred during the follow-up period.Kaplan-Meier survival curve analysis showed that there were no statistically significant differences in all-cause-free and HOCM-free survival rates between patients in PTSMA group and surgical myectomy group(P=0.089 and 0.110,respectively).Conclusion PTSMA is safe and effective for the treatment of patients with HOCM,and the long-term survival rate of patients after PTSMA is similar as patients undergoing classical surgical myectomy surgery.
作者
郑顺文
施鸿毓
戴锦杰
陈晖
吴卫华
仇兴标
Zheng Shunwen;Shi Hongyu;Dai Jinjie;Chen Hui;Wu Weihua;Qiu Xingbiao(Department of Cardiology,Shanghai Chest Hospital,Shanghai Jiao Tong University,Shanghai 200030,China)
出处
《中华心血管病杂志》
CAS
CSCD
北大核心
2020年第4期294-301,共8页
Chinese Journal of Cardiology
关键词
心肌病
肥厚性
存活率
经皮室间隔化学消融术
室间隔心肌切除术
Cardiomyopathy
hypertrophic
Survival rate
Percutaneous transluminal septal myocardial ablation
Septal myectomy
作者简介
通信作者:仇兴标,Email:qiuxingbiao@hotmail.com。
