摘要
目的探索全胸腔镜下经左心房二尖瓣入路心肌切除术(thoracoscopic transmitral myectomy,TTM)对肥厚型梗阻性心肌病(hypertrophic obstructive cardiomyopathy,HOCM)患者的早期治疗效果.方法术前通过超声心动图及心脏核磁共振共同评估患者心室壁肥厚范围及二尖瓣形态和功能,在全胸腔镜下经二尖瓣行心肌切除术,总结手术方法并分析术后早期手术效果.结果2019年4月至2019年10月,我病区单一术者共完成TTM 15例.经术前影像学评估后发现:6例(40.0%)室间隔肥厚局限于基底段,9例(60.0%)合并左心室中部室间隔肥厚;2例(13.3%)术前超声心动图发现二尖瓣后叶腱索断裂.心肌切除后,二尖瓣处理如下:11例(73.3%)患者行前叶扩大,3例(20.0%)患者为直接缝合前叶至二尖瓣环,1例(6.7%)行二尖瓣生物瓣置换.全组无围手术期死亡、室间隔穿孔、残余左心室流出道梗阻及完全房室传导阻滞者.主动脉中位阻断时间、体外循环时间、术后呼吸机使用时间、ICU停留时间及术后住院时间分别为129.0(116.0,147.0)min、184.0(158.0,227.0)min、22.0(9.0,26.0)h、3(2,7)天、9(7,14)天.全组无失访,中位随访时间为4(2,5)个月.1例(6.7%)患者因A3区撕裂于术后3个月行再次二尖瓣成形术,室间隔厚度和左心室流出道压差下降明显(术前对随访),分别为[(19.3±3.3)mm对(8.9±4.4)mm(P=0.001)]和[(90.8±23.2)mmHg对(8.9±4.4)mmHg(P<0.001)](1 mmHg=0.133 kPa);随访无患者残存SAM现象;二尖瓣中量以上反流患者数量由12例(80.0%)下降至1例(6.7%)(P<0.001).结论对于手术指征合适的HOCM患者,TTM是一项安全有效的术式,能够良好地暴露室间隔(尤其是中部)梗阻部位、消除左心室流出道梗阻及SAM相关二尖瓣反流.术中应仔细处理二尖瓣前叶,减少因补片大小或缝合导致的残余二尖瓣反流发生.
Objective To explore the early surgical outcomes of Thoracoscopic Transmitral Myectomy(TTM)on patients with hypertrophic obstructive cardiomyopathy(HOCM).Methods Preoperative echocardiography and cardiac magnetic resonance were used to evaluate the patient's hypertrophy extent,mitral valve morphology and function.Myocardial resection was performed via the trans-mitral approach under total thoracoscopy,and the surgical methods and early results were analyzed.Results From April 2019 to October 2019,a total of 15 cases of TTM were performed by a single surgeon in our ward.Preoperative imaging evaluation revealed that 6 patients(40.0%)had predominantly hypertrophic basal septum while another 9 patients(60.0%)had concomitant midventricular septal hypertrophy.Two(13.3%)patients were interrogated ruptured posterior mitral chord by preoperative echocardiogram.After myocardial resection,the mitral valve was treated as follows:11 patients(73.3%)undenvent anterior leaflet enlargement,and 3(20.0%)were directly reattached to mitral valve annulus,and 1(6.7%)underwent bioprosthetic mitral replacement.There was no case of perioperative death,ventricular septal perforation,residual left ventricular outflow tract obstruction and complete atrioventricular block.Median aortic crossclamp time,cardiopulmonary bypass time,postoperative ventilator use time,ICU stay time,and postoperative hospital stay were 129.0min(116.0,147.0),184.0 min(158.0,227.0),22.0 h(9.0,26.0),3 days(2,7)and 9 days(7,14)respectively.No patient lost to follow up,the median follow-up time was 4 months(2,5).One patient(6.7%)underwent mitral angioplasty three months after surgery due to a tear in the A3 area;the ventricular septal thickness and left ventricular outflow tract pressure decreased significantly(preoperative vs follow-up),and were(19.3±3.3)mm vs.(8.9±4.4)mm(P=0.001),(90.8±23.2)mmHg vs.(8.9±4.4)mmHg(1 mmHg=0.133kPa)(P<0.001)respectively;no residual SAM was observed during follow-up.Patients with moderate-to severe mitral regurgitation were decreased from 12(80.0%)before surgery to 1(6.7%)during fol-knv up(P<0.001).Conclusion TTM is a safe and effective procedure for HOCM patients with appropriate surgical indications,providing better exposure to septum from basal to apical area,eliminating left ventiicular outflow tract obstruction and SAM-related mitral regurgitation.The anterior mitral valve leaflet should be carefully treated during surgery to reduce the occurrence of residual mitral regurgitaLion resulted in inappropriate selection of patch size and suturing technique.
作者
唐亚捷
刘健
陈钊
赵俊飞
马介旭
魏培坚
刘彦俊
邱海龙
朱伟
刘辉
庄建
郭惠明
Tang Yajie;Liu Jian;Chen Zhao;Zhao Junfei;Ma Jiexu;Wei Peijian;Liu Yarijun;Qiu Hailong;Zhu Wei;Liu Hui;Zhuang Jian;Guo Huiming(Department of Cardiac Surgery,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangdong Cardiovascular Institute,Guangzhou 5100801 China;Shantou University Medical College,Shantou 515041,China;Departments of Echocardiography,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangdong Cardiovascular Institute,Guangzhou 510080,China;Department of Radiology,Guangdong Provincial People's Hospital,Guangdong Academy of Medical Sciences,Guangzhou 510080,China;Guangdong Provincial Key Laboratory of South China Structural Heart Disease,Guangzhou 510080,China)
出处
《中华胸心血管外科杂志》
CSCD
北大核心
2020年第8期472-477,共6页
Chinese Journal of Thoracic and Cardiovascular Surgery
关键词
肥厚型梗阻性心肌病
二尖瓣反流
心肌切除术
Hypertrophic obstructive cardiomyopathy
Mitral regurgitation
Myectomy
作者简介
通信作者:郭惠明,Email:guohuiming@163.net。
