中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

外科治疗肥厚型梗阻性心肌病合并冠心病的处理策略及早中期结果

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目的 总结肥厚型梗阻性心肌病(HOCM)合并冠状动脉粥样硬化性心脏病的患者行改良扩大 Morrow 术时同期冠状动脉旁路移植术(CABG)的围术期处理策略及早期结果。 方法 回顾性分析 2012 年 1 月至 2017 年 12 月阜外医院住院二部实施手术治疗的 HOCM 合并冠心病的患者 32 例,男 20 例、女 12 例,年龄 37~67(53.7±8.7)岁;术前出现胸闷症状者 24 例,胸痛症状者 14 例,晕厥史 6 例。手术前后及随访期常规行心脏超声心动图、心电图及胸部 X 线片、核磁共振检查,评价心功能、左室流出道及二尖瓣的结构和功能变化。 结果 全部患者均接受改良扩大 Morrow 术联合 CABG,术前左室流出道峰值压差(LVOTG)为 40~152(79.6±28.7)mm Hg,同期行心肌桥松解术 4 例,二尖瓣置换术 2 例,二尖瓣成形术 3 例,三尖瓣成形术 3 例,改良迷宫手术 2 例。全组无术中死亡及术后 30 天内死亡。患者合并行 CABG 的分支包括前降支 26 例,对角支 16 例,回旋支 8 例,右冠状动脉 11 例。合并行 CABG 搭桥 1 支的患者 15 例,合并行 CABG 搭桥 2 支的患者 5 例,合并行 CABG 搭桥 3 支的患者 12 例,平均 CABG 支数(1.9±0.6)支。术后 ICU 时间 1~13(4.1±2.8)d,术后住院时间 6~30(12.6±5.5)d,术后未见严重并发症,术后切口愈合不良 1 例,术后新发左束支传导阻滞 6 例。术后左室流出道峰值压差(79.6±28.7 mm Hg vs. 10.8±5.9 mm Hg,P<0.001),室间隔厚度[(1.9±0.4)cmvs. (1.3±0.5)cm,P<0.001]与术前比较均明显降低。术后二尖瓣反流程度较术前明显减轻(P<0.001),二尖瓣前向运动(SAM 征)基本消失。本组术后随访 6~68 (38.8±20.6) 个月,随访患者症状均消失,心动能 NYHA 分级级别较术前降低 I~II 级,无远期死亡、并发症或再次手术。 结论 对于肥厚型梗阻性心肌病合并冠心病的患者行改良扩大 Morrow 术时同时行冠状动脉旁路移植术是安全的。可明显改善患者的生存率及症状,起到协同作用,不增加患者的手术并发症。

Objective To summarize the perioperative management strategies and early results of modified Morrow expanded operation and coronary artery bypass grafting (CABG) in patients with obstructive hypertrophic cardiomyopathy (HOCM) and coronary atherosclerotic heart disease. Methods Between Jane 2012 and Dec 2017, in second inpatient department of Fuwai Hospital, 32 patients (20 females and 12 males) underwent modified expanded Morrow operation and coronary artery bypass grafting. The median age was (53.7±8.7) years (interquartile range 37 to 67) Preoperative chest distress symptoms in 24 patients, chest pain symptoms in 14patients, history of syncope in 6patients. Cardiac echocardiography, electrocardiogram, chest X-ray, MRI were performed routinely after operation and follow-up to analyze structure and function of heart and mitral valve. Results All patients underwent modified and expanded Morrow combined with coronary artery bypass grafting. The preoperative left ventricular outflow tract peak pressure difference (LVOTG) was 40 to 152 (79.6±28.7) mmHg. Four patients underwent myocardial bridge releasing in the same period, mitral valve replacement in 2 patients, mitral valve angioplasty in 3 patients, Maze operation in 2 patients and tricuspid valveoplasty in 3 patients. There was no hospital mortality. CABG surgery in patients with branches including anterior descending artery in 26 patients, diagonal branch in 16 patients, left circumflex in 8 patients, right coronary artery in 11 patients. There were 15 patients with one CABG bridge number, 5 patients with two bridge numbers, and 12 patients with 3 bridge numbers. The average CABG count was 1.9±0.6. The postoperative ICU time ranged from 1–13 (4.1±2.8) days and postoperative hospital stay ranged from 7 to 30 (12.6±5.5) days. No severe postoperative complications were found and 1 patient had postoperative incision healing. The postoperative new arrhythmia including left bundle branch block in 6 patients. Compared with the preoperative values, Postoperative left ventricular outflow tract peak pressure (79.6±28.7 mm Hg vs. 10.8±5.9 mm Hg, P<0.001), interventricular septum thickness (1.9±0.4 cmvs. 1.3±0.5 cm, P<0.001) were decreased obviously. Mitral valve closure is good or only mild reflux, mitral valve forward movement (SAM sign) disappeared. The patients were followed up for 6-68 months, with an average of (38.8±20.6) months. All patients were followed up with symptoms disappeared or only mild symptoms. NYHA classification decreased I to II grade after surgery, without long-term mortality, complications or reoperation. Conclusions For patients with hypertrophic obstructive cardiomyopathy with coronary atherosclerotic heart disease, the application of improved expand morrow operation at the same time undergoing coronary artery bypass grafting is safe. This can significantly improve patient survival and reduce symptoms, play a synergistic effect, and does not increase the patient's surgical complications.

关键词: 肥厚型梗阻性心肌病; 冠状动脉粥样硬化性心脏病; 外科手术

Key words: Hypertrophic obstructive cardiomyopathy; coronary atherosclerotic heart disease; surgical treatment

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