超声心动图在肥厚型梗阻性心肌病化学消融术中的应用
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摘要
目的:应用多普勒超声心动图及化学消融术中心导管检查比较肥厚型梗阻性心肌病(HOCM)左室流出道压力阶差(LVOTG)测定相关性,并评价超声心动图在肥厚型梗阻性心肌病经皮室间隔化学消融术(PTSMA)治疗及临床随访中的应用价值。
方法:选取吉林大学中日联谊医院1998年3月至2006年9月心内科住院的行无水酒精化学消融术的肥厚型梗阻性心肌病患者40例。分别于术前常规行多普勒超声心动图检查及术中(超声检查当日)行心导管检查,测量左室流出道压力阶差;术前及术后3、6个月超声心动图测量心脏舒张功能指标E/A及LVOTG,用统计学软件进行整理分析。
结果:术前多普勒超声心动图测量左室流出道压力阶差为59±26mmHg,术中消融前心导管测量左室流出道压力阶差为70±30mmHg,术后3个月LVOTG为25±12mmHg,术后6个月LVOTG为11±9mmHg;术前超声心动图测量E/A为0.4±0.05,术后3个月E/A为1.0±0.08,术后6个月E/A为1.1±0.07;术前纽约心功能(NYHA)3.0±0.9,术后3个月NYHA为2.6±1.1,术后6个月NYHA为2.0±0.7。
结论:超声心动图与心导管所测左室流出道压力阶差相关性较好(相关系数r=0.85,p﹥0.05);术前及术后3、6个月相比,LVOTG持续下降,E/A有所增高,LVOTG与E/A呈负相关,LVOTG与NYHA心功能分级呈正相关。故超声心动图对于评价肥厚型梗阻性心肌病术前压力阶差及化学消融术后的疗效是一个无创的有价值的检查方法。
Hypertrophic obstructive cardiomyopathy(HOCM)is chara- cterized by asymmetric hypertrophy of the interventricular septum(IVS),a narrowed left ventricular outflow tract(LVOT)and the subsequent symptoms caused by the obstruction of LVOT.Reducing the left ventricular outflow tract pressure gradient(LVOTG)is the clinical aim for symptomatic patients with HOCM.Some drug-refractory patients may benefit from the implantation of a DDD pacemaker, with a decrease in LVOTG and improvement of symptoms.However, this therapeutic option is not generally recommended.Septal myectomy is an effective method,but has a high perioperation mortality. Percutaneous transluminal septal myocardial ablation (PTSMA) is a promising non-surgical procedure carried out in recent years, with minimal injury,high safety and the same effectiveness as surgical myectomy.
Objective Testing the left ventricular outflow tract pressure gradient ( LVOTG ) of hypertrophic obstructive cardiomy- opathy(HOCM) to compare dependablity of the two methods.Simultaneously, appraising the value of echocardiogram in percutaneous transluminal septalmyocardial ablation clinic follow-up of hypertrophic obstructive cardiomyopathy.
Method 40 patients with hypertrophic obstructive cardiomyo- pathy during March 1998 to September 2006 in the third clinical hospital of JiLin University who were given anhydrous alcohol septalmyocardial ablation carry out Doppler echocardiography test before operation and cardiac catheterization during operation (the same day with echocardiography), Measuring the left ventricular outflow tract pressure gradient. Measuring the parameter of cardiac diastolic function E/A and LVOTG before the operation and 3 as well as 6 months after the operation. Sorting and analyzing by statistically software.
Result The left ventricular outflow tract pressure gradient tested by Doppler echocardiography is 59±26mmHg and it is 70±30mmHg tested by ductus before operation.The LVOTG is 25±12mmHg three months after the operation and 11±9mmHg six months after operation.E/A tested by Doppler echocardiography before the operation is 0.4±0.05. It is 1.0±0.08 three months after theoperation and 1.1±0.07 six months after operation.The NYHA is 3.4±1.2 before the operation.It is 2.6±1.1 three months after the operation and 2.0±0.7 six months after the operation.
Conclusion The left ventricular outflow tract pressure gradient that is separatly tested by echocardiography and ductus has better dependablity(coefficient correlation=0.85,P﹥0.05). Com- paring the three phases(before operation, three months after the operation six months after operation), LVOTG reduced continuously and the E/A raised invariably. The two had inverse correlation. LVOTG and NYHA had direct correlation. So echocardiography is a non-destructive and valuable examination in appraising the gradient pressure of hypertrophic obstructive cardiomyopathy before operation and the effect of percutaneous transluminal septalmyo- cardial ablation.
方法:选取吉林大学中日联谊医院1998年3月至2006年9月心内科住院的行无水酒精化学消融术的肥厚型梗阻性心肌病患者40例。分别于术前常规行多普勒超声心动图检查及术中(超声检查当日)行心导管检查,测量左室流出道压力阶差;术前及术后3、6个月超声心动图测量心脏舒张功能指标E/A及LVOTG,用统计学软件进行整理分析。
结果:术前多普勒超声心动图测量左室流出道压力阶差为59±26mmHg,术中消融前心导管测量左室流出道压力阶差为70±30mmHg,术后3个月LVOTG为25±12mmHg,术后6个月LVOTG为11±9mmHg;术前超声心动图测量E/A为0.4±0.05,术后3个月E/A为1.0±0.08,术后6个月E/A为1.1±0.07;术前纽约心功能(NYHA)3.0±0.9,术后3个月NYHA为2.6±1.1,术后6个月NYHA为2.0±0.7。
结论:超声心动图与心导管所测左室流出道压力阶差相关性较好(相关系数r=0.85,p﹥0.05);术前及术后3、6个月相比,LVOTG持续下降,E/A有所增高,LVOTG与E/A呈负相关,LVOTG与NYHA心功能分级呈正相关。故超声心动图对于评价肥厚型梗阻性心肌病术前压力阶差及化学消融术后的疗效是一个无创的有价值的检查方法。
Hypertrophic obstructive cardiomyopathy(HOCM)is chara- cterized by asymmetric hypertrophy of the interventricular septum(IVS),a narrowed left ventricular outflow tract(LVOT)and the subsequent symptoms caused by the obstruction of LVOT.Reducing the left ventricular outflow tract pressure gradient(LVOTG)is the clinical aim for symptomatic patients with HOCM.Some drug-refractory patients may benefit from the implantation of a DDD pacemaker, with a decrease in LVOTG and improvement of symptoms.However, this therapeutic option is not generally recommended.Septal myectomy is an effective method,but has a high perioperation mortality. Percutaneous transluminal septal myocardial ablation (PTSMA) is a promising non-surgical procedure carried out in recent years, with minimal injury,high safety and the same effectiveness as surgical myectomy.
Objective Testing the left ventricular outflow tract pressure gradient ( LVOTG ) of hypertrophic obstructive cardiomy- opathy(HOCM) to compare dependablity of the two methods.Simultaneously, appraising the value of echocardiogram in percutaneous transluminal septalmyocardial ablation clinic follow-up of hypertrophic obstructive cardiomyopathy.
Method 40 patients with hypertrophic obstructive cardiomyo- pathy during March 1998 to September 2006 in the third clinical hospital of JiLin University who were given anhydrous alcohol septalmyocardial ablation carry out Doppler echocardiography test before operation and cardiac catheterization during operation (the same day with echocardiography), Measuring the left ventricular outflow tract pressure gradient. Measuring the parameter of cardiac diastolic function E/A and LVOTG before the operation and 3 as well as 6 months after the operation. Sorting and analyzing by statistically software.
Result The left ventricular outflow tract pressure gradient tested by Doppler echocardiography is 59±26mmHg and it is 70±30mmHg tested by ductus before operation.The LVOTG is 25±12mmHg three months after the operation and 11±9mmHg six months after operation.E/A tested by Doppler echocardiography before the operation is 0.4±0.05. It is 1.0±0.08 three months after theoperation and 1.1±0.07 six months after operation.The NYHA is 3.4±1.2 before the operation.It is 2.6±1.1 three months after the operation and 2.0±0.7 six months after the operation.
Conclusion The left ventricular outflow tract pressure gradient that is separatly tested by echocardiography and ductus has better dependablity(coefficient correlation=0.85,P﹥0.05). Com- paring the three phases(before operation, three months after the operation six months after operation), LVOTG reduced continuously and the E/A raised invariably. The two had inverse correlation. LVOTG and NYHA had direct correlation. So echocardiography is a non-destructive and valuable examination in appraising the gradient pressure of hypertrophic obstructive cardiomyopathy before operation and the effect of percutaneous transluminal septalmyo- cardial ablation.
引文
1. Kimmelstiel CD, Maron BJ. Role of percutaneous septal ablation in hypertrophic obstructive cardiomyopathy[J]. Circulation, 2004, 109:452-456
2. Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology Clinical Expert Con-sensus Document on Hypertrophic Cardiomyopathy[J]. J Am CollCardiol, N2003,42:1687-1713
3. Sigwart U. Nonsurgical myocardial reduction for hypertrophic obstructive cardiomyopathy [J].Lancet,1995 ,346(8969):211-214
4. 中华心血管病杂志编委会.经皮经腔间隔心肌消融术治疗专题组.经皮经腔间隔心肌消融术治疗的参考意见[J].中华心血管病杂志.2001, 29 (7) : 434-435
5. 辽宁省化学消融术协作组.经皮经冠状动脉室间隔化学消融术治疗梗阻性肥厚型心肌病的近期疗效观察 中华心血管病杂志.2001,29(1):8-11
6. 张运主编.多普勒超声心动图学.青岛:青岛出版社.1988.9:180
7. 王 新 房 . 超 声 心 动 图 学 〔 M 〕 . 北 京 : 人 民 卫 生 出 版社,1999.543-550
8. Seggenwiss H, Gieichmann U,Faber L, et al. Percutancous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: Acute results and 3-month follow- up in 25 patients[J]. J Am Coll Cardiol, 1998, 31(2):252- 258
9. Lakkis NM,Nagueh SF, Kleiman NS,et al.Echocardiography- guided ethanol septal reduction forhypertrophic: obstructive cardiomyonathy,Circulation, 1998,98(17):1750- 1755
10.李大主.室间隔心肌消融术治疗梗阻性肥厚型心肌病的现状[J].临床心血管杂志,2003, 19(6): 323
11.赵林阳,王大伟,杨平,等,经导管化学消融心肌治疗肥厚型梗阻性心肌病:附一例报告[J].中华心血管病杂志,1998,26:70-71
12.辽宁省化学消融术协作组.经皮经冠状动脉室间隔化学消融术治疗梗阻型心肌病近期疗效观察[J].中华心血管病杂志,2001,29:8-11
13.Seggewiss H, Faber L,Ziemssen P, et al. One-year follow-up after echocardiographically guided percutaneous septal ablation in hypertrophic: obstructive cardiomyophathy. Dtsch Med Wochenschr 2001, 126(15): 424- 429
14.Braunwald,陈灏珠.心脏病学〔M〕.北京:人民卫生出版社,2001 .1270-1290
1. Kimmelstiel CD, Maron BJ. Role of percutaneous septal ablation in hypertrophic obstructive cardiomyopathy[J]. Circulation, 2004,109: 452-456
2. Maron BJ, McKenna WJ, Danielson GK, et a1. American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy[J]. J Am Coll Cardiol,2003,42:1687-1713
3. 闫明洲,赵林阳等,双腔起搏器治疗肥厚性梗阻性心肌病的临床观察[J]. 白求恩医科大学报,2000,26(2)630-631
4. Sigwart U. Nonsurgical myocardial reduction for hypertrophic obstructive cardiomyopathy[J]. Lancet,1995,346:211-214
5. Knight C, Kurbaan A, Seggewiss H, et al. Nonsurgical septal reduction for hypertrophic obstructive cardiomyopathy[J]. Circulation,1997,95:2075-2081
6. Seggewiss H, Gieichmann U, Faber L, et al. Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: acute result and 3 month follow upin 25 patients[J]. J Am Coll Cardiol.,1998,31:252-258
7. Lakkis NM, Nagueh SF, Kleiman NS, et al. Echocardiography -guided ethanol septal reduction for hypertrophic obstructive cardiomyopathy[J] . Circulation.,1998,98:1750-1755
8. Boekstegers P, Steinbigler P, Molnar A, et al. Pressure–guided nonsurgieal myocardial reduction induced by small septal infarctions in hypertrophic obstructive cardiomyopathy[J]. J Am Coll Cardiol,2001,38:846-853
9. Nagueh SF, Ommen SR, Lakkis NM, et al. Comparison of ethanol septal reduction therapy with surgical myectomy for the treatment of hypertrophic cardiomyopathy[J]. J Am Coll Cardio1,2001,38: 1701–1706
10. Faber L, Meissner A, Ziemssen P, et al. Percutaneous transluminal septal myocardial ablation for hypertrophic cardiomyopathy[J]. Heart, 2000,83:326-331
11.Qin JX, Shiota T, Lever HM, et al. Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery[J]. J Am Coll Cardiol, 2001,38:1994-2000
12.Firoozi S, Elliott PM, Sharma S, et al. Septal myotomy- myectomy and transcoronary septal alcohol ablation in hypertrophic cardiomyopathy[J]. Eur Heart J, 2002,23:1617– 1624
13.Walter BF, Maron BJ, Epstein SE, et al. Transmural Myocardial infarction in hypertrophic cardiomyopathy: a cause of conversion from left ventricular asymmetry to symmetry and from normal-sized to dilated left ventricular cavity[J]. Chest, 1981,79:461-465
14.Kuhn H, Gietzen F, Leuner C, et al. Indution of subaortic septal isc hernia to reduce obstruction in hypertrophic obstructive cardiomyopathy: Study to develop a new catheter-based concept of treatment [J]. Eur Heart J, 1997,18:846-851
15.Faber L, Seggewiss H, Gleichmann U. percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: results with respect to intraprocedural myocardial contrast echocardiography[J]. Circulation, 1998, 98:2415-2421
16.Chang SM, Lakkis NM, Etc. Predicators of outcome after alcoholseptal ablation therapy in patients with hypertrophic obstructive cardiomyopathy[J]. Circulation, 2004,109:824-827
17.Maron BJ, Role of alcohol septal ablation in treatment of obstructive hypertrophic cardiomyopathy[J]. Lancet, 2000,355: 425-426
18.Lakkis NM, Nagueh SF, Dunn JK, et al. Nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyo- pathy:one year follow up[J]. J Am Coll Cardiol, 2000,36: 852-855
19.Gietzen FH, Leuner CJ, Raute-Kreisen U, et al. Acute and long-term results after transcoronary ablation of septal hypertrophy (TASH):Catheter interventional treatment for hypertrophic obstructive cardiomyopathy [J]. Eur Heart J, 1999,20:1342–1354
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35.Lakkis NM, Nagueh SF, Dunn JK, et al. Nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy: one year follow-up[J]. J Am Coll Cardiol
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2. Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology Clinical Expert Con-sensus Document on Hypertrophic Cardiomyopathy[J]. J Am CollCardiol, N2003,42:1687-1713
3. Sigwart U. Nonsurgical myocardial reduction for hypertrophic obstructive cardiomyopathy [J].Lancet,1995 ,346(8969):211-214
4. 中华心血管病杂志编委会.经皮经腔间隔心肌消融术治疗专题组.经皮经腔间隔心肌消融术治疗的参考意见[J].中华心血管病杂志.2001, 29 (7) : 434-435
5. 辽宁省化学消融术协作组.经皮经冠状动脉室间隔化学消融术治疗梗阻性肥厚型心肌病的近期疗效观察 中华心血管病杂志.2001,29(1):8-11
6. 张运主编.多普勒超声心动图学.青岛:青岛出版社.1988.9:180
7. 王 新 房 . 超 声 心 动 图 学 〔 M 〕 . 北 京 : 人 民 卫 生 出 版社,1999.543-550
8. Seggenwiss H, Gieichmann U,Faber L, et al. Percutancous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: Acute results and 3-month follow- up in 25 patients[J]. J Am Coll Cardiol, 1998, 31(2):252- 258
9. Lakkis NM,Nagueh SF, Kleiman NS,et al.Echocardiography- guided ethanol septal reduction forhypertrophic: obstructive cardiomyonathy,Circulation, 1998,98(17):1750- 1755
10.李大主.室间隔心肌消融术治疗梗阻性肥厚型心肌病的现状[J].临床心血管杂志,2003, 19(6): 323
11.赵林阳,王大伟,杨平,等,经导管化学消融心肌治疗肥厚型梗阻性心肌病:附一例报告[J].中华心血管病杂志,1998,26:70-71
12.辽宁省化学消融术协作组.经皮经冠状动脉室间隔化学消融术治疗梗阻型心肌病近期疗效观察[J].中华心血管病杂志,2001,29:8-11
13.Seggewiss H, Faber L,Ziemssen P, et al. One-year follow-up after echocardiographically guided percutaneous septal ablation in hypertrophic: obstructive cardiomyophathy. Dtsch Med Wochenschr 2001, 126(15): 424- 429
14.Braunwald,陈灏珠.心脏病学〔M〕.北京:人民卫生出版社,2001 .1270-1290
1. Kimmelstiel CD, Maron BJ. Role of percutaneous septal ablation in hypertrophic obstructive cardiomyopathy[J]. Circulation, 2004,109: 452-456
2. Maron BJ, McKenna WJ, Danielson GK, et a1. American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy[J]. J Am Coll Cardiol,2003,42:1687-1713
3. 闫明洲,赵林阳等,双腔起搏器治疗肥厚性梗阻性心肌病的临床观察[J]. 白求恩医科大学报,2000,26(2)630-631
4. Sigwart U. Nonsurgical myocardial reduction for hypertrophic obstructive cardiomyopathy[J]. Lancet,1995,346:211-214
5. Knight C, Kurbaan A, Seggewiss H, et al. Nonsurgical septal reduction for hypertrophic obstructive cardiomyopathy[J]. Circulation,1997,95:2075-2081
6. Seggewiss H, Gieichmann U, Faber L, et al. Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: acute result and 3 month follow upin 25 patients[J]. J Am Coll Cardiol.,1998,31:252-258
7. Lakkis NM, Nagueh SF, Kleiman NS, et al. Echocardiography -guided ethanol septal reduction for hypertrophic obstructive cardiomyopathy[J] . Circulation.,1998,98:1750-1755
8. Boekstegers P, Steinbigler P, Molnar A, et al. Pressure–guided nonsurgieal myocardial reduction induced by small septal infarctions in hypertrophic obstructive cardiomyopathy[J]. J Am Coll Cardiol,2001,38:846-853
9. Nagueh SF, Ommen SR, Lakkis NM, et al. Comparison of ethanol septal reduction therapy with surgical myectomy for the treatment of hypertrophic cardiomyopathy[J]. J Am Coll Cardio1,2001,38: 1701–1706
10. Faber L, Meissner A, Ziemssen P, et al. Percutaneous transluminal septal myocardial ablation for hypertrophic cardiomyopathy[J]. Heart, 2000,83:326-331
11.Qin JX, Shiota T, Lever HM, et al. Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery[J]. J Am Coll Cardiol, 2001,38:1994-2000
12.Firoozi S, Elliott PM, Sharma S, et al. Septal myotomy- myectomy and transcoronary septal alcohol ablation in hypertrophic cardiomyopathy[J]. Eur Heart J, 2002,23:1617– 1624
13.Walter BF, Maron BJ, Epstein SE, et al. Transmural Myocardial infarction in hypertrophic cardiomyopathy: a cause of conversion from left ventricular asymmetry to symmetry and from normal-sized to dilated left ventricular cavity[J]. Chest, 1981,79:461-465
14.Kuhn H, Gietzen F, Leuner C, et al. Indution of subaortic septal isc hernia to reduce obstruction in hypertrophic obstructive cardiomyopathy: Study to develop a new catheter-based concept of treatment [J]. Eur Heart J, 1997,18:846-851
15.Faber L, Seggewiss H, Gleichmann U. percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: results with respect to intraprocedural myocardial contrast echocardiography[J]. Circulation, 1998, 98:2415-2421
16.Chang SM, Lakkis NM, Etc. Predicators of outcome after alcoholseptal ablation therapy in patients with hypertrophic obstructive cardiomyopathy[J]. Circulation, 2004,109:824-827
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