McIntosh C L, Maron B J, Cannon R O, Klues H G
Surgery Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md. 20852.
Circulation. 1992 Nov;86(5 Suppl):II60-7.
Several operations (most commonly ventricular septal myotomy-myectomy and also mitral valve replacement) have been performed to relieve symptoms and obstruction to left ventricular outflow in patients with hypertrophic cardiomyopathy (HCM).
In an effort to establish an alternative to mitral valve replacement, combined septal myotomy-myectomy and suture plication of the anterior mitral valve leaflet was performed in a subgroup of 36 severely symptomatic patients with obstructive HCM. These patients were selected primarily because the mitral leaflets were judged morphologically at the time of operation to be of sufficient size relative to that of the outflow tract to represent a risk for residual systolic septal contact and outflow obstruction. The effects of operation were assessed in 34 patients; of the 33 with preoperative symptoms, 28 (85%) reported substantial functional improvement after surgery over an average follow-up of 2.2 years. Of 29 patients with complete hemodynamic data, basal outflow gradient was obliterated or reduced substantially by surgery (to < or = 35 mm Hg) in 26 patients (90%) and for the group from 81 +/- 42 to 16 +/- 24 mm Hg (p < 0.001); provocable gradient with isoproterenol infusion also decreased considerably (from 109 +/- 50 to 47 +/- 25 mm Hg; p < 0.001). Echocardiographic studies showed that plication limited the systolic anterior motion of anterior mitral leaflet. There was no hemodynamic evidence of mitral stenosis, and in only one patient did mitral regurgitation increase after surgery.
Mitral valve plication combined with myotomy-myectomy in obstructive HCM 1) can be performed safely and does not adversely alter mitral valve function, 2) relieves symptoms and outflow obstruction under basal and provocable conditions, and 3) may represent an alternative to mitral valve replacement in selected patients with elongated and enlarged mitral leaflets.
已开展多种手术（最常见的是室间隔肌切开-心肌切除术，还有二尖瓣置换术）来缓解肥厚型心肌病（HCM）患者的症状及左心室流出道梗阻。
为寻求二尖瓣置换术的替代方法，对36例有严重症状的梗阻性HCM患者亚组实施了联合室间隔肌切开-心肌切除术及二尖瓣前叶缝合折叠术。选择这些患者主要是因为在手术时判定二尖瓣叶在形态上相对于流出道有足够大小，存在残余收缩期室间隔接触及流出道梗阻风险。对34例患者的手术效果进行了评估；在33例术前有症状的患者中，28例（85%）在平均2.2年的随访期后报告术后功能有显著改善。在29例有完整血流动力学数据的患者中，26例（90%）手术使基础流出道梯度消失或大幅降低（至≤35 mmHg），该组基础流出道梯度从81±42 mmHg降至16±24 mmHg（p<0.001）；静注异丙肾上腺素激发的梯度也显著降低（从109±50 mmHg降至47±25 mmHg；p<0.001）。超声心动图研究显示，折叠术限制了二尖瓣前叶的收缩期前移。没有二尖瓣狭窄的血流动力学证据，术后仅1例患者二尖瓣反流增加。
梗阻性HCM患者二尖瓣折叠术联合肌切开-心肌切除术1）可安全实施且不会对二尖瓣功能产生不利影响，2）可缓解基础及激发状态下的症状和流出道梗阻，3）对于二尖瓣叶拉长和增大的特定患者可能是二尖瓣置换术的替代方法。
