Balaram Sandhya K, Sherrid Mark V, Derose Joseph J, Hillel Zak, Winson Glenda, Swistel Daniel G
Division of Cardiothoracic Surgery, St. Luke's-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, New York, New York 10025, USA.
Ann Thorac Surg. 2005 Jul;80(1):217-23. doi: 10.1016/j.athoracsur.2005.01.064.
Extended myectomy for left ventricular outflow tract obstruction (LVOTO) due to hypertrophic cardiomyopathy (HCM) has good long-term results. In addition to the midseptal resection (R) for HCM, our group has introduced a novel variation in anterior leaflet plication (P) and release (R) of papillary muscle attachments. We sought to investigate the medium-term success of this three-step repair that addresses all aspects of complex HCM pathology.
Nineteen patients underwent resection-plication-release repair for complex HCM pathology. Transesophageal echocardiography was performed on all patients preoperatively and postoperatively to assess adequacy of resection, left ventricular outflow tract gradients, and mitral valve function. All patients underwent transthoracic outpatient echocardiography at a mean follow-up of 2.4 +/- 2.1 years (range, 0.5 to 6).
The average age of the patients was 57 +/- 14 years. The preoperative peak LVOTO was 137 +/- 45 mm Hg. The average degree of mitral regurgitation was 3.1. The average length of stay was 7.5 +/- 3.3 days. There were no readmissions or deaths in the group. Initial postoperative transesophageal echocardiography demonstrated marked reduction in LVOTO to 10 +/- 17 mm Hg (p < 0.0001) and significant improvement in mitral regurgitation to 0.2 (p < 0.0001). In follow-up, the LVOT gradient remained low at 6 +/- 14 (p > 0.0001) and mitral regurgitation remained insignificant at 0.4 (p < 0.0001).
Anterior leaflet plication and papillary muscle release are logical adjuncts to septal resection in the treatment of the complicated pathophysiology of obstructive HCM. Durable long-term results can be achieved with an aggressive approach to mitral valve pathology in conjunction with extended myectomy.
因肥厚型心肌病（HCM）导致左心室流出道梗阻（LVOTO）而进行的扩大心肌切除术具有良好的长期效果。除了针对HCM的室间隔中部切除术（R）外，我们团队还引入了一种新颖的前叶折叠术（P）以及乳头肌附着的松解术（R）。我们试图研究这种针对复杂HCM病理各个方面的三步修复术的中期成功率。
19例患者接受了针对复杂HCM病理的切除 - 折叠 - 松解修复术。所有患者在术前和术后均接受经食管超声心动图检查，以评估切除的充分性、左心室流出道梯度和二尖瓣功能。所有患者在平均随访2.4±2.1年（范围为0.5至6年）时接受了经胸门诊超声心动图检查。
患者的平均年龄为57±14岁。术前左心室流出道峰值梗阻为137±45 mmHg。二尖瓣反流的平均程度为3.1级。平均住院时间为7.5±3.3天。该组患者无再次入院或死亡情况。术后初期经食管超声心动图显示左心室流出道梗阻显著降低至10±17 mmHg（p<0.0001），二尖瓣反流显著改善至0.2级（p<0.0001）。在随访中，左心室流出道梯度保持在较低水平，为6±14（p>0.0001），二尖瓣反流仍不明显，为0.4级（p<0.0001）。
前叶折叠术和乳头肌松解术是治疗梗阻性HCM复杂病理生理过程中室间隔切除术的合理辅助手段。积极处理二尖瓣病变并结合扩大心肌切除术可取得持久的长期效果。
