Hirata Yasutaka, Chen Jonathan M, Quaegebeur Jan M, Mosca Ralph S
Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA.
J Thorac Cardiovasc Surg. 2009 May;137(5):1168-72. doi: 10.1016/j.jtcvs.2008.11.039. Epub 2009 Feb 5.
Substantial controversy persists regarding the need and efficacy of a routine myectomy in the treatment of discrete subaortic stenosis. Although some believe myectomy more effectively relieves subaortic narrowing, this is uncertain, and complications, including heart block and aortic valve injury, are concerns. The aims of the study were as follows: (1) to analyze the role of enucleation for relief of subaortic stenosis and the risk factors associated with recurrence and reoperation and (2) to delineate the characteristics of the patients who might benefit from enucleation alone.
From January 1990 through May 2007, 221 patients with subaortic stenosis underwent biventricular repair. Of those, 106 patients had discrete subaortic stenosis. The preoperative peak left ventricular outflow tract gradient, as determined by means of transthoracic echocardiographic analysis, was 67.3 +/- 29 mm Hg. Forty patients had previous operations for other intracardiac anomalies. Mean age at repair was 7 years. Sixty-one patients underwent isolated enucleation, and 45 patients underwent concomitant myectomy. Patients with recurrent subaortic stenosis whose first operation was performed elsewhere were excluded from analysis.
There was 1 early death and 1 late death. The postoperative peak left ventricular outflow gradient decreased to 12.5 +/- 12.9 mm Hg (P < .001). No patient had development of heart block or required a pacemaker. A recurrent gradient of greater than 30 mm Hg was found in 26 (27%) patients, and 8 (7.5%) patients had reoperations. Actuarial freedom from reoperation rates at 5, 10, and 15 years were 94.7% +/- 1.8%, 89.6% +/- 3.5%, and 84.8% +/- 4.9%, respectively.Of those patients who had not undergone a previous cardiac operation, there were no significant differences in the rates of recurrence (28% vs 27%) or reoperation (4.7% vs 4.4%) between the enucleation group and the concomitant myectomy group. For the patients who had a previous cardiac operation, the concomitant myectomy group had a significantly lower rate of recurrence (44% for enucleation vs 13% for enucleation plus myectomy, P = .031).
For those patients undergoing primary operations for discrete subaortic stenosis, routine myectomy does not offer superior relief of left ventricular outflow tract obstruction; enucleation alone provides good results in this selected population. However, in those patients with associated cardiac anomalies, concomitant additional myectomy is recommended.
关于在治疗局限性主动脉瓣下狭窄时进行常规心肌切除术的必要性和疗效，目前仍存在大量争议。尽管一些人认为心肌切除术能更有效地缓解主动脉瓣下狭窄，但这并不确定，且包括心脏传导阻滞和主动脉瓣损伤在内的并发症令人担忧。本研究的目的如下：（1）分析摘除术在缓解主动脉瓣下狭窄中的作用以及与复发和再次手术相关的危险因素；（2）明确可能仅从摘除术中获益的患者特征。
从1990年1月至2007年5月，221例主动脉瓣下狭窄患者接受了双心室修复术。其中，106例患者为局限性主动脉瓣下狭窄。经胸超声心动图分析测定的术前左心室流出道峰值梯度为67.3±29 mmHg。40例患者曾因其他心脏内异常接受过手术。修复时的平均年龄为7岁。61例患者接受了单纯摘除术，45例患者接受了同期心肌切除术。首次手术在其他地方进行的复发性主动脉瓣下狭窄患者被排除在分析之外。
有1例早期死亡和1例晚期死亡。术后左心室流出峰值梯度降至12.5±12.9 mmHg（P <.001）。没有患者发生心脏传导阻滞或需要植入起搏器。26例（27%）患者出现复发性梯度大于30 mmHg，8例（7.5%）患者接受了再次手术。5年、10年和15年的再次手术无事件生存率分别为94.7%±1.8%、89.6%±3.5%和84.8%±4.9%。在那些未曾接受过心脏手术的患者中，摘除术组和同期心肌切除术组在复发率（28%对27%）或再次手术率（4.7%对4.4%）方面没有显著差异。对于曾接受过心脏手术的患者，同期心肌切除术组的复发率显著较低（摘除术组为44%，摘除术加心肌切除术组为13%，P = 0.031）。
对于那些因局限性主动脉瓣下狭窄接受初次手术的患者，常规心肌切除术并不能更好地缓解左心室流出道梗阻；单纯摘除术在这一特定人群中能取得良好效果。然而，对于那些伴有心脏异常的患者，建议同期进行额外的心肌切除术。
