Division of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
J Thorac Cardiovasc Surg. 2010 Mar;139(3):634-40. doi: 10.1016/j.jtcvs.2009.07.079.
Apical hypertrophic cardiomyopathy is a morphologic variant in which the hypertrophy is primarily localized to the apex of the left ventricle. A subset of patients have progressive, drug-refractory diastolic heart failure with severely limiting symptoms caused by low cardiac output. Heart transplantation has been the only therapeutic option available for such patients. This study analyzes clinical and hemodynamic outcomes of a novel surgical technique to improve diastolic filling by means of left ventricular cavity enlargement.
Forty-four symptomatic patients underwent apical myectomy to augment left ventricular end-diastolic volume. Myectomy was performed through an apical incision, and hypertrophic muscle was excised at the apex and midventricle. Information from a prospective database was supplemented by surveys, patient contact, and medical records.
The mean age of the patients was 50 +/- 17 years, and 66% were women. All patients were severely limited with dyspnea, 61% had angina, and 59% had syncope/presyncope. Ninety-one percent of patients were in New York Heart Association class III or IV. A mean of 16 +/- 7 g of muscle was removed. Preoperative and postoperative hemodynamic catheterization (n = 14) showed a decrease in left ventricular end-diastolic pressure from 28 +/- 9 to 24 +/- 7 mm Hg (P = .002) and an increase in end-diastolic volume index from 55 +/- 17 to 68 +/- 18 mL/m(2) (P = .003). Invasive measurements of stroke volume increased from 56 +/- 17 to 63 +/- 19 mL (P = .007). Of the 42 patients who survived to hospital discharge, 41 had improvement in symptoms. Mean peak maximum oxygen consumption with exercise (n = 5) increased from 13.5 +/- 4.4 to 15.8 +/- 4.6 mL/kg per minute. Survival at 1, 3, and 5 years was 95%, 81%, and 81%, respectively. At follow-up of 2.6 +/- 3.1 years, 23 (74%) patients were in New York Heart Association class I or II. One patient underwent heart transplantation 5 years after apical myectomy.
Apical myectomy improves functional status by decreasing left ventricular end-diastolic pressure, improving operative compliance, and increasing stroke volume. This procedure might be of value in other patients with hypertrophic cardiomyopathy who have severe hypertrophy and small left ventricular end-diastolic volume.
心尖肥厚型心肌病是一种形态学变异，其肥厚主要局限于左心室的尖部。一部分患者有进展性、药物难治性舒张性心力衰竭，由于心输出量低导致严重限制症状。心脏移植一直是这些患者唯一的治疗选择。本研究分析了一种通过扩大左心室腔来改善舒张充盈的新型手术技术的临床和血流动力学结果。
44 名有症状的患者接受心尖切除术以增加左心室舒张末期容积。心尖切除术通过心尖切口进行，肥厚的心肌在心尖和心室中部被切除。通过前瞻性数据库的信息补充调查、患者联系和病历。
患者的平均年龄为 50 ± 17 岁，66%为女性。所有患者均因呼吸困难严重受限，61%有胸痛，59%有晕厥/先兆晕厥。91%的患者为纽约心脏协会（NYHA）心功能分级 III 或 IV 级。平均切除 16 ± 7 g 肌肉。术前和术后心导管检查（n = 14）显示左心室舒张末期压从 28 ± 9 降至 24 ± 7 mmHg（P =.002），舒张末期容积指数从 55 ± 17 增至 68 ± 18 mL/m2（P =.003）。侵入性测量的每搏量从 56 ± 17 增加到 63 ± 19 mL（P =.007）。42 例存活至出院的患者中，41 例症状改善。运动时最大摄氧量峰值的平均峰值（n = 5）从 13.5 ± 4.4 增加到 15.8 ± 4.6 mL/kg/min。1 年、3 年和 5 年的生存率分别为 95%、81%和 81%。在 2.6 ± 3.1 年的随访中，23 例（74%）患者 NYHA 心功能分级为 I 或 II 级。1 例患者在接受心尖切除术 5 年后进行了心脏移植。
心尖切除术通过降低左心室舒张末期压、改善顺应性和增加每搏量来改善心功能状态。对于有严重肥厚和左心室舒张末期容积较小的其他肥厚型心肌病患者，该手术可能具有价值。
