Shenouda John, Silber David, Subramaniam Mythri, Alkhatib Basil, Schwartz Richard K, Goncalves John A, Naidu Srihari S
From the Hypertrophic Cardiomyopathy Treatment Center and the Cardiac Catheterization Laboratory, Division of Cardiology, Winthrop University Hospital, 120 Mineola Blvd, Suite 500, Mineola, NY, 11501, USA.
Curr Treat Options Cardiovasc Med. 2016 Mar;18(3):17. doi: 10.1007/s11936-016-0440-3.
The dilemma of the patient with both AS and LVOTO is now commonly encountered in clinical practice; indeed, physicians must be aware of the complex interaction and coexistent nature of both diseases, especially as both HOCM and TAVR have increased in awareness and prevalence. Importantly, the clinician must be aware of the complex interplay hemodynamically, with the two diseases confusing the TTE imaging and potentially affecting each other anatomically and clinically. There is no set guideline on how to approach this from a surgical or percutaneous approach, but we have outlined a set of recommendations which should serve the clinician and patient well. The three cases that are presented illustrate that methodical diagnosis in addition to the order of treatment do indeed matter. In the first case, there was AS and an underestimated LVOT gradient that was also present. Once the AS was corrected, the true LVOT gradient potential was evidenced and she decompensated, likely because there was a rapid decrease in afterload. Patients with concomitant LVOTO are not able to adjust quickly to the hemodynamic changes created by the rapid decline in afterload, as, for example, in HOCM patients who receive nitroglycerin. The second case demonstrated that when the LVOTO was severe and the AS nonsignificant (mild or moderate), the patient was able to live without symptoms for several years after successful alcohol septal ablation (ASA). She eventually needed an aortic valve and mitral valve replacement but that was postponed for several years until the AS became more significant, and the surgical risk was lowered by the elimination of the need for concomitant myectomy. In the last case, the patient was able to have both an ASA and TAVR within 3 months of each other without hemodynamic compromise. Indeed, this latter therapy sequence may be the best way to treat patients with both diseases in the future, as both ASA and TAVR continue to evolve into intermediate and lower-risk patient populations and the safety of ASA continues to be evident.
患有主动脉瓣狭窄（AS）和左心室流出道梗阻（LVOTO）的患者所面临的困境在临床实践中如今已很常见；实际上，医生必须了解这两种疾病的复杂相互作用和共存性质，尤其是肥厚型梗阻性心肌病（HOCM）和经导管主动脉瓣置换术（TAVR）的知晓度和患病率都有所增加的情况下。重要的是，临床医生必须了解这两种疾病在血流动力学方面的复杂相互作用，它们会使经胸超声心动图（TTE）成像结果混淆，并可能在解剖学和临床上相互影响。对于如何从外科手术或经皮介入的角度处理这种情况，目前尚无既定的指南，但我们已列出了一套建议，这对临床医生和患者都应该很有帮助。所呈现的三个病例表明，除了治疗顺序外，有条不紊的诊断确实很重要。在第一个病例中，存在AS且左心室流出道梯度被低估。一旦AS得到纠正，左心室流出道真正的梯度潜力就显现出来，患者出现失代偿，可能是因为后负荷迅速降低。合并LVOTO的患者无法迅速适应后负荷快速下降所带来的血流动力学变化，例如接受硝酸甘油治疗的HOCM患者。第二个病例表明，当LVOTO严重而AS不显著（轻度或中度）时，患者在成功进行酒精室间隔消融术（ASA）后能够无症状地生活数年。她最终需要进行主动脉瓣和二尖瓣置换，但这被推迟了数年，直到AS变得更严重，并且由于无需同时进行心肌切除术，手术风险降低。在最后一个病例中，患者能够在彼此相隔3个月内先后进行ASA和TAVR，且没有血流动力学损害。实际上，随着ASA和TAVR不断向中低风险患者群体发展，并且ASA的安全性持续显现，后一种治疗顺序可能是未来治疗这两种疾病患者的最佳方法。
