Spirito Paolo, Rossi Jessica, Maron Barry J
Hypertrophic Cardiomyopathy Center, Policlinico di Monza, Monza, Italy.
HCM Institute, Division of Cardiology, Tufts Medical Center, Boston, MA, USA.
Ann Cardiothorac Surg. 2017 Jul;6(4):369-375. doi: 10.21037/acs.2017.05.09.
At present, surgical septal myectomy is regarded as the "gold standard" treatment for most patients with obstructive hypertrophic cardiomyopathy (HCM) and drug-refractory symptoms. However, the best results are obtained by those surgeons who have extensive experience with this operation at a small number of referral centers. In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to myectomy to reduce LV outflow gradient and heart failure symptoms in patients with obstructive HCM. However, certain features of alcohol ablation limit its applicability to carefully selected patients. Because this procedure involves the injection of 1-4 mL of 96% ethanol into a septal perforator of the left anterior coronary artery to produce a myocardial infarction (with septal thinning, outflow tract widening and gradient reduction), alcohol ablation is limited by the size and distribution of the septal perforator branches. In addition, rich blood supply from other septal branches not occluded by the balloon and from the posterior descending coronary artery may restrict myocardial ischemia to portions of the septum that do not contribute to outflow obstruction. Septal hypertrophy may be either mild or particularly marked, and abnormalities of mitral valve apparatus may also play a major role in outflow obstruction. When such features are present, alcohol-induced septal thinning is unlikely to significantly reduce the gradient. In addition, persisting uncertainties regarding the risk for ventricular tachyarrhythmias after alcohol ablation suggest this procedure should be limited to patients of advanced age, patients at unacceptable operative risk due to comorbidities, or those with strong aversion to surgery. Further progress in the treatment for patients with obstructive HCM and severe refractory symptoms will come from assuring proper patient selection for alcohol septal ablation, as well as increasing the number of surgeons and centers experienced in performing septal myectomy.
目前，对于大多数有梗阻性肥厚型心肌病（HCM）且药物治疗无效症状的患者，外科室间隔心肌切除术被视为“金标准”治疗方法。然而，只有那些在少数转诊中心对此手术有丰富经验的外科医生才能取得最佳效果。在20世纪90年代中期，经皮酒精间隔消融术被引入作为心肌切除术的替代方法，以降低梗阻性HCM患者的左心室流出道梯度和心力衰竭症状。然而，酒精消融的某些特点限制了其在精心挑选患者中的应用。因为该手术涉及将1 - 4毫升96%的乙醇注入左前冠状动脉的间隔穿支以产生心肌梗死（伴有间隔变薄、流出道增宽和梯度降低），酒精消融受到间隔穿支分支大小和分布的限制。此外，未被球囊阻塞的其他间隔分支以及后降支冠状动脉的丰富血供可能会将心肌缺血限制在对流出道梗阻无影响的间隔部分。间隔肥厚可能较轻或特别明显，二尖瓣装置异常也可能在流出道梗阻中起主要作用。当出现这些特征时，酒精诱导的间隔变薄不太可能显著降低梯度。此外，关于酒精消融后室性心律失常风险仍存在不确定性，这表明该手术应仅限于老年患者、因合并症手术风险不可接受的患者或那些强烈厌恶手术的患者。对于梗阻性HCM和严重难治性症状患者的治疗取得进一步进展将来自确保对酒精间隔消融进行正确的患者选择，以及增加有室间隔心肌切除术经验的外科医生和中心的数量。
