Institute of Cardiovascular Science, University College London, London, UK.
Great Ormond Street Hospital for Children, London, UK.
Eur J Cardiothorac Surg. 2018 Jun 1;53(6):1237-1243. doi: 10.1093/ejcts/ezx458.
Surgical strategies to treat drug refractory left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy include septal myectomy (SM) and, less frequently, mitral valve (MV) repair or replacement. The primary aim of this study was to report the surgical technique and management outcomes in a consecutive group of patients with variable phenotypes of hypertrophic cardiomyopathy in a broad national specialist practice.
A total of 203 consecutive patients, 132 men (mean age 48.6 ± 14.6 years) underwent surgery for the management of LVOTO. Surgical approaches included SM (n = 159), SM with MV repair (n = 25), SM with MV replacement (n = 9) and MV replacement alone (n = 10). Specific surgical approaches were performed based on the underlying mechanism of obstruction. Eleven (5.4%) patients had previous alcohol septal ablation for the management of LVOTO. Concomitant non-mitral cardiac procedures were carried out in 22 (10.8%) patients.
Operative survival rate was 99.0% with 2 deaths within 30 days. The mean bypass time was 92.9 ± 47.8 min, with a mean length of hospital stay of 10.5 ± 7.8 days. Surgical complications included 3 ventricular septal defects requiring repair (1.5%), 1 Gerbode defect surgically repaired, 2 aortic valve repairs (1.0%), 2 transient ischaemic attacks (1.0%) and 4 strokes (2.0%). Thirty-nine (19.2%) patients had perioperative new-onset atrial fibrillation and 8 (3.9%) patients had unexpected atrioventricular block requiring a permanent pacemaker. Mean resting left ventricular outflow tract gradient improved from 70.6 ± 40.3 mmHg preoperatively to 11.0 ± 10.5 mmHg at 1 year postoperatively (P < 0.001). Mean New York Heart Association class improved from 2.6 ± 0.5 preoperatively to 1.6 ± 0.6 at 1 year after the procedure.
In variable phenotypes of LVOTO in hypertrophic cardiomyopathy, an individualized surgical approach provided effective reductions in left ventricular outflow tract gradients and good symptomatic relief with acceptable mortality and morbidity.
治疗肥厚型心肌病药物难治性左心室流出道梗阻（LVOTO）的手术策略包括室间隔心肌切除术（SM），以及较少见的二尖瓣（MV）修复或置换。本研究的主要目的是报告在广泛的国家专科实践中，一组具有不同表型的肥厚型心肌病患者的连续病例中，手术技术和管理结果。
共有 203 例连续患者（132 例男性，平均年龄 48.6±14.6 岁）接受手术治疗 LVOTO。手术方法包括 SM（n=159）、SM 联合 MV 修复（n=25）、SM 联合 MV 置换（n=9）和 MV 单独置换（n=10）。具体手术方法根据梗阻的潜在机制进行选择。11 例（5.4%）患者因 LVOTO 行酒精室间隔消融术。22 例（10.8%）患者同时行非二尖瓣心脏手术。
手术存活率为 99.0%，术后 30 天内死亡 2 例。平均体外循环时间为 92.9±47.8 分钟，平均住院时间为 10.5±7.8 天。手术并发症包括 3 例需要修补的室间隔缺损（1.5%）、1 例 Gerbode 缺损修补、2 例主动脉瓣修复（1.0%）、2 例短暂性脑缺血发作（1.0%）和 4 例中风（2.0%）。39 例（19.2%）患者术后新发心房颤动，8 例（3.9%）患者出现意外房室传导阻滞，需要植入永久性起搏器。术前平均静息左心室流出道梯度为 70.6±40.3mmHg，术后 1 年降至 11.0±10.5mmHg（P<0.001）。术前纽约心脏协会（NYHA）心功能分级平均为 2.6±0.5，术后 1 年降至 1.6±0.6。
在肥厚型心肌病的不同 LVOTO 表型中，个体化手术方法可有效降低左心室流出道梯度，显著改善症状，且死亡率和发病率可接受。
