Hypertrophic Cardiomyopathy Center at Lahey Hospital and Medical Center, Burlington, Massachusetts.
Department of Internal Medicine, Tufts Medical Center, Boston, Massachusetts.
Am J Cardiol. 2022 Sep 15;179:70-73. doi: 10.1016/j.amjcard.2022.05.032. Epub 2022 Jul 11.
Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) and is an important cause of morbidity and embolic stroke. The impact of outflow obstruction and the influence of surgical septal myectomy on the development of new-onset AF has not been well described. Consecutive patients with HCM without previous AF were followed for 5.0 ± 3.6 years for new-onset AF, including 717 with obstruction who did not undergo surgical myectomy (outflow gradients ≥30 mm Hg at rest or after provocation), 555 with nonobstructive HCM (outflow gradients <30 mm Hg), and 503 who underwent surgical myectomy. Patients with obstructive HCM who did not undergo myectomy had a 1.5-fold increased risk for new-onset AF compared with nonobstructive HCM (26% vs 16% at 10 years, hazard ratio = 0.69, p = 0.02). Patients who underwent myectomy had more advanced heart failure (95% vs 18% New York Heart Association class III, p <0.001) and had larger left atrium dimension (42 ± 7 vs 41 ± 7 mm; p <0.01) as compared with patients with obstructive HCM who did not undergo myectomy. However, after myectomy, the risk of new-onset AF was significantly lower than nonoperated obstructive (17% vs 26% at 10 years, p = 0.04) and no different from the risk of AF in patients with nonobstructive HC (hazard ratio 0.95, p = 0.81). In conclusion, patients with HCM with outflow obstruction are at a higher risk for AF compared with patients with nonobstructive HCM. However, after surgical myectomy, the risk for new-onset AF is substantially reduced. In addition to the known benefits of myectomy to permanently relieve outflow tract obstruction and mitral regurgitation, reverse heart failure symptoms, and increase longevity, myectomy is now shown to decrease susceptibility to AF in HCM.
心房颤动（AF）是肥厚型心肌病（HCM）中最常见的持续性心律失常，也是发病率和栓塞性中风的重要原因。流出道梗阻的影响以及外科室间隔心肌切除术对新发 AF 的影响尚未得到很好的描述。连续的无既往 AF 的 HCM 患者接受了 5.0±3.6 年的新发 AF 随访，包括 717 例未接受外科心肌切除术的梗阻患者（静息或激发后流出梯度≥30mmHg），555 例非梗阻性 HCM 患者（流出梯度 <30mmHg）和 503 例接受外科心肌切除术的患者。与非梗阻性 HCM 相比，未接受心肌切除术的梗阻性 HCM 患者新发 AF 的风险增加了 1.5 倍（10 年时为 26% vs 16%，风险比=0.69，p=0.02）。接受心肌切除术的患者心力衰竭更为严重（95% vs 18%纽约心脏协会心功能分级 III，p <0.001），左心房内径更大（42±7 vs 41±7mm；p <0.01）与未接受心肌切除术的梗阻性 HCM 患者相比。然而，手术后新发 AF 的风险明显低于未手术的梗阻性患者（10 年时为 17% vs 26%，p=0.04），与非梗阻性 HCM 患者的 AF 风险无差异（风险比 0.95，p=0.81）。总之，与非梗阻性 HCM 患者相比，HCM 伴流出道梗阻的患者发生 AF 的风险更高。然而，手术后新发 AF 的风险显著降低。除了心肌切除术可永久性缓解流出道梗阻和二尖瓣反流、逆转心力衰竭症状和延长寿命等已知益处外，心肌切除术还可降低 HCM 患者发生 AF 的易感性。
