Faber L, Seggewiss H, Fassbender D, Bogunovic N, Strick S, Schmidt H K, Gleichmann U
Kardiologische Klinik Herz-und Diabeteszentrum NRW Universitätsklinik der Ruhr-Universität Bochum.
Z Kardiol. 1998 Mar;87(3):191-201. doi: 10.1007/s003920050171.
In hypertrophic obstructive cardiomyopathy (HOCM) therapy, surgical myectomy and DDD pacemaker implantation are considered to be established extensions to medical treatment. As an alternative procedure for reducing the left ventricular outflow tract gradient (LVOTG), percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion has been introduced. We report on the acute results and the short-term clinical course following 66 PTSMA interventions in symptomatic patients (pts.) with HOCM.
In pts. who were symptomatic despite adequate drug therapy (31 women, 35 men; mean age 52.9 +/- 15.0 years, range: 16-86) 66 PTSMA interventions were performed (4 pts. with a re-intervention). Septal branches were occluded by injection of 3.5 +/- 1.8 (1.5-11.0) ml ethanol (96%). In the first 30 pts. the target vessel was determined by probatory balloon occlusion (PBO) alone, in the following 36 by additional myocardial contrast echocardiography (MCE). In-hospital follow-up of LVOTG and clinical course were determined.
The invasively determined LVOTG could be reduced by > 50% or eliminated in 54 interventions (82%) with a mean reduction from 71.2 +/- 34.4 (4-174) to 18.0 +/- 21.5 (0-105) mmHg at rest and from 145.7 < or = 42.3 (68-257) to 63.7 +/- 49.3 (0-185) mmHg post extrasystole (p < 0.0001). All pts. experienced angina pectoris within the first 24 hours. The creatine kinase peak was 690 +/- 364 (201-1810) U/l after 11.0 +/- 5.4 (4-24) hours. 45 pts. (68%) developed trifascicular block, requiring temporary, or in 9 cases (14%) permanent, (DDD) pacemaker implantation. Two pts. (3%) died 9 and 2 days after successful intervention, due to uncontrollable ventricular fibrillation associated with betasympathomimetic and theophylline treatment for chronic obstructive pulmonary disease in one case, and fulminant pulmonary embolism in the other. The remaining pts. were discharged after 11.1 +/- 4.6 (5-24) days following an uncomplicated hospital course. The introduction of MCE was associated with a higher percentage of short-term success (92% vs. 70%, p < 0.015).
PTSMA in HOCM is a promising non-surgical technique for septal myocardial reduction with a consecutive reduction of the LVOTG. MCE has shown to be a useful addition to PBO for selection of the target vessel. Possible complications are trifascicular blocks requiring permanent pacemaker implantation and tachycardiac rhythm disturbances. Prospective, long-term observations of larger populations and a comparison with the established forms of therapy are necessary in order to determine the definitive significance of PTSMA.
在肥厚性梗阻性心肌病（HOCM）治疗中，外科心肌切除术和DDD起搏器植入被认为是药物治疗的既定延伸。作为降低左心室流出道梯度（LVOTG）的替代方法，已引入通过酒精诱导间隔支闭塞进行的经皮腔内间隔心肌消融术（PTSMA）。我们报告了对有症状的HOCM患者进行66次PTSMA干预后的急性结果和短期临床病程。
在尽管接受了充分药物治疗仍有症状的患者（31名女性，35名男性；平均年龄52.9±15.0岁，范围：16 - 86岁）中进行了66次PTSMA干预（4名患者进行了再次干预）。通过注射3.5±1.8（1.5 - 11.0）ml乙醇（96%）闭塞间隔支。在前30名患者中，仅通过试探性球囊闭塞（PBO）确定靶血管，在随后的36名患者中，通过额外的心肌对比超声心动图（MCE）确定。确定住院期间LVOTG和临床病程。
在54次干预（82%）中，有创测定的LVOTG可降低>50%或消除，静息时平均从71.2±34.4（4 - 174）mmHg降至18.0±21.5（0 - 105）mmHg，早搏后从145.7≤42.3（68 - 257）mmHg降至63.7±49.3（0 - 185）mmHg（p<0.0001）。所有患者在最初24小时内均出现心绞痛。肌酸激酶峰值在11.0±5.4（4 - 24）小时后为690±364（201 - 1810）U/l。45名患者（68%）出现三分支阻滞，需要临时植入起搏器，9例（14%）需要永久植入（DDD）起搏器。2名患者（3%）在成功干预后9天和2天死亡，1例死于与β - 拟交感神经药和茶碱治疗慢性阻塞性肺疾病相关的无法控制的心室颤动，另1例死于暴发性肺栓塞。其余患者在无并发症的住院病程后11.1±4.6（5 - 24）天出院。MCE的引入与更高的短期成功率相关（92%对70%，p<0.015）。
HOCM中的PTSMA是一种有前景的非手术性间隔心肌减容技术，可使LVOTG持续降低。MCE已被证明是PBO选择靶血管的有用辅助手段。可能的并发症是需要永久植入起搏器的三分支阻滞和快速心律失常。为了确定PTSMA的最终意义，有必要对更大规模人群进行前瞻性长期观察并与既定治疗方式进行比较。
