Lakkis N M, Nagueh S F, Kleiman N S, Killip D, He Z X, Verani M S, Roberts R, Spencer W H
Baylor College of Medicine, Department of Medicine, Cardiology Section, Houston, Tex., USA.
Circulation. 1998 Oct 27;98(17):1750-5. doi: 10.1161/01.cir.98.17.1750.
Left ventricular outflow tract (LVOT) obstruction is frequently responsible for symptoms in hypertrophic obstructive cardiomyopathy (HOCM). Medical therapy is often not sufficient to control these symptoms, and surgical myotomy-myomectomy is required.
We enrolled 33 symptomatic patients with HOCM and obstruction (>/=40 mm Hg gradient at rest or >/=60 mm Hg dobutamine-provoked). By contrast echocardiography, the bulging septum was localized and infarcted by injection of 2 to 5 mL of absolute ethanol into the septal artery(ies) supplying the hypertrophied area. Baseline echocardiograms with Doppler, myocardial perfusion tomograms, and treadmill exercise or pharmacological testing were compared with those at 6 weeks and 6 months. The mean rise in creatine kinase was 1964+/-796 U. All patients experienced symptomatic relief; NYHA class decreased from 3. 0+/-0.5 to 0.9+/-0.6 (P<0.001). Exercise time increased from 286+/-193 to 421+/-181 seconds (P=0.03). The resting and dobutamine-provoked gradient decreased from 49+/-33 and 96+/-34 mm Hg to 9+/-19 (P<0.001) and 24+/-31 mm Hg (P<0.001), respectively. Echocardiograms repeated at 6 weeks after the procedure showed a 28% reduction in septal thickness and 17% reduction in left ventricular mass. Myocardial perfusion imaging showed a "septal amputation pattern," with scarring in the upper and middle septal areas. Complete heart block developed in 11 patients, who then required permanent pacemaker implantation.
Echocardiography-guided ethanol septal reduction in patients with HOCM is a safe, minimally invasive procedure that provides symptomatic relief with improved hemodynamic and left ventricular parameters.
左心室流出道（LVOT）梗阻是肥厚性梗阻性心肌病（HOCM）患者出现症状的常见原因。药物治疗往往不足以控制这些症状，因此需要进行外科心肌切开-心肌切除术。
我们纳入了33例有症状的HOCM梗阻患者（静息时压差≥40 mmHg或多巴酚丁胺激发时压差≥60 mmHg）。通过对比超声心动图，确定肥厚的室间隔部位，然后向供应肥厚区域的间隔动脉内注射2至5 mL无水乙醇使其梗死。将基线多普勒超声心动图、心肌灌注断层扫描以及平板运动试验或药物试验结果与术后6周和6个月时的结果进行比较。肌酸激酶平均升高1964±796 U。所有患者症状均得到缓解；纽约心脏协会（NYHA）心功能分级从3.0±0.5降至0.9±0.6（P<0.001）。运动时间从286±193秒增加至421±181秒（P=0.03）。静息和多巴酚丁胺激发时的压差分别从49±33 mmHg和96±34 mmHg降至9±19 mmHg（P<0.001）和24±31 mmHg（P<0.001）。术后6周复查超声心动图显示室间隔厚度减少28%，左心室质量减少17%。心肌灌注成像显示“室间隔截断模式”，即室间隔上部和中部出现瘢痕。11例患者发生完全性心脏传导阻滞，随后需要植入永久性起搏器。
超声心动图引导下对HOCM患者进行乙醇室间隔消融术是一种安全的微创手术，可缓解症状，改善血流动力学和左心室参数。
