超声心动图监测肥厚梗阻型心肌病经皮冠脉化学消融治疗术的临床意义.doc

超声心动图监测肥厚梗阻型心肌病经皮冠脉化学消融治疗术的临床意义超声心动图监测肥厚梗阻型心肌病经皮冠脉化学消融治疗术的临床意义2011-07-21 何亚乐陈纪言林曙光侯跃双黄新胜冯碧霞许燕李伟茹 【摘要】目的经皮穿隔支室间隔心肌消融(PTSMA)是治疗肥厚梗阻型心肌病的新方法，本文目的是报道超声心动图监测PTSMA的临床价值。方法1例66岁的男性患者药物治疗效果欠佳接受PTSMA术，术前、术中、术后行超声监测。结果消融前导管测左室与流出道的压力差P 60 mmHg，消融第一隔支后P降至25 mmHg。超声术前测峰值压差P 67.2 mmHg，消融后，Doppler即刻显示P动态变化，及时测到P反弹的信息，术后即刻、4小时为34.6 mmHg；第2天75 mmHg，第20天P 23.4 mmHg；病人症状消失。结论PTSMA能有效减除梗阻程度，超声Doppler监测，即时观察目标血管阻断后室壁变薄的部位、范围及其对压差的影响，准确显示压差的动态变化，评价治疗效果和整体收缩功能，对定治疗决策有重要意义。 【关键词】超声监测心肌消融压力阶差 The value of percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy monitored with echocardiography He YaleChen JiyanLin Shuguang （Guangdong Cardiovascular Institute, Guangzhou 510100） 【Abstract】ObjectiveTo report the role of echocardiography in monitoring and assessment of results of the Percutaneous transluminal septal myocardial ablation (PTSMA) which is a new therapeutic method for hypertrophic obstructive cardiomyopathy(HOCM). MethodsPTSMA was performed in a 66 year old man with HOCM who was symptomatic despite adequate drug therapy. Echocardiographic evaluation was performed prior to, during and 4 hours, 1 and 20 days after the procedure. ResultsLeft heart catheterization showed a 60 mmHg pressure gradient (P) across the left ventricular outflow tract (LVOT), first septal branches of the coronary artery were completely blocked by injection of absolute alcohol, the P decreased to 25 mmHg. Doppler echocardiographic measured the P=67.2 mmHg preablation, and decreased significantly as soon as the first septal branch was blocked and then doppler monitored showing the P increased beat by beat. So the proximal segment of this branch was blocked too; P decreased to 34.6 mmHg which last at least 4 hours, 1 days after the P increased to 75 mmHg because hyperdynamic systolic motion of the whole left ventricula walls excepted basical and middle segments of the interventricular septum; P decreased to 23.4 mmHg 20 days after it. The patient felt very well. ConclusionIn the patient with HOCM, PTSMA effec-tually reduced LVOT pressre gradient and septum thickness, each of them may change dynamics. Echocardiography is a useful method to assess these changes and is very important for deciding the treatment. 【Key words】Echocardiographic monitor Pressure gradient Myocardial ablation 用导管技术产生室间隔梗死减少室间隔厚度是1995年Sigwart1首先报道的一种新的治疗肥厚梗阻型心肌病的方法，称为经皮穿隔支室间隔心肌消融，国内甚少开展，超声心动图监测此治疗技术及评价治疗效果的临床价值未见研究报道，我院成功地为1例药物治疗效果不好的病人进行了经皮冠状动脉化学消融术，超声心动图监测了全过程。本文报道术中及术后短期超声改变的特征，探讨其在治疗决策中的临床意义。 对象和方法 一、对象： 患者男性，66岁，反复胸闷胸痛3年，1997年4月确诊为肥厚梗阻型心肌病，服用Betabloc和Diltiazem后症状有所改善。近半年来频繁发作胸闷痛，有时伴晕厥，超声心动图显示室间隔、左室后壁及侧壁增厚，分别为17 mm、24 mm、20 mm，左室流出道流速Vmax 4.26 m/s，瞬间峰值压差P73 mmHg。二尖瓣前叶呈SAM征，返流轻度；左室舒张功能减退，二尖瓣流速E/A 0.42，LVEF 72.5%。 二、方法： 1.导管化学消融方法：经皮穿刺左、右侧股动脉，首先送一普通右心导管入左室腔，自心腔缓慢后撤导管到主动脉并同时记录左室腔、左室流出道、主动脉的连续压力曲线，再把此导管保留在左室内随时用来测压；按常规方法行左右冠状动脉造影，清晰显示供应室间隔的穿隔支；在第一间隔支内置入冠状动脉球囊扩张导管，充张球囊完全阻断血流持续5 min，记录上述压力曲线，如果左室腔与流出道间的压力阶差(P)可下降至少30%时，在此间隔支内注入1 2 mL无水酒精使其永久性闭塞，重复测量压力阶差并观察30 min，治疗有效时可结束导管术；否则应尝试扩大消融范围。做好心脏起搏的静脉穿刺准备。 2. 超声心动图监测方法：术前常规超声检查，术中于冠脉造影后、穿隔支球囊阻断时并持续至抽空后、无水酒精注入后即刻并持续30 min行超声监测，观察室间隔及其他部位的运动情况，测室间隔厚度，连续Doppler测量左室流出道最高流速Vmax及压力阶差，并用录像带记录，过后分析；术后4 h、24 h及第20天超声复查。 结果 一、导管结果： 1.拉管连续测压显示典型的流出道过渡型压力曲线，左室压力165/22 mmHg，流出道压力105/22 mmHg，主动脉压105/60 mmHg，P60 mmHg;导管进入左室腔时诱发室速，回撤至流出道后室速消失，因而导管一直保留在此。 2.有两条穿隔支自前降支发出，球囊阻断第一穿隔支5 min流出道压力上升(P下降)回抽后P升高，