摘要目的 探讨肥厚型梗阻性心肌病(hypertrophic obstructive cardiomyopathy,HOCM)合并中重度二尖瓣反流(mitral regurgitation,MR)的外科治疗策略.方法 收集2014年1月至2017年1月,接受改良Morrow手术的HOCM合并中重度MR患者的临床资料,比较患者手术前、后及术后1年复查结果.结果 所有患者住院期间及术后1年无死亡,均顺利出院,未发生室间隔穿孔、完全性房室传导阻滞等严重并发症.术后1周超声心动图检查结果提示:左心室流出道压差[(93.36±7.93)mmHg对(16.73±2.02)mmHg,1 mmHg=0.133 kPa,P<0.01]、左心室流出道流速[(472.40±22.12)cm/s对(188.40±14.16)cm/s,P<0.01]、室间隔厚度[(19.43±0.77)mm对(16.45±0.76)mm,P<0.01]、二尖瓣结构功能良好、MR面积[(8.41±0.69)cm2对(3.04±0.73)cm2,P<0.01]均较术前显著下降,差异有统计学意义.虽然术后1周超声心动图检查结果提示术后左心室射血分数(LVEF)明显低于术前(0.67±0.07对0.65±0.07,P=0.01),但患者症状明显改善,心功能(NYHA分级)Ⅰ～Ⅱ级.随访患者术后1年超声心动图检查结果提示:左心室流出道压差[(93.36±7.93)mmHg对(16.98±2.33)mm-Hg,P<0.01]、左心室流出道流速[(472.40±22.12)cm/s对(189.33±14.23)cm/s,P<0.01]、室间隔厚度[(19.43±0.77)mm对(16.55±0.83)mm,P<0.01]、二尖瓣结构功能良好、MR面积[(8.41±0.69)cm2对(2.95±0.66)cm2,P<0.01]均较术前显著下降,MR面积显著下降,差异有统计学意义.术后1周与术后1年超声心动图检查结果提示:左心室流出道压差[(16.73±2.02)mmHg对(16.98±2.33)mmHg,P>0.05]、左心室流出道流速[(188.40±14.16)cm/s对(189.33±14.23)cm/s,P>0.05]、室间隔厚度[(16.45±0.76)mm对(16.55±0.83)mm,P>0.05]、MR面积[(3.04±0.73)cm2对(2.95±0.66)cm2,P>0.05],差异无统计学意义,二尖瓣结构及功能良好.术后1年,患者症状改善明显,生活质量明显提高.结论 HOCM常合并MR,改良Morrow手术可充分疏通左心室流出道,进而可消除MR和二尖瓣收缩期前向运动,疗效满意.

abstractsObjective Investigate the therapeutic strategies of hypertrophic obstructive cardiomyopathy ( HOCM ) com-bined with mitral regurgitation(MR).Methods From January 2014 to January 2017, 34 patients with HOCM complicated with moderate to severe MR were enrolled.All patients underwent modified Morrow surgery.Compare the clinical data of pa-tients before and after surgery and the results of one year after surgery .Results There is no patient died during hospitaliza-tion, and all were discharged smoothly without serious complications ( ventricular septal perforation, complete atrioventricular block, etc.) .Results of echocardiography 1 week after surgery suggested: Left ventricular outflow tract pressure difference [(93.36 ±7.93) mmHg vs.(16.73 ±2.02) mmHg,1 mmHg=0.133 kPa, P<0.01], left ventricular outflow tract velocity[(472.40 ±22.12)cm/s vs.(188.40 ±14.16)cm/s, P<0.01], interventricular septal thickness [(19.43 ±0.77) mm vs.(16.45 ±0.76) mm, P<0.01], mitral valve structure and function were good, and MR area [(8.41 ±0.69)cm2 vs. (3.04 ±0.73)cm2, P<0.01], all of which were significantly lower than that before surgery, and the differences were statis-tically significant.Although the results of echocardiography 1 week after surgery indicated that the left ventricular ejection frac-tion(LVEF) was significantly lower than that before surgery(0.67 ±0.07 vs.0.65 ±0.07, P=0.01), the symptoms of the patients were significantly improved, and the cardiac function(NYHA classification) was grade I～II.The results of echocar-diography after 1 year of follow-up suggested that: Left ventricular outflow tract pressure difference [(93.36 ±7.93) mmHg vs.(16.98 ±2.33) mmHg, P<0.01], left ventricular outflow tract velocity [(472.40 ±22.12)cm/s vs.(189.33 ±14.23) cm/s, P<0.01], ventricular septal thickness [(19.43 ±0.77) mm vs.(16.55 ±0.83) mm, P <0.01], mitral valve structure and function well, MR area [(8.41 ±0.69) cm2 vs.(2.95 ±0.66) cm2, P<0.01], and the MR area was signifi-cantly decreased compared with that before operation .The difference was statistically significant .Results of echocardiography 1 week and 1 year after surgery suggest:Left ventricular outflow tract pressure difference [(16.73 ±2.02) mmHg vs.(16.98 ± 2.33) mmHg, P>0.05], left ventricular outflow tract velocity [(188.40 ±14.16)cm/s vs.(189.33 ±14.23)cm/s, P>0.05], ventricular septal thickness [(16.45 ±0.76) mm vs.(16.55 ±0.83) mm, P>0.05], MR area [(3.04 ±0.73) cm2 vs.(2.95 ±0.66) cm2, P>0.05], no statistical significance.One year after the operation, the symptoms and quality of life were significantly improved .Conclusion Hypertrophic obstructive cardiomyopathy often combined with mitral regurgita-tion, modified Morrow operation can fully clear the left ventricular outflow tract, which can eliminate MR and SAM signs, and the results are satisfactory.