CAJ | 학술논문

目的：总结行改良扩大Morrow手术治疗肥厚型梗阻性心肌病（HOCM）术后主要合并症，探讨影响预后的主要因素。方法：回顾性分析2012-06至2014-07阜外心血管病医院由单一术者实施外科手术治疗的HOCM患者139例，男性87例、女性52例，年龄10～67（43.45±14.65）岁，体重26～105（66.46±13.94） kg，术前左心室流出道峰值压差（LVOTGP）为50~270（84.48±44.75）mmHg（1 mmHg=0.133 kPa）。全组均在全麻低温体外循环下行改良扩大Morrow手术，根据术前已知的心脏合并疾病，必要时同期行相应的手术治疗。围术期常规行心脏超声心动图、心电图及X线胸片检查，评价超声心动图检查指标、二尖瓣的结构和功能改变。随访1~24个月。结果：全组无围术期或远期死亡。本组单纯行改良扩大Morrow手术73例（73/139，53%），行改良扩大Morrow手术合并其他手术66例（66/139，47.5%），包括冠状动脉旁路移植术24例，二尖瓣成形术15例，二尖瓣置换术7例，三尖瓣成形术10例，主动脉瓣置换术2例，经胸心脏射频改良迷宫术3例，右心室流出道疏通2例，主动脉瓣下隔膜切除2例，室壁瘤切除术1例。全组机械通气时间8~396（24.05±36.74）h，术后住重症监护病房时间1~27（2.85±3.18）d，术后住院时间5~35（10.11±4.57）d，术后心律失常108例，胸腔积液25例，二次插管1例，气管切开1例，床旁血液滤过治疗1例，主动脉内球囊反搏1例，二次转入重症监护病房3例，无气胸、无二次开胸探查及二次手术。术后左心房内径、左心室流出道峰值压差、室间隔厚度、左心室射血分数与术前比较均减小或降低。二尖瓣关闭好或仅有轻度反流，二尖瓣前向运动基本消失。重症监护病房延时的主要因素为年龄≥55岁，体外循环时间≥120 min，升主动脉阻断时间≥90 min，合并心律失常以及合并右心功能不全。远期随访患者症状消失或仅有轻度症状，生活质量明显改善，心功能Ⅰ~Ⅱ级，无远期死亡、并发症或再次手术。结论：改良扩大Morrow手术治疗HOCM具有良好的手术效果及近远期生存率，同期实施其他手术并未增加并发症及病死率，影响预后的主要因素为高龄、手术时间长、术后难治性心律失常以及合并右心功能不全，围术期采取有效措施尽早纠正心律失常及预防并改善右心功能具有重要意义。目的：總結行改良擴大Morrow手術治療肥厚型梗阻性心肌病（HOCM）術後主要閤併癥，探討影響預後的主要因素。方法：迴顧性分析2012-06至2014-07阜外心血管病醫院由單一術者實施外科手術治療的HOCM患者139例，男性87例、女性52例，年齡10～67（43.45±14.65）歲，體重26～105（66.46±13.94） kg，術前左心室流齣道峰值壓差（LVOTGP）為50~270（84.48±44.75）mmHg（1 mmHg=0.133 kPa）。全組均在全痳低溫體外循環下行改良擴大Morrow手術，根據術前已知的心髒閤併疾病，必要時同期行相應的手術治療。圍術期常規行心髒超聲心動圖、心電圖及X線胸片檢查，評價超聲心動圖檢查指標、二尖瓣的結構和功能改變。隨訪1~24箇月。結果：全組無圍術期或遠期死亡。本組單純行改良擴大Morrow手術73例（73/139，53%），行改良擴大Morrow手術閤併其他手術66例（66/139，47.5%），包括冠狀動脈徬路移植術24例，二尖瓣成形術15例，二尖瓣置換術7例，三尖瓣成形術10例，主動脈瓣置換術2例，經胸心髒射頻改良迷宮術3例，右心室流齣道疏通2例，主動脈瓣下隔膜切除2例，室壁瘤切除術1例。全組機械通氣時間8~396（24.05±36.74）h，術後住重癥鑑護病房時間1~27（2.85±3.18）d，術後住院時間5~35（10.11±4.57）d，術後心律失常108例，胸腔積液25例，二次插管1例，氣管切開1例，床徬血液濾過治療1例，主動脈內毬囊反搏1例，二次轉入重癥鑑護病房3例，無氣胸、無二次開胸探查及二次手術。術後左心房內徑、左心室流齣道峰值壓差、室間隔厚度、左心室射血分數與術前比較均減小或降低。二尖瓣關閉好或僅有輕度反流，二尖瓣前嚮運動基本消失。重癥鑑護病房延時的主要因素為年齡≥55歲，體外循環時間≥120 min，升主動脈阻斷時間≥90 min，閤併心律失常以及閤併右心功能不全。遠期隨訪患者癥狀消失或僅有輕度癥狀，生活質量明顯改善，心功能Ⅰ~Ⅱ級，無遠期死亡、併髮癥或再次手術。結論：改良擴大Morrow手術治療HOCM具有良好的手術效果及近遠期生存率，同期實施其他手術併未增加併髮癥及病死率，影響預後的主要因素為高齡、手術時間長、術後難治性心律失常以及閤併右心功能不全，圍術期採取有效措施儘早糾正心律失常及預防併改善右心功能具有重要意義。
목적：총결행개량확대Morrow수술치료비후형경조성심기병（HOCM）술후주요합병증，탐토영향예후적주요인소。방법：회고성분석2012-06지2014-07부외심혈관병의원유단일술자실시외과수술치료적HOCM환자139례，남성87례、녀성52례，년령10～67（43.45±14.65）세，체중26～105（66.46±13.94） kg，술전좌심실류출도봉치압차（LVOTGP）위50~270（84.48±44.75）mmHg（1 mmHg=0.133 kPa）。전조균재전마저온체외순배하행개량확대Morrow수술，근거술전이지적심장합병질병，필요시동기행상응적수술치료。위술기상규행심장초성심동도、심전도급X선흉편검사，평개초성심동도검사지표、이첨판적결구화공능개변。수방1~24개월。결과：전조무위술기혹원기사망。본조단순행개량확대Morrow수술73례（73/139，53%），행개량확대Morrow수술합병기타수술66례（66/139，47.5%），포괄관상동맥방로이식술24례，이첨판성형술15례，이첨판치환술7례，삼첨판성형술10례，주동맥판치환술2례，경흉심장사빈개량미궁술3례，우심실류출도소통2례，주동맥판하격막절제2례，실벽류절제술1례。전조궤계통기시간8~396（24.05±36.74）h，술후주중증감호병방시간1~27（2.85±3.18）d，술후주원시간5~35（10.11±4.57）d，술후심률실상108례，흉강적액25례，이차삽관1례，기관절개1례，상방혈액려과치료1례，주동맥내구낭반박1례，이차전입중증감호병방3례，무기흉、무이차개흉탐사급이차수술。술후좌심방내경、좌심실류출도봉치압차、실간격후도、좌심실사혈분수여술전비교균감소혹강저。이첨판관폐호혹부유경도반류，이첨판전향운동기본소실。중증감호병방연시적주요인소위년령≥55세，체외순배시간≥120 min，승주동맥조단시간≥90 min，합병심률실상이급합병우심공능불전。원기수방환자증상소실혹부유경도증상，생활질량명현개선，심공능Ⅰ~Ⅱ급，무원기사망、병발증혹재차수술。결론：개량확대Morrow수술치료HOCM구유량호적수술효과급근원기생존솔，동기실시기타수술병미증가병발증급병사솔，영향예후적주요인소위고령、수술시간장、술후난치성심률실상이급합병우심공능불전，위술기채취유효조시진조규정심률실상급예방병개선우심공능구유중요의의。
Objective: To summarize the major post-operative complication of modiifed extended Morrow procedure in patients with hypertrophic obstructive cardiomyopathy (HOCM) and to explore the major factors affecting its prognosis. Methods: We retrospectively analyzed 139 consecutive HOCM patients who received the procedure by same surgeon in our hospital from 2012-06 to 2014-07. There were 87 male and 52 female patients with the age of (10-67) years, body weightof (26-105) kg and pre-operative left ventricular outlfow tract peak gradient (LVOTPG) of (84.48 ± 44.75) mmHg. Concomitant operations were performed with known cardiac disease as necessary. Pre- and post-operative echocardiography, ECG and chest X-ray were examined to assess the adequacy of resection and mitral valve structure and function. Results: There was no peri-operative death. 73/139 (53%) patients received simple modiifed expanded Morrow procedure, the other 66 (47%) patients received concomitant surgery including 21 patients with coronary artery bypass grafting, 15 mitral valve plasty, 7 mitral valve replacement, 10 tricuspid valve plasty, 2 aortic valve replacement, 3 modiifed Maze procedure, 2 unblock of right ventricular outlfow tract, 2 sub aortic membrane resection, 1 ventricular aneurysm resection. The mechanical ventilation time was (24.05±36.74) hours, post-operative ICU and in-hospital stays were (2.85±3.18) days and (10.11±4.57) days; the complications included arrhythmia in 108 cases, pleural effusion in 25 cases, secondary intubation in 1 case, tracheotomy in 1 case, hemoifltration in 1 case, intra-aortic balloon pump in 1 case, back into ICU in 3 cases; no pneumothorax, secondary thoracotomy/operation. The post-operative left atrial diameter, LVOTPG, inter-ventricular septal thickness and LVEF were all decreased; mitral valve closed well or with mild regurgitation, systolic anterior motion (SAM) basically disappeared. The major factors for delayed ICU stay included age≥55 years, female, CPB time≥120 min, AOC time≥90 min, the patients combining with arrhythmia and right ventricular dysfunction. Late follow-up presented that the patients were almost without the symptoms, NYHA classiifcation at (I-II), no late death, complication or re-operation. Conclusion: Modified expand Morrow procedure has good surgical and short/late post-operative effects, concomitant operation does not increase the complication and mortality; correction of arrhythmia and improving right ventricular function at peri-operative period are important for treating the relevant patients.