肥厚型梗阻性心肌消融.pptVIP

肥厚型梗阻性心肌病的化学消融术Percutaneous Transluminal Septal Myocardial Ablation of HypertrophicObstructive Cardiomyopathy 胡奉环 阜外心血管病医院 冠心病中心 Etiology of Hypertrophic Cardiomyopathy (HCM) Hypertrophic cardiomyopathy (HCM) is inherited as a Mendelian autosomal dominant trait. Estimated prevalence of 0.2% (0.16% in China). It is caused by mutations in 11 genes coding for sarcomeric proteins . Pathophysiology of HCM Ventricular hypertrophy Left Ventricular Outflow （LVOT）Pressure Gradient（PG) Diastolic dysfunction Arrhythmia Myocardial ischemia LVOTPG Left Ventricular Outflow Tract（LVOT） Pressure Gradient (PG) are produced by Apposition with the ventricular septum. Systolic anterior motion (SAM) of the mitral valve. LVOTPG SAM现象 流出道压差 Therapy β-Blockers Verapamil Disopyramide Septal myectomy PTSMA DDD Pacing ICD Primary/secondary prevention of high-risk Sudden Death. Therapy PTSMA：适于瓣下或室中部梗 阻的肥厚型心肌病患者，效果肯定，具有创伤小、花费时间短等特点。但不适于合并瓣膜病和严重肥厚者（30mm） 外科治疗（改良MORROW术）缓解梗阻彻底，适于合并瓣膜病等复杂病例。但创伤大，需体外循环 Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) Sigwart was the first to report a successful nonsurgical myocardial reduction after occlusion of the septal branch using 96% alcohol. PTSMA aims directly to reduce the hypertrophied interventricular septum with associated expansion of the LVOT and reduction of the subaortic gradient. Indications Symptomatic HCM patients with a NYHA class of at least Ⅲ despite of optimal therapy. Patients with substantial side-effects of medication high outflow tract gradients (≥50mmHg at rest or≥100mmHg under stress) can be verified. 术前评估 临床症状：头晕、黑蒙、运动耐量低、心绞痛 Echo MRI CAG 核素心肌显像 Holter 激发试验 ECHO 评估 室壁厚度及部位：基底、中部或心尖 流出道梗阻程度：SAM现象和压差 ECHO 评估 LVOTPG (PG=219mmHg) MRI评估 室壁厚度及部位 流出道宽度 激发试验—隐匿性梗阻 证实了激发试验全性和有效性。 区分梗阻类型（静息型和潜在型)。 明确介入和外科治疗适应证。 冠脉造影：评估冠脉病变和间隔支 左心室造影评估 评估梗阻部位和测压 流出道最窄处距主动脉瓣约25mm压差80mmHG LVOTPG 靶间隔支的确定 PTSMA操作技术的关键是确定靶间隔支。 间隔支的大小及分布变异很大，20%的患者第1间隔支供应右心室的游离壁；40%的患者瓣下室间隔不是完全由第1间隔支供应，5%的患者不能确定靶间隔区域。 室间隔由多个细小间隔支供应的操作难度较大。 冠脉