美国肥厚型心肌病外科手术(LVOT)技术要领 Septal Myectomy for Hypertrophic Cardiomyopathy-Mayo clinic.pdfVIP

肥厚性心肌病外科手术技术要点（美国 Mayo Clinic）Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy -- Mayo Clinic: Surgical Technique Faculty and Disclosures processing CME Information 1. Summary and Introduction 2. History of Surgical Treatment 3. Indications for Operation 4. Surgical Technique 5. Septal Myectomy: Long-term Results 6. Recurrent LVOTO After Septal Myectomy 7. Septal Myectomy After Alcohol Septal Ablation 8. Conclusions 9. Key Points Surgical Technique Over the past three decades, the technique for septal myectomy used at the Mayo Clinic has evolved from the classic Morrow myotomy and myectomy, to a more extensive left ventricular septal myectomy (Figure 1).[25] Operations are guided by intraoperative transesophageal echocardiography (TEE) with particular attention paid to the septal anatomy and thickness, and mitral valve function. Access is gained through a median sternotomy and direct intracardiac pressures are measured simultaneously in the left ventricle and aorta. If the left ventricular outflow tract (LVOT) gradient is low ( 30 mmHg) because of anesthesia, isoproterenol is administered or premature ventricular contractions are induced to determine the maximal gradient. Standard cardiopulmonary bypass with normothermia or mild hypothermia (32-34 ºC) is used, and during aortic occlusion, the heart is protected by infusion (approximately 1,000 ml) of antegrade cold blood cardioplegia into the aortic root, followed by additional doses administered selectively into the left and right coronary ostia every 10-20 min. A transverse aortotomy is made, carried rightward toward 1 the noncoronary sinus and down to the aortic annulus, and retracted with pledgeted sutures. Optimum visualization of the ventricular septum is facilitated by posterior displacement of the left ventricle