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| 局限型主动脉瓣下狭窄的狭窄切除并伴或不伴间隔肌肉切开术的作用 |
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| The role of enucleation with or without septal myectomy for discrete subaortic stenosis |
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| Hirata Y, Chen JM, Quaegebeur JM 2009/10/10 12:21:37 |
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| J Thorac Cardiovasc Surg, 2009, |
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| View at Publisher |
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Objective:
Substantial controversy persists regarding the need and efficacy of a routine myectomy in the treatment of discrete subaortic stenosis. Although some believe myectomy more effectively relieves subaortic narrowing, this is uncertain, and complications, including heart block and aortic valve injury, are concerns. The aims of the study were as follows: (1) to analyze the role of enucleation for relief of subaortic stenosis and the risk factors associated with recurrence and reoperation and (2) to delineate the characteristics of the patients who might benefit from enucleation alone.
Methods:
From January 1990 through May 2007, 221 patients with subaortic stenosis underwent biventricular repair. Of those, 106 patients had discrete subaortic stenosis. The preoperative peak left ventricular outflow tract gradient, as determined by means of transthoracic echocardiographic analysis, was 67.3±29mmHg. Forty patients had previous operations for other intracardiac anomalies. Mean age at repair was 7 years. Sixty-one patients underwent isolated enucleation, and 45 patients underwent concomitant myectomy. Patients with recurrent subaortic stenosis whose first operation was performed elsewhere were excluded from analysis.
Results:
There was 1 early death and 1 late death. The postoperative peak left ventricular outflow gradient decreased to 12.5±12.9mmHg (P<.001). No patient had development of heart block or required a pacemaker. A recurrent gradient of greater than 30mmHg was found in 26 (27%) patients, and 8 (7.5%) patients had reoperations. Actuarial freedom from reoperation rates at 5, 10, and 15 years were 94.7%±1.8%, 89.6%±3.5%, and 84.8%±4.9%, respectively. Of those patients who had not undergone a previous cardiac operation, there were no significant differences in the rates of recurrence (28% vs 27%) or reoperation (4.7% vs 4.4%) between the enucleation group and the concomitant myectomy group. For the patients who had a previous cardiac operation, the concomitant myectomy group had a significantly lower rate of recurrence (44% for enucleation vs 13% for enucleation plus myectomy, P=.031).
Conclusions:
For those patients undergoing primary operations for discrete subaortic stenosis, routine myectomy does not offer superior relief of left ventricular outflow tract obstruction; enucleation alone provides good results in this selected population. However, in those patients with associated cardiac anomalies, concomitant additional myectomy is recommended. |
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 疾病资源中心
病例分析 [栏目介绍]
王燕燕 王曙
上海交通大学附属瑞金医院内分泌科
患者，女，69岁。2009年1月无明显诱因下出现乏力，当时程度较轻，未予以重视。2009年3月患者乏力症状加重，尿色逐渐加深，大便习惯改变，颜色变淡。4月18日入我院感染科治疗，诉轻度头晕、心慌，体重减轻10kg。无肝区疼痛，无发热，无腹痛、腹泻、腹胀、里急后重，无恶性、呕吐等。入院半月前于外院就诊，查肝功能：ALT 601IU/L，AST 785IU/L，TBIL 97.7umol/L，白蛋白 41g/L，甲状腺功能：游离T3 30.6pmol/L，游离T4 51.9pmol/L，心电图示快速房颤。
医学数据库
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