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Medical HEALTH "> Medical Pediatrics Abstract ablation interventional treatment of hypertrophic obstructive cardiomyopathy in 16 cases of nursing rerecommended online full-text collection of this Yellow Jiangxi Gannan Chung Mei Yan Xiaoyan First Affiliated Hospital of Medical College Internal Medicine, Jiangxi 341000, China, "Journal of Chronic Diseases" 2010 Volume 12 No. 2 fast-food prizes Report Summary: Objective: hypertrophic obstructive cardiomyopathy percutaneous septal myocardial ablation points Care. Methods: Retrospective analysis of percutaneous transluminal septal myocardial ablation in 16 cases of hypertrophic obstructive cardiomyopathy data, focusing on preoperative and postoperative physical and psychological care and observation of the disease. Results: 16 patients with hypertrophic obstructive cardiomyopathy after a careful treatment and care, were cured and discharged without serious complications. Conclusion: Preoperative psychological care, health education, postoperative myocardial enzyme monitoring, ECG monitoring, oxygen therapy is a reasonable rehabilitation of patients with an important guarantee. Number of pages: 2 Page Range :183-184 Key words: Cardiomyopathy, Hypertrophic / surgery / care catheter ablation subject classification: R725.422.04 [medicine, HEALTH "Pediat Pediatric within SCIENCES" Pediatric Cardiology, vascular diseases] Related articles: subject
Diagnosis: For the obstructive HCM, the diagnosis is mainly based on clinical pr


esentation and characteristic systolic murmur left sternal border. Echocardiography is extremely important non-invasive diagnostic methods. In addition, there are many diagnostic value of physical examination techniques, the most significant is suddenly upright from squatting after the hemodynamic changes. Squatting can increase venous return, aortic pressure rise and the increase in ventricular volume, reduced left ventricle and outflow tract pressure gradient, so that the noise mitigation, and suddenly upright with the opposite effect, causing outflow tract obstruction can be enhanced, noise enhancement; addition Valsa . [show] Diagnosis: For the obstructive HCM, the diagnosis is mainly based on clinical presentation and characteristic systolic murmur left sternal border. Echocardiography is extremely important non-invasive diagnostic methods. In addition, there are many diagnostic value of physical examination techniques, the most significant is suddenly upright from squatting after the hemodynamic changes. Squatting can increase venous return, aortic pressure rise and the increase in ventricular volume, reduced left ventricle and outflow tract pressure gradient, so that the noise mitigation, and suddenly upright with the opposite effect, causing outflow tract obstruction can be enhanced, noise enhancement; addition Valsalva action would also make the noise enhancement. Of coronary heart disease symptoms or similar symptoms, especially in young patients, with characteristic ECG changes, echocardiography and cardiovascular imaging, etc. can make a diagnosis. Positive family history is also helpful in the diagnosis.
Laboratory tests: endomyocardial biopsy: fluorescence immunoassay method found in catecholamine levels increased left ventricular hypertrophy. Histologic findings of myocardial hypertrophy disordered singular Department of hypertrophic cardiac cells.
Other laboratory examinations:
1. The most common abnormalities in ECG left ventricular hypertrophy and ST-T changes, deep inverted T waves, sometimes very similar to the "coronal T", if found in young patients with hypertrophic cardiomyopathy should be vigilant. Atrioventricular block and bundle branch block are more common, abnormal Q wave was 30% to 50%, large and deep Q waves may appear in the chest left ventricular leads, but also can occur in any limb on the lead. Presence or absence of Q wave and the degree of obstruction has little, Q wave generating mechanism is not very clear, but the arrangement of myocardial fiber disorders, fibrosis, degeneration, heart electrical activity in the septum and left ventricular abnormal pathways are abnormal Q waves may be the reason.
2. Echocardiography
(1) ventricular septal hypertrophy, septal activity is poor, smaller ventricular chamber, left ventricular systolic diameter narrowing, septal and left ventricular free wall thickness r 1.3 to 1. (2) left ventricular outflow tract obstruction, generally <20mm.
(3) mitral valve is often moved forward in the systolic and ventricular hypertrophy in . The systolic forward began the first 1 / 3 of the end of the contraction in the 1 / 3 were platform-like and ventricular septal , the formation of outflow tract obstruction, and in the contraction of the last 1 / 3 back in place.
(4) early diastolic mitral valve opening, anterior septal s again, and in the diastolic mitral valve and the interventricular septum when the distance between the smaller than normal.
(5), aortic valve closure in early systole, isovolumic relaxation time prolonged, which reflects the reduced ventricular compliance in.
3.X-ray examination the heart slightly increased, mainly by left ventricular and left atrium can also be expanded.
4. Left ventricular angiography showed reduced left ventricular cavity deformation, was S-shaped subaortic stenosis, ventricular wall thickening, irregular thickening of the ventricular heart chamber broke into the left atrium may also develop. Ventriculography in addition to the above phenomenon, the heart shadow can still display a different form, as subaortic hypertrophy, apical hypertrophy, in the middle Ministry of hypertrophic and so on.

[Hide] treatment options: edit this paragraph back catalog, including both therapeutic principles: relieve symptoms include: palpitations, dizziness, shortness of breath, chest pain, etc., should improve heart failure and hemodynamic effects; prevention of sudden death : Asymptomatic, such as ventricular septal hypertrophy is not obvious, normal ECG and no obstructive symptoms at rest, no history of syncope, can be followed up without special treatment. 1. General treatment (1) to avoid intense physical activity or emotional excitement, even if the rest had no significant obstruction of the patient, emotional or physical labor, they may be . [show] principles of treatment consists of two aspects: mitigation Symptoms include: palpitations, dizziness, shortness of breath, chest pain, etc., should improve heart failure and hemodynamic effects; prevention of sudden death: the asymptomatic, such as ventricular septal hypertrophy is not obvious, normal ECG, and resting No obstructive symptoms and no history of syncope, can be followed up without special treatment.
1. General treatment
(1) to avoid intense physical activity or emotional excitement, even if the rest had no significant obstruction of the patient, emotional or physical labor, they may appear or existing symptoms of obstructive obstructive symptoms.
(2) reduce the heart caution before and after the load of drugs and measures, this is different from other heart diseases, especially when heart failure occurs when the digitalis preparations and diuretics to enhance ventricular contractility and blood volume reduction, anti- ventricular obstruction may be aggravated, if the rapid ventricular rate of heart failure have atrial fibrillation, can be used digitalis.
2. Medical therapy
(1) -blockers remain the drug of choice treatment HCM, cardiac patients due to the high sensitivity of catecholamine, -blockers can block the effects of catecholamines, decreased myocardial contractility and by slowing the heart rate, prolong diastolic filling period, increased diastolic volume, reduce the left ventricular outflow tract obstruction and the prevention, treatment of arrhythmias. In addition, -blockers can slow down the heart rate, prolong diastolic ventricular filling, and a negative inotropic effect through the reduction of myocardial oxygen consumption, it can effectively relieve angina pectoris in patients with dyspnea and improve exercise tolerance and prevents movement of the outflow tract obstruction associated with the increase, especially for obstructive HCM. According to statistics, -blockers can make 33% to 50% improvement in symptoms of patients to propranolol (Inderal) the longest application history can be self-30mg / d, the gradually increased to 120mg / d , or until the resting heart rate of not less than 60 times / min for the maximum effective dose, to maintain applications, to 2 years often see patients. In recent years there metoprolol (25 ~ 100mg / d) reversal of cardiac hypertrophy.
(2) calcium channel blockers: is the treatment of symptomatic hypertrophic cardiomyopathy important drug. The drug selectively inhibit the cell membrane Ca2 influx, reduced utilization of intracellular Ca2 and membrane and Ca2 binding force, to reduce intracellular calcium overload and reduce the consumption of ATP in myocardial cells, interference excited contraction coupling, inhibition of myocardial contraction, improve left ventricular diastolic function and regional wall motion of the non-synchronization, reduce subendocardial ischemia, which will help reduce the left ventricular outflow tract obstruction, lower left ventricular outflow tract pressure gradient, long-term use may be a good effect. Calcium channel blockers verapamil in the most commonly used. When -blockers is not valid, the use of verapamil for 60% of the patients improved the symptoms get better, which is better verapamil reduce outflow tract obstruction and improving left ventricular diastolic function. Calcium channel blockers should be avoided and -blockers in combination, but with marked outflow tract obstruction and (or) significant pulmonary hypertension or severe diastolic dysfunction, may be combined with caution, but the blood should be avoided severe hemodynamic changes. In addition, other calcium channel blockers such as diltiazem can also be used for HCM, and nifedipine due to have a strong vasodilator, causing blood pressure, outflow tract obstruction increased, HCM negative, should be avoided.
(3) the treatment of heart failure: symptoms of HCM with severe heart failure patients may be in the application of blockers or verapamil was added on the basis of appropriate diuretics to improve symptoms of pulmonary congestion, but there is diastolic dysfunction, should be taken to avoid excessive diuresis, affecting ventricular filling.
(4) the treatment of atrial fibrillation: about 20% of adult patients with atrial fibrillation may be, is an important complication of HCM, also lead to thromboembolism, heart failure and death, one of the reasons the increase; In addition, rapid atrial fibrillation The ventricular rate can be reduced diastolic ventricular filling, reduced cardiac output, leading to deterioration of the disease, and should be actively treated. Atrial fibrillation to sinus rhythm in the event immediately, or at least control the ventricular rate to improve the symptoms of most patients. Amiodarone on the recovery and (or) maintenance of sinus rhythm is effective, -blockers or verapamil can effectively control the ventricular rate. In addition, chronic or recurrent atrial fibrillation should be anticoagulated patients with paroxysmal atrial fibrillation therapy.
(5) the prevention of infective endocarditis: infective endocarditis is the main complication of HCM, and the morbidity and mortality and disease related to the occurrence of left ventricular outflow tract obstruction due mainly to make the left ventricular ejection and the formation of the high turbulence flow, ventricular contraction and ventricular septal anterior mitral repeated exposure to the sport, as well as mitral regurgitation, etc., resulting in chronic endocardial injury, constitute the basis of occurrence of infective endocarditis. Neoplasm can occur in the mitral valve and (or) aortic and mitral valve and ventricular septal points. HCM has been reported the incidence of infective endocarditis complicated by approximately 0.5% to 5%, which increased significantly with the left atrium ( 50mm) were a higher incidence. Therefore, associated with left atrial enlargement in patients with HCM should use antibiotics to prevent the occurrence of infective endocarditis.
(6) prevention of sudden death: prevention and treatment of amiodarone on ventricular arrhythmias in HCM merger effective and can reduce symptoms, improve exercise tolerance. HCM prone to rapid ventricular arrhythmia and sudden death, which may be related to myocardial cell lineage and myocardial fibrosis caused by abnormal cardiac electrophysiological abnormalities. Sudden death can occur in asymptomatic or very mild symptoms in patients with left ventricular hypertrophy, or not very serious in patients with left ventricular outflow tract obstruction and no significant correlation. At present, most studies suggest that sudden death and certain types of gene mutation. Clinically, HCM who have family history of premature death, there can not explain the history of repeated syncope, recurrent non-sustained ventricular tachycardia or sustained ventricular tachycardia who had severe diffuse left ventricular hypertrophy (wall thickness 30mm), as well as abnormal blood pressure response after exercise, are considered at high risk of sudden death in patients department, claims for these patients are placed amiodarone or ICD as primary prevention; and the recovery of a history of cardiac arrest and recurrent who sustained ventricular tachycardia, ICD is the first choice for prevention of sudden death.
(7) Other: The symptoms of patients and medical treatment fails, consider using other interventions such as surgery, alcohol ablation, or dual-chamber pacing, in order to achieve to reduce outflow tract obstruction, to relieve symptoms, prevent complications purposes.
surgical treatment: surgical treatment carried out in the late 20th century, 50, the indication is clear outflow tract obstruction, ventricular septal and left ventricular free wall thickness r 1.5, the resting pressure gradient 50mmHg, with a serious effort failure and poor medical treatment in HCM patients. The goal of surgery is to widen the left ventricular outflow tract, elimination and (or) release and left ventricular outflow tract obstruction, reduce the outflow tract pressure gradient, while improving the forward movement of mitral valve systolic with the interventricular septum. But for those who exist only when certain triggers significant pressure gradient of patients, whether surgery is controversial. The most widely used surgical approach is by way of the septal part of the aortic heart surgery and cardiac septal extension of the dissection technique. Basal segment of septal hypertrophy in patients with aortic incision approach commonly used to select right coronary aortic valve and the junction of the left lower lobe resection of the crown (Bigelow resection) or right coronary aortic valve below the cut (Morrow resection); of the associated mitral valve was significantly longer in patients with myocardial resection can be simultaneously and mitral valve tuck surgery to reduce the abnormal forward mitral valve surgery; only mild hyperplasia of the interventricular septum, anterior septum at the base by 18mm thick who had cardiac surgery result in higher risk of ventricular septal perforation, surgery should be carefully chosen; for mitral valve disease (such as mitral valve prolapse) were severe mitral regurgitation, papillary muscle abnormalities mitral valve into the ventricle cavity formation in central obstruction, and Morrow still serious postoperative symptoms or outflow obstruction not relieved, should mitral valve replacement. Most patients can relieve symptoms, mitral regurgitation and outflow tract pressure gradient almost disappeared completely. Treatment centers in North America and Europe about 1,500 cases of surgical data show that more than 70% of patients outflow tract pressure gradient after surgery can be completely eliminated or significantly reduced, symptoms can be for 5 years or 5 years. Surgical complications included left bundle branch block, complete atrioventricular block (of which 5% of the required permanent pacemaker placement), ventricular septal defect, aortic regurgitation, cardiac arrhythmias and progressive left ventricular dysfunction, etc. With the improved surgical methods and intraoperative guidance of echocardiography ventricular septal position and extent of resection, has led to significantly reduce complications. Surgery and postoperative mortality was 8%. In recent years, experienced medical centers, surgical mortality rate has been below 2%. The elderly or in combination with other heart surgery, the risk increases. Now that the surgery can relieve symptoms and improve cardiac function, but it can improve the prognosis of this disease there is no clear conclusion.
percutaneous transluminal septal myocardial ablation (PTSMA): PTSMA surgery in recent years the development of the new technology. In 1994, Gietzen so that the temporary occlusion catheter through the first interval of the left coronary artery branch can alleviate obstructive HCM patients with outflow tract obstruction, Sigwart in 1995, the first clinical application of the technology. Ventricular hypertrophy of the law is related to the blood supply to support (mostly the left anterior descending coronary artery branch first interval) within the slow injection of 96% uniform 99% ethanol 0.5 ~ 3.0ml, to produce chemical occlusion, anterior septum basal segment led to myocardial infarction, so that it myocardial thinning, reducing or eliminating left ventricular hypertrophy and outflow tract pressure gradient, relief of symptoms. Currently, the international observation of treatment by nearly a thousand cases of PTSMA that close, more reliable medium-term efficacy, clinical improvement and a considerable interval between resection of the improvement of left ventricular pressure gradient is more effective than pacing. Such as Seggewiss PTSMA 80% of patients reported after the left ventricular pressure gradient less than 50% before surgery, after 3 months to further improvements; 45% of patients with left ventricular pressure gradient disappeared, the average cardiac function was significantly better. PTSMA main indication for drug treatment fails or can not tolerate surgery, accompanied by ventricular septal thickness 18mm, subaortic obstruction, resting left ventricular outflow tract pressure gradient 50mmHg, or when the resting state, although the pressure gradient is only 30 ~ 50mmHg, but Stress 70mmHg, and no serious symptoms in patients with left ventricular enlargement OHCM. Mild symptoms, as well as with severe mitral valve disease, coronary artery disease or three left bundle branch block caught suited to the treatment of this Act; young or the elderly must be carefully considered. PTSMA most common complications of non-target myocardial infarction, degree atrioventricular block or ventricular arrhythmias and even death. Intraoperative myocardial contrast echocardiography can PTSMA better efficacy, and avoid the misuse of non-target ablation zone, reduce complications, especially due to degree atrioventricular block and required permanent pacemaker implantation were 25% from to 13%. However, alcohol septal ablation can cause scarring, which induce life-threatening ventricular tachycardia and sudden death risk tendency, and the left ventricular function in patients on long-term effects, yet to be confirmed by prospective, randomized study. This method is technically demanding, is still in clinical trials should be carried out with experience in the heart center, and highly selective cases. The key to successful treatment is the right choice ventricular hypertrophy associated with blood sticks to be more precise evaluation of the efficacy of long-term follow-up results of cases.
permanent dual-chamber pacemaker (DDD) treatment: the aim is through the atrioventricular synchronization, change the ventricular activation sequence, the earliest ventricular activation started right ventricular apex, right ventricular hypertrophy caused by cardiac chambers shift thereby reducing left ventricular outflow tract obstruction, and to avoid before mitral valve systolic motion. Early double-blind controlled study of non-, DDD pacing can improve symptoms and reduce the left ventricular outflow tract obstruction, and 5 years after the reported hemodynamic improvement still. Since 1997, several randomized double-blind crossover clinical trial, including 12 European centers randomized double-blind PIC (Pacemaker in cardiomyopathy) study and MPATHY research are to AAI pacing mode as a control to assess the efficacy of DDD pacing. Most results, DDD pacing on left ventricular outflow tract obstruction, the quality of life and exercise tolerance improved significantly compared with baseline, the improvement of the pressure gradient is better than the control group; but there are also around 36% reported no improvement in symptoms, or even worse, 40% of patients no significant decrease of left ventricular outflow tract obstruction or even increased, suggesting that DDD pacing on pressure gradient and improve symptoms of non-constancy. Therefore, the exact effect of DDD pacing in patients requires further study, the method still can not serve as the primary treatment for HCM. DDD pacing in patients with current indications are limited to symptomatic patients with HCM can not tolerate medical therapy or medical therapy, with or without indications of surgery or ablation, or high risk factors is not willing to undergo surgery, as well as other indications for pacing therapy to be the line of patients. [Hide] prevention and prognosis: Edit this paragraph back catalog prognosis: hypertrophic cardiomyopathy have a high degree of differences in natural history. Slow course of many patients, long-term survival can be asymptomatic for many years, but sudden death can occur in the course of each period. Some patients with asymptomatic or sudden death shortly after the onset of symptoms, was diagnosed with the disease at autopsy. Goodwin that the majority of patients can survive for several decades. Part of the female patients without heart failure medical therapy and close observation in the next pregnancy and childbirth are often capable of performing. Information has been reported, 50% to 70% of the patients were followed up for several years the disease remained stable, 20% to 30% of patients with disease progression or death. There . [Display]


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