经皮间隔支化学消融治疗肥厚梗阻性心肌病尤士杰(英文)课件

PercutaneousSeptalMyocardialAblation(PASMA)CardiovascularInstitute&FuWaiHospitalCardiovascularInstitute&FuWaiHospitalChineseAcademyofMedicalScienceChineseAcademyofMedicalScienceYouShiJieMDYouShiJieMD2010.7.23GuiYang2010.7.23GuiYang2010.7.23GuiYang2010.7.23GuiYang经皮间隔支化学消融治疗肥厚梗阻性心肌病经皮间隔支化学消融治疗肥厚梗阻性心肌病PercutaneousSeptalCardiovascul1IntroductionTreatmentofsymptomaticpatientswithHOCMaimstoTreatmentofsymptomaticpatientswithHOCMaimstoreducesymptoms,improvefunctioncapacityandprovidereducesymptoms,improvefunctioncapacityandprovidebetterqualitylife.betterqualitylife.AimsdirectlytoreducethehypertrophiedinterventricularAimsdirectlytoreducethehypertrophiedinterventricularseptumwithconsecutiveexpansionoftheLVoutflowtractseptumwithconsecutiveexpansionoftheLVoutflowtractandreductionoftheLVoutflowtractgradientandandreductionoftheLVoutflowtractgradientandimprovedistolicfunctionLV.improvedistolicfunctionLV.First choice druges treatmentFirst choice druges treatment.AtleastAtleast 10%10%ofpatientswithofpatientswithmarkedoutflowtractobstructionhaveseveresymptoms,markedoutflowtractobstructionhaveseveresymptoms,whichareunresponsivetomedicaltherapy.whichareunresponsivetomedicaltherapy.HOCMMyectomyHOCMMyectomyDDD-PMDDD-PMICDICDPTSMAPTSMAIntroductionTreatment of sympt2Hypertrophic cardiomyopathy Epidemiological characteristicsHypertrophiccardiomyopathyincidenceofHypertrophiccardiomyopathyincidenceof0.2%0.2%(1:500),(1:500),0.16%0.16%inourcountryinourcountry.Thevastmajorityofpatientswithnosymptoms,Thevastmajorityofpatientswithnosymptoms,25%25%ofoutflowtractobstructionoccurredofoutflowtractobstructionoccurredonlyaboutonlyabout5-10%5-10%ofpatientswithdrugofpatientswithdrugtreatmentsfailorcauseserioussideeffectsoftreatmentsfailorcauseserioussideeffectsofdrugseffectivedose.drugseffectivedose.RequiretreatmentorsurgicalinterventioninRequiretreatmentorsurgicalinterventioninpatientstreatedwithonlyveryfewparts.patientstreatedwithonlyveryfewparts.Hypertrophic cardiomyopathy Ep3Pathophysiologic and clinical characteristics of HOCM VentricularhypertrophyVentricularhypertrophyLeftventricularoutflowtractpressuregradientLeftventricularoutflowtractpressuregradientMyocardialischemia-anginapectoris.Myocardialischemia-anginapectoris.Arrhythmia-Arrhythmia-ventriculartachycardia,fibrillation.Clinicalmanifestations:dizziness,amaurosis,Clinicalmanifestations:dizziness,amaurosis,syncope,exertionalshortnessofbreath,anginasyncope,exertionalshortnessofbreath,anginapectoris,heartdisfunctionandsuddendeath.pectoris,heartdisfunctionandsuddendeath.Generallyconsidered:moreseverehypertrophy,Generallyconsidered:moreseverehypertrophy,outflowtractobstructionneartheLVOTsit,theoutflowtractobstructionneartheLVOTsit,themorehighertheobstructivepressuregradientweremorehighertheobstructivepressuregradientwerethemoreobviousclinicalsymptomsandthegreaterthemoreobviousclinicalsymptomsandthegreaterthepotentialthreat.thepotentialthreat.Pathophysiologic and clinical 4The natural course of outflow tract obstructionLevelanyages.thereisabigdifferenceinNaturalhistoryThenaturalcourseThenaturalcoursenotsure.Themorecardiachypertrophy,thehigherthepressuregradient,thegreatertheriskofsuddendeath.Theoutflowtractpressuregradientoftheclinicalimportanceoftheissueremainscontroversial,butitisgenerallyconsideredanimportantclinicalprocessindicators.Nnualmortalityrateof2-4%,theincidenceofsuddendeath1%The natural course of outflow 5T The symptomshe symptomsWhethertheobstructionproducedtheclinicalsymptoms?notonlywiththedegreeofoutflowtractobstructionandoutflowtractpressuregradient,aswellastheobstructionsite.Butalsowithventriculardiastolicfunctionandtheadequacyofvenousreturnisalsocloselyrelated.Increasetheheartbeforeandafterloadandmyocardialcontractilityoftencausenoticeableclinicalsymptoms.Therefore,itwillbecomemoreapparentafterexercise.Thepatientsshouldbetreatment.The symptoms Whether the obs6Diastolic dysfunctionDiastolic dysfunctionAllpatientshaddiastolicdysfunctionHowthepressuregradientandsymptomsAndtheextentanddistributionofthehypertrophyhasnothingtodo.Whethernormalorsmallventricularcavity,duetoincreasedheartweight,ventricularvolumereduction,myocardialfibrosis,leavingventricularstiffnessincreased,compliancedecreasedandcausedthediastolicfunctiondamage.Pulmonaryvenouspressureandend-diastolicpressure wereincreasedandheartdisfunction.Diastolic dysfunction All pati7systolic functionsystolic functionSystolicfunctionisnormalorsupranormalinHCOMSystolicfunctionisnormalorsupranormalinHCOMBothobstructionandnon-obstruction,SystolicBothobstructionandnon-obstruction,Systolicdysfunctionoccursinsmallsubsetdysfunctionoccursinsmallsubset(10-15%)(10-15%)Resultofprogressiveimpairmentofsystolicfunction.Resultofprogressiveimpairmentofsystolicfunction.Thistransformation:wallthinning,cavitydilation,Thistransformation:wallthinning,cavitydilation,andfibrosis,increasedmortalityandfibrosis,increasedmortality11%11%(annual)and(annual)andriskofSCD.riskofSCD.ConventionalUCG,M-mode,orEF,fractionalConventionalUCG,M-mode,orEF,fractionalshorteningpreserveddespiteimpaimentlong-axisshorteningpreserveddespiteimpaimentlong-axisfunctionfunctionTissueDopplerimage(TD)-derivedsystolicvelocities:TissueDopplerimage(TD)-derivedsystolicvelocities:inthebasalinferoseptalandanterolateralwallinthebasalinferoseptalandanterolateralwallroutinelyinallpatientsonsubsequentscans.routinelyinallpatientsonsubsequentscans.systolic functionSystolic func8Myocardial ischemiaMyocardial ischemiaMyocardialischemia,thesymptomsofanginapectorisare:High-powersothatleftventricularmyocardialoxygenconsumptionincreased;Cardiaccontractionstrengthofoppressionthelargemyocardialcoronaryartery;Intramyocardialsmallcoronaryarterystenosisandintimalthickeningabnormalities,leading to leading to cardiac hypertrophy and coronary artery oxygen cardiac hypertrophy and coronary artery oxygen required due to an imbalance of oxygen supplyrequired due to an imbalance of oxygen supply.Myocardial ischemiaMyocardial 9Arrhythmia and Arrhythmia and sudden deathsudden deathHOCMofpatientswithabnormalmyocardialcellsandthearrangementofdisorderprovidesabasisforthearrhythmia.However,abnormalmyocardialarrangementandspontaneousarrhythmiasandventricularfibrillationthreshold,thepreciserelationshipisunclear.About25%ofpatientsmayhavenon-sustainedventriculartachycardia,thearrhythmiaissuddendeathofagoodpredictor,and negative and negative predictive accuracy is 97%.predictive accuracy is 97%.Arrhythmia and sudden death HO10Risk factors for sudden death Risk factors for sudden death High-risk:High-risk:1Suddendeathoccurredinasuccessful1Suddendeathoccurredinasuccessfulrescuerescue2continuousmonomorphicventricular2continuousmonomorphicventriculartachycardiatachycardiaClinicalriskfactors:Clinicalriskfactors:1non-sustainedventriculartachycardia1non-sustainedventriculartachycardia2movementabnormalbloodpressure2movementabnormalbloodpressureresponse(response(25mmHg)25mmHg)3unexplainedsyncope3unexplainedsyncope4early-onsetfamilyhistoryofsudden4early-onsetfamilyhistoryofsuddendeathdeath5severeleftventricularhypertrophy5severeleftventricularhypertrophy30mm30mm Risk factors for sudden death 11The purpose of the treatment PTMSA TreatmentofsymptomaticpatientswithTreatmentofsymptomaticpatientswithHOCMHOCMThePTMSAtreatmentofHOCMisaobstructionbyblockingathesupplybloodofpartsoftheseptalhypertrophyofmyocardialandmyocardialinjuryintheregion,leadingtotheareaofmyocardialnecrosis,myocardialcontractilefunctiondisappeared,Widenedtheleftventricularoutflowtract,whileloweringtheoutflowtractobstructionandthecardiacoutputincrease.Andimproveclinicalsymptomsandhemodynamics.The purpose of the treatment P12PTSMA indication (1)Clinical indicationClinical indicationSymptomaticpatientsSymptomaticpatientsDrugrefractoryseveresaideffectsmedicalDrugrefractoryseveresaideffectsmedicaltreatmenttreatmentFunctionalclassIIIorIVFunctionalclassIIIorIVFunctionalclassIIwithobjectivelimitationorFunctionalclassIIwithobjectivelimitationorriskfactorsriskfactorsRecurrentexercise-inducedsyncopesRecurrentexercise-inducedsyncopesFailureofpriormyectomyorDDD-PMFailureofpriormyectomyorDDD-PMComorbitiywithincreasedsurgicalrisk.Comorbitiywithincreasedsurgicalrisk.PTSMA indication (1)Clinical 13PTSMA indication (2)Hemodynamic indication in symptomatic patientsHemodynamic indication in symptomatic patientsThepressuregradientatrest50mmHgor100mmHgwithprovocation.In2008ESCmeeting,SeggewisethatLVgradientLVgradient3030 mmHgatrestorProvocableLVgradientmmHgatrestorProvocableLVgradient6060mmHg.mmHg.ValsalvaValsalva Postextrasystole.Postextrasystole.Nodobutaminegradients(Drugs)Nodobutaminegradients(Drugs)(There is no information that reduce the LVOT pressure to There is no information that reduce the LVOT pressure to reduce sudden death,but the LVOT 30mmHg and increased reduce sudden death,but the LVOT 30mmHg and increased risk of death directly related to,risk of death directly related to,New Eng l J Med 2003;348:295-303)New Eng l J Med 2003;348:295-303)PTSMA indication (2)Hemodynam14Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy Survival According to Outflow Tract GradientSurvival According to Outflow Tract GradientBJMaronetal;JAMA281:650-655,1999Hypertrophic Cardiomyopathy S15PTSMA indication(3)Morophologic indicationEchocariographySubaorrticSAM-associatedgradientMid-cavitarygradientCaution:papillarymuscleinvolvement:MCENoprolongedmitralleafletsCoronaryangiographysuitableseptalbranch.PTSMA indication(3)Moropholog16Outflow tract obstruction sign in EchocardiographM-modeechocardiograminobstructivehypertrophiccardiomyopathyshowingsystolicanteriormotionofthemitralvalve(SAM)(arrowsindicatingseptumandmitralvalveleafletcontact)Outflow tract obstruction sign17Morphologic of HOCMNewclassficationofHOCMNewclassficationofHOCMMethods:theywereclassifiedMethods:theywereclassifiedinto4typesaccordingtotheinto4typesaccordingtotheechocardiographicresults:echocardiographicresults:TypeITypeI:localsubaortic:localsubaorticobstructionofHOCM;obstructionofHOCM;TypeIITypeII:predominantin:predominantinmidventicularobstruction;midventicularobstruction;TypeIIITypeIII:diffuseseptal:diffuseseptalhypertrophicobstructioninhypertrophicobstructioninoutflowtractandoutflowtractandmidventicularobstruction;midventicularobstruction;TypeIVTypeIV:multiposition:multipositionhypertrophicobtruction.hypertrophicobtruction.1.asymmetricalseptalhypertrophy1.asymmetricalseptalhypertrophy(ASH),(ASH),2.Idiopathic2.Idiopathichypertrophicsubaorticstenosishypertrophicsubaorticstenosis(IHSS),(IHSS),3.Apicalor3.ApicalorJapaneseHCMJapaneseHCM.InthisformofnonobstructiveHCM,.InthisformofnonobstructiveHCM,thethickestpartoftheleftventricleisatthetiporapexthethickestpartoftheleftventricleisatthetiporapexofthepump.4.theobstructionisnotintheoutflowofthepump.4.theobstructionisnotintheoutflowtractbutinthemiddleoftheventricle.Atunnelleadstractbutinthemiddleoftheventricle.Atunnelleadsintoadilatedapicalportion,calledananeurysm,whichintoadilatedapicalportion,calledananeurysm,whichhasthinwalls.hasthinwalls.Morphologic of HOCM18Our classfication in PTSMAOurtypingintheI-typeandMaronintheI-typingwasthesameassuitableforPTSMAtreatmentandMaronsII-typeincludesthetypeIIandtypeIIIofourmodel,itissuitablePTSMAtreatment.Therefore,ourIV-typeclassificationisthefirstmadebyultrasoundimagingfeaturesofHOCM,accordingtoitscharacteristicsinlinewithPTSMAtreatment.Our classfication in PTSMA O19Target vessel Selectablationofregionalimportance,Selectablationofregionalimportance,particularlyinthetargetvesselisnotclearwhoparticularlyinthetargetvesselisnotclearwhotheseptalbranchtheseptalbranchThefirstseptalbranchofthesizeandThefirstseptalbranchofthesizeanddistributionaregreatvariationdistributionaregreatvariation 20%20%ofpatientsfirstbranchwassuppliedthefreeofpatientsfirstbranchwassuppliedthefreewallofrightventriclewallofrightventricle 40%40%ofpatientswithofpatientswithsubaorticofseptalisnotofseptalisnotcompletelysupportedbythefirstseptalbranchcompletelysupportedbythefirstseptalbranch 5%5%ofpatientscannotdeterminethetargetvesselofpatientscannotdeterminethetargetvesseloftheregionoftheregionTarget vessel Select ablation 20Contrast echocardiography method in the target vesse choice1.Injectionofasmallamountofdye(1-2ml)throughtheguidewirelumenoftheinflatedballooncatheterangiographically2.Priortoalcoholinjection1-2mlofechocontrastmediumisadministeredthroughthecentrallumenoftheballooncatheterunderUCG.determinesthesupplyareaofthetargetseptalbranch.Ensurethatnoareasinvolvingnon-obstructive,suchasthepapillarymusclesandventricularfreewallandotherparts.Contrast echocardiography meth21Myocardial-Contrast-Echo in HOCMAvoidLADballooningExcludeLADleakageMyocardial-Contrast-Echo i22Septal Ablation in HOCMMyocardial-Contrast-EchoLevovistIn the interval of contrast agent injected into the branch to observe the distribution of vascular contr AlcoholShadowSeptal Ablation in HOCMMyocar23 Levovist shadow Levovist shadow24Echosequence:SubaorticseptumEchosequence:SubaorticseptumastargetbregionintypicalSAM-astargetbregionintypicalSAM-associated,subaorticobstraction,(associated,subaorticobstraction,(Ddottedline),Ddottedline),EtestinjectionoftheechocontrastEtestinjectionoftheechocontrastagentinballoonofthethefirstsetalagentinballoonofthethefirstsetalbranchofaforwardbranchofbranchofaforwardbranchofpositionhighlightingbebasalhalfofpositionhighlightingbebasalhalfofseptumplusaRVpapillarymuscleseptumplusaRVpapillarymuscle(whitearrows).(whitearrows).Aftersuper-Aftersuper-selectiveballoonofselectiveballoonofotherbranchoffirstotherbranchoffirstseptalbranch.septalbranch.CorrectCorrectopacification.opacification.Echo sequence:Subaortic septu25MCEN=222No MCEn=30PSeptal branches(n)1.00.11.30.20.0001Alcohol(ml)2.90.93.92.40.0001Balloon size(mm)1.90.42.40.20.0001CK max(U/l)5342487454200.001CK-MB max(U/l)623096620.0001H.Seggewissetal,49thScientificSessionsACC,2000H.Seggewissetal,49thScientificSessionsACC,2000Septal Ablation in HOCMAcute Results/Ablation TechniqueMCENo MCEPSeptal branches(n)126H.Seggewissetal,49thScientificSessionsACC,2000H.Seggewissetal,49thScientificSessionsACC,2000Septal Ablation in HOCMAcute Results/Ablation Techniquep0.05p2.5mmandtoolong.Itisverybigseptalbranch2.5mmandtoolong.ThereisquitedangertoPTMSAThereisquitedangertoPTMSAIt is very big septal branch 40PTSMA contraindications NosignificantpressuregradientinhypertrophicNosignificantpressuregradientinhypertrophiccardiomyopathyorverydiffuseobstructive.cardiomyopathyorverydiffuseobstructive.MergeotherneedssurgeryheartdiseaseMergeotherneedssurgeryheartdiseaseMitralvalveabnormalitiesandtheirownformMitralvalveabnormalitiesandtheirownformofpapillarymusclesinvolvedintheformationofofpapillarymusclesinvolvedintheformationofpressuregradient,ormitralvalvepressuregradient,ormitralvalveprolapseandprolapseand regurgitation.regurgitation.Contrastechocardiographycannotdeterminecannotdeterminetargetvesselortheobstructionofregionalnotargetvesselortheobstructionofregionalnosuitabletargetvessel.suitabletargetvessel.Targetvesselsupplytonon-obstructionotherTargetvesselsupplytonon-obstructionotherregionssuchas:papillarymuscle,freewall,etc.regionssuchas:papillarymuscle,freewall,etc.NotsuitableNotsuitableOver-the-wireballoon.PTSMA contraindications No sig41PTSMA complications (1)HospitalmortalityrateHospitalmortalityrate:1-2%:1-2%DDD-pacemaker:DDD-pacemaker:2-10%2-10%MyocardialinfarctionMyocardialinfarction Reason:Reason:alcoholalcoholleakageleakageintothepartsofintothepartsofinappropriate,inappropriate,collateralcollateralbranchopening,alcoholbranchopening,alcoholintotheinappropriatepartscauseno-reflow,LADintotheinappropriatepartscauseno-reflow,LAD/LM/RCAinjury/LM/RCAinjuryEmergencysurgeryEmergencysurgeryReason:Reason:coronaryarteryinjury,acutemitralcoronaryarteryinjury,acutemitralregurgitation(papillarymusclerupture)regurgitation(papillarymusclerupture)Bundlebranchblock:aboutBundlebranchblock:about50%50%andRBBB-andRBBB-basedbasedPTSMA complications (1)Hosp42PTSMA complications (2)HeightorIII-AVBHeightorIII-AVB Factors:Factors:whetherwhetherthemethodofapplicationofthemethodofapplicationofmyocardialcontrastechocardiography.myocardialcontrastechocardiography.DoseDoseofalcoholandofalcoholandspeedspeed.Leftanteriordescendingarterydissection,Leftanteriordescendingarterydissection,coronarythrombosis,ventricularfibrillationandcoronarythrombosis,ventricularfibrillationandventriculartachycardia,acutemitralventriculartachycardia,acutemitralregurgitation,rightventricularinfarction,leftregurgitation,rightventricularinfarction,leftventricularfreewallinfarction.ventricularfreewallinfarction.PTSMA complications (2)Heig43PTSMA shortcomings InjuryoftheleftcoronaryarteryrequiredInjuryoftheleftcoronaryarteryrequiredemergencybypassorstentemergencybypassorstentCannotenterthetargetseptalbranchCannotenterthetargetseptalbranchCannotdeterminethetargetbranchofsupportCannotdeterminethetargetbranchofsupportFormitralandpapillarymuscleanomaliesandFormitralandpapillarymuscleanomaliesandabnormalseptalhypertrophythebestchoicetheabnormalseptalhypertrophythebestchoicethesurgerysurgeryMitralvalveinjuryrequiredemergencysurgery.Mitralvalveinjuryrequiredemergencysurgery.PermanentconductionblockoccurstreatmentPermanentconductionblockoccurstreatmentshouldbePMshouldbePMPTSMA shortcomings Injury of t44PTSMA limitationsuSomeyoungpatientstoreducethepressuregradienteffectisnotsatisfactory,thepossiblereasons:Theseptalbranchwithgoodcollateralcirculation.uThevesselcannotthoroughorincompleteablation(remainingsmallerbranches),self-revascularization.uAhigherdegreeofseptalhypertrophy,ahigherdegreeoffibrosis,Partsoftheseptalablationscarformationpoor.PTSMA limitations Some young p45PTSMA in Fuwai HospitalFromDec2000toMay2009,171patientsunderwentPTSMAinFuwaiHospital.Proceduresuccesswasachievedin141patients，successratewas82.6%.PTSMA in Fuwai HospitalFrom 46Patient CharacteristicsCharacteristicsPatients(n=171)Age(yrs)45.3717.71 Men/women122/49 (71.35%/28.65%)Symptoms Dyspnea93 (54.39%)Angina73(42.69%)Syncope76 (44.44%)NYHA functional class（II/III/IV）136(79.53%)/32(18.72%)/3(1.75%)Family history42 (24.6%)Medication Beta-blockers106 (62%)Verapamil52 (30.4%)Diltiazem38 (22.2%)Amiodanone13(7.6%)Patient CharacteristicsCharact47Results of PTSMAPTSMA(n=171)pSeptalthickness(pre-PTSMA)22.675.35mmSeptalthickness(post-PTSMA3days)20.684.61mmNSSeptalthickness(post-PTSMA6months)16.774.39mm0.05LVOTPG(pre-PTSMA)97.5838.23mmHgLVOTPG(post-PTSMA3days)52.3635.7mmHg0.001LVOTPG(post-PTSMA6months)47.2638.62mmHg0.001LADiameter(pre-PTSMA)43.787.33mmLADiameter(post-PTSMA3days)42.417.52mmNSLADiameter(post-PTSMA6months)32.7615.58mm0.05Results of PTSMAPTSMA(n=171)p48Complications in our patientsIn-hospitaldeathIn-hospitaldeath UptoMay2009,twopatientsdiedinthose171UptoMay2009,twopatientsdiedinthose171patientspatients（1.17%1.17%）whounderwentPTSMAinwhounderwentPTSMAinFuwaiHospital.OnewasbecauseofalcoholFuwaiHospital.OnewasbecauseofalcoholleakagetotheLeftanteriordecendingartery,leakagetotheLeftanteriordecendingartery,anotheroccurreddrug-inducedliverinjury.anotheroccurreddrug-inducedliverinjury.CompleteheartblockCompleteheartblockTransitorytrifascicularblocksoccurredatarateTransitorytrifascicularblocksoccurredatarateofof 52.05%52.05%（89patients).89patients).OnlyonepatientOnlyonepatient(0.59%)(0.59%)underwentpermanentunderwentpermanentpacemakerimplantationduetopermanentpacemakerimplantationduetopermanentcompleteAVpleteAVblock.Complications in our patientsI49Complications in our patientsOnepatient(0.59%)occurredventricularfibrillation,butherecoveredwellaftertheprocedure.Rightbundlebranchblockoccurredatarateof48.54%（83in171patients).NodissectionsoftheLMandLAD.NoemergencyCABGAcutemitralregurgitationalsodidnotoccur.Complications in our patientsO50Follow-up in our patients by echo LeftventricularoutflowtractpressuregradientwasLeftventricularoutflowtractpressuregradientwascontinuedtoasignificantdecreaseisanimportantcontinuedtoasignificantdecreaseisanimportantfeature:feature:Comparedwiththeacutephase,Comparedwiththeacutephase,56%56%ofpatients3ofpatients3monthsrestingandstim