经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件

IntroductionTreatmentofsymptomaticpatientswithHOCMaimstoreducesymptoms,improvefunctioncapacityandprovidebetterqualitylife.AimsdirectlytoreducethehypertrophiedinterventricularseptumwithconsecutiveexpansionoftheLVoutflowtractandreductionoftheLVoutflowtractgradientandimprovedistolicfunctionLV.Firstchoicedrugestreatment.

Atleast

10%

ofpatientswithmarkedoutflowtractobstructionhaveseveresymptoms,whichareunresponsivetomedicaltherapy.HOCMMyectomyDDD-PMICDPTSMAIntroductionTreatmentofsympt1HypertrophiccardiomyopathyEpidemiologicalcharacteristicsHypertrophiccardiomyopathyincidenceof0.2%(1:500),0.16%inourcountry

.Thevastmajorityofpatientswithnosymptoms,

25%ofoutflowtractobstructionoccurredonlyabout5-10%ofpatientswithdrugtreatmentsfailorcauseserioussideeffectsofdrugseffectivedose.Requiretreatmentorsurgicalinterventioninpatientstreatedwithonlyveryfewparts.

HypertrophiccardiomyopathyEp2PathophysiologicandclinicalcharacteristicsofHOCM

VentricularhypertrophyLeftventricularoutflowtractpressuregradientMyocardialischemia-anginapectoris.Arrhythmia-ventriculartachycardia,fibrillation.Clinicalmanifestations:dizziness,amaurosis,syncope,exertionalshortnessofbreath,anginapectoris,heartdisfunctionandsuddendeath.Generallyconsidered:moreseverehypertrophy,outflowtractobstructionneartheLVOTsit,themorehighertheobstructivepressuregradientwerethemoreobviousclinicalsymptomsandthegreaterthepotentialthreat.Pathophysiologicandclinical3ThenaturalcourseofoutflowtractobstructionLevel–anyages.thereisabigdifferenceinNaturalhistoryThenaturalcoursenotsure.Themorecardiachypertrophy,thehigherthepressuregradient,thegreatertheriskofsuddendeath.

Theoutflowtractpressuregradientoftheclinicalimportanceoftheissueremainscontroversial,butitisgenerallyconsideredanimportantclinicalprocessindicators.Nnualmortalityrateof2-4%,theincidenceof

suddendeath≤1%

Thenaturalcourseofoutflow4Thesymptoms

Whethertheobstructionproducedtheclinicalsymptoms?notonlywiththedegreeofoutflowtractobstructionandoutflowtractpressuregradient,aswellastheobstructionsite.Butalsowithventriculardiastolicfunctionandtheadequacyofvenousreturnisalsocloselyrelated.Increasetheheartbeforeandafterloadandmyocardialcontractilityoftencausenoticeableclinicalsymptoms.Therefore,itwillbecomemoreapparentafterexercise.Thepatientsshouldbetreatment.ThesymptomsWhethertheobs5Diastolicdysfunction

Allpatientshaddiastolicdysfunction–HowthepressuregradientandsymptomsAndtheextentanddistributionofthehypertrophyhasnothingtodo.Whethernormalorsmallventricularcavity,duetoincreasedheartweight,ventricularvolumereduction,myocardialfibrosis,leavingventricularstiffnessincreased,compliancedecreasedandcausedthediastolicfunctiondamage.Pulmonaryvenouspressureandend-diastolicpressure

wereincreasedandheartdisfunction.DiastolicdysfunctionAllpati6systolicfunctionSystolicfunctionisnormalorsupranormalinHCOMBothobstructionandnon-obstruction,Systolicdysfunctionoccursinsmallsubset(10-15%)

Resultofprogressiveimpairmentofsystolicfunction.Thistransformation:wallthinning,cavitydilation,andfibrosis,increasedmortality11%(annual)andriskofSCD.ConventionalUCG,M-mode,orEF,fractionalshorteningpreserveddespiteimpaimentlong-axisfunctionTissueDopplerimage(TD)-derivedsystolicvelocities:inthebasalinferoseptalandanterolateralwallroutinelyinallpatientsonsubsequentscans.systolicfunctionSystolicfunc7MyocardialischemiaMyocardialischemia,thesymptomsofanginapectorisare:High-powersothatleftventricularmyocardialoxygenconsumptionincreased;Cardiaccontractionstrengthofoppressionthelargemyocardialcoronaryartery;Intramyocardialsmallcoronaryarterystenosisandintimalthickeningabnormalities,leadingtocardiachypertrophyandcoronaryarteryoxygenrequiredduetoanimbalanceofoxygensupply.MyocardialischemiaMyocardial8Arrhythmiaandsuddendeath

HOCMofpatientswithabnormalmyocardialcellsandthearrangementofdisorderprovidesabasisforthearrhythmia.However,abnormalmyocardialarrangementandspontaneousarrhythmiasandventricularfibrillationthreshold,thepreciserelationshipisunclear.About25%ofpatientsmayhavenon-sustainedventriculartachycardia,thearrhythmiaissuddendeathofagoodpredictor,andnegativepredictiveaccuracyis97%.

ArrhythmiaandsuddendeathHO9RiskfactorsforsuddendeathHigh-risk:

1Suddendeathoccurredinasuccessfulrescue

2continuousmonomorphicventriculartachycardia

Clinicalriskfactors:

1non-sustainedventriculartachycardia

2movementabnormalbloodpressureresponse(≥25mmHg)

3unexplainedsyncope

4early-onsetfamilyhistoryofsuddendeath

5severeleftventricularhypertrophy>30mm

Riskfactorsforsuddendeath10ThepurposeofthetreatmentPTMSA

TreatmentofsymptomaticpatientswithHOCMThePTMSAtreatmentofHOCMisaobstructionbyblockingathesupplybloodofpartsoftheseptalhypertrophyofmyocardialandmyocardialinjuryintheregion,leadingtotheareaofmyocardialnecrosis,myocardialcontractilefunctiondisappeared,Widenedtheleftventricularoutflowtract,whileloweringtheoutflowtractobstructionandthecardiacoutputincrease.Andimproveclinicalsymptomsandhemodynamics.ThepurposeofthetreatmentP11Thevesselcannotthoroughorincompleteablation(remainingsmallerbranches),self-revascularization.RiskfactorsforsuddendeathFamilyhistoryAvoidLADballooningNodobutaminegradients(Drugs)In-hospitaldeathSeptalAblationinHOCM

Myocardial-Contrast-Echo(pre-PTSMA)DrugrefractoryseveresaideffectsmedicaltreatmentMorophologicindicationItisverybigseptalbranch>2.59%)occurredventricularfibrillation,butherecoveredwellaftertheprocedure.ThekeysofTechnologyPTSMALADiameterAmiodanoneMyocardial-Contrast-EchoinHOCM53%)/32(18.HypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientIdiopathichypertrophicsubaorticstenosis(IHSS),3.NoemergencyCABGPTSMAindication(1)ClinicalindicationSymptomaticpatientsDrugrefractoryseveresaideffectsmedicaltreatmentFunctionalclassIIIorIVFunctionalclassIIwithobjectivelimitationorriskfactorsRecurrentexercise-inducedsyncopesFailureofpriormyectomyorDDD-PMComorbitiywithincreasedsurgicalrisk.Thevesselcannotthoroughor12PTSMAindication(2)HemodynamicindicationinsymptomaticpatientsThepressuregradientatrest>50mmHgor>100mmHgwithprovocation.In2008ESCmeeting,SeggewisethatLVgradient≧30mmHgatrestorProvocableLVgradient≧60mmHg.ValsalvaPostextrasystole.Nodobutaminegradients(Drugs)

(ThereisnoinformationthatreducetheLVOTpressuretoreducesuddendeath,buttheLVOT>30mmHgandincreasedriskofdeathdirectlyrelatedto,NewEnglJMed2003;348:295-303)

PTSMAindication(2)Hemodynam13HypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientBJMaronetal;JAMA281:650-655,1999HypertrophicCardiomyopathy

S14PTSMAindication(3)MorophologicindicationEchocariography

SubaorrticSAM-associatedgradientMid-cavitarygradientCaution:papillarymuscleinvolvement:MCENoprolongedmitralleafletsCoronaryangiographysuitableseptalbranch.PTSMAindication(3)Moropholog15Outflowtractobstructionsign

inEchocardiographM-modeechocardiograminobstructivehypertrophiccardiomyopathyshowingsystolicanteriormotionofthemitralvalve(SAM)(arrowsindicatingseptumandmitralvalveleafletcontact)Outflowtractobstructionsign16

MorphologicofHOCMNewclassficationofHOCMMethods:theywereclassifiedinto4typesaccordingtotheechocardiographicresults:TypeI:localsubaorticobstructionofHOCM;TypeII:predominantinmidventicularobstruction;TypeIII:diffuseseptalhypertrophicobstructioninoutflowtractandmidventicularobstruction;TypeIV:multipositionhypertrophicobtruction.1.asymmetricalseptalhypertrophy(ASH),2.Idiopathichypertrophicsubaorticstenosis(IHSS),3.ApicalorJapaneseHCM.InthisformofnonobstructiveHCM,thethickestpartoftheleftventricleisatthetiporapexofthepump.4.theobstructionisnotintheoutflowtractbutinthemiddleoftheventricle.Atunnelleadsintoadilatedapicalportion,calledananeurysm,whichhasthinwalls.MorphologicofHOCM17OurclassficationinPTSMAOurtypingintheI-typeandMaronintheI-typingwasthesameassuitableforPTSMAtreatmentandMaron'sII-typeincludesthetypeIIandtype

IIIofourmodel,itissuitablePTSMAtreatment.Therefore,ourIV-typeclassificationisthefirstmadebyultrasoundimagingfeaturesofHOCM,accordingtoitscharacteristicsinlinewithPTSMAtreatment.OurclassficationinPTSMAO18Target

vessel

Selectablationofregionalimportance,particularlyinthetargetvesselisnotclearwhotheseptalbranch

Thefirstseptalbranchofthesizeanddistributionaregreatvariation

20%ofpatientsfirstbranchwassuppliedthefreewallofrightventricle

40%ofpatientswithsubaorticofseptalisnotcompletelysupportedbythefirstseptalbranch

5%ofpatientscannotdeterminethetargetvesseloftheregionTargetvesselSelectablation19Contrastechocardiographymethod

inthetargetvesse

choiceInjectionofasmallamountofdye(1-2ml)throughtheguidewirelumenoftheinflatedballooncatheterangiographicallyPriortoalcoholinjection1-2mlofechocontrastmediumisadministeredthroughthecentrallumenoftheballooncatheterunderUCG.determinesthesupplyareaofthetargetseptalbranch.Ensurethatnoareasinvolvingnon-obstructive,suchasthepapillarymusclesandventricularfreewallandotherparts.Contrastechocardiographymeth20Myocardial-Contrast-Echo

inHOCM

AvoidLADballooningExcludeLADleakageMyocardial-Contrast-Echoi21SeptalAblationinHOCM

Myocardial-Contrast-EchoLevovistIntheintervalofcontrastagentinjectedintothebranchtoobservethedistributionofvascularcontr

AlcoholShadowSeptalAblationinHOCM

Myocar22(ThereisnoinformationthatreducetheLVOTpressuretoreducesuddendeath,buttheLVOT>30mmHgandincreasedriskofdeathdirectlyrelatedto,NewEnglJMed2003;348:295-303)keysofTechnologyofPTSMAContrastechocardigraphyMitralvalveinjuryrequiredemergencysurgery.2%(1:500),0.TreatmentofsymptomaticpatientswithHOCMaimstoreducesymptoms,improvefunctioncapacityandprovidebetterqualitylife.43monthslater,90%ofthepatientsofthepressuregradientcompletelyeliminatedbyechocardiographicDoseofalcoholandspeed.ContrastechocardigraphyPatientCharacteristicsBeta-blockersThepatientsshouldbetreatment.Patients(n=171)20%ofpatientsfirstbranchwassuppliedthefreewallofrightventricle(pre-PTSMA)(pre-PTSMA)FailureofpriormyectomyorDDD-PMFunctionalclassIIIorIVOnewasbecauseofalcoholleakagetotheLeftanteriordecendingartery,anotheroccurreddrug-inducedliverinjury.Cardiaccontractionstrengthofoppressionthelargemyocardialcoronaryartery;

Levovistshadow(Thereisnoinformationthat23Echosequence:SubaorticseptumastargetbregionintypicalSAM-associated,subaorticobstraction,(Ddottedline),EtestinjectionoftheechocontrastagentinballoonofthethefirstsetalbranchofaforwardbranchofpositionhighlightingbebasalhalfofseptumplusaRVpapillarymuscle(whitearrows).Aftersuper-selectiveballoonofotherbranchoffirstseptalbranch.Correctopacification.Echosequence:Subaorticseptu24MCEN=222NoMCEn=30PSeptalbranches(n)1.0±0.11.3±0.2<0.0001Alcohol(ml)2.9±0.93.9±2.4<0.0001Balloonsize(mm)1.9±0.42.4±0.2<0.0001CKmax(U/l)534±248745±420<0.001CK-MBmax(U/l)62±3096±62<0.0001H.Seggewissetal,49thScientificSessionsACC,2000SeptalAblationinHOCM

AcuteResults/AblationTechniqueMCENoMCEPSeptalbranches(n)125H.Seggewissetal,49thScientificSessionsACC,2000SeptalAblationinHOCM

AcuteResults/AblationTechniquep<0.05p<0.01H.Seggewissetal,49thScien26keysofTechnologyofPTSMA

Thekeytechnology:

identificationThepressuregradientatsubaorticandleftventricularidentificationsuitableoftargetseptalbranches.Mustbeinsertedtemporarypacemaker(topreventtheconductionblock).

Simultaneousmonitoringofaorticandleftventricularpressure.

Heparin(topreventcatheterinducedthrombosis).

AnalgesicGuidingcatheter:supportingflexibleandlowinjurySuitableOver-the-wireballooncatheterkeysofTechnologyofPTSMATh27ThekeysofTechnology

PTSMAIntraoperativeultrasoundmonitoringContrastechocardigraphyPaycloseattentiontothepressuregaugeunderfluoroscopy(observationballoonexpansionofstate).Injectionofalcoholdoseandspeeddeterminewhethershouldinjury(catheteroralcohol)andtheintervalbranchblock(necrosisstate)conditions1(withcomplications)or2septalbranches

ablationdidnotsignificantlyreducethepressure,andnoincreasealcoholdoseRemoveballoonshouldbeemptyingalcoholoftheballooncatheter

andstagnationinjectionalcoholThekeysofTechnologyPTSMAIn28A51-year-oldwoman’sLVOTgradientwasmonitoredcontinuouslyjustbeforetheballoonocclusion.(PG=80mmHg)LVAOA51-year-oldwoman’sLVOTgra29HerLVOTgradient10minutesafterseptalablation（PG=12mmHg）LVAOHerLVOTgradient10minutesa30A36-year-oldman’sLVOTgradienttestedbyDopplerechocardiographybeforePTSMA(PG=219mmHg)A36-year-oldman’sLVOTgradi31HisLVOTgradient6monthsafterPTSMA(PG=15mmHg)HisLVOTgradient6monthsaft32经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件33经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件34经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件35PG120mmHgbeforeprocedurePG120mmHgbeforeprocedure36Therefore,itwillbecomemoreapparentafterexercise.IntroductionMorophologicindicationComparedwiththeacutephase,56%ofpatients3monthsrestingandstimulatethepressuregradientwillcontinuetodeclinefurther;Comparedwith3-monthperiod,43%ofpatientsoneyearthepressuregradientisstillfurtherreduced.HisLVOTgradient6monthsafterPTSMA(PG=15mmHg)(pre-PTSMA)(post-PTSMA6months)53%)/32(18.ThereisquitedangertoPTMSAThepressuregradientatrest>50mmHgor>100mmHgwithprovocation.Andimproveclinicalsymptomsandhemodynamics.PTSMAindication(2)CONCLUSIONS53%)/32(18.Myocardialinfarction

Reason:alcoholleakageintothepartsofinappropriate,collateralbranchopening,alcoholintotheinappropriatepartscauseno-reflow,LAD/LM/RCAinjuryGreatattentionAbout25%ofpatientsmayhavenon-sustainedventriculartachycardia,thearrhythmiaissuddendeathofagoodpredictor,andnegativepredictiveaccuracyis97%.Nnualmortalityrateof2-4%,theincidenceofsuddendeath≤1%ExcludeLADleakage59%)underwentpermanentpacemakerimplantationduetopermanentcompleteAVblock.PG=40mmHgafterinjectionof4.8mlalchoholTherefore,itwillbecomemore37GreatattentionEchocardiographyshowedventricularseptalhypertrophyover30mminHOCM,necessarytoperformeingPTSMAshouldbeverycautiousandcareful.Maybetherewereathickseptalbranch,andcontrolwide,and

collateral-richseptalbranchofsupport,treatmenthadahigherriskandimprovetheclinicalsymptomsandhemodynamicshavedifficulties,sosurgerymytomcemaybeabetterchoice.GreatattentionEchocardiog38Itisverybigseptalbranch>2.5mmandtoolong.ThereisquitedangertoPTMSAItisverybigseptalbranch>39PTSMAcontraindications

Nosignificantpressuregradientinhypertrophiccardiomyopathyorverydiffuseobstructive.

Mergeotherneedssurgeryheartdisease

Mitralvalveabnormalitiesandtheirownformofpapillarymusclesinvolvedintheformationofpressuregradient,ormitralvalveprolapseandregurgitation.

Contrastechocardiographycannotdeterminetargetvesselortheobstructionofregionalnosuitabletargetvessel.

Targetvesselsupplytonon-obstructionotherregionssuchas:papillarymuscle,freewall,etc.

NotsuitableOver-the-wireballoon.PTSMAcontraindicationsNosig40PTSMAcomplications(1)

Hospitalmortalityrate:1-2%DDD-pacemaker:2-10%

Myocardialinfarction

Reason:alcoholleakageintothepartsofinappropriate,collateralbranchopening,alcoholintotheinappropriatepartscauseno-reflow,LAD/LM/RCAinjury

Emergencysurgery

Reason:coronaryarteryinjury,acutemitralregurgitation(papillarymusclerupture)Bundlebranchblock:about50%andRBBB-basedPTSMAcomplications(1)Hosp41PTSMAcomplications(2)

HeightorIII°-AVB

Factors:

whetherthemethodofapplicationofmyocardialcontrastechocardiography.

Doseofalcoholandspeed.Leftanteriordescendingarterydissection,coronarythrombosis,ventricularfibrillationandventriculartachycardia,acutemitralregurgitation,rightventricularinfarction,leftventricularfreewallinfarction.PTSMAcomplications(2)Heig42PTSMAshortcomings

Injuryoftheleftcoronaryarteryrequiredemergencybypassorstent

Cannotenterthetargetseptalbranch

CannotdeterminethetargetbranchofsupportFormitralandpapillarymuscleanomaliesandabnormalseptalhypertrophythebestchoicethesurgery

Mitralvalveinjuryrequiredemergencysurgery.

PermanentconductionblockoccurstreatmentshouldbePMPTSMAshortcomingsInjuryoft43PTSMAlimitations

Someyoungpatientstoreducethepressuregradienteffectisnotsatisfactory,thepossiblereasons:Theseptalbranchwithgoodcollateralcirculation.Thevesselcannotthorough

orincompleteablation(remainingsmallerbranches),self-revascularization.Ahigherdegreeofseptalhypertrophy,ahigherdegreeoffibrosis,Partsoftheseptalablationscarformationpoor.

PTSMAlimitationsSomeyoungp44PTSMAin

FuwaiHospitalFromDec2000toMay2009,171patientsunderwentPTSMAinFuwaiHospital.Proceduresuccesswasachievedin141patients，successratewas82.6%.PTSMAin

FuwaiHospitalFrom45PatientCharacteristicsCharacteristicsPatients(n=171)Age(yrs)45.37±17.71Men/women122/49(71.35%/28.65%)SymptomsDyspnea93(54.39%)Angina73(42.69%)Syncope76(44.44%)NYHAfunctionalclass（II/III/IV）136(79.53%)/32(18.72%)/3(1.75%)Familyhistory42(24.6%)MedicationBeta-blockers106(62%)Verapamil52(30.4%)Diltiazem38(22.2%)Amiodanone13(7.6%)PatientCharacteristicsCharact46Atleast10%ofpatientswithmarkedoutflowtractobstructionhaveseveresymptoms,whichareunresponsivetomedicaltherapy.Simultaneousmonitoringofaorticandleftventricularpressure.Postextrasystole.DrugrefractoryseveresaideffectsmedicaltreatmentSubaorrticSAM-associatedgradientAtleast10%ofpatientswithmarkedoutflowtractobstructionhaveseveresymptoms,whichareunresponsivetomedicaltherapy.ExcludeLADleakageGreatattentionPatientCharacteristicsNYHAfunctionalclass（II/III/IV）FunctionalclassIIwithobjectivelimitationorriskfactorskeysofTechnologyofPTSMAHowthepressuregradientandsymptomsAfter

3months40%ofpatientswithpressuregradientcompletelyreduced,ayearlaterthisvaluewaspromotedto62%.BJMaronetal;JAMA281:650-655,1999Transitorytrifascicularblocksoccurredatarateof52.Onepatient(0.Echosequence:SubaorticseptumastargetbregionintypicalSAM-associated,subaorticobstraction,(Ddottedline),Thepressuregradientatrest>50mmHgor>100mmHgwithprovocation.Level–anyages.In-hospitaldeathLeftventricularoutflowtractpressuregradientwascontinuedtoasignificantdecreaseisanimportantfeature:ResultsofPTSMAPTSMA(n=171)pSeptalthickness(pre-PTSMA)22.67±5.35mm

Septalthickness(post-PTSMA3days)20.68±4.61mmNSSeptalthickness(post-PTSMA6months)16.77±4.39mm<0.05LVOTPG(pre-PTSMA)97.58±38.23mmHgLVOTPG(post-PTSMA3days)52.36±35.7mmHg<0.001LVOTPG(post-PTSMA6months)47.26±38.62mmHg<0.001LADiameter(pre-PTSMA)43.78±7.33mm

LADiameter(post-PTSMA3days)42.41±7.52mmNSLADiameter(post-PTSMA6months)32.76±15.58mm<0.05Atleast10%ofpatientswith47ComplicationsinourpatientsIn-hospitaldeath

UptoMay2009,twopatientsdiedinthose171patients（1.17%）whounderwentPTSMAinFuwaiHospital.OnewasbecauseofalcoholleakagetotheLeftanteriordecendingartery,anotheroccurreddrug-inducedliverinjury.CompleteheartblockTransitorytrifascicularblocksoccurredatarateof

52.05%（89patients).

Onlyonepatient(0.59%)underwentpermanentpacemakerimplantationduetopermanentcompleteAVblock.ComplicationsinourpatientsI48ComplicationsinourpatientsOnepatient(0.59%)occurredventricularfibrillation,butherecoveredwellaftertheprocedure.Rightbundlebranchblockoccurredatarateof48.54%（83in171patients).NodissectionsoftheLMandLAD.NoemergencyCABGAcutemitralregurgitationalsodidnotoccur.ComplicationsinourpatientsO49Follow-upinourpatientsbyecho

Leftventricularoutflowtractpressuregradientwascontinuedtoasignificantdecreaseisanimportantfeature:Comparedwiththeacutephase,56%ofpatients3monthsrestingandstimulatethepressuregradientwillcontinuetodeclinefurther;Comparedwith3-monthperiod,43%ofpatientsoneyearthepressuregradientisstillfurtherreduced.After

3months40%ofpatientswithpressuregradientcompletelyreduced,ayearlaterthisvaluewaspromotedto62%.43monthslater,90%ofthepatientsofthepressuregradientcompletelyeliminatedbyechocardiographicFollow-upinourpatientsbye50CONCLUSIONSPTSMAisaneffectivenon-surgicalprocedureforsymptomaticpatientsandassociatedwithLVOTOinHOCMbecauseofitslowriskanditssignificanthemodynamicandsymptomaticimprovement.Ablationareashouldbeappropriate,assmallaspossible,toavoidalargescarformation.EchocardiographicobservationsplaysanimportantroleinthatwillhelptofinalizedefinethechoiceofseptalablationandtheablationefficacyandreducerisksandLong-termfollow-upoftreatmentefficacy

.CONCLUSIONSPTSMAisaneffecti51Advice

Whohavenosymptomsormildsymptomsofthepatient,determinednottoconsiderthelinetoreduceoutflowtractobstructionofanytherapeuticinterventionmeasures(includingsurgicalandinterventionaltreatment)!!!AdviceWhohavenosymptoms52经皮间隔支化学消融治疗肥厚梗阻性心肌病英文课件53PTSMAindication(1)ClinicalindicationSymptomaticpatientsDrugrefractoryseveresaideffectsmedicaltreatmentFunctionalclassIIIorIVFunctionalclassIIwithobjectivelimitationorriskfactorsRecurrentexercise-inducedsyncopesFailureofpriormyectomyorDDD-PMComorbitiywithincreasedsurgicalrisk.PTSMAindication(1)Clinical54PTSMAindication(2)HemodynamicindicationinsymptomaticpatientsThepressuregradientatrest>50mmHgor>100mmHgwithprovocation.In2008ESCmeeting,SeggewisethatLVgradient≧30mmHgatrestorProvocableLVgradient≧60mmHg.ValsalvaPostextrasystole.Nodobutaminegradients(Drugs)

(ThereisnoinformationthatreducetheLVOTpressuretoreducesuddendeath,buttheLVOT>30mmHgandincreasedriskofdeathdirectlyrelatedto,NewEnglJMed2003;348:295-303)

PTSMAindication(2)Hemodynam55HypertrophicCardiomyopathy

SurvivalAccordingtoOutflowTractGradientBJMaronetal;JAMA281:650-655,1999HypertrophicCardiomyopathy

S56Increasetheheartbeforeandafterloadandmyocardialcontractilityoftencausenoticeableclinicalsymptoms.PaycloseattentiontothepressuregaugeSeptalbranches(n)TreatmentofsymptomaticpatientswithHOCM53%)/32(18.Therefore,ourIV-typeclassificationisthefirstmadebyultrasoundimagingfeaturesofHOCM,accordingtoitscharacteristicsinlinewithPTSMAtreatment.HemodynamicindicationinsymptomaticpatientsSeptalthicknessCONCLUSIONSNosignificantpressuregradientinhypertrophiccardiomyopathyorverydiffuseobstructive.ComplicationsinourpatientsPermanentconductionblockoccurstreatmentshouldbePMPTSMAlimitationsPostextrasystole.Themorecardiachypertrophy,thehigherthepressuregradient,thegreatertheriskofsuddendeath.In2008ESCmeeting,SeggewisethatLVgradient≧30mmHgatrestorProvocableLVgradient≧60mmHg.determinewhethershouldinjury(catheteroralcohol)andtheintervalbranchblock(necrosisstate)conditions(post-PTSMA6months)Follow-upinourpatientsbyechoPG=40mmHgafterinjectionof4.Level–anyages.ContrastechocardigraphyA36-year-oldman’sLVOTgradienttestedbyDopplerechocardiographybeforePTSMA(PG=219mmHg)Increasetheheartbeforeand57PTSMAcontraindications

Nosignificantpressuregradientinhypertrophiccardiomyopathyorverydiffuseobstructive.

Mergeotherneedssurgeryheartdisease

Mitralvalveabnormalitiesandtheirownformofpapillarymusclesinvolvedintheformationofpressuregradient,ormitralvalveprolapseandregurgitation.

Contrastechocardiographycannotdeterminetargetvesselortheobstructionofregionalnosuitabletargetvessel.

Targetvesselsupplytonon-obstructionotherregionssuchas:papillarymuscle,freewall,etc.

NotsuitableOver-the-wireballoon.PTSMAcontraindicationsNosig58PatientCharacteristicsCharacteristicsPatients(n=171)Age(yrs)45.37±17.71Men/women122/49(71.35%/28.65%)SymptomsDyspnea93(54.39%)Angina73(42.69%)Syncope76(44.44%)NYHAfunctionalclass（II/III/IV）136(79.53%)/32(18.72%)/3(1.75%)Familyhistory42(24.6%)MedicationBeta-blocker