1、PercutaneousSeptalMyocardialAblation(PASMA)CardiovascularInstitute&FuWaiHospitalCardiovascularInstitute&FuWaiHospitalChineseAcademyofMedicalScienceChineseAcademyofMedicalScienceYouShiJieMDYouShiJieMD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 ventricular tachycardia,fibrillation Level any ages.there is a
2、 big difference in Natural history not sure.The more cardiac hypertrophy,the higher the pressure gradient,the greater the risk of sudden death.The outflow tract pressure gradient of the clinical importance of the issue remains controversial,but it is generally considered an important clinical proces
3、s indicators.Nnual mortality rate of 2-4%,the incidence of sudden death 1%Whether the obstruction produced the clinical symptoms?not only with the degree of outflow tract obstruction and outflow tract pressure gradient,as well as the obstruction site.But also with ventricular diastolic function and
4、the adequacy of venous return is also closely related.Increase the heart before and after load and myocardial contractility often cause noticeable clinical symptoms.Therefore,it will become more apparent after exercise.The patients should be treatment.All patients had diastolic dysfunction How the p
5、ressure gradient and symptoms And the extent and distribution of the hypertrophy has nothing to do.Whether normal or small ventricular cavity,due to increased heart weight,ventricular volume reduction,myocardial fibrosis,leaving ventricular stiffness increased,compliance decreased and caused the dia
6、stolic function damage.Pulmonary venous pressure and end-diastolic pressure were increased and heart disfunction.systolic functionsystolic functionMyocardial ischemiaMyocardial ischemia Myocardial ischemia,the symptoms of angina pectoris are:High-power so that left ventricular myocardial oxygen cons
7、umption increased;Cardiac contraction strength of oppression the large myocardial coronary artery;Intramyocardial small coronary artery stenosis and intimal thickening abnormalities,leading to leading to cardiac hypertrophy and coronary artery oxygen cardiac hypertrophy and coronary artery oxygen re
8、quired due to an imbalance of oxygen supplyrequired due to an imbalance of oxygen supply.sudden deathsudden death HOCM of patients with abnormal myocardial cells and the arrangement of disorder provides a basis for the arrhythmia.However,abnormal myocardial arrangement and spontaneous arrhythmias an
9、d ventricular fibrillation threshold,the precise relationship is unclear.About 25%of patients may have non-sustained ventricular tachycardia,the arrhythmia is sudden death of a good predictor,and negative and negative predictive accuracy is 97%.predictive accuracy is 97%.The purpose of the treatment
10、 PTMSA The PTMSA treatment of HOCM is a obstruction by blocking a the supply blood of parts of the septal hypertrophy of myocardial and myocardial injury in the region,leading to the area of myocardial necrosis,myocardial contractile function disappeared,Widened the left ventricular outflow tract,wh
11、ile lowering the outflow tract obstruction and the cardiac output increase.And improve clinical symptoms and hemodynamics.The pressure gradient at rest 50mmHg or 100mmHg with provocation.In 2008 ESC meeting,Seggewise that BJ Maron et al;JAMA 281:650-655,1999Outflow tract obstruction sign in Echocard
12、iographM-mode echocardiogram in obstructive hypertrophic cardiomyopathy showing systolic anterior motion of the mitral valve(SAM)(arrows indicating septum and mitral valve leaflet contact)Our classfication in PTSMA Our typing in the I-type and in the I-typing was the same as suitable for PTSMA treat
13、ment and Marons II-type includes the type II and type III of our model,it is suitable PTSMA treatment.Therefore,our IV-type classification is the first made by ultrasound imaging features of HOCM,according to its characteristics in line with PTSMA treatment.subaortic 1.Injection of a small amount of
14、 dye(1-2ml)through the guidewire lumen of the inflated balloon catheter angiographically2.Prior to alcohol injection 1-2ml of echo contrast medium is administered through the central lumen of the balloon catheter under UCG.determines the supply area of the target septal branch.Ensure that no areas i
15、nvolving non-obstructive,such as the papillary muscles and ventricular free wall and other parts.Avoid LAD ballooningExclude LAD leakageLevovist In the interval of contrast agent injected into the branch to observe the distribution of vascular contrAlcohol Shadow Levovist shadowMCEN=222No MCEn=30PSe
16、ptal 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)623096620.0001p0.05p0.01 of The pressure gradient Guiding catheter:supporting flexible and low injury Suitable Over-the-wire balloon catheter Intraoperative ultr
17、asound monitoring Contrast echocardigraphy 1(with complications)or 2 septal branches ablation did not significantly reduce the pressure,and no increase alcohol dose Remove balloon should be emptying alcohol of the balloon catheter and stagnation injection alcoholLVAOLVAOHis LVOT gradient 6 months af
18、ter His LVOT gradient 6 months after PTSMA(PTSMA(PG=15mmHg)PG=15mmHg)Echocardiography showed ventricular septal hypertrophy over 30 mm in HOCM,necessary to performeing PTSMA should be very cautious and careful.May be there were a thick septal branch,and control wide,and collateral-rich septal branch
19、 of support,treatment had a higher risk and improve the clinical symptoms and hemodynamics have difficulties,so surgery mytomce may be a better choice.Contrast echocardiography Over-the-wire balloon.Patient CharacteristicsCharacteristicsPatients(n=171)Age(yrs)45.3717.71 Men/women122/49 (71.35%/28.65
20、%)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%)PTSMA(n=171)pSeptal thickness(pre-PTSMA)22.675.35mm Septal th
21、ickness(post-PTSMA 3days)20.684.61mm NS Septal thickness(post-PTSMA 6months)16.774.39mm 0.05LVOTPG(pre-PTSMA)97.5838.23mmHgLVOTPG(post-PTSMA 3days)52.3635.7mmHg 0.001LVOTPG(post-PTSMA 6months)47.2638.62mmHg0.001LA Diameter(pre-PTSMA)43.787.33mm LA Diameter(post-PTSMA 3days)42.417.52mm NSLA Diameter(post-PTSMA 6months)32.7615.58mm 0.05 Ablation area should be appropriate,as small as possible,to avoid a large scar formation.Advice
