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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2020, Vol. 17 ›› Issue (05) : 421 -426. doi: 10.3877/cma.j.issn.1672-6448.2020.05.006

所属专题： 文献；

心血管超声影像学

Liwen术式治疗肥厚型心肌病合并完全性右束支传导阻滞的临床研究
徐博1, 刘金成1,†(), 李静2, 刘丽文2, 周梦垚2, 左蕾2, 邵红3, 胡芮2, 朱晓丽2, 刘兵4   
  1. 1. 710032　西安，解放军空军军医大学第一附属医院（西京医院）心血管外科
    2. 710032　西安，解放军空军军医大学第一附属医院（西京医院）超声医学科
    3. 710032　西安，空军军医大学第一附属医院心脏内科心电图检查室
    4. 710032　西安，空军军医大学第一附属医院心脏内科
  • 收稿日期:2020-03-11 出版日期:2020-05-01
  • 通信作者: 刘金成
  • 基金资助:
    空军军医大学第一附属医院科技发展基金资助项目计划任务书(YYKJFZJJ2018Y002); 陕西省重点项目(2017ZDXM-SF-058); 陕西省重点研发计划项目(2019KW-076); 西京医院新技术、新业务资助项目(417432A); 陕西省重点科技创新团队(2014KCT-20)

Liwen procedure for treatment of complete right bundle branch block in a patient with hypertrophic cardiomyopathy

Bo Xu1, Jincheng Liu1,†(), Jing Li2, Liwen Liu2, Mengyao Zhou2, Lei Zuo2, Hong Shao3, Rui Hu2, Xiaoli Zhu2, Bing Liu4   

  1. 1. Department of Cardiac Surgery, First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Hypertrophic Cardiomyopathy International Cooperation Center, the First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Multidisciplinary Consultation Center of Hypertrophic Cardiomyopathy, Shaanxi Province; Multidisciplinary Clinic and Genetic Counseling Center of Hypertrophic Cardiomyopathy, Xijing Hospital, Xi'an 710032, China
    2. Department of the Ultrasound, First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Hypertrophic Cardiomyopathy International Cooperation Center, the First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Multidisciplinary Consultation Center of Hypertrophic Cardiomyopathy, Shaanxi Province; Multidisciplinary Clinic and Genetic Counseling Center of Hypertrophic Cardiomyopathy, Xijing Hospital, Xi'an 710032, China
    3. Cardiac Electrocardiogram Examination Room, the First Affiliated Hospital of Air Force Military Medical University (Xijing Hospital), Xi’an 710032, China
    4. Department of Cardiology, the First Affiliated Hospital of Air Force Military Medical University (Xijing Hospital), Xi’an 710032, China
  • Received:2020-03-11 Published:2020-05-01
  • Corresponding author: Jincheng Liu
  • About author:
    Corresponding author: Liu Jincheng, Email:
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引用本文：

徐博, 刘金成, 李静, 刘丽文, 周梦垚, 左蕾, 邵红, 胡芮, 朱晓丽, 刘兵. Liwen术式治疗肥厚型心肌病合并完全性右束支传导阻滞的临床研究[J]. 中华医学超声杂志（电子版）, 2020, 17(05): 421-426.

Bo Xu, Jincheng Liu, Jing Li, Liwen Liu, Mengyao Zhou, Lei Zuo, Hong Shao, Rui Hu, Xiaoli Zhu, Bing Liu. Liwen procedure for treatment of complete right bundle branch block in a patient with hypertrophic cardiomyopathy[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2020, 17(05): 421-426.

目的

Liwen术式即经胸超声心动图引导下经皮心肌内室间隔射频消融术治疗肥厚型心肌病（HCM）合并完全性右束支传导阻滞（RBBB）的病例进行临床研究，为此类患者提供新的临床治疗方案。

方法

纳入2017年在空军军医大学西京医院肥厚型心肌病诊治中心接受Liwen术式治疗的梗阻性肥厚型心肌病患者，对其临床资料进行回顾性分析。在2年随访期间，采用经胸超声心动图评价患者室间隔厚度、左心室流出道峰值压力阶差等，运动负荷心动图评价患者左心室流出道峰值压力阶差和运动总时间等，12导联心电图监测患者心脏的电活动改变，心脏核磁评估心肌纤维化情况及消融范围。

结果

术后2年，患者左心室流出道（LVOT）峰值压差明显降低（静息LVOT压差：从130 mmHg降至8 mmHg；运动激发后LVOT压差：从181 mmHg降至28 mmHg），室间隔（IVS）厚度变薄（前IVS厚度：从15 mm降至8 mm；后IVS厚度：从16 mm到8 mm）；纽约心功能分级从Ⅲ级降低至Ⅰ级，运动时间由6 min增加至8 min。术前心电图提示存在RBBB，术后6个月起至2年，RBBB消失。

结论

Liwen术式可以有效解除LVOT梗阻的同时促使心律失常发生良性转归。

关键词: 心肌病，肥厚性, 消融技术, 完全性右束支传导阻滞, 心律失常
Objective

To assess the efficacy Liwen procedure in the treatment of complete right bundle branch block (RBBB) in a hypertrophic cardiomyopathy (HCM) patient to provide a new treatment for such patients.

Methods

We retrospectively analyzed the clinical data of an HCM patient who was treated by Liwen procedure on September 2017 at the Hypertrophic Cardiomyopathy Center of Xijing Hospital of Air Force Military Medical University. During 2 years of follow-up, the interventricular septum (IVS) thickness and left ventricular outflow tract (LVOT) peak gradient were measured by transthoracic echocardiography, stress-induced gradient and total exercise time were measured by stress echocardiography, cardiac electrical activity was monitored by a 12-lead electrocardiogram, and myocardial fibrosis and ablation area were examined by cardiac magnetic resonance.

Results

At the 2-year follow-up, the patient showed significant reductions in peak LVOT gradients (resting gradient: from 130 mmHg to 8 mmHg; stress-induced gradient: from 181 mmHg to 28 mmHg) and IVS thickness (anterior IVS: from 15 mm to 8 mm; posterior IVS: from 16 mm to 8 mm). The reductions in IVS thickness and LVOT gradients were associated with improvements in the New York Heart Association class (from 3 to 1) and total exercise time (from 6 min to 8 min). Pre-procedure ECG indicated the presence of RBBB, which disappeared from 6 months after Liwen procedure.

Conclusion

Liwen procedure is a new technique which can effectively relieve LVOT obstruction and cause good cardiac outcome.

Key words: Cardiomyopathy, hypertrophic, Ablation technique, Liwen procedure, Complete right bundle branch block
图1，2 Liwen术式操作过程。图1a为超声引导下经皮、经肋间、经心外膜进针；图1b为进针时应避开心尖部小血管；图1c为箭头所示为针尖；图2a为心肌内室间隔射频消融；图2b为虚线框为前间隔内强回声消融区；图2c为虚线框内为后间隔消融区
图3 Liwen术式术前及术后6个月、2年超声心动图的变化。图a为术前室间隔厚度15 mm，左心室流出道梗阻，SAM征（＋）；图b为术后6个月室间隔厚度减薄至10 mm，左心室流出道梗阻解除，SAM征（-）；图c为术后2年室间隔厚度进一步减薄至8 mm，SAM征（-）；图d为术前左心室流出道血流呈湍流，二尖瓣反流14.3 ml；图e为术后6个月左心室流出道血流呈层流，二尖瓣反流消失；图f为术后2年左心室流出道血流恢复正常，二尖瓣反流消失；图g为左心室流出道峰值压差为130 mmHg；图h为术后6个月左心室流出道峰值压差降至12 mmHg；图i为术后2年左心室流出道压差降至8 mmHg（箭头所示为左心室流出道）
图4 Liwen术式术前及术后6个月、2年心脏核磁及心电图的变化。图a为绿色线条圈出患者心肌纤维化；图b，c为红色虚线框为消融后改变
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