肥厚型心肌病的临床研究

发布时间：2018-05-13 16:47

  本文选题：肥厚型心肌病 + 心房颤动　； 参考：《北京协和医学院》2016年博士论文

【摘要】：第一部分伴有非瓣膜病性心房颤动、CHA2DS2-VASc评分≤1分,且未接受抗凝治疗的肥厚型心肌病患者发生缺血性脑卒中和系统性栓塞的风险研究背景及研究目的：目前,尚缺乏有关伴有非瓣膜性病心房颤动、CHA2DS2-VASc评分≤1分,且未接受抗凝治疗的肥厚型心肌病患者发生缺血性脑卒中和系统性栓塞(ischemic stroke and systemic embolism,iSSE)的风险的数据。本研究的目的是调查此类患者发生iSSE的风险。研究方法：本研究回顾了阜外医院1994年1月至2014年3月间所有合并非瓣膜性病心房颤动的肥厚型心肌病患者的病历资料。主要终点事件是缺血性脑卒中和系统性栓塞的复合终点事件。通过随访来确定是否发生终点事件,及终点事件发生的时间。研究结果：本研究回顾了522例合并非瓣膜性病心房颤动的肥厚型心肌病患者的病历资料。其中108例患者(20.7%)满足本研究的入选条件,即：CHA2DS2-VASc评分≤1分,且未接受抗凝治疗。全部入选这108例患者,构成本研究的研究人群。经过中位2.4年的随访(最短0.6年,最长14.1年；共计376.2人年),共有2例患者(1.8%)发生缺血性脑卒中。1例发生在随访第一年,造成该患者死亡：另1例发生在随访第四年,造成该患者瘫痪。未见其他血栓栓塞性事件发生。随访第一年主要终点事件的发生率为0.9%(95%置信区间,0.0%～5.0%)。每一百人年主要终点事件发生率为0.5(95%置信区间,0.1～1.9)。研究结论：伴有非瓣膜病性心房颤动、CHA2DS2-VASc评分≤1分,且未接受抗凝治疗的肥厚型心肌病患者发生缺血性脑卒中和系统性栓塞的风险似乎不高。是否应该将所有伴有非瓣膜病性心房颤动的肥厚型心肌病患者划入缺血性脑卒中和系统性栓塞的高危人群,并推荐接受抗凝治疗有待商榷。需要入选较大样本的多中心研究来验证本研究的结果。第二部分药物难治性肥厚型梗阻性心肌病患者酒精室间隔消融术与保守治疗生存率的比较研究背景及研究目的：酒精室间隔消融术对药物难治性肥厚型梗阻性心肌病患者生存率的影响尚不清楚。本研究旨在比较药物难治性肥厚型梗阻性心肌病患者酒精室间隔消融术与保守治疗的预后。研究方法：本研究连续入选274例伴有严重药物难治性症状的肥厚型梗阻性心肌病患者。其中,酒精室间隔消融术组229例,保守治疗组45例。主要终点事件是全因死亡和心脏骤停复苏成功的复合终点事件。研究结果：经过中位4.3年的随访,酒精室间隔消融术组中13例患者(5.7%)发生了主要终点事件,保守治疗组中8例患者(17.8%)发生了主要终点事件。酒精室间隔消融术组5年和10年生存率分别为94.5%和93.0%。保守治疗组5年和10年生存率分别为78.3%和72.2%。酒精室间隔消融术组生存率显著优于保守治疗组(10g-rank p=0.009).多元Cox回归分析显示,主要终点事件的独立预测因子为：酒精室间隔消融术治疗(危险比,0.22；95%置信区间,0.08-0.60；p=0.003)和最大室间隔厚度(危险比,1.14每毫米；95%置信区间,1.03-1.27；p=0.011)。研究结论：(1)在药物难治性肥厚型梗阻性心肌病患者中,接受酒精室间隔消融术者生存率较好；(2)接受酒精室间隔消融术治疗的药物难治性肥厚型梗阻性心肌病患者生存率优于接受保守治疗者；(3)酒精室间隔消融术可能具有改善药物难治性肥厚型梗阻性心肌病患者长期生存率的作用。第三部分酒精室间隔消融术治疗伴和不伴极度室间隔肥厚的药物难治性肥厚型梗阻性心肌病患者的疗效比较研究背景及研究目的：有关酒精室间隔消融术治疗伴有极度室间隔肥厚的药物难治性肥厚型梗阻性心肌病患者的效果的数据较为缺乏。本研究旨在比较酒精室间隔消融术治疗伴和不伴极度室间隔肥厚的药物难治性肥厚型梗阻性心肌病患者的疗效。研究方法：本研究分析了17例伴有极度室间隔肥厚和256例不伴极度室间隔肥厚的药物难治性肥厚型梗阻性心肌病患者的临床资料。研究结果：两组基线左心室腔内压力阶差和限制性症状相似。酒精室间隔消融术后中位随访1.1年时,极度室间隔肥厚组左心室腔内压力阶差为48.5±40.4 mm Hg,非极度室间隔肥厚组左心室腔内压力阶差为40.9±35.2 mm Hg(p=0.329).极度室间隔肥厚组纽约心功能分级Ⅲ/Ⅳ级心力衰竭者占5.9%,非极度室间隔肥厚组纽约心功能分级Ⅲ/Ⅳ级心力衰竭者占16.9%(p=0.392)。极度室间隔肥厚组纽约心功能分级Ⅲ/Ⅳ级心力衰竭者占5.9%,非极度室间隔肥厚组纽约心功能分级Ⅲ/Ⅳ级心力衰竭者占10.2%(p=0.871)。研究结论：酒精室间隔消融术治疗伴和不伴极度室间隔肥厚的药物难治性肥厚型梗阻性心肌病患者的效果是相似的。酒精室间隔消融术可以应用于治疗不适合或不愿意接受室间隔心肌切除术的伴有极度室间隔肥厚的药物难治性肥厚型梗阻性心肌病患者。
[Abstract]:The first part was associated with non valvular atrial fibrillation, the CHA2DS2-VASc score was less than 1, and the risk of ischemic stroke and systemic embolism in patients with hypertrophic cardiomyopathy without anticoagulant treatment was studied. At present, there is still a lack of atrial fibrillation associated with non valvular venereal disease, the CHA2DS2-VASc score is less than 1, and it is not accepted. The risk of ischemic stroke and systemic embolism (ischemic stroke and systemic embolism, iSSE) in patients with hypertrophic cardiomyopathy in anticoagulant therapy. The purpose of this study was to investigate the risk of iSSE in such patients. The study reviewed all the combined non valvular valves in Fuwai Hospital from January 1994 to March 2014. The medical records of patients with hypertrophic cardiomyopathy of venereal atrial fibrillation. The main terminal event is a compound endpoint of ischemic stroke and systemic embolism. Follow up to determine whether the endpoint event is occurring, and the time of the endpoint event. Results: 522 cases of non valvular VD atrial fibrillation were reviewed in this study. The medical records of patients with type 108 cardiomyopathy (20.7%) were satisfied with the conditions of the study. The CHA2DS2-VASc score was less than 1, and the anticoagulant treatment was not accepted. All the 108 patients were selected to form the study group. After a median of 2.4 years of follow-up (the shortest 0.6 years, the longest 14.1 years, a total of 376.2 years), there were 2 patients (the total of 2 patients). 1.8%).1 cases of ischemic stroke occurred in the first year of follow-up, resulting in the death of the patient: the other 1 cases were followed up for fourth years, causing the patient to be paralyzed. No other thromboembolic events occurred. The incidence of major end points of the first year of follow-up was 0.9% (95% confidence interval, 0% to 5%). The rate of 0.5 (95% confidence interval, 0.1 to 1.9). Conclusions: the risk of ischemic stroke and systemic embolism in patients with hypertrophic cardiomyopathy with non valvular atrial fibrillation, with non valvular atrial fibrillation, is not high. Whether there should be a hypertrophic myocardium with non valvular atrial fibrillation should be found. Patients who are at risk of ischemic stroke and systemic embolism and recommend anticoagulant therapy are open to discussion. A multicenter study is needed to verify the results of this study. A comparative study of the survival rate of alcohol ventricular septal ablation and conservative treatment in second patients with refractory hypertrophic obstructive cardiomyopathy. Background and research objectives: the effect of alcohol ventricular septum ablation on the survival rate of patients with drug-refractory hypertrophic obstructive cardiomyopathy is not clear. The purpose of this study was to compare the prognosis of alcohol ventricular septum ablation and conservative treatment in patients with refractory hypertrophic obstructive cardiomyopathy. Research methods: 274 consecutive patients were enrolled in this study. Patients with severe drug refractory symptoms were hypertrophic obstructive cardiomyopathy. Among them, 229 cases of alcohol ventricular septum ablation group and 45 cases in conservative treatment group. The main terminal event was the combined end event of all causes of death and cardiac arrest resuscitation. Results: after a median follow-up of 4.3 years, 13 patients in the alcohol ventricular septum group (5.7%) The main endpoint event occurred in 8 patients (17.8%) in the conservative treatment group. The 5 and 10 year survival rates of the alcohol ventricular septum group were 94.5% and the 93.0%. conservative treatment group 5 and 10 year survival rates were 78.3% and the 72.2%. alcohol ventricular septal ablation group was significantly better than the conservative treatment group (10g-rank p=0.0). 09). Multivariate Cox regression analysis showed that the independent predictors of main endpoint events were alcohol ventricular septum ablation (risk ratio, 0.22; 95% confidence interval, 0.08-0.60; p=0.003) and maximum ventricular septum thickness (risk ratio, 1.14 mm; 95% confidence interval, 1.03-1.27; p=0.011). Conclusions: (1) in drug refractory hypertrophic stalks In patients with obstructive cardiomyopathy, the survival rate of patients receiving alcohol interventricular septum ablation was better; (2) the survival rate of patients with refractory hypertrophic obstructive cardiomyopathy treated with alcohol interventricular septal ablation was better than that of those who received conservative treatment; (3) alcohol ventricular septal ablation may have improved drug refractory hypertrophic obstructive cardiomyopathy The effect of long-term survival. Third partial alcohol interventricular septum ablation treatment for patients with refractory hypertrophic obstructive cardiomyopathy with and without extreme ventricular septal hypertrophy: a comparative study background and research objectives: alcohol ventricular septal ablation for the treatment of refractory hypertrophic obstructive cardiac drugs with extreme ventricular septal hypertrophy This study aims to compare the efficacy of alcohol ventricular septum ablation in the treatment of patients with refractory hypertrophic obstructive cardiomyopathy with and without extreme ventricular septal hypertrophy. Methods: 17 cases with extreme ventricular septal hypertrophy and 256 cases without extreme ventricular septal hypertrophy were analyzed in this study. Clinical data of patients with refractory hypertrophic obstructive cardiomyopathy. Results: two groups of baseline left ventricular pressure order difference and restrictive symptoms were similar. After 1.1 years of median follow-up after alcohol interventricular septal ablation, the left ventricular pressure order of the extreme ventricular septal hypertrophy group was 48.5 + 40.4 mm Hg, and the left ventricular cavity in the non extreme ventricular septal hypertrophy group The stress level was 40.9 + 35.2 mm Hg (p=0.329). 5.9% of patients with heart failure in extreme ventricular septal hypertrophy group were grade III / IV heart failure, and 16.9% (p=0.392) in non extreme ventricular septal hypertrophy group (16.9%) with grade III / IV heart failure in the group of non extreme ventricular septal hypertrophy group (5.9% / IV) in extreme ventricular septal hypertrophy group (5.9%) of heart function grade III / IV heart failure, non extreme. 10.2% (p=0.871) of cardiac function grade III / IV heart failure in the ventricular septal hypertrophy group (10.2%). Conclusion: the effect of alcohol ventricular septum ablation therapy for patients with refractory hypertrophic obstructive cardiomyopathy with and without extreme ventricular septal hypertrophy is similar. Alcohol interventricular septal ablation can be used for treatment unsuitable or unwilling. Patients with refractory hypertrophic obstructive cardiomyopathy underwent ventricular septal myocardial resection with ventricular septal hypertrophy.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R542.2
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本文编号：1884006