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摘要：
目的 探讨术中经食管超声心动图（transesophageal echocardiography, TEE）对肥厚型梗阻性心肌病（obstructive hypertrophic cardiomyopathy, HOCM）患者改良Morrow手术中麻醉管理、手术决策的指导作用及效果评价。 方法 选取2015年3月至2019年3月诊断为HOCM，行改良Morrow手术的患者共21例，患者术中均行TEE检查。在食管中段左室流出道长轴切面记录术前、术后左室流出道最窄处直径，右冠瓣下室间隔厚度及长度；经深胃心室长轴切面连续多普勒测量左室流出道血流速度，并计算跨瓣压差；观察二尖瓣、主动脉瓣瓣叶运动及反流情况、室间隔有无穿孔、室壁运动情况；在食管中段四腔心切面记录二尖瓣瓣尖水平、二尖瓣舒张早期充盈（early filling, E）峰流速、心房充盈（atrial filling, A）峰流速、E/A（二尖瓣 E 峰流速与A 峰流速比值）、组织多普勒二尖瓣瓣环心室侧壁舒张早期（early diastolic, e′）峰速度、E/e′（二尖瓣 E 峰流速与二尖瓣环e′速度比值）。 结果 所有患者术中血流动力学平稳，无心室纤颤等恶性不良事件发生。主动脉开放后心脏自动复跳18例（85%），3例（15%）使用临时起搏器；17例（81%）患者不需要使用正性肌力药物，辅助使用小剂量去氧肾上腺素即可顺利脱离心肺转流，4 例（19%）患者需要辅助使用小剂量米力农或同时加用去氧肾上腺素或去甲肾上腺素。CPB时间（124±45） min，主动脉阻断时间（85±21） min。TEE监测左室流出道跨瓣压差由术前（68±8） mmHg（1 mmHg=0.133 kPa）降至术后（16±6） mmHg（P<0.05），主动脉瓣下室壁厚度由术前（30±6） mm 降至术后（19±5） mm（P<0.05），18例（86%）患者术前有中、重度二尖瓣反流，术后TEE检查二尖瓣反流为轻度，二尖瓣前叶收缩期前向运动（systolic anterior motion, SAM）消失。经导管监测主动脉瓣下的跨瓣压差由术前（65±10） mmHg降至术后（20±3） mmHg（P<0.05）。TEE监测患者术前收缩功能正常，而舒张功能有11例异常，所测E/A<0.8，E/e′>14，室间隔侧壁e′<10 cm/s。 结论 TEE监测在麻醉管理、手术决策、效果评价中起到了至关重要的作用，在收缩功能正常的患者中，TEE监测深胃心室长轴跨瓣压差与术中经导管监测主动脉瓣跨瓣压差相关性好。
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Abstract: Ｏｂｊｅｃｔｉｖｅ To evaluate the application of transesophageal echocardiography (TEE) in anesthesia management of obstructive hypertrophic cardiomyopathy (HOCM) during modified morrow operation and to evaluate the effect of TEE on surgical decision-making. Methods Twenty-one HOCM patients who were admitted into our hospital from March 2015 to March 2019 for TEE were selected. All patients underwent transesophageal ultrasound. The diameter of the narrowest left ventricular outflow tract, and subaortic interventricular septal thickness and length were recorded before and after operation. Continuous Doppler flow velocity was measured at the left ventricular outflow tract and the difference of transvalvular pressure was calculated. At point of mitral valve apex, peak velocity and atrial filling (A) and early filling (E) of mitral valve were recorded on four-chamber level of middle esophagus, E/A(mitral valve E peak velocity divided by A peak velocity ratio). Early diastolic (e′) phase of ventricular lateral wall of mitral annulus with tissue doppler, E/e′(mitral valve E peak velocity divided by mitral annulus e′) were recorded. Results Intro-operative aerodynamics was stable and no malignant adverse events such as ventricular fibrillation occurred. There were 18 cases of auto-cardiac resuscitation (85%), 3 cases of temporary pacemaker use (15%), while 17 patients (81%) did not need to use positive inotropic drugs after rebound, but could successfully depart from cardiopulmonary bypass at low doses of deoxyepinephrine. The remaining four patients (19%) required low doses of milrinone or combined with deoxyepinephrine or norepinephrine. The cardiopulmonary bypass (CPB) time was (124±45) min and the aortic occlusion time was (85±21) min. The trans-valvular pressure of left ventricular outflow tract decreased to (68±8) mmHg (1 mmHg=0.133 kPa) to (16±6) mmHg by TEE after operation (P<0.05). Eighteen(86%) patients presented moderate or severe mitral regurgitation before operation. Mitral regurgitation was mild by TEE after operation and systolic anterior motion (SAM) disappeared. The thickness of the subaortic wall decreased from (30±6) mm to (19±5) mm after operation (P<0.05). During the operation, the mean arterial pressure under the aortic valve was monitored by catheter from (65±10) mmHg to (20±3) mmHg (P<0.05). Preoperative systolic function of patients monitored by TEE was normal, while diastolic function was abnormal in 11 cases. The E/A ratio was<0.8, E/e′>14, and the lateral wall of ventricular septum e′ was<10 cm/s. Conclusions TEE plays an important role in anesthesia management, surgical decision-making and evaluation of operation. For patients with normal systolic function, TEE monitoring of transvalvular pressure through deep transgastric lax is consistent with intraoperative monitoring of transvalvular pressure through catheter.
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