發(fā)布時(shí)間：2018-05-13 16:47

  本文選題：肥厚型心肌病 + 心房顫動(dòng)��； 參考：《北京協(xié)和醫(yī)學(xué)院》2016年博士論文

【摘要】：第一部分伴有非瓣膜病性心房顫動(dòng)、CHA2DS2-VASc評(píng)分≤1分,且未接受抗凝治療的肥厚型心肌病患者發(fā)生缺血性腦卒中和系統(tǒng)性栓塞的風(fēng)險(xiǎn)研究背景及研究目的：目前,尚缺乏有關(guān)伴有非瓣膜性病心房顫動(dòng)、CHA2DS2-VASc評(píng)分≤1分,且未接受抗凝治療的肥厚型心肌病患者發(fā)生缺血性腦卒中和系統(tǒng)性栓塞(ischemic stroke and systemic embolism,iSSE)的風(fēng)險(xiǎn)的數(shù)據(jù)。本研究的目的是調(diào)查此類患者發(fā)生iSSE的風(fēng)險(xiǎn)。研究方法：本研究回顧了阜外醫(yī)院1994年1月至2014年3月間所有合并非瓣膜性病心房顫動(dòng)的肥厚型心肌病患者的病歷資料。主要終點(diǎn)事件是缺血性腦卒中和系統(tǒng)性栓塞的復(fù)合終點(diǎn)事件。通過隨訪來確定是否發(fā)生終點(diǎn)事件,及終點(diǎn)事件發(fā)生的時(shí)間。研究結(jié)果：本研究回顧了522例合并非瓣膜性病心房顫動(dòng)的肥厚型心肌病患者的病歷資料。其中108例患者(20.7%)滿足本研究的入選條件,即：CHA2DS2-VASc評(píng)分≤1分,且未接受抗凝治療。全部入選這108例患者,構(gòu)成本研究的研究人群。經(jīng)過中位2.4年的隨訪(最短0.6年,最長(zhǎng)14.1年；共計(jì)376.2人年),共有2例患者(1.8%)發(fā)生缺血性腦卒中。1例發(fā)生在隨訪第一年,造成該患者死亡：另1例發(fā)生在隨訪第四年,造成該患者癱瘓。未見其他血栓栓塞性事件發(fā)生。隨訪第一年主要終點(diǎn)事件的發(fā)生率為0.9%(95%置信區(qū)間,0.0%～5.0%)。每一百人年主要終點(diǎn)事件發(fā)生率為0.5(95%置信區(qū)間,0.1～1.9)。研究結(jié)論：伴有非瓣膜病性心房顫動(dòng)、CHA2DS2-VASc評(píng)分≤1分,且未接受抗凝治療的肥厚型心肌病患者發(fā)生缺血性腦卒中和系統(tǒng)性栓塞的風(fēng)險(xiǎn)似乎不高。是否應(yīng)該將所有伴有非瓣膜病性心房顫動(dòng)的肥厚型心肌病患者劃入缺血性腦卒中和系統(tǒng)性栓塞的高危人群,并推薦接受抗凝治療有待商榷。需要入選較大樣本的多中心研究來驗(yàn)證本研究的結(jié)果。第二部分藥物難治性肥厚型梗阻性心肌病患者酒精室間隔消融術(shù)與保守治療生存率的比較研究背景及研究目的：酒精室間隔消融術(shù)對(duì)藥物難治性肥厚型梗阻性心肌病患者生存率的影響尚不清楚。本研究旨在比較藥物難治性肥厚型梗阻性心肌病患者酒精室間隔消融術(shù)與保守治療的預(yù)后。研究方法：本研究連續(xù)入選274例伴有嚴(yán)重藥物難治性癥狀的肥厚型梗阻性心肌病患者。其中,酒精室間隔消融術(shù)組229例,保守治療組45例。主要終點(diǎn)事件是全因死亡和心臟驟停復(fù)蘇成功的復(fù)合終點(diǎn)事件。研究結(jié)果：經(jīng)過中位4.3年的隨訪,酒精室間隔消融術(shù)組中13例患者(5.7%)發(fā)生了主要終點(diǎn)事件,保守治療組中8例患者(17.8%)發(fā)生了主要終點(diǎn)事件。酒精室間隔消融術(shù)組5年和10年生存率分別為94.5%和93.0%。保守治療組5年和10年生存率分別為78.3%和72.2%。酒精室間隔消融術(shù)組生存率顯著優(yōu)于保守治療組(10g-rank p=0.009).多元Cox回歸分析顯示,主要終點(diǎn)事件的獨(dú)立預(yù)測(cè)因子為：酒精室間隔消融術(shù)治療(危險(xiǎn)比,0.22；95%置信區(qū)間,0.08-0.60；p=0.003)和最大室間隔厚度(危險(xiǎn)比,1.14每毫米；95%置信區(qū)間,1.03-1.27；p=0.011)。研究結(jié)論：(1)在藥物難治性肥厚型梗阻性心肌病患者中,接受酒精室間隔消融術(shù)者生存率較好；(2)接受酒精室間隔消融術(shù)治療的藥物難治性肥厚型梗阻性心肌病患者生存率優(yōu)于接受保守治療者；(3)酒精室間隔消融術(shù)可能具有改善藥物難治性肥厚型梗阻性心肌病患者長(zhǎng)期生存率的作用。第三部分酒精室間隔消融術(shù)治療伴和不伴極度室間隔肥厚的藥物難治性肥厚型梗阻性心肌病患者的療效比較研究背景及研究目的：有關(guān)酒精室間隔消融術(shù)治療伴有極度室間隔肥厚的藥物難治性肥厚型梗阻性心肌病患者的效果的數(shù)據(jù)較為缺乏。本研究旨在比較酒精室間隔消融術(shù)治療伴和不伴極度室間隔肥厚的藥物難治性肥厚型梗阻性心肌病患者的療效。研究方法：本研究分析了17例伴有極度室間隔肥厚和256例不伴極度室間隔肥厚的藥物難治性肥厚型梗阻性心肌病患者的臨床資料。研究結(jié)果：兩組基線左心室腔內(nèi)壓力階差和限制性癥狀相似。酒精室間隔消融術(shù)后中位隨訪1.1年時(shí),極度室間隔肥厚組左心室腔內(nèi)壓力階差為48.5±40.4 mm Hg,非極度室間隔肥厚組左心室腔內(nèi)壓力階差為40.9±35.2 mm Hg(p=0.329).極度室間隔肥厚組紐約心功能分級(jí)Ⅲ/Ⅳ級(jí)心力衰竭者占5.9%,非極度室間隔肥厚組紐約心功能分級(jí)Ⅲ/Ⅳ級(jí)心力衰竭者占16.9%(p=0.392)。極度室間隔肥厚組紐約心功能分級(jí)Ⅲ/Ⅳ級(jí)心力衰竭者占5.9%,非極度室間隔肥厚組紐約心功能分級(jí)Ⅲ/Ⅳ級(jí)心力衰竭者占10.2%(p=0.871)。研究結(jié)論：酒精室間隔消融術(shù)治療伴和不伴極度室間隔肥厚的藥物難治性肥厚型梗阻性心肌病患者的效果是相似的。酒精室間隔消融術(shù)可以應(yīng)用于治療不適合或不愿意接受室間隔心肌切除術(shù)的伴有極度室間隔肥厚的藥物難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.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R542.2
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本文編號(hào)：1884006