| Experimental study on etiology of hypertrophic obstructive cardiomyopathy with atrial fibrillationObjective The aim of this study was to investigate the collagen content and fibrosis in atrium of patients with HOCM and AF,as well as the correlation with the expression of CTGF,mTOR and P4Halpha.To observe the expression of mTOR protein in HOCM with AF and explore the role of P4Halpha in the pathogenesis of HOCM with AF.To further study the significance of CTGF in the occurrence of AF in HOCM patients,and to preliminarily explore the pathogenic remodeling mechanism of fibrosis in the pathogenesis of HOCM combined with AF.Methods Fifteen myocardial specimens excised during Morrow procedure with HOCM and AF were selected as the experimental group(HOCM&AF).Fifteen tissue specimens from simple HOCM patients undergoing Morrow operation were selected as the control group(HOCM).The general condition of atrial wall and collagen content were detected by HE and Mason staining,respectively.The expression of CTGF,mTOR and P4Halpha in atrial wall was detected by immunohistochemistry and Western blot,and the average optical density was compared.The correlation between CTGF,mTOR and P4Halpha and fibrosis was analy2ed.The expression levels of CTGF,mTOR and P4Halpha in all specimens were detected by real-time PCR.Results Histological results showed that compared with the control group,the collagen fibers in the experimental group were obviously proliferated,arranged disorderly and unevenly distributed.Immunohistochemical results showed that CTGF was expressed in all layers of the atrial wall in the experimental group,and the expression of CTGF in the control group was less than that in the control group(P<0.01).The expression of mTOR protein in all layers of the atrial wall in the experimental group was higher than that in the control group(P<0.01).P4Hawas expressed in all layers of the atrial wall in the experimental group,which was more than that in the control group(P=0.001).Western blot results showed that the expression of CTGF,mTOR and P4a in the experimental group was higher than that in the control group,and the difference was statistically significant(all P<0.01).The mRNA expression of CTGF,mTOR and P4Ha was consistent with that of protein.The expression of CTGF,mTOR and P4Ha in the experimental group was higher than that in the control group(all P<0.01).The correlation analysis showed that the average optical density of CTGF was positively correlated with die expression of collagen(r=0.738,P<0.01);the expression of mTOR was positively correlated with the expression of collagen(r=0.614,P<0.01);the expression of mTOR was positively correlated with the expression of CTGF(r=0.64,P<0.01);and the expression of P4Ha was positively correlated with the expression of collagen(r=0.838,P<0.01).Histological analysis of ventricular septal myocardium showed that the collagen content of ventricular septal myocardium in the two groups was higher than that in the normal condition,and the fibrosis in the experimental group was higher than that in the control group.Conclusions In HCM patients with AF5 the levels of CTGF and collagen protein and mRNA are increased,and the expression of stable collagen enzymes(P4Ha)is also increased.Further experimental results show that CTGF may play a role through PI3K/Akt/mToR signaling pathway,suggesting that CTGF and other cytokines and their signaling pathways play an important role in the occurrence and development of HCM patients with atrial fibrillation.CTGF may be involved in the pathogenesis of AF by promoting collagen synthesis,and its exact mechanism needs further study.Study of Morrow&Maze IV operation in the treatment of hypertrophic cbstructive cardiomyopathy complicated with atrial fibrillationObjective The purpose of this study was to summarize the management strategies and clinical outcomes of modified extended Morrow operation and maze IV operation(Morrow/Cox-Maze IV)in patients with hypertrophic obstructive cardiomyopathy(HOCM)and atrial fibrillation.Methods A retrospective analysis was made of 43 patients with atrial fibrillation complicated by HOCM who underwent Morrow/Cox-Maze IV operation in 7 wards of Adult Surgery,Fuwai Hospital from January 2015 to June 2018.There were 28 males(28/43,65%)and 15 females(15/43,35%),including 21 cases of persistent atrial fibrillation and 22 cases of paroxysmal atrial fibrillation.There were 43 cases of chest tightness,10 cases of chest pain and 8 cases of syncope before operation.The age ranged from 31 to 68(53.12+10.45)years.Recurrence of atrial fibrillation,symptoms,improvement of activity tolerance(score),LVOTQ SAM,NYHA and changes of mitral valve structure and function were assessed by telephone or outpatient follow-up.Results All the Cox-maze IV operations were bipolar ablation,including 13 left atrial ablation and 28 bilateral ablation.All patients underwent left atrial appendectomy.There are two perioperative deaths.41 survived patients were sinus rhythm during hospitalization and discharge.Postoperative echocardiography showed that the left atrial diameter,LVOTG and interventricular septum thickness were significantly reduced or decreased compared with those before operation(all P<0.01);the left ventricular end-diastolic diameter was significantly increased(P<0.01);the left ventricular ejection fraction was decreased after operation,but still above the normal value(P<0.01).The degree of mitral and tricuspid regurgitation was significantly less than that before operation(P<0.001),and SAM signs disappeared in all patients.Left atrial ablation was mostly used in paroxysmal atrial fibrillation,and bilateral ablation was mostly used in bilateral atrial ablation.The difference was statistically significant(P<0.01).The number of mitral valvuloplasty in paroxysmal atrial fibrillation was higher than that in persistent atrial fibrillation(P<0.01).The follow-up period was 6-60 months,with an average of(21.88+12.09)months.During the follow-up period,no death occurred in all patients,no permanent pacemaker was installed due to slow heart rate,no reoperation(catheter ablation,etc.).All patients had NYHA cardiac function in grade I and II.At the end of follow-up,the sinus heart rate was maintained at 75.61%(31/41)and 87.80%(36/41)after drug conversion.Although the recurrence rate of persistent atrial fibrillation was higher than that of paroxysmal atrial fibrillation,there was no significant difference between the two groups(P=0.13).Survival analysis showed that the freedom from all AF recurrence after Morrow/Cox-Maze Ⅳ operation was(82.1±6.2)%at 1 year and(71.8±7.7)%at 3 years.The freedom from persistent AF recurrence after Morrow/Cox-Maze IV operation was(72.4±10.6)%at 1 year and that of paroxysmal atrial fibrillation was(70.5±11.4)%,there was no significant difference between the two groups(P=0.88).The freedom from all AF recurrence with arrhythmia control after Morrow/Cox-Maze IV operation was(89.7±4.9)%at 1 year and(83.3±7.7)%at 3 years.The freedom from persistent AF recurrence with arrhythmia control after Morrow/Cox-Maze IV operation was(84.2±8.4)%at 1 year and that of paroxysmal atrial fibrillation was(86.1±9.4)%,there was no significant difference between the two groups(P=0.38).Univariate analysis showed that the risk factors for recurrence of atrial fibrillation were smoking history before operation(OR=13.71,95%CI=1.24-152.15,P=0.003),left atrial diameter before operation(>55 mm)(OR=4.69,95%CI=1.05-20.90,P-0.04),left atrial diameter after operation(>50 mm)(OR=11.00,95%CI=1.48-81.61,P=0.02),left ventricular diameter after operation(>50 mm)(OR=7.81,95%CI=1.45-42.17,P=0.02).Postoperative tricuspid reguigitation(OR=7.25,95%Cl=1.43-36.69,P=0.02).Multivariate analysis showed that the increase of left atrial diameter(>50 mm)after operation(OR=22.43,95%Cl=1.50-335.02,P=0,02),and the increase of left ventricular diameter(>50 mm)after operation(OR=33.35,95%Cl=2.45-453.59,P=0.01)were independent risk factors for recurrence of atrial fibrillation.Conclusions Morrow/Cox-maze IV procedure are safe and effective for patients with hypertrophic obstructive cardiomyopathy complicated with atrial fibrillation.Postoperative sinus rhythm rate can be maintained at a satisfactory level,significantly improve the cardiac function classification and the quality of life,ameliorate symptoms of patients.Drug control can improve the maintenance rate of sinus heart rate after the recurrence of atrial fibrillation.The increase of left atrial diameter and left ventricular diameter after operation are independent risk factors for the recurrence of atrial fibrillation.The study of surgical treatment of hypertrophic obstructive cardiomyopathy with coronary artery diseaseObjective The purpose of this study was to summarize the perioperative management strategies and early outcomes of modified extended Morrow coronary artery bypass grafting(CABG)and myocardial bridge release in patients with hypertrophic obstructive cardiomyopathy(HOCM)combined with coronary atherosclerotic heart disease or myocardial bridge.Methods A retrospective analysis was made on 32 patients with HOCM complicated with coronary heart disease and 36 patients with myocardial bridge from January 2012 to December 2017 in Fuwai Hospital.Cardiac echocardiography,electrocardiogram,chest X-ray and nuclear magnetic resonance(NMR)were routinely performed before,after and during the follow-up period to evaluate the changes of cardiac function,left ventricular outflow tract and mitral valve structure and function.Results There was no intraoperative death and no death within 30 days after operation.The branches of CABG included anterior descending branch in 26 cases,diagonal branch in 16 cases,circumflex branch in 8 cases and right coronary artery in 11 cases.There were 15 patients with one CABG bridge number,5 patients with two bridge numbers,and 12 patients with 3 bridge numbers.The average CABG count was(1.9±0.6).There were 34 patients with anterior descending myocardial bridge and 2 patients with posterior descending myocardial bridge.The length of myocardial bridge ranged from 7 mm to 50 mm,with an average length of 21.8+15.5 mm.Postoperative ICU time was 1-13(4.1+2.8)days,and hospitalization time was 6-30(12.6+5.5)days.There were no serious complications after operation.The peak pressure difference and interventricular septum thickness of left ventricular outflow tract were significantly decreased after operation compared with those before operation(P<0.001).The degree of mitral regurgitation was significantly reduced after operation(P<0.001),and the forward motion of mitral valve(SAM sign)disappeared.The follow-up period ranged from 6 to 68 months,with an average of(38.5+20.5)months.The symptoms disappeared.The NYHA grading of cardiac function was lower than that of pre-operation.There was no long-term death,complications or reoperation.Conclusions For patients with hypertrophic obstructive cardiomyopathy and coronary heart disease,it is safe to perform both modified extended Morrow procedure and coronary artery bypass grafting;for patients with partial hypertrophic obstructive cardiomyopathy and myocardial bridge,it is safe to perform both modified extended Morrow procedure and myocardial bridge lysis.It can significantly improve the survival rate and symptoms of patients,play a synergistic role,and do not increase surgical complications. |
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