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Topic：肥厚性梗阻性心肌病行心脏手术—诱导后10分钟血压突然下降
Cardiac surgery for hypertrophic obstructive cardiomyopathy – blood pressure suddenly decreases 10 min after induction
Presenter：方开云
Moderator：童传耀，刘虹
病例介绍
Case Introduction
一名40岁（身高：170厘米，体重：81千克）诊断为肥厚性梗阻性心肌病(HOCM)的女性计划进行择期心脏外科手术行间隔肌切除。此病诊断于2013年，当时她被发现患有心脏收缩期杂音，并有肥厚性梗阻性心肌病家族史。自诊断以来，她的症状更加明显，出现晕厥前症状，发作了数次非持续性室性心动过速，功能能力下降。术前四个月进行的经胸超声心动图检查发现同心性肥厚性梗阻性心肌病，间隔占优。同时观察到明显的左室流出道静息压力梯度为160 mm Hg，同时伴有中等程度的收缩前运动（SAM），后向性二尖瓣关闭不全（MR）和双房扩大。瓦尔萨尔瓦（Valsalva）动作没有发现压力梯度的显着增加。她十二年前在全身麻醉下进行部分肾切除术，没有围手术期问题。她唯一的药物是美托洛尔25毫克，每天两次。其余术前评估均无异常。
病人进入手术室，放置了左侧桡动脉导管和16号外周静脉。使用洗必太无菌技术插入动脉管。应用标准监测后，她的动脉血压为140/70 mmHg，心律为每分钟70。开始输注0.5 μg/kg/min 苯肾上腺素，一旦患者的平均动脉血压（MAP）升高了10 mm Hg，便用 4 毫克咪达唑仑，500 微克 芬太尼， 50 毫克异丙酚和 80 毫克罗库溴铵。在超声引导下放置了尺寸 8.5（法式度量）右颈内静脉导管。但是，在放置后大约10分钟后，患者突然出现60/30 mmHg的低血压而没有心动过速，这时给予1000 mL 晶体液和 800 微克苯肾上腺素，但是没有反应。
A 40-yr-old (height: 170 cm, body mass: 81 kg) female diagnosed with HOCM was scheduled for an elective, surgical septal myectomy. The investigations which confirmed this diagnosis had been completed in 2013 as she was found to have a systolic murmur and had an extensive family history of maternal relatives with HOCM. Since the initial diagnosis, she became more symptomatic, developing presyncopal symptoms with several episodes of non-sustained ventricular tachycardia and decreasing functional capacity. A transthoracic echocardiogram, performed four months prior to surgery, revealed concentric HOCM with septal predominance. A significant LVOT resting gradient of 160 mm Hg was observed, along with moderate systolic anterior motion (SAM), posteriorly directed mitral regurgitation (MR), and biatrial enlargement. No significant increase of the gradient was seen with the Valsalva manoeuvre. Her past medical history was significant regarding a partial nephrectomy performed under general anaesthesia twelve years ago with no perioperative issues. Her only medication was metoprolol 25 mg twice a day. The remainder of her preoperative evaluations were unremarkable.
The patient was prepared for surgery with the placement of a left radial arterial line and a 16 gauge peripheral IV. Sterile technique with chlorhexidine was used to insert the arterial line. After applying standard monitoring, her arterial blood pressure was 140/70 mm Hg with a heart rate of 70 per min. An infusion of phenylephrine running at 0.5 μg kg-1 min-1 was started and once the patient’s mean arterial blood pressure (MAP) had risen by 10 mm Hg, general anaesthesia was induced intravenously with 4 mg of midazolam, 500 μg of fentanyl, 50 mg of propofol, and 80 mg of rocuronium. The ultrasound-guided placement of an 8.5 French right internal jugular sheath introducer was performed. However, by the end of placement, approximately 10 minutes post-induction, the patient abruptly developed hypotension of 60/30 mm Hg without tachycardia that was unresponsive to an infusion of 1000 mL of crystalloid and 800 μg of phenylephrine administered in successive boluses.
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