Особенности фиброзного поражения миокарда, ассоциированные с жизнеугрожающими желудочковыми тахиаритмиями у больных постинфарктным кардиосклерозом и неишемической кардиомиопатией

Читать PDF

Аннотация

Цель исследования – выявить особенности фиброзно-рубцового поражения миокарда, ассоциированные с возникновением желудочковых тахиаритмий (ЖТ) у больных с постинфарктным кардиосклерозом (ПИКС) и неишемической кардиомиопатией (НИКМП).
Материалы методы. В исследование включено 50 пациентов (41 мужчина и 9 женщин), возраст 60±13 лет, из них 30 больных с ПИКС и 20 пациентов с НИКМП, которым выполнены эхокардиография и магнитно-резонансная томография (МРТ) сердца с контрастированием, а затем имплантированы кардиовертеры-дефибрилляторы (КВД) или ресинхронизирующие устройства с функцией дефибриллятора (СРТ-Д) с целью профилактики внезапной сердечной смерти.
Результаты. По результатам проспективного наблюдения [медиана 26 (22–37) мес] приступы ЖТ зарегистрированы у 20 (67%) из 30 больных ПИКС и у 5 (25%) из 20 пациентов с НИКМП. По данным однофакторного и ROC-анализов признаков между больными с наличием и отсутствием рецидивов ЖТ, у больных ПИКС возникновение ЖТ ассоциировано с выявлением по данным МРТ трансмурального фиброза в 3 и более сегментах левого желудочка (ЛЖ), которые преимущественно располагались в средних отделах нижней и нижнебоковой стенок ЛЖ. Независимыми предикторами возникновения ЖТ у больных НИКМП являлись наличие нетрансмурального фиброзного поражения ЛЖ объемом более 4,5% по МРТ сердца с контрастированием и низкая фракция выброса ЛЖ (менее 26%) по эхокардиографии.
Заключение. Для определения показаний к имплантации КВД и СРТ-Д с целью первичной профилактики внезапной сердечной смерти целесообразно учитывать не только значение фракции выброса ЛЖ, но и характер фиброзно-рубцового поражения миокарда по данным МРТ сердца с контрастированием.

Ключевые слова: желудочковая тахикардия, внезапная сердечная смерть, постинфарктный кардиосклероз, неишемическая кардиомиопатия, магнитно-резонансная томография сердца, фиброз левого желудочка, прогнозирование, кардиовертер-дефибриллятор.

________________________________________________

Aim. To identify the features of myocardial scar and fibrosis associated with the occurrence of malignant ventricular tachyarrhythmias (VTs) in high-risk patients with ischemic (ICMP) and non-ischemic cardiomyopathy (NICMP).
Materials and methods. This prospective study included 50 patients (41 men, 9 women), age = 60 ± 13 years, 30 patients of them with ICMP and 20 patients with NICMP, who underwent echocardiography (Echo) and contrast magnetic resonance imaging (MRI) of the heart followed by implantation of cardioverter-defibrillators (ICD) or resynchronizing devices with defibrillator (CPTD) to prevent sudden cardiac death.
Results. Sustained VTs were reported in 20/30 (67%) patients with ICMP and in 5/20 (25%) patients with NICMP on follow-up [26 (22–37) months]. Successive univariate and ROC-analyses of Echo and MRI-indices between patients with and without recurrence of VTs found different results for ICMP and NICMP patients groups. In ICMP patients the VTs were associated with wide transmural fibrosis on contrast MRI that covered 3 or more segments of left ventricular. These segments were preferably localized in the middle parts of the inferior and inferolateral segments of the left ventricle. The independent predictors of VTs in NICMP patients were non-transmural fibrosis at 4.5% of the left ventricular mass by contrast MRI as well as low left ventricular ejection fraction (less than 26%) by Echo.
Conclusion. To determine the indications for implantation of the ICD and CRTD for primary prevention of sudden cardiac death, it is advisable to take into account not only the value of ejection fraction of left ventricular, but also the features of the fibrosis of the left ventricle by contrast MRI of the heart.

Keywords: ventricular tachycardia, sudden cardiac death, ischemic cardiomyopathy, non-ischemic cardiomyopathy, magnetic resonance tomography of the heart, left ventricular fibrosis, prognosis, cardioverter-defibrillator.

Список литературы

1. Velasco A, Stirrup J, Reyes E, Hage FG. Guidelines in review: Comparison between AHA/ACC and ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Nucl Cardiol. 2017;24:1893-901.
2. Qu Z, Weiss JN. Mechanisms of ventricular arrhythmias: from molecular fluctuations to electrical turbulence. Annu Rev Physiol. 2015; 1-32.
3. Waks JW, Buxton AE. Risk stratification for sudden cardiac death after myocardial infarction. Annu Rev Med. 2018;69:147-64.
4. Бокерия Л.А., Ревишвили А.Ш., Неминущий Н.М. Внезапная сер-дечная смерть. М.: ГЭОТАР-Медиа, 2011; 267 с. [Bokeria LA, Revishvili ASh, Neminushii NM. Sudden cardiac death. M.: GEOTAR-Media, 2011; 267 (In Russ.)].
5. Santangeli P, Epstein AE. Sudden cardiac death: lessons learned from cardiac implantable rhythm devices. Card Electrophysiol Clin. 2017;9:749-59.
6. Priori SG, Blomström-Lundqvist C, Mazzanti A, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Europace. 2015;17:1601-87.
7. Yan А, Shayne А, Brown К, et al. Characterization of the peri-infarct zone by contrast-enhanced cardiac magnetic resonance imaging is a powerful predictor of post-myocardial infarction mortality. Circulation. 2006;114: 32-9.
8. Синицын В.Е., Мершина Е.А., Ларина О.М. Возможности магнитно-резонансной томографии и в диагностике кардиомиопатии. Клин. и эксперимент. хир. журнал им. акад. Б.В. Петровского. 2014;1:54-63. [Sinitsyn VE, Mershina EA, Larina OM. Cardiac magnetic resonance imaging opportunities in the diagnosis of cardiomyopathy. Clin. Experiment Surg. Petrovsky J. 2014;1:54-63 (In Russ.)].
9. Stukalova OV. Late-enhancement contrast cardiac MRI – new diagnostic tool in cardiac diseases. REJR. 2013;3:7-17. [Стукалова О.В. Магнитно-резонансная томография сердца с отсроченным контрастированием – новый метод диагностики заболеваний сердца. REJR. 2013; 3:7-17].
10. Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocaardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105(4):539-42.
11. Lang RM, Bierig M, Devereux RB. Recommendations for Chamber Quantification: A Report from the American Society of Echocardiographys Guidelines and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Society of Echocardiography. J Am Soc Echocardiogr. 2005;18(12):1440-63.
12. Lown B, Wolf M. Approaches to sudden death from coronarheart disease. Circulation. 1971;44:130-42.
13. Lown B. Sudden cardiac death: biobehavioral perspective. Circulation. 1987;76:1186-96.
14. Yoshiga Y, Mathew S, Wissner E, et al. Correlation between substrate location and ablation strategy in patients with ventricular tachycardia late after myocardial infarction. Heart Rhythm. 2012;9:1192-9. doi: 10.1016/j.hrthm.2012.03.058
15. Culic V. Inferior myocardial infarction scars could be more arrhythmogenic than anterior ones. Europace. 2010;12:597. doi: 10.1093/europace/eup445
16. Lacroix D, Warembourg H, Klug D, et al. Intraoperative computerized mapping of ventricular tachycardia: differences between anterior and inferior myocardial infarctions. J Cardiovasc Electrophysiol. 1999;10:781-90.
17. Køber L, Thune JJ, Nielsen JC, Haarbo J, et al. DANISH Investigators. Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. N Engl J Med. 2016;375:1221-30.

________________________________________________

1. Velasco A, Stirrup J, Reyes E, Hage FG. Guidelines in review: Comparison between AHA/ACC and ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Nucl Cardiol. 2017;24:1893-901.
2. Qu Z, Weiss JN. Mechanisms of ventricular arrhythmias: from molecular fluctuations to electrical turbulence. Annu Rev Physiol. 2015; 1-32.
3. Waks JW, Buxton AE. Risk stratification for sudden cardiac death after myocardial infarction. Annu Rev Med. 2018;69:147-64.
4. [Bokeria LA, Revishvili ASh, Neminushii NM. Sudden cardiac death. M.: GEOTAR-Media, 2011; 267 (In Russ.)].
5. Santangeli P, Epstein AE. Sudden cardiac death: lessons learned from cardiac implantable rhythm devices. Card Electrophysiol Clin. 2017;9:749-59.
6. Priori SG, Blomström-Lundqvist C, Mazzanti A, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Europace. 2015;17:1601-87.
7. Yan А, Shayne А, Brown К, et al. Characterization of the peri-infarct zone by contrast-enhanced cardiac magnetic resonance imaging is a powerful predictor of post-myocardial infarction mortality. Circulation. 2006;114: 32-9.
8. [Sinitsyn VE, Mershina EA, Larina OM. Cardiac magnetic resonance imaging opportunities in the diagnosis of cardiomyopathy. Clin. Experiment Surg. Petrovsky J. 2014;1:54-63 (In Russ.)].
9. Stukalova OV. Late-enhancement contrast cardiac MRI – new diagnostic tool in cardiac diseases. REJR. 2013;3:7-17.
10. Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocaardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105(4):539-42.
11. Lang RM, Bierig M, Devereux RB. Recommendations for Chamber Quantification: A Report from the American Society of Echocardiographys Guidelines and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Society of Echocardiography. J Am Soc Echocardiogr. 2005;18(12):1440-63.
12. Lown B, Wolf M. Approaches to sudden death from coronarheart disease. Circulation. 1971;44:130-42.
13. Lown B. Sudden cardiac death: biobehavioral perspective. Circulation. 1987;76:1186-96.
14. Yoshiga Y, Mathew S, Wissner E, et al. Correlation between substrate location and ablation strategy in patients with ventricular tachycardia late after myocardial infarction. Heart Rhythm. 2012;9:1192-9. doi: 10.1016/j.hrthm.2012.03.058
15. Culic V. Inferior myocardial infarction scars could be more arrhythmogenic than anterior ones. Europace. 2010;12:597. doi: 10.1093/europace/eup445
16. Lacroix D, Warembourg H, Klug D, et al. Intraoperative computerized mapping of ventricular tachycardia: differences between anterior and inferior myocardial infarctions. J Cardiovasc Electrophysiol. 1999;10:781-90.
17. Køber L, Thune JJ, Nielsen JC, Haarbo J, et al. DANISH Investigators. Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. N Engl J Med. 2016;375:1221-30.

Авторы

Н.Б. ШЛЕВКОВ, А.А. ЖАМБЕЕВ, А.Ж. ГАСПАРЯН, В.Н. ШИТОВ, О.В. СТУКАЛОВА

ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия

________________________________________________

N.b. SHLEVKOV, A.a. ZHAMBEEV, A.z. GASPARYAN, V.n. SHITOV, O.v. STUKALOVA

Department of clinical electrophysiology and roentgenosurgical methods of treatment of cardiac arrhythmias. National Medical Research Cardiology Center, Moscow, Russia

Назад к списку

Цель портала OmniDoctor – предоставление профессиональной информации врачам, провизорам и фармацевтам.