Альманах клинической медицины. 2015; : 11-18
СОПРЯЖЕННОСТЬ ЭЛЕКТРОФИЗИОЛОГИЧЕСКИХ И ПЕРФУЗИОННЫХ ИЗМЕНЕНИЙ МИОКАРДА ЛЕВОГО ЖЕЛУДОЧКА ПРИ ПОСТИНФАРКТНЫХ АНЕВРИЗМАХ С ЖЕЛУДОЧКОВОЙ ТАХИКАРДИЕЙ
https://doi.org/10.18786/2072-0505-2015-38-11-18Аннотация
Актуальность. Наличие желудочковой тахикардии у больных с постинфарктной аневризмой левого желудочка (ЛЖ) предполагает нарушения миокардиальной перфузии.
Цель – определение взаимосвязи электрофизиологических и перфузионных изменений миокарда ЛЖ у больных ишемической болезнью сердца с постинфарктной аневризмой и желудочковой тахикардией.
Материал и методы. Обследованы 23 больных с постинфарктной аневризмой ЛЖ, идущих на операцию аневризмэктомии и/или аортокоронарного шунтирования. В обследование было включено внутрисердечное электрофизиологическое исследование (ЭФИ) с трехмерной электроанатомической реконструкцией ЛЖ и перфузионная однофотонная эмиссионная компьютерная томография миокарда с 99mTc-Технетрилом.
Результаты. У большинства (68%) сегментов ЛЖ с нормальной электрической проводимостью (амплитуда электрического потенциала более 1,5 мВ, 1-я группа ЭФИ) перфузия миокарда была более 70% (аккумуляция радиофармпрепарата от максимального включения в миокард); сегменты переходной зоны (амплитуда электрического потенциала 0,5–1,5 мВ, 2-я группа ЭФИ) находились в равной степени (по 18%) в зонах гипоперфузии 31–69% и 45–54%; большинство (52%) сегментов с «электрофизиологическим рубцом» (амплитуда электрического потенциала менее 0,5 мВ, 3-я группа ЭФИ) находились в зоне аперфузии (менее 30%); сегменты с нулевой проводимостью (4-я группа ЭФИ) были также в зоне аперфузии и частично (20%) в гипоперфузии до 44%. При оценке процента перфузии каждого сегмента в отдельности оказалось, что сегменты 1-й группы ЭФИ перфузируются на уровне 61% (48–71%) от максимального значения перфузии миокарда ЛЖ, сегменты 2-й группы ЭФИ – 45% (34–56%), сегменты 3-й группы ЭФИ – 35% (30–46%), сегменты 4-й группы ЭФИ – 26% (21–31%). Все группы пациентов были достоверно связаны с перфузией миокарда как в полуколичественной шкале, то есть по группам перфузии (от 0 до 4) (V = 93,5; p < 0,001), так и в количественной шкале с обратным коэффициентом корреляции (r = -0,56; p < 0,001), то есть чем больше процент перфузии сегмента, тем выше вероятность его нахождения в 1-й группе ЭФИ.
Заключение. Электрофизиологическое состояние ЛЖ зависит от перфузии миокарда. Электрофизиологически нормальный миокард с электрическим потенциалом более 1,5 мВ, переходная зона (0,5–1,5 мВ) и зона с потенциалом менее 0,5 мВ достоверно различаются между собой по проценту перфузии – 61, 45 и 35% соответственно.
Список литературы
1. DiDonato M, Sabatier M, Dor V, Buckberg G; RESTORE Group. Ventricular arrhythmias after LV remodelling: surgical ventricular restoration or ICD? Heart Fail Rev. 2004;9(4):299–306.
2. Sosa E, Jatene A, Kaeriyama JV, Scanavacca M, Marcial MB, Bellotti G, Pileggi F. Recurrent ventricular tachycardia associated with postinfarction aneurysm. Results of left ventricular reconstruction. J Thorac Cardiovasc Surg. 1992;103(5):855–60.
3. Kautzner J. Clinical application of electro-anatomical mapping in the treatment of arrhythmias. In: Kautzner J, Kirstein Pedersen A, Peichl P, editors. Electro-anatomical mapping of the heart. London: Remedica Publishing; 2006.p. 3.8–3.14.
4. Babokin V, Shipulin V, Batalov R, Popov S. Surgical ventricular reconstruction with endocardectomy along radiofrequency ablation-induced markings. J Thorac Cardiovasc Surg. 2013;146(5):1133–8.
5. Cuocolo A, Acampa W, Nicolai E, Pace L, Petretta M, Salvatore M. Quantitative thallium-201 and technetium 99m sestamibi tomography at rest in detection of myocardial viability in patients with chronic ischemic left ventricular dysfunction. J Nucl Cardiol. 2000;7(1):8–15.
6. Окунева ГН, Чернявский АМ, Булатецкая ЛМ, Воронова ИП, Власов ЮА, Бобошко АВ, Мироненко СП. Миокардиальный кровоток на разных участках сердца у больных ишемической болезнью сердца до и после реваскуляризации. Кардиология. 2002;42(5):52–4. Okuneva GN, Chernyavskiy AM, Bulatetskaya LM, Voronova IP, Vlasov YuA, Boboshko AV, Mironenko SP. Miokardial'nyy krovotok na raznykh uchastkakh serdtsa u bol'nykh ishemicheskoy bolezn'yu serdtsa do i posle revaskulyarizatsii [Myocardial blood flow in various regions of the heart in patients with ischemic heart disease before and after revascularization]. Kardiologiya [Сardiology]. 2002;42(5):52–4 (in Russian).
7. Rahimtoola SH. The hibernating myocardium. Am Heart J. 1989;117(1):211–21. 8. Dor V, Sabatier M, Montiglio F, Civaia F, DiDonato M. Endoventricular patch reconstruction of ischemic failing ventricle. A single center with 20 years experience. Advantages of magnetic resonance imaging assessment. Heart Fail Rev. 2004;9(4):269–86.
8. Menicanti L, Castelvecchio S, Ranucci M, Frigiola A, Santambrogio C, de Vincentiis C, Brankovic J, Di Donato M. Surgical therapy for ischemic heart failure: single-center experience with surgical anterior ventricular restoration. J Thorac Cardiovasc Surg. 2007;134(2):433–41.
9. Лишманов ЮБ, Чернов ВИ, ред. Радионуклидная диагностика для практических врачей. Практическое руководство. Томск: STT; 2004. 394 с. Lishmanov YuB, Chernov VI, editors. Radionuklidnaya diagnostika dlya prakticheskikh vrachey. Prakticheskoe rukovodstvo [Radionuclide diagnostics for practicing physicians. A handbook]. Tomsk: STT; 2004. 394 p. (in Russian).
10. Pereztol-Valdes O, Candell-Riera J, SantanaBoado C, Angel J, Aguade-Bruix S, Castell-Conesa J, Garcia EV, Soler-Soler J. Correspondence between left ventricular 17 myocardial segments and coronary arteries. Eur Heart J. 2005;26(24):2637–43.
11. Бокерия ЛА, Федоров ГГ. Хирургическое лечение больных с постинфарктными аневризмами сердца и сопутствующими тахиаритмиями. Грудная и сердечно-сосудистая хирургия. 1994;(4):4–8. Bokeriya LA, Fedorov GG. Khirurgicheskoe lechenie bol'nykh s postinfarktnymi anevrizmami serdtsa i soputstvuyushchimi takhiaritmiyami [Surgical treatment of patients with post infarction heart aneurysms and concomitant tachyarrhythmias]. Grudnaya i serdechno-sosudistaya khirurgiya [Thoracic and Cardiovascular Surgery]. 1994;(4):4–8 (in Russian).
12. Moran JM. Postoperative ventricular arrhythmia. Ann Thorac Surg. 1984;38(4):312–3. 14. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML; Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346(12):877–83.
13. Marrouche NF, Verma A, Wazni O, Schweikert R, Martin DO, Saliba W, Kilicaslan F, Cummings J, Burkhardt JD, Bhargava M, Bash D, Brachmann J, Guenther J, Hao S, Beheiry S, Rossillo A, Raviele A, Themistoclakis S, Natale A. Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy. J Am Coll Cardiol. 2004;43(9):1715–20.
14. Дор В, ДиДонато М, Сивая Ф. Постинфарктное ремоделирование левого желудочка: магнитно-резонансная томография для оценки патофизиологии после реконструкции левого желудочка. Грудная и сердечно-сосудистая хирургия. 2014;(3):14–27. Dor V, DiDonato M, Civaya F. Postinfarktnoe remodelirovanie levogo zheludochka: magnitnorezonansnaya tomografiya dlya otsenki patofiziologii posle rekonstruktsii levogo zheludochka [Post myocardial infarct left ventricular remodeling: role of magnetic resonance imaging for the assessment of its pathophysiology after left ventricular reconstruction]. Grudnaya i serdechno-sosudistaya khirurgiya [Thoracic and Cardiovascular Surgery]. 2014;(3):14–27 (in Russian).
Almanac of Clinical Medicine. 2015; : 11-18
CONCORDANCE OF ELECTROPHYSIOLOGICAL AND PERFUSION ABNORMALITIES IN THE LEFT VENTRICULAR MYOCARDIUM IN POST INFARCTION ANEURYSMS WITH VENTRICULAR TACHYCARDIA
https://doi.org/10.18786/2072-0505-2015-38-11-18Abstract
Background: Ventricular tachycardia in patients with post infarction aneurysm of the left ventricle (LV) suggests the presence of myocardial perfusion abnormalities.
Aim: To determine a relationship between electrophysiological and perfusion abnormalities inLV myocardium in patients with coronary heart disease, post infarction aneurysms and ventricular tachycardia.
Materials and methods: We assessed 23 patients with post infarctionLV aneurysms who were candidates for surgical removal of the aneurysm and/or coronary artery bypass grafting. Methods of assessment included intracardiac electrophysiology study (EPS) with a 3D electro-anatomical reconstruction ofLV, as well as perfusional one-photon emission computer tomography of the myocardium with 99mTc-Technetril.
Results: In most (68%) ofLV segments with normal electrical conductivity (electric potential magnitude above 1.5 mV, EPS group 1), myocardial perfusion exceeded 70% (accumulation of the radionuclide agent in percentages from maximal myocardial uptake). The transitional zone segments (electric potential magnitude of 0.5–1.5 mV, EPS group 2) comprised equal (18% each) in the zones with low perfusion proportions (31–69% and 45–54%). Most (52%) segments with “electrophysiological scar” (electric potential magnitude below 0.5 мВ, EPS group 3) were in the zone with no perfusion (< 30%). Segments with zero conductivity (EPS group 4) were located also in the zone with no perfusion and partially (20%) in the hypoperfusion (up to 44%) zone. Assessment of perfusion percentage in each individual segment showed that EPS group 1 segments were perfused at 61% (48–71%) of maximal LV myocardial perfusion, EPS group 2 segments, at 45% (34–56%), EPS group 3 segments, at 35% (30–46%), and EPS group 4 segments, at 26% (21–31%). In all patients groups, there was a significant correlation with myocardial perfusion on the semiuantitative scale (i.e., perfusion groups from 0 to 4) (V = 93.5; p < 0,001), as well as negative correlation on the quantitative scale (r = -0,56; p < 0,001), thereby demonstrating that segments with higher perfusion have higher probability to be in EPS group 1.
Conclusion: Electrophysiological characteristics ofLV depend on myocardial perfusion. Electrophysiologically normal myocardium with electric potential above 1.5 mV, the transitional zone (0.5–1.5 mV) and the zone with potential of < 0.5 mV differ significantly in their perfusion percentages (61, 45 and 35%, respectively).
References
1. DiDonato M, Sabatier M, Dor V, Buckberg G; RESTORE Group. Ventricular arrhythmias after LV remodelling: surgical ventricular restoration or ICD? Heart Fail Rev. 2004;9(4):299–306.
2. Sosa E, Jatene A, Kaeriyama JV, Scanavacca M, Marcial MB, Bellotti G, Pileggi F. Recurrent ventricular tachycardia associated with postinfarction aneurysm. Results of left ventricular reconstruction. J Thorac Cardiovasc Surg. 1992;103(5):855–60.
3. Kautzner J. Clinical application of electro-anatomical mapping in the treatment of arrhythmias. In: Kautzner J, Kirstein Pedersen A, Peichl P, editors. Electro-anatomical mapping of the heart. London: Remedica Publishing; 2006.p. 3.8–3.14.
4. Babokin V, Shipulin V, Batalov R, Popov S. Surgical ventricular reconstruction with endocardectomy along radiofrequency ablation-induced markings. J Thorac Cardiovasc Surg. 2013;146(5):1133–8.
5. Cuocolo A, Acampa W, Nicolai E, Pace L, Petretta M, Salvatore M. Quantitative thallium-201 and technetium 99m sestamibi tomography at rest in detection of myocardial viability in patients with chronic ischemic left ventricular dysfunction. J Nucl Cardiol. 2000;7(1):8–15.
6. Okuneva GN, Chernyavskii AM, Bulatetskaya LM, Voronova IP, Vlasov YuA, Boboshko AV, Mironenko SP. Miokardial'nyi krovotok na raznykh uchastkakh serdtsa u bol'nykh ishemicheskoi bolezn'yu serdtsa do i posle revaskulyarizatsii. Kardiologiya. 2002;42(5):52–4. Okuneva GN, Chernyavskiy AM, Bulatetskaya LM, Voronova IP, Vlasov YuA, Boboshko AV, Mironenko SP. Miokardial'nyy krovotok na raznykh uchastkakh serdtsa u bol'nykh ishemicheskoy bolezn'yu serdtsa do i posle revaskulyarizatsii [Myocardial blood flow in various regions of the heart in patients with ischemic heart disease before and after revascularization]. Kardiologiya [Sardiology]. 2002;42(5):52–4 (in Russian).
7. Rahimtoola SH. The hibernating myocardium. Am Heart J. 1989;117(1):211–21. 8. Dor V, Sabatier M, Montiglio F, Civaia F, DiDonato M. Endoventricular patch reconstruction of ischemic failing ventricle. A single center with 20 years experience. Advantages of magnetic resonance imaging assessment. Heart Fail Rev. 2004;9(4):269–86.
8. Menicanti L, Castelvecchio S, Ranucci M, Frigiola A, Santambrogio C, de Vincentiis C, Brankovic J, Di Donato M. Surgical therapy for ischemic heart failure: single-center experience with surgical anterior ventricular restoration. J Thorac Cardiovasc Surg. 2007;134(2):433–41.
9. Lishmanov YuB, Chernov VI, red. Radionuklidnaya diagnostika dlya prakticheskikh vrachei. Prakticheskoe rukovodstvo. Tomsk: STT; 2004. 394 s. Lishmanov YuB, Chernov VI, editors. Radionuklidnaya diagnostika dlya prakticheskikh vrachey. Prakticheskoe rukovodstvo [Radionuclide diagnostics for practicing physicians. A handbook]. Tomsk: STT; 2004. 394 p. (in Russian).
10. Pereztol-Valdes O, Candell-Riera J, SantanaBoado C, Angel J, Aguade-Bruix S, Castell-Conesa J, Garcia EV, Soler-Soler J. Correspondence between left ventricular 17 myocardial segments and coronary arteries. Eur Heart J. 2005;26(24):2637–43.
11. Bokeriya LA, Fedorov GG. Khirurgicheskoe lechenie bol'nykh s postinfarktnymi anevrizmami serdtsa i soputstvuyushchimi takhiaritmiyami. Grudnaya i serdechno-sosudistaya khirurgiya. 1994;(4):4–8. Bokeriya LA, Fedorov GG. Khirurgicheskoe lechenie bol'nykh s postinfarktnymi anevrizmami serdtsa i soputstvuyushchimi takhiaritmiyami [Surgical treatment of patients with post infarction heart aneurysms and concomitant tachyarrhythmias]. Grudnaya i serdechno-sosudistaya khirurgiya [Thoracic and Cardiovascular Surgery]. 1994;(4):4–8 (in Russian).
12. Moran JM. Postoperative ventricular arrhythmia. Ann Thorac Surg. 1984;38(4):312–3. 14. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML; Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346(12):877–83.
13. Marrouche NF, Verma A, Wazni O, Schweikert R, Martin DO, Saliba W, Kilicaslan F, Cummings J, Burkhardt JD, Bhargava M, Bash D, Brachmann J, Guenther J, Hao S, Beheiry S, Rossillo A, Raviele A, Themistoclakis S, Natale A. Mode of initiation and ablation of ventricular fibrillation storms in patients with ischemic cardiomyopathy. J Am Coll Cardiol. 2004;43(9):1715–20.
14. Dor V, DiDonato M, Sivaya F. Postinfarktnoe remodelirovanie levogo zheludochka: magnitno-rezonansnaya tomografiya dlya otsenki patofiziologii posle rekonstruktsii levogo zheludochka. Grudnaya i serdechno-sosudistaya khirurgiya. 2014;(3):14–27. Dor V, DiDonato M, Civaya F. Postinfarktnoe remodelirovanie levogo zheludochka: magnitnorezonansnaya tomografiya dlya otsenki patofiziologii posle rekonstruktsii levogo zheludochka [Post myocardial infarct left ventricular remodeling: role of magnetic resonance imaging for the assessment of its pathophysiology after left ventricular reconstruction]. Grudnaya i serdechno-sosudistaya khirurgiya [Thoracic and Cardiovascular Surgery]. 2014;(3):14–27 (in Russian).
