Helikoidna ventrikularna miokardna traka Torent-Guasp-a kao osnova za hirurško lečenje postinfarktno remodelovane leve komore

Abstract

Uvod: Veličina, oblik i raspored vlakana postinfarktno remodelovane leve komore (LV), uz prisustvo ishemije i funkcionalne mitralne regurgitacije (MR), značajno utiču na lošu prognozu pacijenata sa ishemijskom kardiomiopatijom (ICM). Koncept helikoidne ventrikularne miokardne trake (HVMT) Torrent-Guasp-a, omogućio je razvoj savremene, integrativne strategije (“3V” - eng. “vessel, valve, ventricle”) komorne restorativne hirurgije (SVR), za korekciju morfološko-funkcionalnih posledica postinfarktnog ventrikularnog remodelovanja (PVR). Cilj: Dokazati da integrativna strategija SVR dovodi do značajnog poboljšanja strukturnih i funkcionalnih ehokardiografskih (ECHO) parametara PVR-LV, u neposrednom, ranom i udaljenom periodu postoperativnog praćenja. Metode: U sklopu prospektivne kohortne studije, u Klinici za kardiohirurgiju KCS, (jul 2005. - februar 2010.), integrativna SVR strategija je primenjena kod 40 pacijenata, prosečne starosti 62.2 ± 8.2 godina (72.5% muškarci). Preoperativni klinički i elektrofiziološki status, medikamentozna terapija, morfološki i funkcionalni ECHO parametri LV, mitralnog valvularnog (MV) aparata i desne komore (RV), poređeni su sa odgovarajućim postoperativnim nalazima u neposrednom (˂ 6), ranom (6-12) i kasnom periodu (˃ 12 meseci) postoperativnog praćenja. Rezultati: Prosečno vreme praćenja: 22.2 ± 13.8 meseci. Ukupni mortalitet: 12.5% (operativni 0.0%; intrahospitalni 7.5%; rani 2.5% i kasni 2.5%). Količnici operativnog (0.0) i hospitalnog mortaliteta (0.4): ˂ 1. Ukupno aktuarijalno preživljavanje: 95.0% (hospitalno); 90.0% (prva i druga) i 77.1% (treća, četvrta i peta godina). Verovatnoća preživljavanja bez naknadnih hospitalizacija zbog srčanih razloga: 94.6% (hospitalno); 89.2% (prva i druga) i 74.3% (treća, četvrta i peta godina). Primenjena SVR strategija je dovela do statistički značajnog poboljšanja svih preoperativnih, kliničkih (NYHA III/IV: 100% vs. 23.4%; CCS III/IV: 100% vs. 0.0%), morfoloških i funkcionalnih ECHO parametara LV (LV-EF: 31.8% vs. 46.1% ; LV-EDD: 62.4 mm vs. 53.7 mm; LV-ESD: 47.7 mm vs. 40.3 mm; LV-EDV: 236.8 mL vs. 172.9 mL; LV-ESV: 138.7 mL vs. 90.3 mL; LV-EDVI: 123.6 mL/m2 vs. 90.6 mL/m2;, LV-ESVI: 72.5 mL/m2 vs. 47.1 mL/m2; i LV-SI: 0.59 vs. 0.49), MV (MR 3/4+: 22.5% vs. 0.0%) i RV (PAPs: 40.6 mmHg vs. 31.4 mmHg; TAPSE: 15.7 mm vs. 17.9 mm) - koje se održava u svim sukcesivnim periodima, tokom petogodišnjeg praćenja. Prosečna redukcija preoperativnog LV-ESVI=35%, prosečna rezidualna LV-ESVI=47 a prosečno poboljšanje LV-EF=15%. Atrijalna fibrilacija je bila češća (p=0.039) unutar 6 meseci nakon SVR (29.7%) nego preoperativno (10.8%). Pacijenti su medikamentozno tretirani u skladu sa preporukama za terapiju ICM. Nezavisni prediktori preživljavanja su bili: infarkt miokarda u ICU i dijaliza u ICU. ECHO kriterijumi efikasnosti SVR (LV-ESVI ≥ 30%, rezidualni LV-ESVI ≤ 60mL/m2) nisu uticali na preživljavanje. Analiza uz pomoć ROC krive ukazuje da je postizanje oba kriterijuma najvalidnije u smislu prognoze ishoda. Redukcija LV-ESVI ≥ 30% je senzitivniji i specifičniji kiterijum, od rezidualnog LV-ESVI ≤ 60mL/m2. Nijedan preoperativni parameter nije bio nezavisni prediktor postizanja kriterijuma efikasnosti SVR. Analiza uz pomoć ROC krive ukazuje da je LV-EDVI ≤ 115.7 mL/m2 najvalidniji u smislu prognoze postizanja oba kriterijuma efikasnosti SVR, a da su LV-EDD ≤ 66.0 mm; LV-EDV ≤ 227.0 mL i LVEDVI ≤ 148.3mL/m2 validni za prognozu postizanja rezidualnog LV-ESVI ≤ 60mL/m2. Zaključak: SVR je efikasna i bezbedna operacija za korekciju PVR-LV, koja predstavlja pouzdanu privremenu („bridge to transplant“) ili trajnu („destination therapy“) alternativu transplantacionoj hirurgiji. Integracija koncepta HVMT u savremene strategije geometrijske SVR, pruža bolji uvid u patoanatomiju i patofiziologiju PVR-LV, omogućuje adekvatnu selekciju i tumačenje relevantnih dijagnostičkih nalaza, bolju stratifikaciju rizika

Background: Size, shape and fiber orientation of post-infarction remodeled left ventricle (LV), in a presence of ischemia and functional mitral regurgitation (MR), significantly affect prognosis in patients with ischemic cardiomyopathy (ICM). The helical ventricular myocardial band (HVMT) of Torrent-Guasp has enabled development of contemporary, integrative (“3V” - “vessel, valve, ventricle”) surgical ventricular restorative (SVR) strategy, aimed to correct morphological and functional consequences of the post-infarction ventricular remodeling (PVR). Objective: To prove that integrative SVR produces significant improvements of structural and functional echocardiography (ECHO) parameters of PVR-LV in the immediate, early and late postoperative follow-up period. Methods: As a part of prospective cohort study, conducted at Clinic for Cardiac Surgery CCS (July 2005. - February 2010.), integrative SVR strategy was applied in 40 patients, with mean age of 62.2 ± 8.2 years (72.5% male). Preoperative clinical and electrophysiological status, drug therapy, morphological and functional ECHO parameters of the LV, mitral valve (MV) and the right ventricle (RV), were compared to appropriate measures in immediate (˂ 6), early (6-12) and late (˃ 12 months) follow-up. Results: Mean follow-up time: 22.2 ± 13.8 months. Overall mortality: 12.5% (operative 0.0%; hospital 7.5%; early 2.5% and late 2.5%). Operative (0.0) and hospital mortality ratio (0.4): ˂ 1. Overall actuarial survival: 95.0% (hospital); 90.0% (1st and 2nd) and 77.1% (3rd, 4th and 5th year). Probability of survival without hospitalizations for cardiac reasons: 94.6% (hospital); 89.2% (1st and 2nd) i 74.3% (3rd, 4th and 5th year). Applied SVR strategy resulted in statistically significant improvements of all preoperative clinical (NYHA III/IV: 100% vs. 23.4%; CCS III/IV: 100% vs. 0.0%), morphological and functional ECHO parameters of the LV (LV-EF: 31.8% vs. 46.1% ; LV-EDD: 62.4 mm vs. 53.7 mm; LV-ESD: 47.7 mm vs. 40.3 mm; LV-EDV: 236.8 mL vs. 172.9 mL; LV-ESV: 138.7 mL vs. 90.3 mL; LV-EDVI: 123.6 mL/m2 vs. 90.6 mL/m2;, LV-ESVI: 72.5 mL/m2 vs. 47.1 mL/m2; i LV-SI: 0.59 vs. 0.49), MV (MR 3/4+: 22.5% vs. 0.0%) and the RV (PAPs: 40.6 mmHg vs. 31.4 mmHg; TAPSE: 15.7 mm vs. 17.9 mm) - which sustained in each successive time frame, during the 5-year follow-up. Mean reduction of preoperative LV-ESVI=35%, mean residual LV-ESVI=47 and mean improvement of LV-EF=15%. Atrial fibrillation was more frequent (p=0.039) within 6 months after SVR (29.7%) than preoperatively (10.8%). Patients received medical therapy in accordance with ICM treatment guidelines. Independent predictors of survival were: myocardial infarction in ICU dialysis in ICU. ECHO criteria of SVR efficiency (LV-ESVI ≥ 30%, residual LV-ESVI ≤ 60mL/m2) did not affect survival. ROC curve analysis revealed that the achievement of both criteria was the most valid for the outcome prognosis. Reduction of LV-ESVI ≥ 30% was more sensitive and specific than LV-ESVI ≤ 60mL/m2. None of the preoperative parameters was the independent predictor for attaining the SVR efficiency criteria. ROC curve analysis revealed LV-EDVI ≤ 115.7 mL/m2 to be the most valid for the prognosis of combined criteria, while LV-EDD ≤ 66.0 mm; LV-EDV ≤ 227.0 mL i LV-EDVI ≤ 148.3mL/m2 were valid for the prognosis of residual LV-ESVI ≤ 60mL/m2 attainment. Conclusions: SVR is safe and efficient procedure for the patients with PVR-LV, being a reliable temporary („bridge to transplant“) or even permanent („destination therapy“) alternative to the heart transplant surgery. Integrating the HVMT concept into contemporary strategies of geometric SVR, offers better insight in pathoanatomy and pathophysiology of PVR-LV, helping to select and interpret the most relevant diagnostic findings, stratify the risk and improve patient selection, all being the essential prerequisites for the success of this procedure.