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). Preope...rativni 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.
