cardiotomskСибирский журнал клинической и экспериментальной медициныSiberian Journal of Clinical and Experimental Medicine2713-29272713-265XTSU publishing10.29001/2073-8552-2015-30-1-85-91cardiotomsk-149Research ArticleКЛИНИЧЕСКИЕ ИССЛЕДОВАНИЯCLINICAL STUDIESДиссинхрония миокарда и ответ на сердечную ресинхронизирующую терапиюMyocardial dyssynchrony and response to cardiac resynchronization therapyЛебедеваВиктория КимовнаLebedevaV. K.viktkim@rambler.ruЛюбимцеваТамара АлексеевнаLubimcevaT. A.toma0704@mail.ruТрукшинаМария АлександровнаTrukshinaM. A.noemail@neicon.ruЛясниковаЕлена АлександровнаLyasnikovaE. A.noemail@neicon.ruЛебедевДмитрий СергеевичLebedevD. S.lebedevdmitry@mail.ruФГБУ "Северо-западный федеральный медицинский исследовательский центр им. В.А. Алмазова" Минздрава РоссииРоссияFederal North-West Medical Research Centre n.a. V.A. AlmazovRussian Federation2015060920163018591Copyright © Лебедева В.К., Любимцева Т.А., Трукшина М.А., Лясникова Е.А., Лебедев Д.С., 20162016Лебедева В.К., Любимцева Т.А., Трукшина М.А., Лясникова Е.А., Лебедев Д.С.Lebedeva V.K., Lubimceva T.A., Trukshina M.A., Lyasnikova E.A., Lebedev D.S.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.sibjcem.ru/jour/article/view/149

Цель исследования: дать сравнительную оценку зон максимальной внутрижелудочковой диссинхронии (ВЖД) миокарда и локализации желудочковых электродов у пациентов с различным ответом на сердечную ресинхронизирующую терапию (СРТ). Материал и методы. Ретроспективное исследование, включающее пациентов (n=40) с синусовым ритмом, полной блокадой левой ножки пучка Гиса (ПБЛНПГ), фракцией выброса левого желудочка (ФВ) <35%, III и IV функциональным классом (ФК, NYHA) хронической сердечной недостаточности (ХСН) на оптимальной медикаментозной терапии, которым была имплантирована система СРТ. Под рентгеноскопическим контролем правопредсердный (ПП) электрод имплантировался в ушко ПП, правожелудочковый (ПЖ) электрод -в область межжелудочковой перегородки (МЖП) или верхушку Пж, ЛЖ электрод - в одну из вен коронарного синуса. Средний возраст составил 60,9±11,4 лет, 65% мужчин (n=26), 35% женщин (n=14), ишемический генез кардиомиопатии (КМП) был выявлен в 52,5% случаев. Период наблюдения после имплантации СРТ составил 12,0±1,7 мес. Пациенты были разделены на группы: 1-я группа, n=20 - высокий ответ на СРТ (уменьшение конечно-систолического объема ЛЖ - КСО >15%, относительный прирост ФВ ЛЖ ≥10%); 2-я группа, n=20 - недостаточный ответ на СРТ (отсутствие динамики размеров, объемов, ФВ ЛЖ). Для топической оценки зоны стимуляции желудочковых электродов использовался векторный анализ ЭКГ в начале и в конце периода наблюдения (разделение ЛЖ на 12 условных сегментов, ПЖ - на 3 сегмента). Межжелудочковая (МЖД) и внутрижелудочковая диссинхрония миокарда определялись при помощи эхокардиографии (ЭхоКГ) с тканевой допплерографией. Результаты. Исходно группы не различались по полу, возрасту и параметрам ЭхоКГ с тканевой допплерографией. Отсутствие исходной ВЖД наблюдалось у 7 пациентов 1-й группы и 8 пациентов 2-й группы, р=0,503; КМП ишемического генеза значимо превалировала во 2-й группе (75%, n=15, р=0,014). Дислокаций электродов за весь период наблюдения выявлено не было, имело место смещение ЛЖ электрода в пределах вены коронарного синуса в 3 случаях. Конечные размеры, объемы и ФВ ЛЖ между группами были различны (р<0,001); средняя ФВ ЛЖ 1-й группы составила 44,9±5,9%, 2-й группы - 26,9±6,4%. Совпадение зоны максимальной ВЖД с местом имплантации ЛЖ электрода было больше в 1-й группе, р=0,028. Конечные значения МЖД были в пределах нормы в обеих группах наблюдения, отсутствие ВЖД наблюдалось в 95% 1-й группы, 80% - 2-й группы, р=0,493. Выводы: совпадение зоны максимальной диссинхронии миокарда с местом имплантации ЛЖ электрода ассоциировано с высоким ответом на СРТ в отдаленные сроки наблюдения. Недостаточный ответ может быть обусловлен неоптимальной позицией ЛЖ электрода - несовпадением места имплантации с зоной ВЖД, а также расположением желудочковых электродов вблизи друг друга.

The aim of the study was to provide comparative analysis of the zones with maximum intraventricular myocardial dyssynchrony (IVD) and the localizations of ventricular electrodes in patients with differential responses to cardiac resynchronization therapy (CRT). Materials and Methods: Retrospective study comprised patients (n=40) who had sinus rhythm, complete left bundle branch block (LBBB), left ventricular (LV) ejection fraction (EF) <35%, and NYHA functional class III and IV chronic heart failure (CHF). Patients received optimal drug therapy and were implanted with a system for CRT. Mean age was 60.9±11.4 years, 65% men (n=26), 35% women (n=14); cardiomyopathy of ischemic genesis was found in 52.5% of cases. Under X-ray control, right atrial (RA) lead was implanted in the Ra appendage, right ventricular (RV) lead was implanted in the interventricular septum (iVs) or the RV apex, and LV lead was implanted in one of coronary sinus veins. Period of follow up after CRT device implantation was 12.0+1.7 months. Patients were divided into groups: group 1 (n=20) with strong response to CRT (decrease in LV end-systolic volume (ESV) >15%, relative increase of LV eF ≥10%), and group 2 (n=20) with insufficient response to CRT (the absence of dynamics in the sizes, volumes, and LV EF). For topical evaluation of the zone of stimulation with ventricular electrode, a vector analysis of ECG was performed in the beginning and the end of the follow up period (VL was divided in 12 segments, RV was divided in 3 segments). Intraventricular and interventricular dyssynchrony of the myocardium was detected by echocardiography with tissue Doppler sonography. Results: initially, the groups did not differ in regard to gender, age, and parameters of echocardiography with tissue Doppler sonography. The absence of initial IVD was observed in 7 patients of group 1 and in 8 patients of group 2, p = 0.503, cardiomyopathy of ischemic genesis significantly prevailed in group 2 (75%, n=15, р=0.014). Dislocation of the leads was not documented for the entire period of the study, displacement of LV electrodes within the vein of the coronary sinus occurred in three cases. The final sizes, volumes, and LV EF values differed between the groups (р < 0.001), mean LV EF was 44.9±5.9% in group 1 and 26.9±6.4% in group 2. Overlapping of maximum IVD zone with the site of LV electrode implantation was more significant in group 1, р = 0.028. Final values of IVD were within normal ranges in both groups, the absence of IVD was observed in 95% and 80% of patients in group 1 and group 2, respectively, р = 0.493. Conclusions: correspondence of the myocardial zone with maximum dyssynchrony to the site of the Lv lead implantation was associated with a high response to CRT in the long term. Insufficient response can be caused by a non-optimal positioning of the LV electrode, lack of agreement between implantation site and IVD zone, and by positions of the ventricular electrodes close to each other.

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The authors declare that there are no conflicts of interest present.