#1
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Øóíòèðîâàíèå ÑÒÎ
Óâàæàåìûå êîëëåãè, ñ âàøåé òî÷êè çðåíèÿ íóæíî ëè øóíòèðîâàòü õðîíè÷åñêóþ êîðîíàðíóþ îêêëþçèþ, â ðàìêàõ áîëüøîé îïåðàöèè íà ñåðäöå, åñëè íåò èøåìèè è ïðèçíàêîâ æèçíåííîñïîñîáíîãî ìèîêàðäà â äàííîì áàññåéíå?
Ñàìî ñîáîé ïîäðàçóìåâàåòñÿ, ÷òî àáñîëþòíûå ïîêàçàíèÿ äëÿ îïåðàöèè, êàê òàêîâîé, èìåþòñÿ. |
#2
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Ïî-ìîåìó, åñëè íåò æèçíåñïîñîáíîãî ìèîêàðäà, òî íå íàäî ðåâàñêóëÿðèçèðîâàòü â ëþáîì ñëó÷àå.
Èëè òû íàø¸ë êàêóþ-òî äüÿâîëüñêóþ ñòàòüþ ?
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Àáóãîâ Ñåðãåé Àëåêñàíäðîâè÷. Ðîññèéñêèé Íàó÷íûé Öåíòð Õèðóðãèè èì. àêàäåìèêà Á.Â. Ïåòðîâñêîãî. |
#3
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Âèäèìî, ïðè ÕÒÎ, íà ôîíå èçâåñòíûõ ìèîêàðäèàëüíûõ ðóáöîâ (ÏÈÊÑ, àíåâðèçìà ËÆ) îïèðàòüñÿ òîëüêî íà êîðîíàðîãðàììû áåññìûñëåííî, âûïîëíåíèå ñòðåññ-ÝÕÎ ìàëîèíôîðìàòèâíî è åñëè î÷åíü õî÷åòñÿ øèòü øóíòû, òî ëó÷øå âîñïîëüçîâàòüñÿ ìåòîäàìè ðóäèîíóêëèäíîé äèàãíîñòèêè.
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#4
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Íàïðèìåð, òàêîé ñëó÷àé.
Ìóæ÷èíà 46 ëåò áåç êîðîíàðíîãî àíàìíåçà, ðàííèå ñðîêè íèæíåãî ÈÌ. Ñòåíòèðîâàíèå îñòðîé îêêëþçèè ÏÊÀ â ðàííèå ñðîêè. Íà ÊÀà õðîíè÷åñêàÿ îêêëþçèÿ ÏÍÀ. Äðóãèõ ïîðàæåíèé íåò. Òå÷åíèå çàáîëåâàíèå îñëîæíÿåòñÿ îòðûâîì çàäíåé ïàïèëëÿðíîé ìûøöû. Áîëüíîé îòïðàâëÿåòñÿ â îïåðàöèîííóþ. Äîëæíû ëè õèðóðãè, êðîìå ïî÷èíêè ìèòðàëüíîãî êëàïàíà, øóíòèðîâàòü ÏÍÀ? |
#5
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ÈÌÕÎ. Åñëè ÷åëîâåêà ñ ïðîêñèìàëüíîé îêêëþçèåé ÏÍÀ íåò ðóáöîâ â ïåðåäíåé ñòåíêå ïî ÝÊà è ÝõîÊÑ, òî äàæå ïðè îòñóòñòâèè ãèïîêèíåçîâ â ïîêîå è ïðèçíàêîâ èøåìèè äàííîé îáëàñòè íóæíî âûïîëíèòü ÌÊØ ÏÍÀ.
Õîòÿ, êîíå÷íî, ìîæíî è èìïëàíòèðîâàòü DES - íî ýòî óæå â ïëàíîâîì ïîðÿäêå ïîñëå ñòàáèëèçàöèè. |
#6
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Íà÷íó ñ òîãî, ÷òî ïîñòàðàþñü ïîèñêàòü ëèòåðàòóðíûå ïîäòâåðæäåíèÿ. Îäíàêî, óâàæàåìûé, Dmblok, íóæíî ñðàçó îãîâîðèòüñÿ, ÷òî ðå÷ü èäåò î ãåìîäèíàìè÷åñêè íåñòàáèëüíîì ïàöèåíòå, êîòîðîìó íåâîçìîæíî âûïîëíèòü íàãðóçî÷íûé òåñò.
Íà ñàìîì äåëå èñõîæó, (êàê ìíå êàæåòñÿ) èç çäðàâîãî ñìûñëà. Ïðîãíîñòè÷åñêè íåáëàãîïðèÿòíî èìåòü ïðîêñèìàëüíóþ îêêëþçèþ ÏÍÀ â 46 ëåò ïðè ëþáîì òèïå êðîâîñíàáæåíèÿ ìèîêàðäà. Ñòîèò çàìåòèòü, ÷òî ó ïàöèåíòà ïðîâîäèëàñü ðåâàñêóëÿðèöèÿ â áàññåéíå ÏÊÀ, è åñëè ðàññìàòðèâàòü åãî ñ ïîçèöèé CAD Prognostic Index (Coronary Revascularization Update), òî 5-ëåòíÿÿ âûæèâàåìîñòü ïàöèåíòîâ ñ äâóõñîñóäèñòûì ïîðàæåíèåì, > 95% prox.LAD ñîñòàâëÿåò 79% íà ÎÌÒ. Õîòÿ âîïðîñ ðåâàñêóëÿðèçàöèè ÕÒÎ ÿâëÿåòñÿ äîñòàòî÷íî äèñêóòàáåëüíûì. |
#7
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Ïîïðîáóþ àïåëëèðîâàòü îáùåèçâåñòíûìè ôàêòàìè ([Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ])
In a consecutive series of 2007 patients undergoing intended PCI of a nonacute coronary occlusion at the Mid America Heart Institute between 1980 and 1999, technical success was achieved in 74.4% and procedural success in 69.9% of cases. Compared with those patients in whom the procedure was successful, the in-hospital occurrence of major adverse ñardiac events was significantly higher among patients with procedural failure (3.2% versus 5.4%; P0.02). Long-term survival was similar in patients with successful CTO recanalization compared with a matched cohort of patients undergoing successful angioplasty of nonoccluded lesions and significantly greater than in patients in whom attempted CTO revascularization failed (10-year survival 73.5% with CTO success versus 65.0% with CTO failure; P0.001). By multivariate analysis, failure to successfully recanalize the CTO was an independent predictor of reduced survival (hazard ratio 1.4; P0.0003). Similarly, a time-independent benefit of total occlusion recanalization has been observed in the British Columbia Cardiac Registry, in which attempted revascularization of CTO lesions accounted for 15% of all PCI procedures.59 Among 1458 patients with CTOs, successful percutaneous revascularization was associated with increased survival and a reduced need for surgical revascularization over a 7-year follow-up period (both P0.001). CTO success was associated with a 56% relative reduction in late mortality (hazard ratio 0.44; 95% CI, 0.30 to 0.64) prospective Total Occlusion Angioplasty Study–Società Italiana di Cardiologia Invasiva (TOASTGISE), successful PCI of a CTO (attempted in 390 lesions in 369 patients) was associated with a reduced 12-month incidence of cardiac death or MI (1.1% versus 7.2%; P0.005), a reduced need for coronary artery bypass surgery (2.5% versus 15.7%; P0.0001), and greater freedom from angina (88.7% versus 75.0%; P0.008). In the overall study population, the only factor associated with enhanced 1-year event-free survival was successful CTO recanalization (odds ratio 0.24; P0.018). In a study by Kim et al, of 44 patients with 58 CTO segments and fixed SPECT perfusion defects had only subendocardial infarction involving 50% of the thickness of the left ventricle by MRI, including 12 patients (21%) in whom no evidence of infarction was present. Territories without extensive infarction at baseline demonstrated significant regional wall motion improvement after PCI, with subsequent resolution of ischemia demonstrated by adenosine stress MRI. |
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#8
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à ÷åì ýòà ñèòóàöèÿ "ëó÷øå"? Íå äóìàþ, ÷òî íàëîæåíèå ÌÊØ ñèëüíî çàòÿíåò âðåìÿ îïåðàöèè, íàâåðíÿêà áóäåò âûïîëíÿòñÿ off-pump, ÷òî íå äîëæíî ñóùåñòâåííî óâåëè÷èòü âåðîÿòíîñòü ïåðèîïåðàöèîííûõ îñëîæíåíèé. Òåì áîëåå, ÷òî ðå÷ü èäåò î ÏÌÆÀ. Ãëàâíîå, ÷òî ìû óâåðåíû â íàëè÷èè æèçíåñïîñîáíîãî ìèîêàðäà (è äàæå â îòñóòñòâèè ðóáöîâ) â äàííîé îáëàñòè.
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#9
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off-pump ïî÷èíèòü ìèòðàëüíûé êëàïàí íåâîçìîæíî...
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#10
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Öèòàòà:
È âñå ýòî ïðè òîì, ÷òî òèï êîðîíàðíîãî êðîâîñíàáæåíèÿ íå èçâåñòåí... PS/ È åùå, ðàçâå òàêîé âîïðîñ íå ïîâîä äëÿ îïðåäåëåíèÿ ãîðÿ÷î îáñóæäàåìîãî FFR? |
#11
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Öèòàòà:
Íó è ñàìîå ãëàâíîå, ÷òîáû åãî èçìåðèòü, íóæíî ïðîéòè ïðîâîäíèêîì çà îêêëþçèþ. Âñå æå, âîïðîñ î ðåâàñêóëÿðèçàöèè îêêëþçèè ëîãè÷íåé ðåøàòü äî ïðîõîæäåíèÿ îêêëþçèè ïðîâîäíèêîì... À â ïðèâåäåííîì ïðèìåðå íåò íè äîêàçàòåëüñòâ íàëè÷èÿ æèçíåñïîñîáíîãî ìèîêàðäà, íè äîêàçàòåëüñòâ îòñóòñòâèÿ æèçíåñïîñîáíîãî ìèîêàðäà, íî íà ÝÕÎ è íà îïåðàöèè áóäåò âèäíî - ìèîêàðä òàì, èëè òîíêîñòåííûé ðóáåö. |
#12
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Öèòàòà:
Ñîâåðøåííî ñîãëàñåí, ÷òî âñå ýòî äîëæíî îïðåäåëÿòüñÿ äî îïåðàöèè. Íå ïîíÿòíî, ïî÷åìó ýòî íå ñäåëàíî. Òåì áîëåå, êàê Âû ñïðàâåäëèâî çàìåòèëè, FFR â ýòîì ñëó÷àå íå ðàáîòàåò Èçâèíèòå. |
#13
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Êàê áûëî çàìå÷åíî âûøå - ñëó÷àé óðãåíòíûé. Íà ñåðèè ÝÕÎ íàðóøåíèé ñîêðàòèìîñòè â çîíå áàññåéíà ÏÍÀ - íåò.  òîì ÷èñëå è íà ôîíå ìåðöàíèÿ-òðåïåòàíèÿ ïðåäñåðäèé ñ ×ÑÑ - 150-160. ×åì íå íàãðóçî÷íûé òåñò?) Îñíîâàíèé ïîäîçðåâàòü ïåðåíåñåíûé ðàíåå ïåðåäíèé ÈÌ è/èëè èøåìèþ ïåðåäíåé ñòåíêè íåò íèêàêèõ. Âðåìåíè íà ïðîâåäåíèå äîïîëíèòåëüíûõ èññëåäîâàíèé íå òàê óæ è ìíîãî, íà ôîíå ÎËÍ.
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#14
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Öèòàòà:
È, ïîòîì, åñëè Âû ñ÷èòàåòå, ÷òî êèíåòèêà â áàññåéíå ÏÍÀ ñîõðàíåíà, ãäå äîêàçàòåëüñòâà, ÷òî "ïàøåò" åå ìèîêàðä áåç èøåìèè? Ìåðöàíèå ïðåäñåðäèé? À íåëüçÿ ëè ññûëî÷êó íà ïåðâîèñòî÷íèê? PS Óæå áîëåå 30 ëåò èùó õîòü îäíó ññûëî÷êó, ãäå áûëî áû ïîêàçàíî, ÷òî êîëëàòåðàëüíûé êðîâîòîê (ïðè îêêëþçèè ýïèêàðäèàëüíîé ê.à.) ïîçâîëÿåò ïîëíîñòüþ ïîääåðæèâàòü òå æå ðåçåðâû ìèîêàðäèàëüíîãî êðîâîòîêà, ÷òî áûëè ïðè èíòàêòíîé ýïèêàðäèàëüíîé ê.à. |
#15
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Íà ôîíå ÎËÍ - ïîêàçàíà ïîëíàÿ ðåâàñêóëÿðèçàöèÿ. Äàæå åñëè åñòü îñíîâàíèÿ ñ÷èòàòü, ÷òî îñíîâíàÿ ïðè÷èíà å¸ - ìèòðàëüíàÿ íåäîñòàòî÷íîñòü.
Ìíå êàæåòñÿ, â ïðèâåäåííîì ñëó÷àå åñòü êàêîé-òî ïîäâîõ... Õèðóðãè íå ñòàëè øóíòèðîâàòü ÏÌÆÀ? |