cardioКардиологияKardiologiia0022-90402412-5660Kardiomag10.18087/cardio.2021.7.n1420cardio-1420Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИRESEARCH ARTICLESМеханическая диссинхрония в прогнозе ответа на ресинхронизирующую терапию у пациентов с дилатационной кардиомиопатиейMechanical Dyssynchrony for Prediction of the Cardiac Resynchronization Therapy Response in Patients with Dilated Cardiomyopathyhttps://orcid.org/0000-0002-1513-8614ЗавадовскийК. В.ZavadovskijK. V.

д.м.н, руководитель лаборатории радионуклидных методов исследования НИИ кардиологии Томского НИМЦ

MD, head of the department of Nuclear Medicine, Cardiology Research Institute, Tomsk NRMC

konstz@cardio-tomsk.ruhttps://orcid.org/0000-0001-5564-3802СаушкинВ. В.SaushkinV. V.

к.м.н., с.н.с. лаборатории радионуклидных методов исследования НИИ кардиологии Томского НИМЦ

Ph.d, senior researcher, department of Nuclear Medicine, Cardiology Research Institute, Tomsk NRMC

saushkin.w@gmail.comhttps://orcid.org/0000-0002-0193-9453ВарламоваЮ. В.VarlamovaYu. V.

к.м.н., врач-радиолог лаборатории радионуклидных методов исследования НИИ кардиологии Томского НИМЦ

Ph.D., radiologist, department of Nuclear Medicine, Cardiology Research Institute, Tomsk NRMC

jul13@bk.ruhttps://orcid.org/0000-0001-9453-1635МишкинаА. И.MishkinaA. I.

м.н.с. лаборатории радионуклидных методов исследования НИИ кардиологии Томского НИМЦ

junior researcher, department of Nuclear Medicine, Cardiology Research Institute, Tomsk NRMC

anna123.2013@gmail.comhttps://orcid.org/0000-0001-9887-8214ШипулинВ. В.ShipulinV. V.

аспирант лаборатории радионуклидных методов исследования НИИ кардиологии Томского НИМЦ

Postgraduate student, department of Nuclear Medicine, Cardiology Research Institute, Tomsk NRMC

shipartphoto@gmail.comhttps://orcid.org/0000-0001-9764-3982ЛебедевД. И.LebedevD. I.

к.м.н., врач по рентгенэндоваскулярным диагностике и лечению  отделения хирургического лечения сложных нарушений ритма сердца и электрокардиостимуляции НИИ кардиологии Томского НИМЦ

Ph.D., endovascular surgeon, department of Interventional Arrhythmology, Cardiology Research Institute, Tomsk NRMC

titze@mail.ruhttps://orcid.org/0000-0002-9050-4493ПоповС. В.PopovS. V.

академик, д.м.н., руководитель отделения хирургического лечения сложных нарушений ритма сердца и электрокардиостимуляции НИИ кардиологии Томского НИМЦ

full Member of the Russian Academy of Sciences, MD, head of the department of Interventional Arrhythmology, Cardiology Research Institute, Tomsk NRMC

psv@cardio-tomsk.ruФГБНУ НИИ кардиологии, «Томский национальный исследовательский медицинский центр РАН», ТомскРоссияCardiology Research Institute, Tomsk National Research Medical Center, TomskRussian Federation2021310720216171421Copyright © Kardiomag, 20212021KardiomagKardiomaghttps://cardio.elpub.ru/jour/about/submissions#copyrightNoticehttps://cardio.elpub.ru/jour/article/view/1420

Цель    Оценка прогностической значимости показателей механической диссинхронии (МД) левого желудочка, определенных по данным синхронизированной с электрокардиограммой (ЭКГ) перфузионной сцинтиграфии миокарда (ЭКГ–ПСМ), в прогнозе эффективности ресинхронизирующей терапии (РТ) у пациентов с хронической сердечной недостаточностью (ХСН).

Материал и методы  В проспективное исследование были включены 32 пациента с ХСН неишемической этиологии и наличием стандартных показаний к РТ. Все пациенты прошли полное клинико-инструментальное обследование, включающее суточное мониторирование ЭКГ, эхокардиографию (ЭхоКГ). С целью оценки перфузии, контрактильной функции и МД миокарда левого желудочка (ЛЖ) всем пациентам до РТ была проведена перфузионная сцинтиграфия миокарда в состоянии покоя. Помимо размера дефекта перфузии в покое и показателей гемодинамики, определяли МД ЛЖ. Для анализа диссинхронии использовали следующие показатели: стандартное отклонение фазы (PSD), ширину фазовой гистограммы (HBW), асимметрию и крутизну фазовой гистограммы. Для оценки эффективности лечения через 6 мес после РТ были проведены оценка клинического статуса пациентов (шкала оценки клинического состояния пациентов с ХСН) и ЭхоКГ. Критерием положительного ответа на РТ считали увеличение фракции выброса (ФВ) ЛЖ на 5 % и / или снижение конечного систолического объема (КСО) ЛЖ на 15 % по сравнению с дооперационными значениями.

Результаты   По данным ЭКГ–ПСМ у всех пациентов были выявлены сцинтиграфические признаки тяжелой ХСН с дилатацией полости ЛЖ (конечный диастолический объем – КДО 246 [217; 269] мл), а также выраженной механической и электрической диссинхронии. Показатели механической диссинхронии имели следующие значения: PSD 53 [41; 61]°, HBW 176 [136; 202]°, асимметрия 1,62 [1,21; 1,89], крутизна 2,81 [1,21; 3,49]. Длительность QRS составила 165 [155; 175] мс. При этом перфузия миокарда ЛЖ была умеренно нарушена (размер дефекта перфузии в покое 4 [3; 10] %). Средний срок наблюдения после установки ресинхронизирующего устройства составил 6±1,7 мес. Согласно выбранным критериям, 20 (63 %) пациентов были расценены как ответившие на лечение, 12 (37 %) – как не ответившие на лечение. До имплантации кардиоресинхронизирующего устройства ответившие и не ответившие на лечение различались только по МД ЛЖ (PSD 44 [35; 54]° vs 63 [58; 72]°; p=0,0001); HBW 158 [118; 179]° vs 205 [199; 249]°; p=0,0001; асимметрия 1,77 [1,62; 2,02] vs 1,21 [0,93; 1,31]; p=0,0001; крутизна 3,03 [2,60; 3,58] vs 1,21 [0,19; 1,46]; p=0,0001) соответственно. По результатам однофакторного логистического регрессионного анализа было установлено, что значения МД являлись статистически значимыми предикторами положительного ответа на РТ. При многофакторном логистическом анализе крутизны фазовой гистограммы (отношение шансов – ОШ 1,196; 95 % доверительный интервал – ДИ 1,04–1,37) и PSD (ОШ 0,67; 95 % ДИ 0,47–0,97) были определены как независимые предикторы ответа на РТ. По результатам ROC-анализа при PSD <55° и крутизне фазовой гистограммы >1,54 можно прогнозировать успешность РТ (AUC= 0,92; р=0,0001).

Заключение     Показатели МД ЛЖ, определенные с помощью ЭКГ–ПСМ, позволяют прогнозировать эффективность РТ у пациентов с ХСН неишемического генеза. В этой группе пациентов высокие значения стандартного отклонения и низкие величины крутизны фазовой гистограммы явились независимыми критериями отсутствия ответа на РТ через 6 мес наблюдения.

Aim      To evaluate the predictive value of indexes of left ventricular mechanical dyssynchrony (MD) as determined by data of electrocardiogram (ECG)-gated myocardial perfusion scintigraphy (ECG-MPS) for prediction of the efficacy of resynchronization therapy (RT) in patients with chronic heart failure (CHF).

Material and methods  This prospective study included 32 patients with nonischemic CHF and standard indications for RT. All patients underwent complete clinical an instrumental examination, including 24-h ECG monitoring and echocardiography (EchoCG). In order to evaluate the left ventricular (LV) myocardial perfusion, contractile function, and MD, myocardial perfusion scintigraphy was performed for all patients at rest prior to RT. In addition to the perfusion defect size at rest and hemodynamic parameters, LV MD was determined. The following indexes were used for analysis of dyssynchronization: phase standard deviation (PSD), phase histogram bandwidth (HBW), and phase histogram asymmetry and steepness. The treatment efficacy was evaluated by the clinical status of patients (clinical condition evaluation scale for CHF patient) and EchoCG at 6 months following RT. The criteria for a positive response to RT were an increase in LV ejection fraction (EF) by 5% and/or a decrease in the LV end-diastolic volume by 15% compared to preoperative values.

Results According to ECG-MPS findings, all patients had scintigraphic signs of severe CHF with dilated LV cavity (end-diastolic volume, EDV 246 [217; 269] ml) and also of pronounced mechanical and electrical dyssynchrony. The values of mechanical dyssynchrony were PSD 53 [41; 61], HBW 176 [136; 202], asymmetry 1.62 [1.21; 1.89], and steepness 2.81 [1.21; 3.49]. The QRS duration was 165 [155; 175] msec. Furthermore, the LV perfusion was moderately impaired (perfusion defect size 4 [3; 10] %). Mean follow-up duration after implantation of the resynchronizing device was 6±1.7 mos. According to the selected criteria, 20 (63 %) patients were considered as responders and 12 (37 %) patients as non-responders. Before implantation of the cardiac synchronizing device, responders and non-responders differed only in LV MD (PSD 44 [35; 54] vs. 63 [58; 72]; p=0.0001); HBW 158 [118; 179] vs. 205 [199; 249]; p=0.0001; asymmetry 1.77 [1.62; 2.02] vs. 1.21 [0.93; 1.31]; p=0.0001; steepness 3.03 [2.60; 3.58] vs. 1.21 [0.19; 1.46]; p=0.0001), respectively. A one-factor logistic regression analysis showed that MD values were statistically significant predictors of a positive response to RT. A multi-factor logistic analysis of phase histogram steepness (odds ratio, OR 1.196; 95 % confidence interval, CI 1.04–1.37) and PSD (OR 0.67; 95 % CI 0.47–0.97) were identified as independent predictors for the response to RT. According to results of the ROC analysis, a PSD <55 and a phase histogram steepness >1.54 may predict the effectiveness of RT (AUC= 0.92; р=0.0001).

Conclusion      LV MD parameters determined with ECG-MPS allow predicting the effectiveness of RT in patients with nonischemic CHF. In this patient group, high values of standard deviation and low values of phase histogram steepness were independent predictors for the absence of response to RT after 6 mos. of follow-up.

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