Вісник серцево-судинної хірургії 2018 ішемічна хвороба серцяCoronary revascularization provides symptomatic relief from coronary artery disease (CAD) and improves short and long-term outcomes in patients with CAD. The optimal revascularization strategy is still controversial among interventional and conventional approaches for coronary revascularization, although coronary artery bypass grafting (CABG) remains the standard of care for patients with three-vessel or left main coronary artery disease, since the use of CABG, as compared with percutaneous interventions (PCI), resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events (MACE) at 1 year according to SYNTAX study (SYNergy Between PCI With TAXus and Cardiac Surgery). The optimal revascularization strategy should combine a minimally invasive surgical procedure that reduces perioperative risk, while maximizing long-term patency of conduit for CABG along with patient's survival rates.Hybrid coronary revascularization (HCR) was first introduced in 1996 [1] as a promise to full coronary artery revascularization minimizing surgical trauma and adverse cardiovascular events. The initial concept was launched by Dr. Gianni from Imperial college of London and included small number of patients, who received favorable outcomes in terms of hospital stay, duration of extubation and 6-month period survival. The hybrid approach refers to the combination of CABG and PCI, namely providing anastomosis of left internal mammary artery (LIMA) to left anterior descending artery (LAD), typically via minimally invasive technique and PCI for remaining (non-LAD) vessels.The rationale for HCR lies in the well-established survival benefit conferred by LIMA-to-LAD grafts and the use of new DES-stent platforms featuring low stent restenosis and thrombosis rates compared with venous graft stenosis and occlusion rates [2]. The superior patency of LIMAto-LAD graft provides prophylaxis against future proximal LAD lesions, which translates into better event-free survival and relief of angina. The benefits of bypassing other non-LAD coronary vessels are much less clear. Conduits for a non-LAD vessel may include other arterial grafts (complete arterial revascularization), but the saphenous vein is by far the most commonly used. A major limitation of CABG with great saphenous vein grafts (GSV) lies in the high graft failure rates with reports ranging from 13% to 29% at 1 year and up. Newer drug-eluting stent (DES) platforms with (e.g., everolimus-eluting stents (EES) or zotarolimus-eluting stents (ZES) or without (bioresorbable polymer-based or polymer-free stents) durable polymers show favorable outcomes, with 1-year target lesion revascularization (TLR) rates as low as 3% to 3.25% [4]. Even in high-risk patients and complex lesions, ZES and EES maintain very low 1-year TLR rates of 4.4% and 4%, respectively [5]. Thus, PCI and stenting provide strong competition for SVG revascularization because, unlike an LIMA-LAD graft, disease progression in the proxi...
Введение. Спекл-трекинг в В-режиме (СТЭ) позволяет получить ценную информацию о региональных нарушениях функции левого желудочка (ЛЖ), а использование СТЭ при стрессэхокардиографии с добутамином (ДСЭ) позволяет намного эффективнее диагностировать ишемию миокарда.Цель. Изучить диагностическую точность спекл-трекинга в В-режиме (СТЭ) при проведении стресс-эхокардиографии с добутамином (ДСЭ) у пациентов с подозрением на ИБС по сравнению с коронарной ангиографией (КАГ).Материалы и методы. Мы проспективно обследовали 140 пациентов (84 (60,0%) мужчины) с подозрением на ИБС. Всем была выполнена СТЭ-ДСЭ перед КАГ.Результаты. Средняя ФВ ЛЖ составляла 54,4±15,8%. Гемодинамика на протяжении проведения ДСЭ у пациентов значимо не страдала (15 (12,9%) случаев суправентрикулярных и желудочковых нарушений ритма низких градаций транзиторного характера, купировавшихся спонтанно в большинстве случаев).Количество положительных результатов ДСЭ составило 116 (82,9%), в том числе 2 (1,7%) ложноположительных. Также было 2 (8,3%) ложно-негативных результата: однососудистые незначимые (50–70%) поражения с хорошо развитыми коллатералями. По итогам теста и КАГ выполнено 96 (82,3%) вмешательств по реваскуляризации миокарда – 86 (89,6%) ПТКА и 10 (10,4%) А(М)КШ.Чувствительность и специфичность результатов ДСЭ с СТЭ относительно КАГ составили 98,3% и 91,7% соответственно, с очень высокой общей точностью метода (AUC=0,98) и отношением рисков (OR=627,0, p<0,0001). Чувствительность и специфичность ДСЭ с СТЭ относительно определения показаний к вмешательству составили 97,9% и 91,7% соответственно, с высокой общей точностью (AUC=0,95; OR=564,0, p<0,0001). Комбинированная оценка ΔGLS и ΔИЛС относительно выявления ишемии миокарда показала более низкую достоверную чувствительность 86,2% (р=0,0002) и специфичность 80,4% (р=0,0064) при более низкой интегральной точности методики (AUC 0,83, р<0,0001).Заключение. СТЭ-ДСЭ – безопасный оптимальный метод диагностики ишемии и оценки жизнеспособности и коронарного резерва у пациентов с подозрением на ИБС. Учитывая более низкую точность оценки ΔGLS и ΔИЛС по сравнению с данными общего результата теста ДСЭ с СТЭ, а также частый прирост стрейна у значительного количества пациентов с положительной пробой при диагностике ишемии и оценке коронарного резерва рекомендуется оценка общего результата теста, а не динамики значений стрейна. Introduction. Two-dimensional speckle tracking (STE) provides valuable information regarding regional left ventricle (LV) myocardial function. STE during dobutamine stress-echocardiography (DSE) significantly increases diagnostic effectiveness of myocardial ischemia.Purpose. To study the diagnostic accuracy of B-mode speckle tracking (STE) during dobutamine stress-echocardiography (DSE) in patients with CAD suspicion compared to coronary angiography (CAG).Materials and methods. We prospectively studied 140 patients (84 (60.0%) men) with CAD suspicion – all of them underwent STE-DSE before CAG.Results. The average LV EF was 54.4±15.8%. Hemodynamics during DSE did not alter significantly (15 (12.9%) cases of supraventricular and ventricular transitory low-grade arrhythmia, stopping spontaneously in most cases).There were 116 (82.9%) positive DSE results, including 2 (1.7%) false positive cases. In addition, there were 2 (8.3%) false negative results: 1-vessel insignificant lesions (50–70%) with well-developed collaterals. According to STE-DSE and CAG results, 96 (82.3%) revascularization interventions were performed – 86 (89.6%) PCI’s and 10 (10.4%) CABG surgeries.Sensitivity and specificity of STE-DSE results were 98.3% and 91.7%, respectively, with very high general method accuracy (AUC=0.98) and odds ratio (OR=627.0, p<0.0001). Sensitivity and specificity of STE-DSE results regarding the definition of indications for revascularization intervention were 97.9% and 91.7%, respectively, with high general accuracy (AUC=0.95; OR=564.0, p<0.0001). Combined quantification of ΔGLS and ΔWMSI regarding primary ischemia diagnosis showed significantly lower sensitivity 86.2% (р=0.0002) and specificity 80.4% (р=0.0064) with significantly lower integral method accuracy (AUC 0.83, р<0.0001).Conclusion. STE-DSE is a safe optimal method for diagnostics of myocardial ischemia, as well as for myocardial viability and coronary reserve evaluation in patients with CAD suspicion. Taking into account significantly lower accuracy of ΔGLS and ΔWMSI quantification if compared to integral STE-DSE test result, as well as frequent GLS growth during the test in significant proportion of patients with CAD, we recommend evaluating general test result, but not the GLS dynamics during diagnostics of primary ischemia and coronary reserve evaluation.
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