Shipulin Vladimir M, Kazakov Vitaly A, Suhodolo Irina V, Krivoshekov Evgeny V, Lezhnev Alexander A, Kozlov Boris N, Vaizov Valery Ch, Miller Andrey A
Cardio-vascular Department, Tomsk Institute of Cardiology, Kievskaya street 111a, Tomsk, Russia, 634012.
Interact Cardiovasc Thorac Surg. 2007 Dec;6(6):772-7. doi: 10.1510/icvts.2007.159426. Epub 2007 Sep 20.
To reveal morphological factors causing unfavorable follow-up outcome of surgical treatment of patients with ischemic cardiomyopathy (ICMP) and with left ventricle (LV) aneurysm according to the data of intraoperative biopsies of LV myocardium and right atrium (RA) auricle.
The object of the study was to examine biopsy material of LV myocardium and RA auricle from 36 patients with ICMP. Clinical criteria of patients' inclusion into the study were: ESI LV >80 ml/m(2), EDP LV >30 mmHg, LV EF <40%, presence of akinetic and dyskinetic areas in LV, angina of II-IV class CCS, heart failure of II-IV class NYHA. The following morphometrical parameters were estimated for revelation of postoperative remodeling risk factors: parenchymal-stromal ratio (PSR), trophic index (TI), pericapillar diffusion zone (PDZ), Kernogan index (KI) and specific volume of granules of natriuretic factor (NUF) in atrial cardiomyocytes.
In all the patients LV EF increased significantly (from 36.4+/-4.1% to 46.3+/-4.2%) (P<0.05) in the early postoperative period; LV EDI decreased (from 139.3+/-11.2 ml/m(2) to 108.4+/-8.9 ml/m(2)) (P<0.05). In the follow-up period (one year) all the patients were divided into two groups: in 28 patients (the 1st group) volume of the cavity, contractile function of LV remained satisfactory. In the other eight patients (the 2nd group) there was significant decrease of LV EF (up to 33.9+/-10.2%) due to increase of LV EDI [up to 129.2+/-10.1 ml/m(2) (P<0.05)]. Grade of MR preoperatively was 1.21+/-0.5 and 1.47+/-0.9, correspondingly, for the patients with positive and negative changes in the follow-up postoperative period. Drawing morphological parallels of postoperative heart remodeling in patients with ICMP showed that diffusive, lymphocytic-macrophage inflammatory infiltration of myocardial stroma in combination with severe fibrosis (PSR<1.5), low TI (<0.015) and greater value of PDZ (>1000 microm) and KI (>1.6) of LV myocardium are the factors connected with unfavorable follow-up results of surgical treatment. Moreover, we showed an inverse correlative relationship between content of NUF granules in the cardiomyocytes of RA auricle and the outcomes of the Dor procedure.
Thus, a combination of the foregoing features is a morphological predictor of postoperative heart remodeling in patients with ICMP.
根据左心室（LV）心肌和右心耳（RA）心耳的术中活检数据，揭示导致缺血性心肌病（ICMP）合并左心室室壁瘤患者手术治疗随访结果不佳的形态学因素。
本研究的对象是检查36例ICMP患者的左心室心肌和右心耳活检材料。将患者纳入研究的临床标准为：左心室舒张末期容积指数（ESI LV）>80 ml/m²，左心室舒张末期压力（EDP LV）>30 mmHg，左心室射血分数（LV EF）<40%，左心室存在运动减弱和运动障碍区域，加拿大心血管学会（CCS）II-IV级心绞痛，纽约心脏协会（NYHA）II-IV级心力衰竭。为揭示术后重塑危险因素，评估了以下形态学参数：实质-间质比（PSR）、营养指数（TI）、毛细血管周围扩散区（PDZ）、克诺根指数（KI）和心房心肌细胞中利钠因子颗粒的比容（NUF）。
所有患者术后早期左心室射血分数均显著增加（从36.4±4.1%增至46.3±4.2%）（P<0.05）；左心室舒张末期容积指数降低（从139.3±11.2 ml/m²降至108.4±8.9 ml/m²）（P<0.05）。在随访期（一年），所有患者分为两组：28例患者（第一组）心室容积、左心室收缩功能保持良好。另外8例患者（第二组）左心室射血分数显著降低（降至33.9±10.2%），原因是左心室舒张末期容积指数增加[增至129.2±10.1 ml/m²（P<0.05）]。术后随访期有阳性和阴性变化的患者术前二尖瓣反流分级分别为1.21±0.5和1.4±0.9。对ICMP患者术后心脏重塑进行形态学对比显示，心肌间质的弥漫性、淋巴细胞-巨噬细胞炎性浸润合并严重纤维化（PSR<1.5）、低TI（<0.015）以及左心室心肌更大的PDZ值（>1000微米）和KI值（>1.6）是与手术治疗随访结果不佳相关的因素。此外，我们发现右心耳心肌细胞中NUF颗粒含量与Dor手术结果呈负相关。
因此，上述特征的组合是ICMP患者术后心脏重塑的形态学预测指标。
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