Benetis Rimantas, Simukauskiene Agne, Jankauskiene Loreta, Kavoliūniene Ausra
Department of Cardiology, Kaunas University of Medicine, Kaunas, Lithuania.
Medicina (Kaunas). 2007;43(11):909-17.
The high morbidity and mortality in patients with serious heart failure is a therapeutic challenge for current medicine. The leading cause of left ventricular dysfunction remains ischemic heart disease. Coronary artery bypass surgery is a treatment of choice in moderate-to-severe ischemic cardiomyopathy. The scarcity of completed prospective randomized clinical trials and high surgical risks create significant uncertainty concerning the optimal current treatment strategy. The role of imaging techniques of assessment for myocardial viability based on current guidelines may be very important in clinical decision-making. Present paper reviews some of the relevant literature concerning surgical treatment of ischemic cardiomyopathy and current evidence-based recommendations on this method of treatment. In advanced heart failure, coronary revascularization alone is an insufficient treatment modality. In the presence of moderate-to-severe ischemic mitral regurgitation, mitral valve repair or replacement should be considered at coronary artery bypass grafting surgery. One of the most common mechanisms of ischemic mitral regurgitation is Carpentier's type IIIb dysfunction, in which an undersized mitral anuloplasty might be helpful. Surgery of left ventricular shape and volume restoration leads to improvement of left ventricular function in patients with ischemic cardiomyopathy. When the results from three ongoing prospective randomized studies--the Surgical Treatment for Ischemic Heart Disease trial, Heart Failure Revascularization trial, the PET and Recovery Following Revascularization-2 trial--determining outcome of revascularization versus medical therapy are available, clinicians will have reliable data for making decisions concerning the optimum treatment strategy. At present, the choice of management still remains based on the data obtained from available retrospective trials or the state of art in the field.
严重心力衰竭患者的高发病率和死亡率是当前医学面临的治疗挑战。左心室功能障碍的主要原因仍然是缺血性心脏病。冠状动脉搭桥手术是中重度缺血性心肌病的首选治疗方法。完整的前瞻性随机临床试验稀缺以及手术风险高，使得当前最佳治疗策略存在很大不确定性。基于现行指南的心肌存活评估成像技术在临床决策中可能非常重要。本文综述了一些关于缺血性心肌病外科治疗的相关文献以及目前基于证据的该治疗方法推荐。在晚期心力衰竭中，单纯冠状动脉血运重建是一种不足的治疗方式。在存在中重度缺血性二尖瓣反流时，冠状动脉搭桥手术应考虑二尖瓣修复或置换。缺血性二尖瓣反流最常见的机制之一是Carpentier IIIb型功能障碍，此时二尖瓣环成形术过小可能会有帮助。左心室形状和容积恢复手术可改善缺血性心肌病患者的左心室功能。当三项正在进行的前瞻性随机研究——缺血性心脏病外科治疗试验、心力衰竭血运重建试验、血运重建后PET与恢复-2试验——确定血运重建与药物治疗结果的数据可用时，临床医生将拥有可靠数据来做出关于最佳治疗策略的决策。目前，治疗方案的选择仍然基于从现有回顾性试验获得的数据或该领域的最新技术水平。
