Parade U, Klingel K, Kandolf R, Gawaz M, Schreieck J
Abteilung für Kardiologie, Medizinische Universitätsklink Tübingen.
Dtsch Med Wochenschr. 2010 Jun;135(22):1122. doi: 10.1055/s-0030-1247612. Epub 2010 May 31.
A 65-year-old male patient with rapid increasing shortness of breath and newly diagnosed atrial fibrillation was admitted to our hospital.
The ECG revealed atrial fibrillation. Echocardiography showed severe decreased left ventricular function. The magnetic resonance imaging (MRI) scan confirmed the severe reduced left ventricular function with a two graded mitral regurgitation as well as a pronounced late enhancement in the posterobasal area of the interventricular septum. Cardiac catheterisation showed mild diffuse atherosclerosis of the coronary arteries without stenotic lesions. Multiple myocardial biopsies of the right ventricle revealed extensive remodelling processes with focal fibrosis in presence of mononuclear cell infiltrates, T-wave alternans and the heart rate variability were positive.
DIAGNOSIS, TREATMENT AND COURSE: Nonischaemic cardiomyopathy (NICM) with severe reduced left ventriucular function was diagnosed. After successful electrical cardioversion and initiation of a sufficient heart failure treatment, the clinical symptoms as well as left ventricular function improved significantly.
Risk stratification of sudden cardiac death remains a clinical challenge especially in NICM. Significantly predictors in ischaemic cardiomyopathy, such as heart rate turbulance (HRT) and T-wave alternans, are not useful or have no importance in NICM. However, the prognosis does not correlate with restricted left ventricular function in NICM. Cardiac MRI or marker of autonomic dysfunction could be helpful in risk stratification. How far late enhancement is a surrogate parameter or the real substrate for life threatening arrhythmias is still unclear. Non-invasive risk stratification could be helpful in borderline decisions, however, it should not be taken mandatory. Close-meshed control intervals of the clinical status under optimal medication are recommended, followed by a implantation of an implantable cardioverter-defibrillator (ICD) if needed. ICD implantation is superior to medical treatment in persistent depressed left ventricular function. The ideal time for ICD implantation in newly diagnosed NICM remains unclear at the moment.
一名65岁男性患者，因呼吸急促迅速加重且新诊断为房颤入住我院。
心电图显示房颤。超声心动图显示左心室功能严重下降。磁共振成像（MRI）扫描证实左心室功能严重降低，伴有二尖瓣反流二级以及室间隔后基底区域明显延迟强化。心脏导管检查显示冠状动脉轻度弥漫性动脉粥样硬化，无狭窄病变。右心室多次心肌活检显示广泛的重塑过程，伴有局灶性纤维化及单核细胞浸润，T波交替和心率变异性均为阳性。
诊断、治疗及病程：诊断为非缺血性心肌病（NICM），左心室功能严重降低。成功进行电复律并开始充分的心力衰竭治疗后，临床症状及左心室功能显著改善。
心脏性猝死的风险分层仍然是一项临床挑战，尤其是在NICM中。缺血性心肌病中的重要预测指标，如心率震荡（HRT）和T波交替，在NICM中无用或不重要。然而，NICM的预后与左心室功能受限无关。心脏MRI或自主神经功能障碍标志物可能有助于风险分层。延迟强化在多大程度上是危及生命心律失常的替代参数或真正基质仍不清楚。非侵入性风险分层在临界决策中可能有用，但不应强制采用。建议在最佳药物治疗下密切监测临床状态，必要时植入植入式心脏复律除颤器（ICD）。在左心室功能持续低下时，ICD植入优于药物治疗。目前新诊断NICM中ICD植入的理想时间仍不清楚。
