Muñoz Carvajal I, Concha Ruiz M
Servicio de Cirugía Cardiovascular, Hospital Reina Sofía, Córdoba.
Rev Esp Cardiol. 1998;51 Suppl 3:106-13.
Ventricular dysfunction caused by ischemia is frequently a consequence of episodes of myocardial infarction which occur in the context of coronary disease, as well as of the ischemic situation in patients with severe failure in the main coronary arteries. The physiopathological mechanisms, as well as the therapeutic possibilities, are different in the case of diagnosed necrosis of myocardium or in situations of its circulatory deficiency, and, in the latter case, they depend on the period of absence of blood flow to the ischemic area, and on the occurrence of reperfusion of the area at the end of the ischemic event, the existence of an adequate collateral flow, etc. Classically, moderate degrees of ischemic ventricular dysfunction were considered as a preferential indication for revascularization surgery, together with the existence of coronary disease anatomically suitable for bypass. However, severe degrees of ventricular dysfunction were regarded as a contraindication to surgery, as they were considered irreversible due to an ischemic myocardiopathy which could not be palliated by an ulterior revascularization. These patients were referred to heart transplantation or to medical treatment when they did not fulfill the criteria to be included in transplantation programmes. In a later stage, due to a scarcity of donors for transplantation and to the disappointing results of pharmacological treatment in these patients, revascularization operations begun to be performed on patients with severe heart failure. Although initial results were not comparable to the ones obtained nowadays, work continued on this track and rapid improvement was achieved when particular clinical and diagnostic patterns were followed. Thus the concept of myocardial viability was created, presently being a central criterion in deciding which patients should go through revascularization. There are different methods to assess viability, and new ones are added to the diagnostic arsenal every day. With an adequate assessment of this concept, it is presently possible to really predict which patients may obtain clinical and functional improvement from their coronary disease in spite of severe deterioration of their cardiac function. This article analyzes the physiopathology of ventricular dysfunction, present methods to detect the viability of myocardial cells, as well as present indications and results obtained with ventricular revascularization in patients with severe depression of ventricular function as an alternative, currently well established, to heart transplantation.
由缺血引起的心室功能障碍通常是冠心病背景下发生的心肌梗死发作的结果，也是主要冠状动脉严重衰竭患者缺血情况的结果。在心肌诊断性坏死或其循环不足的情况下，生理病理机制以及治疗可能性是不同的，在后一种情况下，它们取决于缺血区域无血流的时间、缺血事件结束时该区域再灌注的发生情况、是否存在足够的侧支血流等。传统上，中度缺血性心室功能障碍被认为是血管重建手术的优先指征，同时存在解剖上适合搭桥的冠心病。然而，严重的心室功能障碍被视为手术禁忌症，因为它们被认为由于缺血性心肌病而不可逆转，而这种心肌病无法通过后续的血管重建得到缓解。这些患者在不符合移植项目纳入标准时，会被转诊进行心脏移植或接受药物治疗。在后期，由于移植供体短缺以及这些患者药物治疗效果不佳，开始对严重心力衰竭患者进行血管重建手术。尽管最初的结果无法与现在获得的结果相比，但在这条道路上继续努力，当遵循特定的临床和诊断模式时，取得了快速进展。因此，心肌存活的概念应运而生，目前它是决定哪些患者应接受血管重建的核心标准。有不同的方法来评估存活情况，每天都有新的方法加入诊断手段。通过对这一概念的充分评估，目前有可能真正预测哪些患者尽管心功能严重恶化，但仍可能从冠心病中获得临床和功能改善。本文分析了心室功能障碍的生理病理学、检测心肌细胞存活的现有方法，以及对心室功能严重减退患者进行心室血管重建的现有指征和结果，作为目前已确立的心脏移植的替代方法。
