Abstract
to assess dynamics of diastolic function for detection of development of diastolic dysfunction (DD) and it's causes, to evaluate the effect of DD on prognosis in the postoperative period in patients with acquired heart diseases. We included in this study 112 patients with aortic and mitral valve diseases (90 men, 22 women, median age 51 [35; 57] years). All patients underwent echocardiography (echo), tissue Doppler, speckle tracking echo prior to surgery, in the early postoperative period (8-14 days) and in 12-36 months after surgery. In 28 patients dynamic contrast-enhanced magnetic resonance imaging was also performed. Patients were divided into groups according to prognosis: group 0 - without complications; group 1 - with postoperative heart failure (HF) and preserved left ventricular ejection fraction (EF); group 2 - with HF and EF <45 %. The following parameters were used for identifying left ventricular (LV) DD: septal velocity es <7 cm / sec, lateral el <10 cm / sec, average E / e ratio >14, left atrial (LA) volume index >34 ml / m2, peak tricuspid regurgitation velocity >2.8 m / sec. Initially diastolicLV function was normal in 34 of 112 patients (30.4 %), in early postoperative period DD emerged in 9 (26.5 %) of these patients. The appearance of LV DD was associated with decrease of septal es immediately after surgery and its subsequent progressive decline in the long-term postoperative period from 8.5±0.71 to 4.6 ±0.53 cm / sec (p=0.005). Worsening of diastolic function and lowering of septal velocity was detected namely in patients with presence of fibrosis. In the group of other patients in whom fibrosis was not studied and the degree of DD increased there was a transient decrease of lateral el (from 10.2±3.1 to 7.5±2.43 cm / sec, p=0.035) and an increase of the E / el (from 10.53±4.07 to 14.5±5.23, p=0.05) in the early period after the operation. There were no correlations between DD and LV EF,LV volumes, and development of arrhythmias. The prognostic model for DD included average longitudinal deformation of LA (global LA longitudinal strain) and E / e ratio on the tricuspid lateral annular velocity. Appearance of DD in postoperative period after correction of acquired heart defects was due to damage of the septal diastolic function which correlated with fibrosis and was indicative of inadequate myocardial protection. The model of development of heart failure with normal EF after operation was designed.
Highlights
The appearance of left ventricular (LV) diastolic dysfunction (DD) was associated with decrease of septal es immediately after surgery and its subsequent progressive decline in the long-term postoperative period from 8.5±0.71 to 4.6 ± 0.53 cm / sec (p=0.005)
In the group of other patients in whom fibrosis was not studied and the degree of DD increased there was a transient decrease of lateral el and an increase of the E / el in the early period after the operation
IVлп – индексированный объем левого предсердия (ЛП); el – диастолическая ско‐ рость движения боковой части фиброзного кольца (ФК) митрального клапана (МК); es – диастолическая скорость септальной части ФК МК; E / e – отношение скорости раннего диастолического потока к ранней скорости движения ФК; l – измерения по боковой стенке; s – измерения в области септальной стенки; 1–2 – сравнение исходных данных и показа‐ телей в раннем послеоперационном периоде; 1–3 – сравнение исходных данных с показателями в отдаленном периоде после операции
Summary
Objective: to assess dynamics of diastolic function for detection of development of diastolic dysfunction (DD) and it’s causes, to evaluate the effect of DD on prognosis in the postoperative period in patients with acquired heart diseases. Нас интересовали не только динамика диастолической функции, но и чрезвычайно интересный вопрос: возникает ли ДД после операции у пациентов с нормальной диастолической функцией? Цель исследования – оценить динамику диастолической функции, выявить вновь возникшую ДД в послеоперационном периоде и ее причины, влияние на прогноз у пациентов с приобретенными пороками сердца. Конечные точки исследования были следующие: симптомы декомпенсации СН с сохраненной ФВ (одышка, отек легких), проявления синдрома низкого сердечного выброса (СВ), появление ДД или ухудшение диастолической функции по данным ЭхоКГ и ТД-ЭхоКГ, смерть. В этой группе после операции отмечены одышка и выраженная дыхательная недостаточность у 2 больных, отек легких у 1 пациента, продленное пребывание в реанимации, длительная искусственная вентиляция легких (у 4), нарушения ритма сердца в виде ФП (у 4), нарушения перфузии внутренних органов в результате синдрома низкого СВ (почечная недостаточность – у 2 пациентов, постгипоксическая энцефалопатия – у 2). Распределение пациентов в зависимости от диастолической функции исходно и в послеоперационном периоде
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