Diastolic dysfunction types in the prediction of viable myocardium functional recovery

Abstract

Background/Aim. It is well known that patients with coronary artery disease and viable tissue as a guarantee of contractile recovery (CR), despite of decreasing ejection fraction (EF) and systolic dysfunction, could have benefit from surgical revascularization. Therefore, relationship between diastolic filling type and early postoperative recovery and complications need to be established. The aim of this study was to investigate the relation between different left ventricular (LV) diastolic filling types and CR in patients after surgical revascularization with differently preserved systolic function. Methods. We investigated 60 patients. All of them had CR estimated by stress echocardiography regardless the extent of recovery of the heart systolic function. Echocardiographic evidence of diastolic dysfunction was estimated by Doppler examination of transmitral diastolic flow. According to the derived different diastolic filling types the patients were divided into three groups: I ? patients with disorder of LV relaxation, II ? with pseudovascularisation, and III ? with restrictive filling type, and according to the value of systolic function into two subgroups: 1) relatively recovered systolic function ? EF > 40% and 2) pronounced LV dysfunction ? EF < 40%. Echocardiographic evaluation was performed before and two week after surgical revascularization. In the preoperative period the medication therapy was optimized. We estimated CR by echocardiografic paremeters but also by detection of cardiovascular events. Results. After CABG the mean value of WMSI LV tended to decrease in any groups: in the group I (n = 12) from 1.64?0.22 to 1.34?0.22; in the group II (n = 22) from 1.85?0.16 to 1.53?0.42, and in the group III (n = 26) from 1.92?0.29 to 1.81?0.52. The lowest improvement of systolic function according to EF value expressed by the number of patients was found in the group of patients with restrictive LV filling type (12; 53.8%) as contrasting to the group with pseudonormalisation (15; 78.9%). In the group of patients with restrictive diastolic filling type also was recorded the highest number of lethal outcomes (6; 23.1%), as well as cardiovascular complications (10; 38.5%). Conclusions. Restrictive LV diastolic filling type was the marker of poor prognosis in the patients with clinical heart failure undergoing surgical revascularization. The patients with heart failure and preserved systolic function were associated with similar prognosis.Uvod/Cilj. Bolesnici sa koronarnom bolescu i vijabilnim miokardom leve komore (LV) kao arantom kontraktilnog oporavka (CR), uprkos snizenoj ejekcijskoj frakciji (EF), koja reprezentuje poremecenu sistolnu funkciju srca, mogu imati bolje prezivljavanje nakon hirurske revaskularizacije ? koronarnog arterijskog bajpas grafta (CABG). Medjutim, povezanost izmedju CR nakon revaskularizacijskih procedura i poremecaja dijastolnog punjenja LV jos uvek nije dovoljno ispitana. Cilj rada bio je da se utvrdi povezanost izmedju razlicitih tipova poremecaja dijastolnog punjenja LV i CR bolesnika sa izrazenom koronarnom bolescu i ocuvanom ili snizenom sistolnom funkcijom srca podvrgnutih CABG. Metode. Studijom je obuhvaceno 50 bolesnika. Stres ehokardiografskim testom kod svih bolesnika utvrdjeno je prisustvo kontraktilne rezerve, bez obzira na stepen ocuvanosti sistolne funkcije srca. Dijastolna funkcija srca odredjivana je dopler ehokardiografskom analizom transmitralnog protoka. Prema tipu dijastolnog punjenja LV bolesnici su bili podeljeni u tri grupe (I ? bolesnici sa poremecajem relaksacije LV, II ? bolesnici sa pseudo normalizacijom i III ? bolesnici sa restriktivnim tipom punjenja LV), a prema ocuvanosti sistolne funkcije u po dve podgrupe (1. relativno ocuvana sistolna funkcija ? EF > 40% i 2. izrazena disfunkcija LV ? EF < 40%). Dva meseca pre i dva meseca nakon CABG utvrdjivano je prisustvo CR na osnovu procene indeksa pokretljivosti (WMSI) LV, EF i pojave pratecih kardiovaskularnih dogadjaja. Rezultati. Nakon CABG srednja vrednost WMSI LV imala je tendenciju opadanja u svim grupama: u I grupi (n = 12) sa 1,64?0,22 na 1,34?0,22, u II grupi (n = 22) sa 1,85?0,16 na 1,53?0,42 i u III grupi (n = 26) sa 1,92?0,29 na 1,81?0,52. Najmanje poboljsanje sistolne funkcije prema vrednosti EF izrazeno brojem bolesnika nadjeno je u grupi bolesnika sa restriktivnim tipom punjenja LV (12, 53,8%), za razliku od grupe sa pseudonormalizacijom (15, 78,9%). U grupi bolesnika sa restriktivnim tipom dijastolnog punjenja zabelezen je i najveci broj smrtnih ishoda ? 6 (23,1%) i kardiovaskularnih komplikacija ? 10 (38,5%). Zakljucak. Bolesnici sa koronarnom bolescu i ocuvanom kontraktilnom rezervom, kod kojih postoji restriktivni tip dijastolnog punjenja LV mogu imati nepovoljniji ishod nakon hirurske revaskularizacije u odnosu na bolesnike sa poremecenom relaksacijom ili pseudonormalizacijom.