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Фибрилляция предсердий после операций аортокоронарного шунтирования: прогностические факторы, особенности диагностики и лечения

Диссертация: Фибрилляция предсердий после операций аортокоронарного шунтирования: прогностические факторы, особенности диагностики и лечения
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Для уменьшения риска возникновения фибрилляции предсердий после операций аортокоронарного шунтирования в условиях искусственного кровообращения рекомендуется пересмотреть используемые методики бикавальной каннюляции, частичного пережатия аорты, дренирования легочных вен и эвакуации кардиоплегического раствора через атриотомный разрез, с целью снижения травматичности предсердий и улучшения… Читать ещё >

Фибрилляция предсердий после операций аортокоронарного шунтирования: прогностические факторы, особенности диагностики и лечения (реферат, курсовая, диплом, контрольная)

Содержание

  • Страница
  • Глава I. Обзор литературы
    • 1. 1. Фибрилляция предсердий после кардиохирургических операций: история развития. 7 вопроса, эпидемиология, время возникновения
    • 1. 2. Последствия возникновения фибрилляции предсердий после операции аортокоронарно- 16 го шунтирования
    • 1. 3. Патофизиология возникновения фибрилляции предсердий после операции аортокоронар-го шунтирования
    • 1. 4. Факторы риска развития фибрилляции предсердий после операции аортокоронарного 21 шунтирования: до-, интра- и послеоперационные
    • 1. 5. Клинико-инструментальные и лабораторные методы оценки некоторых факторов риска 40 развития фибрилляции предсердий после аортокоронарного шунтирования
  • Глава II. Материалы и методы исследования
    • 2. 1. Клиническая характеристика больных
    • 2. 2. Методы исследования
      • 2. 2. 1. Электрокардиографические методы исследования
      • 2. 2. 2. Ультразвуковые методы диагностики
      • 2. 2. 3. Рентгенологическое исследование
      • 2. 2. 4. Коронарография
      • 2. 2. 5. Определение содержания натрийуретических пептидов в плазме крови
      • 2. 2. 6. Статистическая обработка данных
  • Глава III. Результаты исследования и обсуждение полученных результатов
    • 3. 1. Частота встречаемости фибрилляции предсердий после аортокоронарного шунтирова 70 ния с искусственным кровообращением и без искусственного кровообращения
      • 3. 1. 1. Время возникновения фибрилляции предсердий после аортокоронарного 71 шунтирования с искусственным кровообращением и без искусственного кровообращения
      • 3. 1. 2. Связь некоторых интра- и послеоперационных параметров с развитием фибрилляции 72 предсердий после аортокоронарного шунтирования
      • 3. 1. 3. Связь некоторых дооперационных параметров с развитием фибрилляции предсердий 82 после аортокоронарного шунтирования
      • 3. 1. 4. Продолжительность Р-волны, её дисперсии и фильтрованной Р-волны 85 3.1.5.Эхокардиографические данные
      • 3. 1. 6. Особенности вариабельности сердечного ритма
      • 3. 1. 7. Роль определения уровней предшественников натрийуретических пептидов в плазме Ю0 крови и их динамика после аортокоронарного шунтирования
    • 3. 2. Выявление независимых предикторов развития фибрилляции предсердий после аорто- 118 коронарного шунтирования

Фибрилляция предсердий (ФП) является одной из наиболее часто встречающихся аритмий после операций аортокоронарного шунтирования (AKLLI) (частота её встречаемости значительно превосходит таковую в общей популяции и среди неоперированных пациентов с ишемической болезнью сердца). Несмотря на свой преходящий характер (возникает чаще в раннем послеоперационном периоде с пиком встречаемости на 2−4 сутки после операции) и относительно благоприятное течение ФП может приводить к целому ряду осложнений, таких как тромбоэмболия сосудов головного мозга, сердечная недостаточность, жизнеугрожающие желудочковые аритмии, ухудшение качества жизни пациентов и удлинение госпитализации. Хотя увеличение госпитального периода из-за возникновения ФП по сравнению с развитием других послеоперационных осложнений, таких как респираторный дистресс-синдром взрослых, септицемия или пневмония не так велико, кумулятивный вклад ФП (из-за её высокой распространенности) в продолжительность госпитализации довольно высок.

Патофизиология возникновения послеоперационной ФП до конца не ясна и не изучена: предполагается, что в её основе лежат структурные изменения миокарда предсердий (гипертрофия, дилатация, фиброз, миолиз) и отклонения в электрофизиологии (замедление проводимости, дисперсия рефрактерности, уязвимость предсердий к развитию фибрилляции), которые проявляются в результате воздействия различных пусковых факторов, таких как ишемия предсердий, их травма, острое растяжение вследствие объемной перегрузки, неадекватная защита миокарда предсердий, метаболические и электролитные нарушения, системный воспалительный синдром, реперфузионный синдром, гиперадренергический статус и т. д. Для реализации механизма множественного риентри, лежащего в основе ФП по данным большинства исследователей, необходимо существование аритмогенного субстрата и инициирующих факторов (триггеров). В качестве одного из таких триггеров рассматривается искусственное кровообращение, однако свидетельство того, что миниинвазивные операции АКШ лишь незначительно уменьшают численность пациентов с послеоперационной ФП привело к пересмотру концепции о её роли как единственного фактора риска в возникновении этой аритмии. Хотя интраоперационное электрофизиологическое исследование (ЭФИ) в настоящее время с высокой точностью позволяет дифференцировать состояния, которые сопряжены или не сопряжены с высоким риском развития ФП, оно увеличивает продолжительность операции, травматичность для пациента, является дорогостоящим и его осуществление не всегда возможно.

Таким образом, актуальность данной работы очевидна и состоит в поиске независимых неинвазивных маркеров развития ФП после АКШ для выявления групп больных с высоким риском возникновения данной патологии с целью осуществления её адекватной профилактики и лечения.

Целью нашего исследования было выявить предикторы развития фибрилляции предсердий после операций аортокоронарного шунтирования.

В задачи исследования входило:

1. Провести сравнительный анализ частоты встречаемости фибрилляции предсердий после операций аортокоронарного шунтирования в условиях искусственного кровообращения и без него.

2. С помощью неинвазивных методов исследования выявить инструментальные и лабораторные критерии, позволяющие прогнозировать развитие фибрилляции предсердий после аортокоронарного шунтирования и определить среди них наиболее значимые.

3. Установить независимые факторы риска возникновения фибрилляции предсердий после аортокоронарного шунтирования.

Автор выражает глубокую благодарность своим научным руководителям академику РАМН Лео Антоновичу Бокерия и член-корреспонденту РАМН Елене Зеликовне Голуховой за предоставленную возможность выполнить данную работу и всестороннюю поддержку.

Выводы.

1. Больные, перенесшие операцию аортокоронарного шунтирования имеют высокий риск развития фибрилляции предсердий в раннем послеоперационном периоде.

2. Частота встречаемости фибрилляции предсердий одинакова после операций аортокоронарного шунтирования, выполненных в условиях искусственного кровообращения и без него.

3. Пожилых пациентов с длительным анамнезом ишемической болезни сердца, значением фильтрованной Р-волны >150мсек и увеличенным левым предсердием следует относить к группе высокого риска развития фибрилляции предсердий после аортокоронарного шунтирования.

4. Интраоперационными факторами риска возникновения фибрилляции предсердий в раннем послеоперационном периоде при выполнении аортокоронарного шунтирования в условиях искусственного кровообращения следует считать длительность искусственного кровообращения более 175 мин и пережатия аорты более 82 мин, необходимость осуществления внутриаортальной баллонной контрапульсации.

5. Послеоперационными факторами риска возникновения фибрилляции предсердий в раннем послеоперационном периоде следует считать продолжительность искусственной вентиляции легких более 24 часов и развитие пневмоний.

Практические рекомендации.

1. В связи с одинаковой частотой встречаемости фибрилляции предсердий в раннем послеоперационном периоде при операциях аортокоронарного шунтирования как с искусственным кровообращением, так и без него, для выявления больных с высоким риском развития данного нарушения ритма необходимо учитывать совокупность до-, интраи послеоперационных факторов: до операции — возраст пациентов, длительность анамнеза ишемической болезни сердца, значение сигнал-усредненной Р-волны, размеры левого предсердия, во время операции с искусственным кровообращением — время искусственного кровообращения и пережатия аорты, необходимость осуществления внутриаортальной баллонной контрапульсации, после операции — продолжительность искусственной вентиляции легких и возникновение пневмоний.

2. Для уменьшения риска возникновения фибрилляции предсердий после операций аортокоронарного шунтирования в условиях искусственного кровообращения рекомендуется пересмотреть используемые методики бикавальной каннюляции, частичного пережатия аорты, дренирования легочных вен и эвакуации кардиоплегического раствора через атриотомный разрез, с целью снижения травматичности предсердий и улучшения их защиты при таких операциях.

3. Несмотря на дои послеоперационную терапию бета-адреноблокаторами, риск развития фибрилляции предсердий после аортокоронарного шунтирования, выполненного в условиях искусственного кровообращения или без него сохраняется, но при отсутствии подобной терапии частота возникновения этого осложнения может оказаться значительно больше, поэтому в целях профилактики послеоперационной фибрилляции предсердий важно продолжать назначение бета-адреноблокаторов начиная с раннего послеоперационного периода при отсутствии противопоказаний.

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