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205.Анналы аритмологии №1 2012

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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
A?????
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ANNALS
OF ARRHYTHMOLOGY
????????????? ??????-???????????? ??????
??????? 1 ??? ? ??? ??????
??????? ? 2004 ?.
1? 2012
?????? ?????? ? ???????? ????????????? ????????????? ??????-??????????? ???????,
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
Л??б?кзбн╦ к ка??збн╦
ГЯККО ко. д. Г. е?мшнб?? ЙдЕГ
Цк?блак? л? ка??збн╦рмш? ?б?збн╦лсрз╦
Юя ? 03847 сз 25.01.2001 ?.
грб т???? а??к?бл?. Гк с?л? ??рз╦
?зс?с ка??лк? лб осйбз ╥?з╦ а?лбрбл? ? т?о?з╦ мсот╦?зб?? нк╥с ?срт?ска?б?бл? н?╥?о ртсрс╥со ╥ба
т?б????кзбн╦лс?с ткр╦обллс?с ??а?б╞блк? ка??збн?
Из?бзрз?бллсрз╦ а? ?срзс?б?лсрз╦
клыс?о??кк, рс?б?й??бхр?
? ?бмн?ол?? о?зб?к?н??,
лбршз ?бмн?ос??збнк
д??бр ?б??м?кк:
119049, Есрм??, Цблклрмкх т?., 8
ГЯККО ко. д. Г. е?мшнб?? ЙдЕГ
Из?бн клзбннбмзш?н╦лсх
рс╥рз?бллсрзк
??????? ???????? ?. ?. ???????
Мбнбысл ?б??м?кк (499) 236-92-87
Н?мр (499) 236-99-76
E-mail: izdinsob@yandex.ru
http://www.bakulev.ru
К?к?бзбн╦рз?с с ?б?крз???кк р?б?рз??
о?ррс?сх клыс?о??кк ХЮ ? 77-1807
сз 28.02.2000 ?.
А??. ?б??м?кбх Ш╞мб?к? М. Ю.
Мбн. (499) 237-88-61
Цкз. ?б??мзс?? к мс??бмзс??
длзслс?? Ю. г.
Й?╥?м г. Ю.
Дсот╦?зб?л?? ?б?рзм? к с╥??╥сзм?
???ык?брмс?с о?зб?к?н?
Гбтс?с?кл? Е. г.
М???рс?? Е. д.
Гсоб? тс?ткр?л ? тб??з╦ 26.07.2012
Изтб??з?лс ? ГЯККО
ко. д. Г. е?мшнб?? ЙдЕГ
119049, Есрм??,
Цблклрмкх т?срт., 8
Мбн. (499) 236-92-87
Нс?о?з 60в88 1/8
Хб?. н. 9,5
Лрн. тб?. н. 9,3
Л?.-ка?. н. 7,9
Хб??з╦ сырбзл??
Мк??й 500 ?ма.
длл?н? ??кзоснс?кк
2012. ? 1. 1?76
ISSN 1814-6791
Хс?ткрлсх кл?бмр 84535
???????????? ????????
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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CONTENTS
??????
Lectures
5
??????
????????? ?. ?., ???????????? ?. ?. ?????????
????????? ? ????????? ???????????? ??????????? ?????????? ????? ???????? ?? ???????? ??????
??????? ?. ?., ???????? ?. ?. ???????? ???????????? QRS ? ?????? ??????? ????? ????? ????? ???? ? ???????? ? ??????? ????????? ????????? ???????????????
Reviews
Melikulov A. Kh., Maglakelidze D. A. Possible ways
and strategies for prevention of atrial fibrillation
after off-pump surgeries
13
Bockeria L. A., Stupakov S. I. Significance of QRS
duration and left bundle branch block in development and course of congestive heart failure
20
???????????? ??????
??????? ?. ?., ????????? ?. ?., ???????? ?. ?., ????? ?. ?. ????????? ????? ?????? ? ???????????? ? ?????? ????????????????? ???????
????? ????????????? ????????? ??????????
??????? ?????? ? ????? ??????? ????????
??????? ?. ?., ??????? ?. ?., ???????????? ?. ?.,
?????????? ?. ?., ???????? ?. ?., ????????? ?. ?.,
?????? ?. ?., ??????? ?. ?. ???????????????
?????? ??????????? ?????????? ???????????
?????????????????? ??????? ? ????????? ?
????????? ????????????????
??????? ?. ?., ??????? ?. ?., ???????????? ?. ?.,
?????????? ?. ?., ???????? ?. ?., ????????? ?. ?., ????????? ?. ?., ?????? ?. ?., ??????? ?. ?. ???????? ? ?????? ?????????????
?????????? ????????? ??????? ??????????????? ? ?????? ???????????? ?? ? ????? ??????????? ?????????????????? ?????????
??????? ?. ?., ??????? ?. ?., ?????? ?. ?. ?????????? ??????????? ??????????? ???????????? ? ?????????? ?????????? ??????????
??????????? ?????????????????? ???????
Bockeria L. A., Filatov A. G. Mapping of arrhythmias
Original Articles
24
Bockeria L. A., Zelenikin M. A., Golukhova E. Z.,
Batov S. M. Heart rhythm and conduction disturbances in early postoperative period after surgical correction for congenital heart defects in
infants
Bockeria L. A., Bockeria O. L., Bazarsadaeva T. S.,
Volkovskaya I. V., Tetvadze I. V., Melikulov A. Kh.,
Glushko L. A., Kirtbaya L. N. Retrospective analysis of chronic resynchronization therapy outcomes in patients with cardiac insufficiency
32
37
Bockeria L. A., Bockeria O. L., Bazarsadaeva T. S.,
Volkovskaya I. V., Tetvadze I. V., Kislitsyna O. N.,
Mironenko M. Yu., Glushko L. A., Kirtbaya L. N.
Method and assessment of efficiency in applying
different modes of echocardiographic dyssynchrony before and after implantation of resynchronization devices
44
Bockeria L. A., Bockeria O. L., Glushko L. A. Metaanalysis of contemporary clinical trials and longterm outcomes of chronic resynchronization
therapy
?????? ???????????, ? 1, 2012
??????? ?. ?., ??????? ?. ?. ????????????
???????
3
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
4
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??????? ?. ?., ??????? ?. ?., ????????? ?. ?.,
????????? ?. ?. ??????????? ?????????? ???????? ???????????? ????????? ??????? ????????? ?????? ????? ?????
??????? ?. ?., ??????? ?. ?., ?????? ?. ?.,
???????????? ?. ?., ????????? ?. ?., ?????????? ?. ?., ???????? ?. ?. ?????? ?????????
?????????????? ??????? ??????????? ?????????? ? ??????? ???????? ╚???????? III╩:
18 ??? ??????
Brief Reports
Bockeria L. A., Shatalov K. V., Berseneva M. I.,
Koloskova N. N. Case study of right ventricle
arrhythmogenic dysplasia within one family
55
Bockeria L. A., Bockeria O. L., Umarov V. M.,
Bazarsadaeva T. S., Donakanyan S. A., Biniashvili M. B., Satyukova A. S. Case of successful surgical
treatment for atrial fibrillation using ╚Maze III╩
procedure: 18 years on
61
?????? ???????????, ? 1, 2012
???????
Chronicle
?????? ?? ?????????? XVII ?????????????? ??????
????????-?????????? ???????? (27?30 ?????? 2011 ?.)
Articles adapted from XVII All-Russian Congress of
Cardiovascular Surgeons (27?30 November, 2011)
???????? ?. ?., ???????-????????? ?. ?., ?????? ?. ?., ??????? ?. ?., ????????? ?. ?., ??????? ?. ?., ??????? ?. ?., ????????? ?. ?. ??????? ??????????????? ??????????? ?????????? ??? ???????? ??????????? ??????? ?
????? ?? ????????? ????????
66
Zheleznev S. I., Bogachev-Prokofiev A. V., Pivkin A. N., Romanov A. B., Pokushalov E. A., Nazarov V. M., Syrtseva Ya. V., Karaskov A. M.
Treatment of paroxysmal atrial fibrillation in
terms of mitral valve surgery ? is ablation necessary?
??????? ??? ???????
72
Rules for authors
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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5
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╘ ?. ?. ???????, ?. ?. ???????, 2012
??? 616.12-073.97+616.12-008.318
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?. ?. ???????*, ?. ?. ???????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
?????? ? ???????? ????????????? ?????????? ?????? ????? ??????????? ? ?????
XIX ???????? ??? ?????????? ????????? ????????????????? ???????????? ? ???????? ????? ???????? ? ?????????????????? ?????? ??????????????????? (Einthoven W., 1901). ????????????? ???????? ??????????? ????????????????? ?????
????????? ????? ????????? ? ??????????? ???????? ??????? ????????????? ?????? (Forssman W.,
1929), ????????????????? ?????? (Durrer D., 1967)
? ?????? ????????????? (??) ????? ???? (Scherlag D., 1969). ? 1967 ?. D. Durrer ? ?????. ??????? ?
??????????? ???????? ????????? ??????????????? ??????????????????????? (???) ?????? ???
???????????? ???????? ? ????????? ???????????????????????, ??? ??? (???????? ??????????????? ?????????? ?? ??????????????? ???? ?????????? ? ????????? ??????????). ??? ???????? ??????????? ???????? ? ??????????? ?????????? ?
??????? ??? ??????, ??????????? ??????? ????????? ???????. ? 1969 ?. A. Damato ???????????
??????????????? ????? ??????????????? ???????
????? ???? ? ??? ?????? ??? ???????? ????????????? ??????????-????????????? ?????????? ? ????????. ? 1971 ?. H. Wellens ??????????? ?????? ????????? ?????????? ? ??????????????? ???????? ????????????? ??????? ???????????????
???????????? ? ????????? ??????? ??????????
?????? ? ??????????? ?????? ??????????????? ??????????. ??? ???????? ???? ??????? ?????????????????????? ????????????? (???) ?????? [1, 2].
?????? ??? ?????? ? ????????? ? ???????????? ??????????? ????????? K. Rosen ? ?????. ??
?????? (Denes P., 1976), ? ??????????, ? 70?80-? ??.,
???????? ???? ??????? M. Josephson, L. Horowitz
? ????????? ? ????????????, ??????????????
? ?????????????????? ????????????? ????????????. ? ????? 70-? ????? A. Waldo ??? ?????????* ????? ??? ?????????: e-mail: leoan@heart-house.ru
????? ???????, ????????????? ?? ?????????
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╚???????????╩ (? ????? ????? ??????? ???? ?????
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?, ????? ???????, ????????? ???????????? ?????
??????????).
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???? ?????? ??? ??????????? ??????????? ??????? ????????????? ? ??????????? ???????. ???????? ?????????????????? ???????????? ?????? J.
Gal-lagher ? ?????? ???????, ??????????? ?????????????? ??????? ???????. ??? ???????? ???????????? ????????? ? ?????? ???????????? ????????? ?????????????. ? ????? ??????? ?????
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? ?????? ??????????. ??????? ????????? ????????? ?????????? ?? ??????? ?????????????? ??????-?????? ??? ????????? ????? ? ????????????
??????. ?? ???? ?????? ??????????? ??????????
???????-??????? (????? ??????????? ?????? ? ????? ???, ???? ?????? ? ??????? ??????????, ????????? ?????? ???????? ??????, ??????? ?????????? ?????? ? ?? ????? ? ?. ?.). ????? ?????????
?????? ????????? ????????????? ????? ???????????? ?? ???????? ????????? ╚???????╩, ??? ???????????, ????? (?? ╚???????╩ ????? ????? ??????? ?????? QRS-????????? ??? ???????????? ???????????? ????????? ????? ??? ?????? ?-?????
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???????????? ?????????? ? ??????? ???????????
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??????????? (??????, ?????????????? ??? ?????????????? ???????????) [1, 2].
?? ?????????????? ???????? ???????? ???????????? ??????????????? ? ?????????????? ??????????? ?????? ??? ????????, ??? ? ????????
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??????), ??? ????? ??????? ?????????. ?????????????? ???????????? ???????? ???????? ???????????? ?????, ?? ??? ?????????? ??? ????????????? ????????????? ?????????????? ??????????
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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?????? ???????????, ? 1, 2012
?????? ???????????, ? 1, 2012
????????? ???????? (?????? ???????????? ???
????????????? ????????, ???????????? ???? ?????? ????? ?? ??? ? ???), ? ? ????? ╚???????╩ ???????????? ???????????/??????????? ???????.
??????????? ?????, ????????? ??????? ???????????? ?-????? ????? ??? ?? 20 ??, ??????????? ?????
????????, ? ??? ?????????? ????? ?????? ?????
???????? ??????? ??????????????? ???????????.
???????????? ????? ??????????, ????? ?????????? ??????????. ????? ?????????? ???????? ?????????? ????? ?????????, ????????? ??????? ??
????? ????????? ??????????? (╚????????????╩
????????) ? ??????????? ??????????? ? ???????????? ???????? ?????????????? ?????????????
?????????.
??? ???????????? ??????????? ??????? ?????????? ???????????? ?????????????????? ????????? ?????????? ? ?????????? ???????? ??????
??????????, ??????????? ?????????? ? ???????
??????????, ? ????? ?????????? ??????????? ???
???????????? ?????????? ? ??? ????????????????? ??????????. ??????????? ??????? ?????????? ?????? ???????????? ? ?????????? ?????????? ???????????? ?????????, ??????? ???????? ??? ???????????? ? ??????? ???????
??????????????? ?????????, ??? ? ?????????? ?????????-??????, ??????? ?????????????? ???????????? Ensite ??? ????????????????????? ???????????? CARTO. ? ??????-??????? (????????????????? ???????, ??????? ? ?. ?.) ??? ????????
??????? ????????? ????????????? ?????????? ?
???????????? ????????? ?????? ????????? ??????
?-????? ?? 20?60 ?? [3].
?????? ???????????? ??????????? ?? ???????
?? ??? ?????????: ???????????? ????????? ???????? ?????? ? ??????? ???????????? ????????? ??
????? ? ?????, ????????????? ???????????? ?????????????? ??????????? ? ╚?????????????╩
????????????. ?? ???????? ???????? ?????????
?????????? ?? ???????? ???????? ???? ???? ???????. ??? ???????????? ?? ????? ? ????? ?????????
??????????? ??????? ?????????? ?? ????? ?????????? ?? ????? ??????????. ?????????????? ??
?? ????????? ????????, ? ?? ????????? ???? ????????? ???????? ?????. ???????????? ??????? ?
???, ??? ??? ??????? ?????????? ??????? ?????????
? ??????? ??????? ?????????, ?? ???? ?? ???????
???????? ???????????????. ?????????? ? ??,
??? ??? ??????? ???????? ???????, ????? ?????????? ????????????, ? ????? ??, ??? ? ?????????
???????????? ???????? ?????????? ????? ??????????, ???????? ????????????? ????? ??????????? ????? ????, ?? ???????? ?????????? [3, 4].
????????????? ??????????????? ???????????? ?????????????? ??????????? ?????????????
????????? ????? ???????? ???????? ????? ??????????, ??????????????? ?????? ??? ?????? ??????. ??????????? ?????????????????????? ???????????? ? ???????? ?????????? ? ????????????
?????? ?????????????? ???????????????? ????????????, ?? ??????? ??? ????? ???? ????????????
20-???????? ??????????? ????????? (???. 2).
????? ????????? ╚?????????????╩ ????????????, ????? ?????? ???? ??????????? ?? ??????,
????? ??????? ??????? ?????????? ??????? ?????????? ????????, ? ?????????? ????????? ?????
???. 2. ????????????? ????????????? ?????????? ????????????? ??????? EnSite ? ????????????? ????????? ??? ????????? ???????? ???????????? ? ????????????? ??????? ?????????? ?????????? ? ???????? ????? ???????? ???????? (??????? ???????? ? 20-???????? ????????, ???????? ? ?????? ?????????? ??????
?????? ???????????????? ???????, ??????? ???????? ? 10-???????? ????????, ?????????? ? ??????? ??????????? ??????). ? ?????????? ???????????? ???????????? ????? ????? ????? ??????? ? ?????? ??????????
??? ???????? ??????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
??????? ???????????????????????
??? ???????????? ??? ???????????? ??????????? ????????? ? ?????????? ??????, ?????
?????? ??????????????? ???????, ? ??????? ??????
????? ???? ? ? ???????? ??????? ?????????, ? ??????????? ??????????????? ???????? ????????????? ?? ????????? ?????? ?? ??????????-???????????? ??????? ?????? ????? ???????????
?/??? ??????????????? ???????? (?????-?????
Gallagher J.). ? ?????, ??? ???????????? ?????????? ???????? ????? ??????????? ? ???????????? ??????? ? ??????????? ????????, ? ?????????
???. ??? ???????????? ?????? ??????????? ??????? ??? ?????? ?????????? ???????????? ??????????? ???????? ? ?????????? ??????. ??????????? ??????????? ???????? ????? ???????????
???????????????? (????? ??????? ???????????-
??? ??????????? ??? ???????????? ?????????????? ?????????) ???? ????????????? (????? ????????? ???????, ?????, ?????????? ?????? ? ??
?????? ????????? ? ????? ?????????? ????? ?????????? ??????) ????????.
?? ????? ???????? ???????? ? ???????????
?? ??????????? ????????? ??????????? ?????????????? ???????????? ??????????????????? ??????? ??? ??????????? ??????????? ???? ? ????? ??????? ??????????? ??????? ????????????
?????????? ? ??????? ????????????? ???????????
?? ???????????. ??? ???????? ??????????, ? ????? ??? ????????? ????????????? ????????? ????? ?????? ?????????? ????????? ? ??????????????? ?????????? ??????? ????????? [1, 2].
?????? ? ?????? ?? ???? ??????? ??????????????
????? ????????? ???????????, ??? ????????? ???????? ???????????? ???? ??????????? ?????? (?
?????? ?????? ??-???????, ??????????? ?? 30 ?????: ?? 15 ?? ???????? ? ?? ?????? ????????????)
(???. 3).
????????????????? ???????????? ???????????? ? ?????????????? ??????? ??? ???????????????
????????????? ????????????. ??????????? ????????? ??????????? ?? ???? ?????????? (?? ??????? ??????????????? ??????????????? ??????????????????????? ??????????) ? ?? ???????? ??????????? ?????????.
??? ??????????? ?????????? ??????????????
??????????-???????????? ?????????? ?????????? ???????????? ?????????????? ? ??????????????? ??????????? ????? ???????? ??????? ??????? ?????????? ? ???????? ????????????????? ??.
????????? ??????????? ???? ?????? ??, ??????????? ??????????? ?? ????? ??? ?? 40?100 ??.
?????????????? ????????????
??? ??????????? ??????????
??? ?????????????? ???????????? ???????????? ???????? ?? ?????? ?????????? (????????
??????????? ??????) ?????? ???????? ? ?????,
?????????????? ??????? ?????????? ? ????????.
?? ???? ????????? ? ???????????? ??????? ??????????? ????????? ????????? 0,5?2 ??. ???
??????????? ????????????? ?? ?? ???????? ?????????? ????? ???????? ?????????? (??????
5?7 ??), ? ?????? ???????????? ?????????? ?????? ??????????? ?????????? ? ???? ? ????? ?????? ????????????? ??????????. ??? ??????????
??????? ??????????? ???? ??????? ??? ?????????
??????????? ??????? ??????????? ?????? (??
?????????? 1 ??), ?????????? ????? ?????? ?????????? ?? 5 ?? 7 ??. ???? ????? ????????????
??????????? ???????? ??????????? ???????, ???
??? ??? ???????????? ?????????? ???????? ????????? ????????? (??? ???????????? ????????
?????? ???????????, ? 1, 2012
??????? ??????????? ?? ?????????? ??????????
??? ???????-?????? ? ???????????? ??????? ???
??????????. ?? ????? ???????? ???????? ??? ??????????? ??????????? ╚???????????? ???????╩
(???????? ???????????? ??????????? ? ??????? ??????????????) ??? ?????? ????????????? ????????. ? ??????????? ???????????? ???
??????????? ?????????????????? ??? ???????????? ? ??????? ?????????????? ???????, ??? ??????? ?????????? ???????????, ????????, ? ?????? ????????????? ???????????? ?????? ??????????? ???????????? ????. ???????????? ?????
??????? ??????? ? ???, ??? ??????????? ?????
???? ????? ?? ? ????????. ???????????? ??????
???????? ?????????? ?? ???????????? ? ?????????? ╚????????╩ ???????? ???? ????????? ???????
????????????? ???????, ??? ???????? ? ??????????????? ????? ??????? ?????????? ??? ????????????? ???????????? ???????? ?????? ?????????? ??? ??????? ??????? ????????????? ???????? ???????.
????? ?????????? ??????? ???????????? ????????? ???????? ??????? ????????????. ???
???????? ?????????? ?????????-?????? ? ??????? ?????????? ???????????? ??????????; ????????????? ???????????? ???????????? ? ??????? ????????? ?????????, ? ??????? ???????????? ??????????? ??????????????? ??????????;
???????????????????? ???????????? ? ?????????????? ??????? ?????????? ????. ??? ??????????? ??????????? ????? ???????????? ??? ?????????? ????? ?, ???????, ????????? ???????? ??????????? ???????????????????? ???????????.
????? ??????? ???????? ???????? ????????? ?
???????????? ???????? ??? ?????????????? ??????????, ??????? ??????????? ??? ???????????? ?????????? ? ?????? ????? ??????? ????? ??????? [3?5].
9
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
10
?????? ???????????, ? 1, 2012
AV-GROOVE
??
??
???
DATE
???
29
28
30
18
27
1
2
PA
??
3
26
4
??
??
30 27 25
1
5
25
??
24
22 19 17 16 15
11
4
22
21
30
21
6
6
7
2
7
1
8
8
MV
20
TV
20
10
5
3
29
23
22
5
Ao
27
28
24
23
25
26
25
9
10
19
???
19
18
18
?
?
17
17
16 15
15
16
14
14
13
13
12
12
9
10
11
11
?????? ???????????, ? 1, 2012
???. 3. ????????????? ??????????? ?????????????????? ??????????????? ???????????? ??-??????? (?) ?
?????-????? ??????????????? ???????????? ??????????????????? ??????? (?) ??? ???????? ???. ???????????? ? ??????????? ??????????? ????????? ?? 30 ????? (?? ????????????? ????? ??. ?. ?. ????????
????). ???? 1?16 ??????????? ? ?????? ?????????, 17?30 ? ? ?????. ??? ???????????? ???????? ??????????? ??????????? ?????? ? ??????????-???????????? ??????? (?? ? ?? ? ?????? ? ????? ??????????; ??? ?
??? ? ??????? ? ?????? ????? ????; ?? ? ?????; ?? ? ???????? ???????; MV ? TV ? ?????????? ? ??????????????? ??????; Cs ? ???????? (??????????) ????? ??????; AV-GROOVE ? ??????????-???????????? ???????)
????????? ???????) ? ????????? ???????? ???????
?????????? ????????????, ??? ??? ??????????
???????. ? ???????????? ?????????? ??? ??????????? ??????? ????????? ????????? ??????????? ???????????? ??????? ????????? ?????? ??????? ?????????? ???????? ?????????????? ??????????. ??? ????????? ???????? ?????????, ???
?????????? (intrinsic), ?? ??????????? F. Wilson ?
?????., ????????? ?? ????????? ?????????? ???????? (????????? farfield). ?????? ?????? ?????????????? ?????????? ???????????? ???????????
?????????. ????????, ??? ?????????????? ? ??????? ??????????????? ?????????? ?????????
???????? ?????? ????????? ????? (upstroke), ??????? ? ?????? ???????????? ??????????? ??????????? ????????? ????? ???????????? ??????????????? ????????????? ??????????? ?? ????????
(downstroke). ??????? ????????? ?????? ??????????? ?????? ??? ??????? ???????? ???????? ?????????? ??? ?????????????? ?????????? ?? ?0,2 ??
?2,5 ??/??. ? ???????????? ?????? K. Konings ?
?????. ??? ???????? ?????? ????? ???????????
????????????, ?????????????????? ??? ?????????????? ???????????? ? ????????? ? ?????????
??????????????????????? ? ??. ??? ????????
?????? ???? ???????????? (?????? ??????????
1?500 ??). ??? ???? ????? ??? ? 70% ??????? ?????????? ????? ????????? ?????????? ? ???????
???????? ?????????????? ??????????. ????? ?????????? ???????? ??? ??????????????? ???????.
????????? ?????? ??? ??????????? ?????????
??????? ???????????? ?????? ?????? ?????????? (50?1000 ??, 100?500 ?? ??? 100?1000 ??).
????????????? ?????????????????? ???????????? ????????? ????????? ??????, ?? ????????
????? ????????? ???????????? ??????? ? ??????
?????. ? ????????????????? ?????? K. Konings ? ?????. ???????? ?????????? ?????? ?? ?????? ????? ????????? ???????, ??????? ????????????????
???????????????????? ?????????????. ???
???????????? ????? ??? ?????????????? ???????????? ? ??????????? ???????? ???????????????? ????????????? ?????????????????? ????????????.
???????????? ?????? ?????????? ???????????? ??? ??????????? ?????? ????????? ????????? ???????? ????? ???????. ??????????? ?? ????? ???? ????????? ??????????, ??????? ??????
???????????? ???????????? ?????? ?? ??????????.
?? ?????? ??? ??????? ? ????????????????????
?????????? ?????????????. ???????? ?????????
?????????, ?????????? ?? ????????? ???????????? ?????????, ????????????? ?????????? ?????????, ? ????? ╚???????????????╩ ?????????,
??????????? ?????????????? ?????????????
??????? ??????????????????? ??????? ?? ???????? ?????????.
??????????? ???????????? ?????????? ? ??????? ????????????? ??????? ? ???? ???????????
(?? ????? 50?100 ??). ????? ??????????? ???????
????????? ????????? ?????????? ????????????
???????????? ?????????? ????????????? ?????.
??????? ?????????? ╚????????╩ ???????????? ?
????????? ?????? ?????? ?????? (??? ?????? ???????). ???? ????? ??? ????? ???????????? ???????? ?????. ????? ?????? ?????????? ? ????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
11
??????? ?? ????????) ???????, ? ????? ??????????? ??????? ??????? ??? ??????????? ???????? ? ??????????? (?????????, ???????? ???????????) ?? ???? ??????? ???????. ??? ??? ?????
??-??????, ???????? ??????????? ??????? ??????? ? ?????? ??; ??-??????, ??? ???? ??????????? ???????? ???????? ? ????????? ?????
???????, ??? ????? ?????????????? ???????? ????? ????????????? ??????????. ????? ???????,
????????? ???????????? ??????, ?????? ???????????? ? ???? ??????????????? ????????????
(?????? ????????????? ????????????? ????????? ?? 8 ?), ????? ???????? ?????????? ? ????????????? ??????, ??????? ??????? ? ????????
?????? ??????????, ? ????? ??????? ??????? ???????????????? ????????????? ?????????? ? ?????? ???????.
?????????????? ???????????? ??? ?? ?????
????? ??????? ???????????. ??? ????? ??????????? ?????? ? ???????, ???????????? ???????
???????????????, ???? ????????? ?????????, ?????? ?????????? (? ????? ???????????) ? ????????
???????? ? ???????? ???????? ??????? ???? ???????. ? 2010 ?. ? ??????? ?????? ????????-?????????? ???????? ??. ?. ?. ???????? ???? ??? ???????????? ????????? ??? ? ???? ?. ?. ???????
??????????? ????????????? ????????? ??? ??????????????? ???????????? ? ?????-????? ??????????? ??????????? (???. 4).
??? ?????????? ???????? ╚????????╩ ? ????
????????? ? ???????????? ?????????? ???????
?????????? ?????????????? ???????????? ? ???????????? ??????????????? ??????????? ???? ?
???????? ????????????????? ??????????. ?? ?????? ?????????? ?????? ??????????? ?????????????? ???????????????, ??? ? ?????????? ??????? ? ????????????? ????????? ??????????? ??????? ? ?????????? ????? ?????????, ????????? ??
??????????? ??????????.
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? ??????????? ?? ?????????? ????? ???????????,
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?????????? ?????????. ? ????????? ????? ??????????? ????????????? ????????? ????????????
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???????? ??????????, ????????????? ???????????? ?????? ???????????? ??????? ????????????
????? ?? ? ?????? ???????? ??????????, ? ?????
?????? ??????? ???????????????-????????? ??????????? ?? [5].
???????????? ?????? ??? ?? ???? ????? ?????????? ?? ???? ???????. ?????????? ?????????????? ?????????? ???????????? ? ???????
??????? ?????, ? ?????????? ???? ?????????? ????????? ??????. ? ??????? ?? ????????????????
??????????? ???????????? ?? ??????? (?????? ??
???????С? ??????), ???????????? ?????? ???????????? ?????? ???????????? ? ????????? ??????. ??? ????????? ?????????? ??????????? (???-
29
76
77
69
79
78
70
68
28
67
68
80
65
81
83
84
63
71
72
73
64
62
26
82
27
25
41
42
54 55
43
34
40
33
53
44
21
39
56
19
2
7
3
12
17
8
4
46
58
35
14
9
13
48
31
11
15
52
37
33
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47
6
18
57
45
39
10
16
1
61
20
36
5
23
22
49
?
???. 4. ?????-????? ?? ?. ?. ??????? (?) ? ??????? ??? ?????????????? ?????????? (?) ??? ????????????
??????????? ???????????
?????? ???????????, ? 1, 2012
75
74
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
12
?????? ???????????, ? 1, 2012
???????????? ??????????
??? ??????????? ????? ???????????? ???????
??????????? ????????????? ????????-????????? ????????????? ????? ??????????????? ??????????? ?? ???????? ?? ?????? ???????? ???????,
? ??????????? ????????-??????? ???????? ? ?????? ??? ????? ????????? ??? ??????? ??????????? ????? ????????????? ???????. ?????????
???????? ???????????? ??????????????? ??? ??????????? ?????? ??. ?????? ????? ? ?????????? ????? ?????? ????????????? ??????????,
?????????????? QRS-????????? ?? ????? ???????????? ??????????. ?????? ? ??????????????? ? ????? ????????????????, ????????????????? ????????????. ?????????? ? ??????
??????? ?????? ????? ??: ??????????? ????????????????????? ??????????; ??????????? ??????????; ?????????????? ???????????? (???????????? ??) [1, 2].
????? ????????????? ??????????????? ?????????? ? ?????????? ?? ??????????? ??????????????? ?????????? ???????????? ???????
?? ? ??. ??????????????? ??????????? ??????
??????? ╚???????????╩ ?? 15?20 ???, ??????
??????? ????????????? ?????????????? 5?10 ??2.
????? ???????, ?????? ??????? ??????????????? ?? ????? ?????? ????????, ? ????????????
???????????? ???????? ? ????????? ?????????????? ???????????? ? ????? ? ?????? ????? ?????????.
? ???????? 1998 ?. ? ????? ??. ?. ?. ???????? ???? ?????? ???????????? ?????????????
????????????????? ???????????? ?????????????? ??????????? ????? ?????????? ??? ??????????? ????? ??. ???????????? ? ??????????????
??????????? ?? ? ?? ? ??????? ??????????-
PA
RV
6
29
7
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12
34
20
8
5
25
30
16
9
13
46
26
31
40
22
18
27
39
32
15
47
50
CRUX
49
42
23
52
51
CRUX
41
28
33
53
36
38
14
48
35
37
21
17
10
45
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???? ????????????? ???????? ???????, ?????????-
24
19
11
3
4
??????????
LV
1
2
?? ╚?????╩ ? ????????????? ?? ??? ???????????
???????? 128 (64 ?????????????? ?? ? ???????
?????????) ??????????? ??? ?????????? ?? ??
????? ?? (???. 5).
????? ???????? ?? ???????????? ?????? ???????????? ????????? ? ???????????? ????? ????????? ?????? ?? ?? ????????? ? QRS-?????????,
??????? ??????????? ?? ??????????? ?????, ??
???? ???? ??. ??? ???? ????????? ??????? ?????????? ?????? ?????????? ?? ????? 0,5 ??/??.
???????????? ?????????? ?????????????? ??
QRS-????????? ???????????? ??? ????????? ????????????????? ????????? ???????. ?? ????????? ????????? ? ??????????? ?? ?????????????
???????????? ?????????? ????? ????????? ?????????????? ??????????? ?????????? ?? ????? ?????? ????? ?? [1].
43
44
APEX
?
?
???. 5. ?????-????? (?) ? ????????????????? ???? (?) ??????????????? ???????????? ??????????:
? ? ?????? ??????? ????????? ?? 53 ????. ????????? ??? ?????? ??????????? ??????????????? ????????: ???????? ? 11?15,
19?23, 24?28, 29?33, ?????? ? 36?43, 46?53, 45?51. ?? ???????? ??????????? ??????? ????????? ???? ???????? ???????????
??????????-???????????? ???????: 1?5, 6?10, 16?18 (RV ? LV ? ?????? ? ????? ?????????, CRUX ? ?????????????? ????? ??????, ?PEX ? ????????); ? ? ????????????? ???????? ??????? ?? ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
???? ? ????????????????, ????????????? ???????? ?????????? ???????????? ?????? ?????????
?????????? ? ????????? ??????? ??? ????????????? ? ??????????? ???????.
2.
3.
4.
? ? ? ? ??? ? ??
??????? ?. ?. ???????????. ?.: ????????, 1989.
5.
??????????? ?? ????????-?????????? ???????? / ??? ???.
?. ?. ????????????, ?. ?. ???????. 2-? ???., ???. ?.: ????????, 1996.
Gan Xin Yan, Kowey P. Management of Cardiac Arrhythmias.
Springer Science+Business Media, LLC. 2002, 2011.
Saksena S., Camm J. Electrophysiological disorders of the
heart. 1st ed. Elsevier Inc. 2005.
Shenasa M., Borggrefe M., Breithardt G. Cardiac Mapping.
2nd ed. Futura, Blackwell publishing, Inc., 2003.
????????? 10.05.2012
??????
╘ ?. ?. ?????????, ?. ?. ????????????, 2012
??? 616.125
????????? ????????? ? ?????????
???????????? ??????????? ??????????
????? ???????? ?? ???????? ??????
?. ?. ?????????*, ?. ?. ????????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
????????????????? ??????????? ?????????? (????) ? ?????? ??????????, ?????????????, ?? ?????? ???????, ? 30?50% ????????? ????? ???????? ?? ???????? ??????. ??? ????????????? ? ?????????? ?????? ??????????? ? ??????????? ????????????, ?????????? ????? ???????? ?????????????????? ??????????, ????????? ?????????????? ???????? ????????????. ? ????????????
??? ???????? ? ????????? ????????????? ?????? ?? ????????????????? ??????????? ?????????.
????? ?????? ?????? ???????? ????? ??????????? ?????? ? ???????? ?????, ????????? ?????????? ? ?????????? ???????????? ????. ?????????? ????????? ????? ???????? ???? ???????? ???????, ?????????? ??????? ?????? ?????????? ? ????????????? ????????????? ?? ????????
??????. ? ??? ??????????? ???????????? ????????, ??????? ??????? ???? ???????????????? ???
??????? ????? ????. ??? ???????????? ???? ?????????? ? ????????? ????? ???????????? ???????????? ???????????????????????. ?? ????????????????? ?????????? ???????? ???? ????????????? ????-?????????, ? ????????? ?????? ???????????? ? ?????? ???????? ????? ????????
????. ???????? ?? ?? ??? ???? ??????? ???? ?????????????? ?????? ?? ????????????? ??????, ????????, ?????-3 ???????????????? ?????? ?????? ? ????????????????, ?? ?????????? ?
??????????? ??????? ? ??????? ??????????? ????? ????????? ????? ??????????? ??? ???????????? ????.
? ? ? ? ? ? ? ? ? ? ? ? ? : ???????? ?? ???????? ??????, ??????????? ??????????, ????????????.
According to different analyses, postoperative atrial fibrillation (POAF) is the common complication
which is seen in 30?50% patients who underwent off-pump surgery. It is associated with increased mortality risk, survival decrease and increased risk of thromboembolic complications requiring additional
therapeutic intervention. As a whole it results in elevation of expenses for postoperative nursing. The
objective of this article was to review contemporary data concerning risk factors, possible ways and
strategies for POAF prevention. Age, enlargement of left atrial cavity and heart valve surgeries are considered to be the well-known risk factors for POAF development. Moreover, visceral obesity was recently identified as the risk factor for POAF. Biatrial pacing can be an effective and safe method for POAF
prevention. Beta-blockers were considered to be effective agents and amiodarone is often used in cases
of high risk for POAF development. There is not enough data to prove the efficiency of magnium, statin,
omega-3 polyunsaturated fatty acids and corticosteroids in prevention of POAF and their application in
complex therapy along with other agents can be more affective for POAF prevention.
K e y wo r d s : off-pump surgery, atrial fibrillation, prevention.
* ????? ??? ?????????: e-mail: azizmelik@mail.ru
?????? ???????????, ? 1, 2012
1.
13
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
14
?????? ???????????, ? 1, 2012
?
?????????? ?????????? (??) ? ??? ?????
???????????????? ?????????? ????? ???????? ?? ???????? ??????. ????????????? ??, ??
?????? ??????????? ????????????, ?????????? ??
20 ?? 50%, ? ??????????? ?? ??????? ????????????? ????????????????? ??????????? ?????????? (????) ? ?? ????????????? [3]. ??????????
????????, ??? ? ????????? ???? ?????????? ?????????? ???? ??????? ???????? ???? ? ????? ?
?????????? ? ?????????? ???????? ?????????, ??????? ???????? ???????? ?? ???????? ?????? [2].
?? ??????????? ???? ????????? ???? ?? ??
????? ??????. ??? ??????????????, ?????????
???? ????? ?????????????? ???????? [4]. ?????????? ??? ???????? ?????, ?????????????? ???????? ??????? ??????????. ? ????????? ????? ?
???????? ??????????? ??????? ????????????????? ? ??????????????????? ?????? ???????????? ????.
?????? ???????????, ? 1, 2012
????????????? ????
?? ????????? ???????, ???? ??????????? ?
30% ????????? ????? ????????????? ????????
???????????????? ???????????? (???) ? ? 40% ?
????? ?????????????? ??? ???????? ????????
??????. ??? ?????????? ????????? (????????,
?????????????? ???????? ? ???) ???? ????????????? ?? ?????????? ?? 50%. ? ??????? ??-?? ????????? ????????? ???????? ????????? ???????????????????? ??????? ????????? ?????????? ??????? ???????? ????. ????????????????? ??,
??? ???????, ????????? ????? ??????? ? ?????????? ??????? ????? ???????? ? ??????? ????????? ????????????? ?? ?????? ????? ????? ????????. ?? ?????? ??????????? ??????????? ????????????, ? 70% ????????? ?? ????????? ? ??????
??????? ????? ????? ????????, ? ? 96% ? ? ???????
????? ????? ????? ???????? [7].
????????????????? ??, ??????? ?????? ????? ????????? ???????? ? ? ??????????? ???????
??????????? ??? ???????????? ??????????, ? ????????? ?? ????????? ?????????????? ??????????? ???????? ?????????? ????????????? ?? ???????????? ?????????? ???????????. ????? ????,
??? ???? ????????????? ???? ???????? ?????????????????? ?????????? ? ????????? [1], ?????????? ???? ???????? ????????? ??????????, ????????????? ?????????????? ???????????? ? ??????? ???????? ?????????? ??????????, ?????????
? ??????????????? ??? ??????? ???? [21].
Almassi ? ?????. ??????????, ??? ????? 3855 ????????? ????? ???????? ?? ???????? ?????? ???????????? (6 ?????? 3%) ? 6-???????? ???????????
(9 ?????? 4%) ???? ?????????? ???? ????? ????????? ? ??????????? ????. ? ???? ?? ?????? ?
??????? ? ??? ???? ????????? ???? ???????? ??-
???????, ????????????? ????????????????? ?????????? ? ?????????? ? ??????????? ??????????
????????????? ??????? ?? ?????????????????
???????????? ?????????.
??????? ????? ???????? ????
???????? ???????????? ??????????? ???????? ???? ???????? ??????? ?????????. Methew ?
?????. ? ????? ???????????? ????????, ??? ? ?????? ??????? ????? ??????????? ???????? ?? ?????????? ?? 75%. ???????? ?????? 70 ??? ?????
????? ??????? ???? ???????? ??. ??????? ??????? ????????????? ? ??????????????? ? ??????????????? ??????????? ?????????? (?????????,
??????), ??? ???????? ? ????????? ?????????????????????? ??????? ???????? ?????????? ? ????????????? ??????????? ???????????? ??????
??????????, ??????????? ????????? ????????????
? ??????????????, ????????? ??????? ??? ??????????? ???????????, ??? ? ???????? ????? ???????? ????????????? ?????????? ??? ????????
???? [17].
????? ????, ????????? ????? ???????? ????
????????: ??????? ???, ????????? ??????? ??????? (??) ?????? ?????????, ??????????? ?????????? ? ????????, ???????? ?? ???????? ??????,
?????????? ??????? ?????? ??????????, ??????????? ????????????? ??????? ??????, ???????????
???????? ???????????????, ???????? ??????, ????????????? ??????? ??????, ?????????? ? ????????????????? ??????? [18]. ?????, ??? ????? ????????? ???????????????????? ??????? ???????? ???????? ??????????? ??????????? ????????
???? [16]. ????? ????????????? ????????
??? ????? ????????? ?????? 50 ??? ???????? ????????????? ? ??????? ?????? ???????? ??, ?????? ? ????????? ?? 50 ??? ????? ??????????????
?? ???????????. ????????? ??? ? ????????/?????????????? ???????? ?????? ?????????????????
???????? ??????? ?????? ???????? ???? [5].
?????????????? ? ????????? ????
?????????, ??????? ? ?????? ????, ?????
?????????????? ???????? ? ?? ??????????? ????
?? ?? ????? ???????. ? ?????????? ????????????? ????? ???????? ? ????????? ?? ???: ??????????????? ??????????, ?????????? ????????? ?????????????, ????????????????? ?????????? ????
?????????, ???????????????? ?????????? ?????? ???????????????? ????????, ??????? ????????????? ????????, ????????? ?????????????????
?????????, ????????? ?????????? ??????? ???????. ????????? ??????? ????? ???????? ??????????? ?????????????? ? ???????? ? ???????? ????????? ??????????????. ? ???? ???????, ??? ???????? ? ????????????? ?????????????? ????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
???????, ??????? ????????? ????????????????
?????????? ???? [12]. ?????? ???????? ??????????? ??????, ?????????? ??????????????????? ? ???????? ???? ????? ?????? ?????????.
???? ?? ????????? ?????????? ??????????? ?
?????????. ????? ? ????????? ?? ???????? ??????? ??????????? ????????? ????????, ??????? ?
????????? ???????? ??? ???????? ????. ??????
?????????? ??????????? ? ???, ??? ???? ?? ????
????????????? ????????????? ? ?????? ??? ???????? ???????? ? ??????????? ????????? ???
????. ????????, ??? ??????????? ?????????
??????, ????????????? ????? ????????????? ??????? ??? ? ?????????? ????????????????? ??????,
????? ???????? ? ?????????? ?????????? ? ???????? ??????? [23].
?????????? ????????? ?????????????, ????????? ? ??????????? ?????????? ??????? ???????,
???????? ? ????????? ?????????????? ?????????? (?????????? ???????????? ????????????? ??????? ??????????, ????????? ??????????????).
Hogue ? ?????. ? ??????????? ???????????? ????????, ??? ? ????????? ? ???? ?????????? ?????
??????? ??? ????? ?????? ?????????????? ?????????? R?R ??????????????? ?? ?????? ??????????
??, ??????? ?????????????? ??????? ? ??????????
????????????? ??? ????????????????? ???????
???????. ????? ???????, ????????????? ???????
?????????? ??????? ??????? ????? ?????????????? ?????????? ??????? ??????????? ????.
?????????? ???????? ????? ?? ?????????
?????????? ???????? ????. ? ???? ????????????????? ????????????? ???? ????????, ??? ?????????????? ??????? ???????? ????????????, ???????????? ????????????? ????????? ?????????-
????? ???????? ??????????, ??? ????????? ????????????? ?????????????? ???? ???????. ???????
????????, ??? ?????????? ????? ???????? ?? ?????? ? ????????????? ??????????????? ????????
??????????? ??????????? ???????? ????.
???????????? ????????, ??? ??????? ??????
?????????? ????????? ??????, ??????????? ????? ???????? ?????? ????????? ? ??????????? ??????? ?????? ?????????? ????? ???????? ???????
????????? ????? ???????? ????.
????? ??? ????????, ??? ? ???????? ??????????, ?????????????? ???????? ??, ????????????
????? ???????? ?????????? ??????????, ???????????? ???????????????????, ??????????? ?? ????????? ???????????? ??????? ???? ????????????-6,
??????????? ???????????? ???????? ??????????
??????????, ??????????? ? ????????? ?????????????????????? ??????? ??????????, ?????????? ?????????? ??????????-40 ? ???????? (??. ???????) [10].
????, ????????, ??? ??? ???????? ???? ????????? ?????????????????????? ????????, ? ??????? ?????????? ?????????????? ????? ???????,
? ???? ???????, ????????? ? ?????????? ?????????????? ???????? ??????????. ????????? ?????????????? ????????? ?????????? ???????????
???????????? ????????? ????, ??????? ??????????? ? ?????????? ??????????? ????? ????????, ???
??????? ???????, ???????????? ???????????, ???????? ??????, ????????, ?????????? ??????? ?????? ??????????, ??????????? ???????? ??. ????????????????? ? ????????????????? ???????
(????????????? ?????? ? ?????? ???????? ??????????) ????? ???? ???????? ? ??????????? ???????????? ?????????. ?????????? ? ????????????
????????????????? ???????:
?????????????? ?????? ??????????
??????? ???????????? ????????
??????? ???????? ?????????
??????????? ????????
????????? ?????????????? ??????????
?????????????? ????? ???????
????????:
???????????? ?????????????
?????????? ?????????? ???????
???????
?????????? ????????????
(?????????????, ????????????)
????????????????? ???????:
????????? ??????????
??????????? ????????????
???????????
??????????????????????
???????? ??????????
????
????????? ????????????????? ??????????? ??????????
???????????
???????????? ????????????
???????? ??????????
??????????
?????? ???????????, ? 1, 2012
????????????? ???????:
???????? ???????
????????????
???????
?????????
??????????????? ???????
??????????? ?????? ??????????
??????????????? ??????????
?????? ?????????
???????????? ?????? ?????????
????????????? ???????????????????
15
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
16
?????? ???????????, ? 1, 2012
?????? ????? ?????? ?????? ????. ? ????????? ????????? ??????? ???????????? ??????????????????? ? ???????? ????. ??? ??????? ??????????????????????? ????????? ?????????? ????????? (??????????????? ?????????? ??????????,
????????? ???????????? ?/??? ????????? ??????????????? ??? ???????? ??????????) ????????????
????????????????? ??????? ????.
????????? ???????????? ????
?? ??????????? ???? ??? ???????????? ??????????? ???? ???????????? ??? ?????????: ??????, ???????????????????, ?????????? ??????????? ??????????????????????? ? ???????
????????? ?????????????? ?????????? ?? ?????????? ??????? ?????????????????? ???????, ?
??????, ????????????????? ?????????, ????????????? ? ?????????? ?????? ????? ????????????????? ?????????? ??? ???????????? ??????????? ????.
?????? ???????????, ? 1, 2012
??????????? ??????????
????????????? ???????????????? ??????????
??? ???????????? ? ??????? ???? ????? ??? ??????????? (???????????? ??????, ???????? ???????? ??????????, ??????????????? ??????). ??
???? ????? ???????? ??????????????????? ????????? ??? ???????????? ??????????? ?? ?????????? ??????????.
? ??????????? ????????????? (Danish trial,
PASE, MOST), ? ??????? ???? ???????? ???????? ? ????????????? ??????????? ? ??????????
??????????????????????? ?? ?????? ????????
???????? ????????? ???? (????) ? ??????????
???????????? ?????????????, ???? ????????,
??? ??????????? ???????????????? ???????????
??????? ??????? ????????? ?? ? ?? ????????????? ? ?????????? ????? [14]. ????????????, ??? ?
?????? ???????????????? ???????? ???????????
??????????????????????? ????? ?????? ?????????????????????? ?????????, ? ??? ????? ?????????????? ?????????????? ???????? ???????????
??. ??????????? ??????????, ??????????? ?????????????? ????????? ????????????? ??????????, ???????, ? ???? ???????, ???????????? ??????????? ????????? ??? ??????????? ??????????,
???????? ? ?????????? ?????? ?????????? ??????????? ????.
????????, ??? ??? ?????????? ???????????????? ??? ????????????????????????? ???????? ???????????? ???????? ???????????????
???????? ???????????? ???????????. ?? ?? ?????
???? ???????? ?? ??????????? ??????. ?????????? ?????????-?????????? (?????????? ?????????? ? ??????? ???????? ???? ???? ????????????
?????) ????????? ????????? ?????????? ????????-
??????????????? ????, ? ????? ???????? ??????????? ???????????? ?????????? ? ???????? ??????????? ?????????? [8].
??? ???????????? ??????????? ???? ? ????????? ????? ???????????? ???????? ??????????? ?????????? ?????????? ? ??????? ????????? ?????????????? ?????????? [13]. ?????????
??????????????? ??????????? ?????????? ????
?????????? ? ????? ????????? ?????????????
???????????? ????????? ??????????? ??????????? ? ????????? ?? ???????????? ???????????
????????????????? ???????????? ??? ??????
????????????? ???????????????-????????? ??????????????? ??????????. ???? ????????, ???
??? ???????????? ??????????? ??????????? ???????????? ??????? ??????????? ??????????
(??????? ????? ??????? ?????????? ??? ??? ????)
?? ???????? ????????????. ?????????????????????? ???????????? ????????, ??? ?????????? ??
?????? ??????? ??????????? ???????? ?????????
????? ????????? ??????????, ??????????? ????????? ?????????????? ? ? ?????????????? ???????
???????????? ???????????? ???????? ?? ? ????????? ? ??????? ??????? ??????????, ? ??????????? ? ?????????? ????????. ? ???? ?????????????, ? ??????? ?????????? ?????????????? ??????? ?????????? ?????????? ??????????? ?
?????????????? ???????? ?????????????? ??????????? ? ???????????? ?????????? ???? ???????
?????????? ? ????????? ? ???? ? ??????????????? ?????? ??, ???? ????????, ??? ??????????
?????????? ??????????????? ?? ????????????
????????? ?????? ??????? ????????? ??????????, ???????????? ?? ????????????????? ?-?????, ? ?? ???????????? ????????? ???????? ?? ?
?????????? ????? (24 ?????? 47% ? ??????? ????
??????????; p < 0,05) [9].
?????????????? ?????????, ??????????? ??????? ???????????? ?????????? ?????????? ???????????? ???????? ??????????? ????, ??????????? ? ?????????. ??? ????????? ????????????? ? ??????????????????? ?????????, ?????????
???????????? ??? ?????????????? ???????? ??????????, ???????????? ?????????? ????????? ?
?????????????? ????????????? ???????, ???????????? ??? ??????????? ??????????. ??????????
??????? ????????? ??????????, ? ?????????????
????? ?????????? ????????? ?? ???????????. ???
???? ??????????????? ????????????? ?????????
????????? ????????????, ? ????? ?????????? ???????? ????????? ??????????? ???????????? [30].
????????? ????????? ???????? ??????????
?????????? ???????????? ??????????. ?? ????????????????? ????? ????????? ????? ??????????? ???????????? ?????????? ????????? ???
????????? ?? ????? ??????????? (??? ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
?????????? ??? ???????????? ????. ????????? ??????? ?/? ? ???? 1050 ?? ? ??????? 24 ? ?
?????????? ??????? per oris ? ???? 400 ?? ? ??????? 4 ???? ????? ????????. ??????????? ?????????? ????????? ? ?????? AAI ? ??????? ?????????? ? ??????? 6 ? ????? ????????. ??????????
???? ? ?????? ?????????? ????????? ? 20 (27%)
?? 73 ?????????, ? ??????????? ?????? ? ? 29
(33%) ?? 87 (p = 0,523); ? ?????? ?????????? ?????????? ? ? 17 (22%) ?? 77 ????????? ?? ?????????
? 32 (39%) ?? 82 ? ?????? ???????? (p = 0,037) [28].
????????????????? ?????????,
??????????? ??? ???????????? ????
????-?????????
?????????, ??????????? ????-??????????????? ?????????, ?? ??? ??? ???????? ???????? ?????????? ??? ???????????? ????. ????? ????????????? ??????? ???????, ??????? ?????? ?????????? ? ????????? ????? ???????? ??
???????? ??????, ???????????? ???????? ?? ????? ????????? ? ????? ??? ??????????? ????????? ?????.
? ????????????, ??? ????????? ?????????????
????????? ????-??????????, ???? ???????? ?????
???????? ??????? ???????? ????. ? ??????????? ???????? ???????????? Crystal ? ?????. ????????, ??? ????-????????? ????? ??????? ????????????? ? 28 ?????????????, ? ??????? ???? ???????? 4075 ????????? (????????? ?????? 0,35;
95% ????????????? ???????? (??) 0,26?0,49).
T. C. Andrews ? ?????. ???????????? ?????? ??????????, ? ??????? ???? ???????? 24 ????????????. ? ???????????? ???????? ????????? ? ??
????? 30%, ??????? ???? ????????? ???. ???????????????? ?????????? ????-?????????? ?? ?
????? ????????????? ???????? ???? ????????????? ? ?????? ???????? ???????? ??????????????????? ??????????? (????????? ?????? 0,28; 95%
?? 0,21?0,36) [6].
???????
??? ????????, ??????? ????? ????????????
????-??????????????? ?????????? ????? ????????
???????????????? ?????????? III ??????. ? ??????????? 14 ????????????, ? ??????? ???? ???????? 2583 ????????, ??????? ?????????? ? ???????
????-??????????? ? ? ???????. Burgess ? ?????. ????????, ??? ??????? ??????????? ??? ??????????
??????? ???????? ????, ??? ?????? ????-????????? ??? ???????.
?????? ? ?????? ????????????, ??? ???????
?????????? ? ???????????? ? ???? ??????????????
????-???????????? ???????, ????????????? ????????????????? ???????????? ??? ??????????
?????? ???????????, ? 1, 2012
?? ?????? ?????????? ? ???? ? ?? ?????). ???????????? ?????????? ?????????? ???????????????
????? ???????? ? ?????? DDD ? ??????? ????????? ???, ??? ??? ????????? ?? ?????? ? ???????
?????????? ?????? ?????????????? ? ?????????????? ?????? ???????????? ?????? ???. ??????
??????????? ???????? ?????????????? ? ?????????????? ?????? ???????????? ?????? ???. ???????????? ????????? ???????????? ?? ??????????? ?????. ???????????? ?????????? (???)
?????????? ? ???????? ?? 10?15 ?????? ????, ???
??????????? ????, ?? ????????????? ????????
110 ??/???. ??????? ???????????? ??????? ??????????? ???????? ??? ??????? ? ?????? ??????????
?? ????????????? ???.
????????????? ??????????? ?????????? ??????????? ?? ?????? ??????????? ?????????????.
?????????? ???? ???????????? ???????, ??? ????? ??????????? ??????????? ?????????? ????????? ???? ????????????? ??????????? ????.
? ????????????????? ???????????? ???????????? ?????????-?????????? ? ?????????, ???????
??????????? ???, ???????? ???? ?????????????
?? ????????? ? ????????????? ??????????? (12
?????? 36%, p < 0,005) [19].
? ????????????, ??????????? Orr ? ?????., ???? ???????? 230 ?????????, ??????? ?????????
????????????? ??? ? ? ??????? ? ???????? ??
???? ??. ?????? ???????? ???? ????????? ??
??? ??????. ?????? ?????? ? ? ?????????????????
?????????? ??????????? ? ??????? ?????????
?????????????? ?????????? ? ? ?????? ????????.
???????????? ?????????? ??????????? ? ???????
96 ?. ??????? ???? ? ?????? ?????? ?????????
17,9% ?? ????????? ? 33,9% ? ?????? ????????
(?? 0,53; p < 0,0001).
? ?????? ????????????, ??????????? Debrunner
? ?????., ???? ???????? 80 ????????? ??? ?? ?
????????, ??????? ????????? ?????????? ???????? ?? ???????? ?????? (????????, ?????????????? ???????? ? ??? ??? ??? ????). ???????? ???? ????????? ?? ??? ??????. ? ?????? ?????? ? ??????? 72 ? ????? ???????? ????????? ??????????
???????????? ??????????. ?? ?????? ?????? ?????????? ??????? ?????????? ??????????? ??????
?? ???????????. ? ?????? ??? ??????????? ?????????? ????????? ? 8 (20%) ?? 40 ????????? ? ??????? ???? ???? ????? ???????? ?? ????????? ? 18
(45%) ?? 40 ? ?????? ???????? (p = 0,02) [15].
? ????????????, ??????????? White ? ?????.,
???? ???????? 160 ?????????, ??????? ????????????? ?????????? ?????????? ???????? (????????, ?????????????? ???????? ? ??? ??? ??? ????). ??????????? ?????????? ? ??????? ?????????????? ??????????, ????????????? ? ???????
????? ???????, ???????????? ? ???????????
17
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
18
?????? ???????????, ? 1, 2012
???????? ???? ??????? ????? ??????? (6,0 ??????
1,9%, p = 0,004). ? ?????? ???????????? ? ??????????? ????????? ????? ???????? ??? ????????? ??-?? ???????? ???????? ????????? (??????????, ???????????) [24].
? ???????? ??????? ?????????? ???????. ??????
??????? ??????? ? ?????????????? ???????????? ? ?????????? ????????? ?????????? ??????
?????? [29].
?????????
????????, ??? ????????????????? ?????? ????????????????? ????????? ?????????????, ??????? ????? ????????????? ? ????????? ???????????
???????????. ?????????? ????????????, ??? ? ????????????????? ??????? ??????????? ????????? ?????? ??? ???????????? ????, ???????, ???
??????????? ?????? ?????????? ? ???????????
???????????????? ??????????. ?????? ????? ?????????, ?????????? ? ??????, ???? ????, ? ?????? ???????????? ?????????? ??????, ??? ???????????? ????????????? ??????????? [22].
????????? ???????? ?????????? III ?????? ??
????????????? Vaughan?Williams, ? ???????? ??????? ????? ????????? ??????????? ?????? ?????-? ????-??????????????? ??????????, ??? ?????
?????????????? ???????? ??????????? ??????
????????????? ??????? ??????? ? ?????? ?????????? ????? ???????? ?? ???????? ??????. ? ????????????????? ???????????? ????? 124 ????????? ????? ?????????? ???????? ?? ???????? ?????? ?????????, ??????? ?????????? ??? ??????? ?
??????? 1 ?????? ?? ???????? per oris, ??????????
???????? ??????? ???? ? ? 53 ?? 25% (p = 0,003).
? ???????????? ARCH (Amiodarone Reduction in
Coronary Heart), ? ??????? ???? ???????? 300 ?????????, ????????????????? ???????????? ?????????? ?????????? ??????????????? ? ??????
???????? ???????? ???? (35%) ?? ????????? ?
??????? (47%) (p = 0,001). ?????? ? ???????????
18 ????????????????? ???????????? ? ?????????? 1736 ????????? ? ?????? ?????????? ?????????? ????????, ???, ?? ????????? ? 1672 ?????????? ? ?????? ???????, ??? ??????????
?????????? ?????????? ?????????? ???? ????????????? ??????????? ? ?????????? (????????
????? ???????? ????????? ??????????? ? ? ????
????? ??? 1 ? ? ?????). ????????????? ??????????
?????????? ? ????-??????????? ????????? ??????
???????? ?????? [25].
?????? ???????????, ? 1, 2012
????????
????? ???????? ????????????? ????????? ???
????????? ??? ???????????? ? ??????? ???? ???
?????????? ???? ?????????? ? ????? ? ?????????? ????????????????. ???????? ??????????, ?
??????? ??????????? ????????????? ?????????
??? ???????????? ??????????? ????, ?????????? ?????? ???? [27].
????????? ?????????? ???????
????????????? ???????????????????? ?????????? ?????????? ??????? ??? ????????????
???? ??????????? ? ????????? ?????????????.
? ??????????? ??????????? ???? ????????, ???
????????? ?????????? ??????? ????????? ????
???????? ??????????????????? ??????? (????????? ?????? 0,62; 95% ?? 0,41?0,93). ??? ???? ???? ???????? ??????, ??? ?? ????????????????
?????????? ? ????????? ??????? ???????????????
? ?????? ???????? ??????????????????? ??????
??????
???????
? ??????????? ???????? ???? ????????, ??? ?
?????????, ??????????? ???????, ????? ???????? ??? ??????????? ?????? ??????? ????????
????. ? ????????????? ????????????????? ???????????? ARMYDA-3 (Atorvastatin for Reduction
of MYocardial Dysrhythmia After cardiac surgery) ???? ????????????, ??? ???????????????? ?????????? ????????????? ? ???? 40 ?? ? ????? (???????
??? ??????? ?? 7 ???? ?? ????????) ??????????
????????? ??????? ???????? ???? [26].
?????-3 ???????????????? ?????? ???????
? ????????????????? ???????????? ?? ??????
???? ????????, ??? ???????????????? ??????
??????? (????) ???????? ?????????????????
??????????. ? ?????? ???????????? ?? ??????? ????????, ??? ?????????? ??????? ???? per oris
????????? ?????????????? ???????????? ???????? ? ???????? ??. ????????????, ??? ???????????????? ?????? ???? ?????????? ??????????
??????????.
?? ?????? 12-??????? ??????????, ????? ????????? ????????, ??? ??????? ????????????? ????
? ??????? ??????? (??? ????????????? ???????
?????????? ???????????? ????), ??????????
?????? ?????????????????? ??. L. ?alo ? ?????. ?
?????????????? ????????????????? ???????????? 160 ?????????, ??????? ????????? ????????
???, ????????, ??? ?????????? ???? ?? ? ????? ???????? ?????????? ????????? ???? ???????? ???? [11].
????????????????????? ??????
? ?????????????? ???????????? ? ??????????
241 ????????, ??????? ????????? ???, ????????, ??? ????????????????? ?????????? 100 ?? ?????????????? ??????????????? ? ?????? ????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????? ???? ?? ????????? ??????? (58 (48%)
?? 121 ?????? 36 (30%) ?? 120; ????????????????
????????? ?????? 0,54; 95% ?? 0,35?0,83;
p = 0,004) [20].
??????????
??????????? ?????????? ????? ???????? ??
???????? ?????? ???????? ?????????? ?????? ???????????, ??????? ???????? ? ?????????? ???????????. ????? ????, ????????????? ???? ???????? ?????????????????? ??????????, ?????????
?????????????? ???????? ????????????, ??? ?
???????????? ??????? ???????? ?????????????
??????? ?? ????????????????? ???????????? ?????????.
? ????????? ????? ?????????? ?????? ????????? ???????????? ????????????????? ??. ??????????? ?????? ??????????????? ? ???, ???
????-????????? ?????????? ? ????????? ?????
???????????? ? ??????????? ????????? ?? ? ?????
???????? ??? ???????????? ????. ?????????
?????? ??????????? ? ?????? ???????? ????? ???????? ??. ???????????? ??????????????????????? ???????????? ??? ??????????? ????? ???????????? ????. ???????? ?? ?? ??? ??????????
???? ?????????????? ?????? ?? ?????????????
??????, ????????, ?????-3 ???? ? ????????????????????? ???????, ?? ?????????? ? ??????????? ??????? ? ????-??????????? ????? ?????????
????? ???????? ??? ??????????? ???????? ?????
???????? ????.
? ? ? ? ??? ? ??
1.
2.
3.
4.
5.
6.
7.
8.
9.
??????? ?. ?. ???????????? ???????? ??? ???????????
?????????? // ?????? ???????????. 2005. ? 3. ?. 45?55.
??????? ?. ?., ????????? ?. ?., ?????????? ?. ?. ????????????? ??????? ??????????? ??????????: ???? ?
??????????? ???????? // ??????? ? ????.-?????. ???. 1998.
? 1. ?. 7?13.
?????? ?. ?., ??????? ?. ?. ? ??. ??????????? ???????????? ?? ??????????? ? ??????? ????????? ? ????????????
?????????? // ?????. ???????????. 2010. ? 59. C. 53?77.
????????? ?. ?. ??????????? ??????????: ?????????????????????? ????????? ? ????? ??????? ? ???????????????? ??????? // ??????????? ???????. 2003. ? 4.
?. 12?18.
Alqahtani A. A. Atrial fibrillation post cardiac surgery trends
toward management // Heart Views. 2010. Vol. 11. P. 57?63.
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Archbold R. A., Schillings R. J. Atrial pacing for the prevention
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Bailin S. J., Adler S., Giudicis M. Prevention of chronic atrial fibrillation by pacing in the region of Bachmann?s bundle:
results of a multicenter randomized trial // J. Cardiovasc.
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19
10. Burstein B., Comtois P., Michael G. et al. Changes in connexin expression and the atrial fibrillation substrate in congestive heart failure // Circ. Res. 2009. Vol. 105. P. 12?22.
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the prevention of atrial fibrillation after coronary artery bypass
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13. D?Allonnes G. R., Pavin D., Leclercq C. et al. Long-term
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15. Debrunner M., Naegeli B., Genoni M. et al. Prevention of
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16. Dublin S., French B., Glazer N. L. et al. Risk of new-onset
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????????? 07.06.2012
?????? ???????????, ? 1, 2012
??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
20
?????? ???????????, ? 1, 2012
╘ ?. ?. ???????, ?. ?. ????????, 2012
??? 616.124.7-008.313-07+616.12-008.46
???????? ???????????? QRS ? ?????? ???????
????? ????? ????? ???? ? ???????? ? ???????
????????? ????????? ???????????????
?. ?. ???????*, ?. ?. ????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
?????? ???????????, ? 1, 2012
? ??????? ? ?????????? ??????????? ????????? ???????????????? (???) ????? ??????????? ????????? ??????????????????? ??????????, ????????????? ???????? ????? ????? ????, ??????? ??
??????????????????? (???) ?????????? ? ???? ????????? ?????????? ? ???????????? ?????????
QRS ? ???????? ? ?????????? ??????- ? ??????????????? ????????????. ?????????? ?????????
?????? ????????? ????? ??????????????? ??????????? ???????? ? ?????????? ?????????? ??????
?????????? ?????? ? ??????? ??????????.
??????????????? ?????????? ?????? ??? ?????????? ??? ??????? ??????????? ????????? ???,
???????? ???????????????????? ????????? ?????????? ????????.
? ???????????? EVEREST ???????????????? ??????? ???????????? ????????? QRS ? ????????? ?
??? ?? ?????????? ?????????????? ? ??????????. ? ???????????? ???? ???????? 2962 ????????,
?? ??? ? 1641 ???? ?????????? ???????????? ????????? QRS ? ????? 120 ??, ? 1321 ???????? ? ????? 120 ??. ? ??????? ??????? ?????????? ???? ???????????????? 678 ??????? ??????, ?? ??? 307
(18,7%) ? ? ?????? ? ?????????? ?????????? QRS ? 371 (28,1%) ? ? ?????? ? ??????????? QRS. ???? ????????-?????????? ?????????? ???? ?????? ? ????????? ? ??????? QRS ? ????? 3 ??? ?????????? ?????????? 21,1% ? ????????? ? ??????? QRS ? 14,6% ? ? ????????? ? ?????????? QRS, ?
????? 9,9 ??? ? 41,6 ? 32,4% ??????????????.
?? ??????????? ?????????????? ????????????? ???????????? ????????, ??? ????????????? ????????????????? ?????????? ???????? ? ??? ???????? ????????? ????????? QRS ? ????????????
???????????????? ???. ? ???????????? MOST ??????????????? 2010 ?????????, ???????????? ???????????? ?????????? ?? ??????????? ??????? ?????????. ? ???? ???????????? ???? ???????? ?????? ? ???????? ???????????? ??? ??? ???????????? ??????????, ????? M. O. Sweeney ? ?????.
??????? ?????? ??????????? ??????? 1339 ????????? ? ??????? ?????????? ????????????? QRS. ???
?? ????? ?????? ??????? ????? ??????? ??????? ??? ?????? ????????????????? ??????????, ???
????????????????? ? ????? ??????? ??????????? ?????????????? ?? ?????? ??? ? ????? ?????? ???????? ??????????? ?????????? ?????????? ?? ????, ???? ?? ????????? ?????????? ? ?????? DDDR
??? VVI. ??????????? ???????? QRS ???????? ????? ?? ????????? ??? ????????????? ????????????????????????? ??????? ? ??????? ? ???.
????? ???????, ????????? ? ??????? ?????????? QRS ?????????? ????????????????????????? ???????, ???? ??? ??????? ??????????? ??????????????? ???????.
? ? ? ? ? ? ? ? ? ? ? ? ? : ??????????? ????????? ???????????????, ??????? ????? ????? ????? ????,
???????? QRS, ????????????????????????? ???????.
Patients with severe chronic heart failure (CHF) often have such intraventricular conduction disturbances as
left bundle branch block which show morphological and QRS-duration changes on ECG and result in evident
intra- and interventricular dyssinchrony. Delayed left ventricular activation via interventricular septum
results in evident asynchrony at the beginning of left and right ventricular contration.
Diagnostic significance of ECG data increases in presence of CHF clinical signs, especially echocardiographic signs of myocardial dysfunction.
EVEREST study analyzed the influence of QRS duration on number of hospital admissions and mortality in
patients with CHF. The study included 2962 patients, 1614 of them had normal QRS duration ? less than
120 ms, 1321 patients had increased QRS duration ? more than 120 ms. 678 deaths occurred during followup period, 307 (18.7%) of them were from group with normal QRS duration and 371 (28.1%) ? from group
with increased QRS interval. Mortality rate due to cardiovascular causes was more significant in patients
with increased QRS. In 3 months of follow-up the mortality rate was 21.1% in patients with increased QRS
and 14.6% in patients with normal QRS. In 9.9 months of follow-up the rates were 41.6% and 32.4%,
respectively.
Different international studies showed that isolated right ventricular pacing resulted in prolongation of QRS
complex and contributed to CHF progression. 2010 patients were randomized in MOST-study which aimed to
compare dual chamber pacing and right ventricular pacing. Reduction of CHF symptoms was noted in the
course of study in patients who underwent dual chamber pacing, while M.O. Sweeney et al. analyzed the
* ????? ??? ?????????: e-mail: leoan@heart-house.ru
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
21
results of treatment of 1339 patients with initially normal QRS duration. However the authors revealed a
higher rate in group of right ventricular pacing which proved the higher rates of hospital admission for CHF
and more frequent rates for atrial fibrillation occurrence regardless of DDDR or VVI pacing mode. Prolonged
QRS interval is one of the indications for cardiac resynchronization therapy in patients with CHF.
Accordingly, patients with prolonged QRS interval require cardiac resynchronization therapy even if they
undergo optimal drug therapy.
K e y wo r d s : chronic heart failure, left bundle branch block, QRS-complex, cardiac resynchronization therapy.
6 ??. ??????????????? ?????? ?????????? ???????????? ????????? ????????? ???????? ?????
???? [7].
????? ????, ?????????? ??????????????????
????????????, ????????? ? ????? ??????? ?????????? ?????? ? ??????? ??????? ?????? ?????????
?? ????????? ? ????????? ???????? ????? ??????????????? ??????????? [5]. ??? ????? ????????? ?????????? ??????????????? ???????????
??????????, ????? ??????? ?????? ????????? ? ?????? ????????????. ??????????? ?????????? ??????????????? ?????? ?? ???????????? ?????????? ?????????? ??????? [1].
??????????-???????????? ???????????????
??? ?????? ????? ??????????? ?????????? ??????? ????????? ?????? ??: ????????????? ?????
???????????????? ??????????, ?????????? ?????
??????? ???????? ? ???????? ??????????? ???????
? ???????? ??????????? ???????. ??????? ????????, ??? ????????? ??? ?????? ?? ??? ???? ??
???????????.
???????? ???????? ??????????? ? ???????????
????????, ? ???? ???????, ???????? ? ??????????
??????? ??????????????? ?????????? ?????? ?????????. ??? ?????? ????? ? ??????? ????????????????? ???????????? ????????? ??? ?????????,
100
%
QRS, ??
< 90
90
90?120
80
120?170
170?220
70
> 220
60
0
60
120
180
240
300
360
????????????????? ??????????, ???
???. 1. ?????????? ???????????? VEST: ???????????
???????????? ?? ???????????? ????????? QRS ?
??????? ? ????????? ???????????????? [12]
?????? ???????????, ? 1, 2012
??????? ? ?????????? ??????????? ????????? ???????????????? (???) ?????
??????????? ????????? ???????????????????
??????????, ????????????? ???????? ????? ????? ????. ?? ??????????????????? ??? ?????????? ?
???? ????????? ?????????? ? ???????????? ????????? QRS ? ???????? ? ?????????? ??????- ?
??????????????? ???????????? [2].
? ????? ??????? ????????????? ?????? ? ?????????? ???????? ????????? ???????? ?? ?????
???????? ??????????, ??? ????????????? ?????????? ?????????? ?????? ?????????. ??????????
?????????????????? ???????????? ? ???? ??????? ????? ????? ???? ????? ????? ???????? ???????????? ??????????????? [12].
????????? ?????????????????? ????????????, ??? ??????? ????????????????? ?????????
QRS ?????????? ????? 120 ??, ??????????? ?????????????? ? 30% ????????? ? ????????? ?????????
???????????????? [3]. ??? ???? ???????? ???????????????? ???????? ?????? ??????? ????? ?????
????? ???? (?????). ???????????, ??? ???????
???????? QRS ???????? ??????????? ??????????? ???????? ????? ?????? ? ????? ??????? [8].
??? ??????????????? ? ?????????? ??????? ??????????????? ?????? ?????????? ?? ??????? ? ??????? ? ???. ? ?????????????? ????????????
VEST ???? ??????? ??????? ???????????? ????????? QRS ?? ??????????? ??????? ? ?????????
???????????????? (???. 1). ????????, ??? ? ??????? 1 ???? ???????????? ??????? ? ????????? ???????????????? ??? ???????????? ????????? QRS
120?170 ?? ????????? ????? 80%, ??? 170?220 ?? ?
74%, ? ????? 220 ?? ? 62%. ??????????? ?????????? ? ???????????? VEST ? ????????? ?? ????????? ?????????????? ???????? ?????? ????????? (??????? ??????? ????? 40%) ???? ?????????? ???? ? ?????????, ????????????????? QRS
? ??????? ????????? 110 ?? (65%), ??? ? ??? ???
????? ????????? (40%) ?????????? ?? ???????????? ?????????? ?????? ?????????.
?????????? ????????? ?????? ????????? ?????
??????????????? ??????????? ???????? ? ?????????? ?????????? ?????? ?????????? ?????? ?
??????? ?????????? [12].
? ??????? ? ????? ???????? ????? ???????
?????????? ?? ? ?? ????? ????????? 40 ?? ? ?????, ????? ??? ? ????????? ? ?????????? ?????????????????? QRS ??? ??????? ?????????? ??????
???????????? ????????????
?
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
22
?????? ???????????, ? 1, 2012
??? ? ?????????? ?????????? ????????????????
?????????, ????????????????? ? ??????????????
?????????? ?????? ?????????.
???????????????? ?????????????? ?? ???????
?????????? ?????? ?????????? ? ????????? ??????? ?????????? ???????????? ?????????? ????????? ???????? ????? ????? ??????????? ? ?????
??????????. ??? ???? ????????? ?????????? ????????????.
?? ???????? ????????????? ???????? ?????????????? ?????? ?????? ????????? ? ?????????
??????? ???????. ??????????? ??????????????
??????????, ????????????? ?????????? ? ?????????? ???????????? ??? ?????? ??????? ????????? ??????. ????????????? ????????? ???????????? ??????????? ???????????????? ?????????????? ???????? [6].
??????????????? ?????????? ?????? ??? ?????????? ??? ??????? ??????????? ?????????
???, ???????? ?????-????????? ??????????
????????. ??????? ???????? ??? ???? ????? ???????? ?????????????? ? ???????? ????????????? ?????, ? ????? ??????? ??????? ?????? ????????? (?? ??). ???? ?? ???? ?? ?? ?????? ??????????? ??????????? ???????????? ??????? ?
????????? ????????????????. ??? ???? ?????????? ?? ?? ?????? ?? ????? ??????????, ????????? ????????? ?????? (???), ?????????? ????????? ??????????????? (???. 2).
?????????? ???????????? ????????? QRS ???????????? ?????????? ?????????? ? ??????????
?????????????? ??????? ? ???. ??? ???? ???
????????? ????????? ? ?????????? ??????????
QRS ? ??????????? ?????????? ??????????????
?? ?????? ?????????? ??? ??????? ???? ? ????????? ? ??????????? QRS. ?????????????? ??
?????? ??? ???????? ??????? ????????? ????????????? ??????????????? ? ?????? ? ???. ?
??? ?????????? ?????????????? ?? ?????? ???
?????????? ????? 1 ??? ? ???. ???????????????
?????????? ???????????? ????????? QRS ????????
????? ?????? ??? ?????? ????????? ????????
? ?????? ??????? ??? ???????.
M. Gheorghiade ? N. C. Wang ? ????????????
EVEREST ???????????????? ??????? ???????????? ????????? QRS ? ????????? ? ??? ?? ?????????? ?????????????? ? ?????????? [13]. ? ???????????? ????? 4133 ????????, ???????????????????
?? ?????? ??? ? ??????? ?? ?? 40% ? ?????.
????? ?????????? 1029 ????????? ? ????????????????? ?????????????????????????? (???) ?
???????????????-???????????????? (???) ? 142
????????? ? ??????????????? ????????????? QRS
???????? ?????? ?????? 2962 ?????????, ?? ??? ?
1641 ???????? ???? ?????????? ????????????
????????? QRS ? ????? 120 ??, ? 1321 ????????
??? ????????? 120 ??. ??????? ????????????????? ?????????? ?????????? 9,9 ???. ? ???????
????? ??????? ???? ???????????????? 678 ???????
??????, ?? ??? 307 (18,7%) ? ? ?????? ? ?????????? ? 371 (28,1%) ? ? ?????? ? ??????????? ?????????? QRS. ? ????????? ?????????? ???????????
?????? ????????? ????????? ??????. ???? ????????-?????????? ?????????? ???? ?????? ? ????????? ? ??????? QRS, ??? ? ????????? ? ?????????? QRS, ? ????? 3 ??? ?????????? ??????????
21,1 ? 14,6% ??????????????, ? ????? 9,9 ??? ? 41,6
? 32,4% ??????????????. ????? ?????????????? ????????? ?????? ???? ????????, ??? ? ????????? ?
??????????? ?????????? QRS ?? 24% ???? ????
????? ?????????? ? ?? 28% ???? ???? ?????????? ??? ?????????????? ?? ????????-??????????
60
% of patients with event
?????? ???????????, ? 1, 2012
50
40
30
20
10
0
< 20
20?29
30?39
40?49
> 50
Total
LVEF, %
Death/Cardiac Arrest
Definite CHF Events
Sudden Death/Arrest
All CHF Events
???. 2. ??????????? ????? ????????? ?? ??, ?????? ??? ? ????? ???????? ???????????????? ?????? ???
(Hallstrom A. P. ? ?????., 1995)
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
?????????????? ?????????? ??????? ????????????? ??????? ????? ????? ????? ???? ??-?? ?????
??????? ??? ?????????. ????? ? ???????? ????????????? ????? ??????? ???????????? ???????
???????????? QRS ?? ???????? ? ????????????????
??? M. O. Sweeney ? ?????. ???????? ?????? ??
?????????? ??? ??????? ? 2 ???? ????? ?????????????? ?? ?????? ??? ? ????????? ? ??????????
??????? ?????????? QRS ?? ????????? ? ??????????, ? ??????? QRS ?????????? ?? ????? ?????????? ??.
??????? (??? ?????????? ??) ???????????
???????? QRS ????? ????? ??????????? ? ????????? ? ???, ??? ????????????? ??????????, ???
??????? ? ????? ? ????????????? ??????????
?????????? ? ???? ?????????.
????? ?????????? ?? ?????? ???? ? ?????????? ?????????????????? ????????, ???, ? ????
???????, ???????? ?? ?????? ? ???????? ????????????? ??????? ??, ?? ? ? ?????????????? ?????????? ????????????. ? ?????? ???? ????????
?????????????????? ???????? ? ??????? ?? ???
????? ????????????? ??? ???? ?? ??????? ???????
??? [10].
??????????? ???????? QRS ???????? ?????
?? ???????????? ????????? ??? ?????????????
????????????????????????? ??????? ? ??????? ?
???, ??? ???? ?????????? ??????????? ???????????? ??????????????? ? ?????????? ?? ????????????? ? ????????? ? ???????? ????? ?????
????? ????, ?????? ?????? [4].
????? ???????, ????????? ? ??????? ?????????? QRS ?????????? ????????????????????????? ???????, ???? ??? ??????? ???????????
??????????????? ???????.
? ? ? ? ??? ? ??
1.
2.
3.
4.
5.
6.
7.
Chow A. W. C., Lane R. E., Cowie M. R. New pacing technologies for heart failure // Br. Med. J. 2003. Vol. 326.
P. 1073?1077.
Curry C. W., Nelson G. S., Wyman B. T. et al. Mechanical
dyssynchrony in dilated cardiomyopathy with intraventricular
conduction delay as depicted by 3D tagged magnetic resonance
imaging // Circulation. 2000. Vol. 101. E2.
Farwell D., Patel N. R., Hall A. et al. How many people with
heart failure are appropriate for biventricular resynchronizaton? // Eur. Heart J. 2000. Vol. 21. P. 1246?1250.
Gervais R., Leclercq C., Shankar A. et al. Surface electrocardiogram to predict outcome in candidates for cardiac resynchronization therapy: a subanalysis of the CARE-HF trial //
Eur. J. Heart Fail. 2009. Vol. 11. P. 699?705.
Kawaguchi M., Murabayashi T., Fetics B. J. et al.
Quantitation of basal dyssynchrony and acute resynchronization
from left or biventricular pacing by novel echo-contrast variability imaging // J. Am. Coll. Cardiol. 2002. Vol. 39. P. 2052?2058.
Leclercq C., Daubert J.-C. Why biventricular pacing might
be of value in refractory heart failure? // Heart. 2000. Vol. 84.
P. 125?126.
Leclercq C., Gras D., Tang A. et al. InSync Study Group.
Comparative effects of ventricular resynchronization therapy in
heart failure patients with or without coronary artery disease //
Ann. Cardiol. Angeiol. 2004. Vol. 53, ? 4. P. 171?176.
?????? ???????????, ? 1, 2012
?????????? ?? ????????? ? ??????????, ? ??????? ???????? QRS ??????????. ? ???? ???????????? ? ????????? ? ??????????? QRS (45%) ??
?? ??????? ?? ??????????? ? ???? ??????????,
?????? ??? ?? ???????? ?? ?????????? ??????????
?????????????? ? ?????????? ?? ????????? ? ?????????? ? ?????????? QRS. ?? ??????????????
? ?????????? ?? ???????? ????? ?????????? ??????????????? ???????, ?????????? ?-???????????????, ?????????? ??? ? ??????????? ?????????? ???????????? II.
????????? ???????????? ????????? QRS ???????? ??????? ? ????????? ??????? ????????????
??????? ? ???, ??? ?? ????? ??? ?????????? ?????? ??????????? ??? ?????? ??????? ??????? ?????
??????? [13].
??????????? ??????? ??????? ??????? ?
??? ? ??????????? QRS ???????? ????????????????????????? ???????. ???? ????? ?????? ??????????? ? ?????????? ?????????? ?????? ? ??????? ??????????.
?????????????? ????????????? ???????????? ????????? ????????, ??? ????????????? ????????????????? ?????????? ???????? ? ???
???????? ????????? ????????? QRS ? ???????????? ???????????????? ???. ? ????????????
Mode Selection Trial (MOST) ???????????????
2010 ????????? ? ??????????? ????????? ????.
???????????? ???????????? ?????????? ?? ??????????? ??????? ?????????, ??? ???? ???? ???????? ??????, ????????????????? ? ????????
???????????? ??? ??? ???????????? ??????????, ????? M. O. Sweeney ? ?????. ??????? ??????
?????? 1339 ????????? ? ??????? ??????????
????????????? QRS. ??? ?? ????? ?????? ??????? ????? ??????? ????????? ??????? ??? ??????
????????????????? ??????????, ??????? ???????????????? ? ????? ??????? ??????????? ?????????????? ?? ?????? ??? ? ????? ?????? ???????? ??????????? ?????????? ?????????? ?? ????, ??????????? ?? ?????????? ? ?????? DDDR
??? VVI [11]. ???????????? ?????? ???????? ?
???? ????????? ???????????? ????????? QRS,
??????? ?????? ?? ?????????? ?????????????? ??
?????? ???.
??? ???? ???? ?????????????? ?? ?????? ???
???????? ??????????????? ?????????? ???????????? ????????? QRS, ?????????? ?? ????, ????????????? ?? ???????????? ????????? QRS ? ?????????? ?????????? ?? ??? ??? ??? [10]. ?????????
QRS ???????? ? ?????????? ??? ? ?????????
?? 100% ??????????? ??, ????????, ??????????
????????????? ????????????? ?????????????
?????????? ? ?????????? ??????????????? ??????????, ??????? ???????? ? ???????? ????????
??????- ? ??????????????? ????????????. ???-
23
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
24
8.
?????? ???????????, ? 1, 2012
Schuster P., Faerestrand S., Ohm O.-J. Colour tissue veloci-
ty imaging can show resynchronisation of longitudinal left ventricular contraction pattern by biventricular pacing in patients
with severe heart failure // Heart. 2003. Vol. 89, ? 8.
P. 859?864.
9. Sweeney M. O., Ellenbogen K. A., Casavant D. et al.
Multicenter, Prospective, Randomized Safety and Efficacy
Study of a new atrial-based managed ventricular pacing Mode
(MVP) in dual chamber ICDs // J. Cardiovasc. Electrophysiol.
2005. Vol. 16. P. 811?817.
10. Sweeney M. O., Hellkamp A. S. Heart failure during cardiac
pacing // Circulation. 2006. Vol. 113. P. 2082?2088.
11. Sweeney M. O., Hellkamp A. S., Ellenbogen K. A. et al.
Adverse effect of ventricular pacing on heart failure and atrial
fibrillation among patients with normal baseline QRS duration
in a clinical trial of pacemaker therapy for sinus node dysfunction // Circulation. 2002. Vol. 107. P. 2932?2937.
12. Venkateshawar K., Gottipaty K., Krelis P. et al. for the VEST
investigators. The resting electrocardiogram provides a sensitive
and inexpensive marker of prognosis in patients with chronic
congestive heart failure // J. Am. Coll. Cardiol. 1999. Vol. 33.
P. 145A.
13. Wang N. C., Maggioni A. P., Konstam M. A. et al. for the
Efficacy of Vasopressin Antagonism in Heart Failure Outcome
Study With Tolvaptan (EVEREST) Investigators. Clinical
Implications of QRS Duration in Patients Hospitalized With
Worsening Heart Failure and Reduced Left Ventricular Ejection
Fraction // JAMA. 2008. Vol. 299, ? 22. P. 2656?2666.
????????? 04.07.2012
???????????? ??????
╘ ????????? ???????, 2012
??? 616.12-008.318-089.168:616.12-007-053.1-053.2-089.168
????????? ????? ?????? ? ????????????
? ?????? ????????????????? ???????
????? ????????????? ????????? ??????????
??????? ?????? ? ????? ??????? ????????
?. ?. ???????*, ?. ?. ?????????, ?. ?. ????????, ?. ?. ?????
?????? ???????????, ? 1, 2012
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
????. ?????????? ?????? ????????? ????? ? ????????????, ??????????? ? ?????? ????????????????? ??????? ? ????? ??????? ????????, ???????? ??????????????? ???????? ????????? ??- ? ????????????????? ???????? ??? ???????? ?????? ?????? ??????????.
???????? ? ??????. ? ???????????? ???? ???????? 235 ????? ? ???????? ?? 1 ???? ?? 3 ???, ????????????? ?? ?????? ?????????? ??????? ?????? (???) ? ???????? ?????????????? ??????????????
(??). ???????? ?????????? ?? ????????????: ??????? ????? 1 ???? ? ????? 3 ???, ??????? ??????????????? ????????? ????? ?????? ?? ???????????? ?????????????, ????? ???????? ??? ??????
??????? ?????? ????? ????? ???? ??? ??????? ??????????? ???????? ??????? ?????????, ???????
???????? ????? ????? ????? ????? ???? ??? ????????? ? ????? ???????? ???????????????????
??????, ? ????? ????????? ??????????, ?????????? ??? ????????? ??????????????? ?????????????? (??).
??????????. ???????? ????? ? ?????? ????????????????? ??????? ????? ????????????? ?????????
??? ??????????? ???????????? ??????? ? ???? ???????????? ?????????????? ????????? ??????? ????????????. ??? ?????????? 36% ??????? ? ????? ????????? ????????????????? ???????.
??????????????????? ?????????????? ??????????? ? 29% ???????, ????????? ???? ??????????????? ?????????? ? ? 17%, ??-??????? ????????? ???????? ? ? 10%. ????? ???????, ??? ???????
????? 25 ??? ?? ?????? ?????????? ?????????????, ?????????? ??????????? ????? ????????????????? ?? ? ????????? ????? ??? ????????? ??????? ??????????????? ???????????
(????) (70 ? 39 ??? ??????????????) ? ??????? ????? (100 ? 60 ??? ??????????????), ? ???* ????? ??? ?????????: e-mail: leoan@heart-house.ru
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
25
?? ?????????? ??????????? ????? ????????????????? ????????? ????? ??? ????????? ??????? ?????????????? ??????????? (????) (24 ???), ??????? ?? ???????? ?? II? ? II? ??., ?????????? ????????????? ????????? ??????? ?????????????? ??????????? (????) ??? ??????
?????? ?????????? ???? 32 ╟?, ???????? ???????????? ???????? ????????????????? ?????????
?????. ????? ???? ????????, ??? ?????????? ??????????? ????? ????????????????? ?? ? ????????? ????? ? ?????? ????? ? ???????? ?????, ? ????? ?????????? ??????????? ????? ????????????????? ????????? ????? ? ??????? ????? ? ???? ? ???? ???????? ???????????? ???????????? ???????? ??????? ? ?????? ????? ????? ???????????? ?????????????.
??????????. ????????? ??- ? ????????????????? ???????? ????? ???????? ????????? ????? ?
???????????? ? ?????? ????????????????? ??????? ???????? ??????????? ?????? ????? ?? ??????? ??????????. ??? ????? ?????????????? ??????? ????????? ? ???????, ? ????? ???????????? ???????, ??? ???????? ?? ???????? ??????????? ?????????, ????????????? ?? ?????? ??? ?
???????? ??.
? ? ? ? ? ? ? ? ? ? ? ? ? : ????????? ????? ?????? ? ????????????, ????????????? ????????? ?????????? ??????? ??????, ?????? ????????????????? ??????, ????.
? ??????? ?????????? ?????? ???????? ?? ???????? ?????? ?????? ????? 50 ???. ?? ??? ????? ?
???????? ?????? ???? ?????????? ????????????
??????. ??? ??? ???????? ???????? ? ?????????????? ??????? ?????????? ??????? ??????. ??????
??????? ???????? ?????????????? ?? ???????????:
????????? ?????????? ?????????????????? ???
????????????? ??????? ????????????, ??? ? ?????????? ?????????? ?????????????? ?????????????? ? ???????? ???????????????????? ???????.
?? ???? ??? ??????????? ??????? ????????????? ????????, ????????????????? ???????????????????, ??????????????????? ? ???????????????? ?????? ??????? ??????? ?????????? ?????????? ? ???? ?????????? ???????? ???????????.
???????? ??????? ???????? ? ?? ????? ??????
?? ????????? ????? [3, 18, 23]. ?????????????
????? ?????????? ? ?????? ?????????????????
??????? ???????? ? ??????????????? ????????????? ?????????? ?????? ? ?????????? ???????????????? ?????????, ?????????? ??????
?????????? ? ?????????? ??????????? ??????? ? ?
?????????? ??????, ??? ?? ?????? ????????? ? ?????? ???????? ?????? ?????????? ? ? ???????????
???????????? ???????????, ?? ? ???????????? ?????????? ?? ????????????? ???????????? ??????????? ?????????????? ???????.
?????? ????????? ?????, ??????????? ? ????? ? ?????? ????????????????? ???????, ??????
???????????? ??? ?? ????????? ????????, ??? ? ??
??????????? ??????. ???????? ????? ? ????????????????? ??????? ??????????? ???????????? ?
??????????????? ??????????????, ??????????????? ?????????? ? ????????? ???????????? ??
????????? ???????.
?????????????, ??????????? ??????? ? ????????? ????????????????? ??????? ? ????? ???????
???????? ? ??????????? ???????? ?????? ???????? ???????????? ???????? ??????? ?????? ???????? ?????.
? ????? ????????????, ?????? ??????????? ??????? ????????? ????? ? ????????????,
?????? ???????????, ? 1, 2012
Objective. The study aimed to determine the range of rhythm and conduction disturbances in early postoperative period in infants and prove the prognostic value of some pre- and intraoperative factors for development
of such complications.
Material and methods. The study included 235 children aged from 1 to 3 years who underwent surgeries for
congenital heart diseases (CHD) under cardiopulmonary bypass (CPB). Exclusion criteria were: age less than
1 year or more than 3 years, presence of confirmed heart rhythm disturbances before surgery except incomplete or complete right bundle branch block in presence of right ventricular myocardial hypertrophy, left anterior bundle branch block in presence of partial or complete atrioventricular canal defect and sinus tachycardia equal to circulatory failure (CF).
Results. Ventricular arrhythmias such as premature ventricular contraction (PVC) of different character were
frequently seen in early postoperative period after surgical correction of CHD. They were noted in 36% of
overall number postoperative arrhythmias. Supraventricular extrasystole occurred in 29% cases, different
types of supraventricular tachycardias ? in 17%, AV-blocks of different grades ? in 10%. We noted the following predictors for postoperative rhythm disturbance development: age more than 25 months at the moment
of surgery, prolonged CPB and aortic cross-clamping during ventricular septal defect (VSD) (70 and 39 minutes, respectively) and Fallot?s tetralogy correction (100 and 60 minutes, respectively) and exceeding the critical end-point of aortic cross-clamping during atrial septal defect correction (ASD) (24 minutes), presence of
IIA and IIb grade for CF before surgery, surgical correction of ASD under hypothermia of less than 32 ╟C.
Exceeding the critical end-points of CPB and aortic clamping in patients with Fallot?s tetralogy and exceeding the critical end-points of aortic clamping in children with VSD and ASD were shown to be the independent predictors for arrhythmia development in early postoperative period.
Conclusion. Detection of pre- and intraoperative risk factors for rhythm and conduction disturbances development in early postoperative period will contribute to composing the risk groups in terms of this complication.
This can facilitate the early detection, treatment and prevention of arrhythmias which will have an impact on
reducing the morbidity of patients operated for CHD under CPB.
K e y wo r d s : rhythm and conduction disturbances, surgical correction of congenital heart diseases, early
postoperative period, children.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
26
?????? ???????????, ? 1, 2012
??????????? ? ?????? ????????????????? ??????? ? ????? ??????? ????????, ?? ?????????? ??????? ??????????????? ???????? ????????? ??- ?
????????????????? ???????? ??? ???????? ????????? ?????? ??????????.
?????? ???????????, ? 1, 2012
???????? ? ??????
? ???????????? ???? ???????? 235 ????? ? ???????? ?? 1 ?? 3 ???. ??? ???????? ???? ??????????? ?? ?????? ?????????? ??????? ?????? ? ???????? ?????????????? ??????????????.
???????? ?????????? ?? ????????????: ????
?????? 1 ???? ? ?????? 3 ???, ??????? ??????????????? ????????? ????? ?????? ?? ????????????
?????????????, ????? ???????? ??? ?????? ??????? ?????? ????? ????? ???? ??? ??????? ??????????? ???????? ??????? ?????????, ??????? ???????? ????? ????? ????? ????? ???? ??? ????????? ? ????? ???????? ???????????????????
??????, ? ????? ????????? ??????????, ??????????
??? ????????? ??????????????? ??????????????.
???? ???? ????????? ?? ??? ??????. ??????
?????? ????????? 44 ???????, ? ??????? ??????
????????????????? ?????? ?????????? ????????? ????????? ????? ? ????????????. ??????
(???????????) ?????? ???????? ? ???? 191 ???????
? ????????????? ???????? ??????? ?????????????????? ???????.
??????? ????????? ? ??????????? ?????? ??
?????? ???????????? ????????????? ????????
23,8 ╠ 5,5 ???, ? ?????? ???????? ? 21,9 ╠ 5,6 ???.
????? ???? ? ????? ? ?????? ?????? ????????? ? ??????? 11,0 ╠ 2,9 ??, ?? ?????? ?????? ? 10,7 ╠ 2,8 ??.
?? ???????? 1?3 ???????? ????????? ?????????
? ????? ??????, ?????? ???????????? ? ??????
????????.
??????????? ????????? ?? ???? ? ??????
?????? ????????? (????????/???????) 25/19, ??
?????? ? 89/102.
?? ?????? ????? ????????????? ????????? ????? ????????? ???????????? ????????????? 32 ????????, ??? ???? ? ?????? ?????? ?? ???? 10, ? ??
?????? ? 22.
??? ??????????? ???????????? ? ?????????????? ??????? ? 177 ?? 235 ????? ???? ????????
???????? ??????????????? ?????????????? ????????? ??????? ???????????? ? ???? ??????,
?????????? ???????? ??????, ????????? ??????????, ??????? ?????? ? ??????. ??????????? ?????????????? ??????? ? ??????? ????????????
??????????????? ?????????????? (??) ? ?????????????? ?? ??????? ???????????? ? ??????? 1.
?? ?????? ????? ????????? ? 23 ?? ????????
?????????? ?????? ??????? ?????? ????? ?????
????: ? 5 (11,4%) ??????? ? ?????? ?????? ? ? 18
(9,4%) ? ?? ??????. ???????? ??????? ??????
????? ????? ???? ???? ???????? ? 90 ???????, ?
?????? ?????? ??????? ????????????? ???? ????????? ????????? 36,4% ???????, ? ?? ?????? ?????? ?
38,7% ???????.
??? ???????? ???? ??????????? ? ????????
?????????????? ?????????????? ?? ????????
? ??????? ???????? ??? ??????? ???????????
????????.
???? ????????? ?? ? ????? ???????? ?????????? ???????? ???????????? ????????????,
?????????? ??????????? ???????????????????,
???????????????? ???????????????, ??????????2%
2%
2%
2%
4%
2%
8%
38%
4%
16%
20%
????
????
??
????
??
?????
??? + ???
???? + ???
???? + ???
????????????? ????
??????
???. 1. ????????? ????????? ? ????? ??????:
???? ? ?????? ?????????????? ???????????; ???? ? ?????? ??????????????? ???????????; ?? ? ??????? ?????;
???? ? ????????? ????? ???????????????????? ??????;
?? ? ???????????? ?????????; ????? ? ????? ????????
??????????????????? ?????; ??? ? ???????????? ????????????? ???????; ??? ? ?????? ???????? ???????
2%
2%
9%
5%
18%
7%
23%
7%
7%
20%
????
????
??
????
??
?????
??? + ???
???? + ???
????????????? ????
??????
???. 2. ????????? ????????? ? ?????? ??????. ??????????? ?? ??, ??? ?? ???. 1
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
2%
2%
2%
8%
4%
43%
14%
19%
????
????
??
????
??
?????
??? + ???
???? + ???
???? + ???
????????????? ????
??????
???. 3. ????????? ????????? ?? ?????? ??????. ??????????? ?? ??, ??? ?? ???. 1 ? 2
?? ? ? ? ? ? 1
????????????? ????????? ? ???????
? ??????????? ?? ?????? ???????????????
??????????????, ???. (%)
?????? ??
?????? ??????
?????? ??????
0
I
II?
II?
5 (11,4)
13 (29,5)
22 (50)
4 (9,1)
53 (27,7)
85 (44,5)
50 (26,2)
3 (1,6)
???????? ???????????? ??????? ??????? ??????, ?
????? ???????? ???????????? ??????? ????????????. ????????? ????????? ??????????? ???????????? ??????????????? ???, ???????????? ???????? ?????? ? ????????????????????? ????????????.
????????? ????? ????????????? ?? ??????
???????????? ??????????? ???, ??????????? ????????????? ???, ????????????? ??????????????? ???. ???????????? ?????????????? ??????????? ?? ????????????? Lawn?Wolf (1983). ? ???????????? ??????????? ?????????????? II ??????
? ????.
?????????????? ????????? ?????? ?????????
?? ???????????? ?????????? ? ??????? ???????? Primer of Biostatistics, version 4.03 ? Statistica
6.0 for Windows.
?????????? ???????????? ??? ? ╠ ?. ?????? ???????????? ? ??????????????, ???????????????.
????????, ??? ? ????????? ??????? ??????? ????
?????????? ???????, ????????????? ?? ??????
????????? ???????????, ? ????? ????????????? ???
?????????????, ??? ????????? ??????????????
??????????? ???? ??????????? ????? ? ??????????? ???????? ????? ???? ???????????? ??????-
??????????? U-???????? ???????????. ? ???
???????, ????? ??????? ???????? ???????????,
????????????? ? ??????????????? ?????????,
?????????? ???????????? ? ??????????? ?????????????? ??????? ? ???????? ?????????. ???
????????? ???? ????? ?? ???????????? ?????????
????????? ?????????????? ?????? ???????????????? ?????? ? ??????? ?????????? ???????? ??
?2-???????? ? ????????? ??????. ?????????? ?????? ???????? ???????? ????????? ????? ?????
??????????? ????????? ??? ? ?????????? ????????????? ???????? ???????? ???????????? ??????? ?????????????? ?????????????? ??????? ? ??????? ??????????? ????????? ????????? ?
?????????? ?????????? ?? F-???????? ??????.
?????????????? ?????????? ????????????? ?????????? ? ????????? ????????? ?? t-????????
?????????. ?????????? ????????? ?????????????
???????????? ??? ???????? p < 0,05.
??????????
? ????? ???????????? ????? ??????? ????????????? ??????? ? ?????? ????????????????? ??????? ????????? 19% (? 44 ?? 235 ?????????????
?????????). ???? ????????????? 52 ?????????
????? ??????. ??????? ???????? ???????????? ?????????????? ? ????? ?????? ????? ??????? ???????? ? ??????????? ???????? ?????? ????????? 8%,
??????????????? ?????????????? ? 6,4%, ??????????????? ??????? ?????????? ? 3,4%, ???????
???????????? ?????????? ? 0,4%. ????????? ??????????? ???? ???????? ? 1,7% ???????, ? ???????? ??-??????? II ? III ??????? ???? ????????????? ? 0,9 ? 1,3% ??????? ??????????????. ??? ??????? ??????? ??????? ???? ????????, ??? ?
?????? ????????????????? ??????? ????? ????????? ?????????? ??????? ?????? ???????? ????? ??????????? ???????????? ?????????????? ?
37,3%, ??????????????? ?????????????? ? 29,4%,
??????????????? ?????????? ? 15,7%, ?????????
??-???????????? ????????? ??????? ???????????? ? 9,8%.
? 6 ????????? ????? ????????????? ?????????
?????? ?????? ? ???????????? ??????? ???? ????????????? ??? ????????? ???? ???????, ? ?
1 ???????? ? ??? ????.
???? ??????? ???? ??????? ? ????? ?????????
????????????????? ????????? ????? ????????
?? ??????? 4.
???????????? ?????????????? ??????????? ??
????????????? Lawn?Wolf (1983). ? 11 ?? 19 ??????? ?? ???? ????????????? ??????????????
II ??????, ? 7 ? III ??????, ? 1 ? IV? ??????. ?? ???? ????????????? ?? ?????? ?????? ????????????
?????????????? IVB ??????, ?????????? ???????????? ?????????? ? ???????????? ??????????????
?????? ???????????, ? 1, 2012
1%
1%
4%
27
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
28
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2%
8%
6%
4%
29%
15%
36%
???
??
???
??? II ??.
??? III ??.
??
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?????:
??? ? ??????????????? ??????????????; ?? ? ???????????? ??????????????; ??? ? ??????????????????? ???????;
?? ? ????????? ???????????; ??? ? ??????? ???????????? ??????????
???? ╚R ?? ?╩. ??? ?????????? ???????????? ????????? ????? ?? ?????????????? ??????-????
???????????? ???????????? ? ????????????????? ????????????? ???????????????????????.
?????? ? ????? ?????? ???????????? ?????????????? ?????????????? ?????????? ????????? ????????? ????????????.
????????? ????????? ????? ? ??????????? ??
???????? ??????????? ?????? ?????? ????????????
? ??????? 2.
???????? ????? ? ?????????? ????? ?????????? ????????? ????? ??????????? ????? ??????????? ????????? ??????? ?????, ???????? ??????????????? ? ?????????????? ???????????.
??? ?????? ??????? ???????? ????????? ????? ?
?????? ????????????????? ??????? ? ??????????? ?? ????????????????? ???????? ????????, ???
???????????????? ??????? ???? ????????? ???
????????????? ??????? ??????? ?????????? ??????? ??????: ?????? ????????? ???????????????????? ?????? (?????) ? 60% (?????? ? 2 ??
3 ??????? ???? ????????????? ??-??????? III ???????), ??????? ???????? ??????? ? 50%, ???????????? ????????????? ??????? ?? ???????? ????????? ?????? ?????? ????????? ? 40% ? ??. ??? ????????????? ?????????? ????????, ????? ???
?????? ?????????????? ? ??????????????? ???????????, ????????? ????? ? ?????? ????????????????? ??????? ??????????? ? 9,5 ? 19,6% ??????? ?????????????? (???. 5).
??? ????????????? ???????????? ?????????
????? ?????????? ?? ?????? ????? ????? ?????????????? ?????????????, ????? ??? ???????????????, ??? ??????????, ??? ? ??????????????, ? ??
?????? ????????????????? ?????.
??????? ????????? ???????? ? ?????? ??????
?????? ????? ????? ???? ?? ????????? ? ??????????????? ??????? ? ????? ??????????? ???????
?????????? ?? ??????????.
? ?????? ?????? ????????????? ?????????? ??????????? ???????? ? ?? II? ??. (? = 0,004) ? II? ??.
(? = 0,031), ? ?? ????? ??? ?? ?????? ?????? (???????????) ? ? ?? I ??. (? = 0,038).
???????? ?????? ?????? ???? ??????????
?????? ????????? ??????????? ?????? ?? ??????
??????????
??????????????
?????????????
(? = 0,044). ??????? ??????????? ??????? ????? ???? ????????? ? ????? ??????? ?? ????????? ???????
????????????? (? = 0,593).
? ?????? ?????? ??????? ???????????? ?????????????? ?????????????? ??? ????????? ?????????? ??????? ?????? ????????? 100,9 ╠ 35,6 ???,
?? ?????? ?????? ? 68,8 ╠ 32,0 ??? (p < 0,0001).
??????? ?????????? ???? ???????? ???? ?
????????? ???????????? ?????????????????
?? ? ? ? ? ? 2
????????? ????????? ????? ? ?????? ????????????????? ???????
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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30
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61,9 ╠ 27,8 ???, ? ?? ?????? (???????????) ?
38,4 ╠ 23,9 ??? (p < 0,0001).
??? ???????? ????? ????????????? ???????
?????? ?? ?????????? ??????????? ????? ???????????? ?????????????? ?????????????? ? ????????????????? ????????? ?????, ?? ???? ????? ????????? ???????? ???????????, ?????????? ??????? ?????????????? ??????????? ???????????
??????? ???????? ????????????????? ???????.
??? ??????? ????? ????????????????? ?????????????? ??????????????, ????? ???????? ?????????? ????????????? ??????? ???????? ?????????
????? ? ?????? ????????????????? ???????, ????????? 100 ??? (p = 0,034), ? ??????? ????????????????? ?????? ???????? ? 60 ??? (p = 0,034).
??? ???????? ?????????????? ??????????? ???
?????????? ????????? 50 (p = 0,022) ? 24 ???
(p = 0,013) ??????????????, ??????????????? ? 70
(p = 0,027) ? 39 ??? (p = 0,018) ??????????????.
??????? ?????????? ?????? ????????????????? ?????????? ? ?????? ???????????? ????????
29,0 ╠ 1,6 ╟?, ? ?????? ????????? ? 30,0 ╠ 3,0 ╟?
(p = 0,037).
??????? ???????? ????????? ????? ? ??????
????????????????? ??????? ???? ?????????? ???? ? ?????????, ??????? ????????? ?????? ?????? ??????????? ??? ?????? ?????????? ???? 32 ╟C
(p < 0,0001). ??? ???????? ????????, ?????????????? ? ??????????? ?? ???????? ???, ??????????? ??????????? ????? ?? ?????????? ??????
??? ??????? ?????????????? ??????????? (32 ╟C,
p < 0,0001).
????????????? ????????????? ?????? ??????
??? ??????????? ???????? ????????? ????? ?????
??????????? ????????? ???. ????? ???????, ???
??????? ?? ?????? ?????????? ?????????????
?????? 25 ???, ?????????? ??????????? ?????
????????????????? ?? ? ????????? ????? ???
????????? ???? ? ??????? ?????, ? ????? ?????????? ??????????? ????? ?????????????????
????????? ????? ??? ????????? ????, ?????????????????? ??????? ?????????????? ????? ?
????????? ????????????????? ????????? ?????.
????? ? ????? ???????????? ???? ???????? ???????, ??????? ????????? ??????????????
?????: ??????? ?? ???????? ?? II? ? II? ??., ?????????? ????????????? ????????? ???? ???
?????? ?????? ?????????? ???? 32 ╟?.
? ????? ???????????? ??? ??????????? ??????????? ??????????? ???????? ????????? ????? ?
?????? ????????????????? ??????? ? ????? ??????? ????????, ??????? ???? ????????? ??????????? ????????? ??????? ?????? ? ???????? ?????????????? ??????????????, ?? ???????????? ??????
????????????? ?????????. ?? ?????????? ??????,
?????????? ??????????? ????? ????????????????? ?? ? ????????? ????? ? ?????? ????? ? ????????? ??????? ?????, ? ????? ?????????? ??????????? ????? ????????????????? ????????? ????? ?
??????? ????? ? ?????????? ???? ? ???? ???????? ???????????? ???????????? ??????? ? ?????? ????? ????? ???????????? ?????????????.
??????????
?????????? ????? ??????????? ?????????
?????????? ??????? ?????? ?????????? ??? ??????
?????? ???????????, ? 1, 2012
???. 5. ??????? ???????? ????????????????? ????????? ????? ? ??????????? ?? ????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????? ???????????, ? 1, 2012
30
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?????????? ????????? ????????? ?? ?????????
????????????????? ?????? ? ???????? ????? ??
?????? ??????????? ??? ? ??????????. ? ??????????? ??? ???????? ?????????, ?????????? ????????????? ? ???????? ?????????????? ??????????????.
?? ?????? ??????????? ???????, ?????????
????? ? ?????? ????????????????? ??????? ????? ????????? ?????????? ??????? ?????? ? ?????????????? ?????????????? ??????????????
????????? ? 15?48% ??????? [10, 20, 23, 24].
??? ???????? ??????????????? ??????? ????????? ???? ????? ????? ?????????? ?????? ????
????????, ??? ? ????? ? ??????????? ????????
??????? ?????????????????? ??????? ???????????? ??????????? ???? ?????????? ?????? ??
????????? ? ??????????? ??????? (? = 0,044). ???
??????????? ? ??????? ???? ??????? [8]. ?. Pozzi
? ?????. ?????????????????? ???????? ?????????? ? 132 ????????? ? ????????? ╚??????? ?????╩,
???????????????? ?????????? ? ???????? ?? 2,3 ??
63,6 ???. ?????? ???????? ?????? ??????? ????????????? ????????? ????? ?????? ? ???????
??????????? ? ?????? ? ?????????? ????????????????? ???????? [22].
? ????????? ????? ? ?????????? ??? ???? ??????????? ????????? ? ?????? ??????????? ????????? ?????????? ??????? ??????, ?????? ?? ?????? ????????????? ??????????? ????????, ?? ?
??????? ??????????????? ????????? ????????
[2, 12, 17, 18]. ??? ????????? ????????? ?????????? ????????? ? ??????? ?????????? ????????????
????????????? ?????? ????????????? ??????? ???
??????????????? ??????? [2, 9, 16, 22]. ?? ??????
?????? ???????, ????????? ????????? ????? ???
????? ??????? ???????????: ??? ????? ???????
??????????? ?????? ???????????? ?????? ????????-?????????? ??????? ? ?????? ?????????? ???????? ? ?? ?????????? [19], ???? ????????????????? ???????? ???????-????????????? ?????? (???
??????? ? ?????????? ?????????? ? ????? ?????
??????????????), ??????????????? ???????????
???????? ??????????? (??? ??????? ? ??????????? ?????????? ? ????? ????? ??????????????),
???????? ????????? ????? ????? ? ?????????? ??????????????? ??? ??????? ? ?????????? ???????
[2, 5, 15], ? ????? ???????????????? ???????????
???????? ?????????? ? ????????? ? ??? ????????
??????????????????? ???????, ???????????? ?
?????????? ?????????? ?????? ????????? ? ???????? ??????????? ????- ?/??? ???????????? [14, 21,
22]. ????? ????, ??????? ???????? ?????????????
????????????? ????????????? ??????????. ???
?????? ?????????? ???????? ?? ?????? ?????????????? ????????????? ? ??????? ╚??????????╩ ????????????? ????? ?????????, ??????? ????? ????
????????? ??????????? ???????.
?? ?????? A. Garson ? ?????., ???????? ????????? ????? ? ?????? ????? ????? ?????????
??? ?????????? ??????????? ? ??????????? ???????? ?? ?????? ?????????? ????????????? [13].
?. ?. ??????? ????????, ??? ??? ???????????
????????? ??????? ????? ? ????? ?????? 18 ??? ?
????????????????? ??????? ?????????? ????
??????????? ???????????? ????????? ????? ??
????????? ? ??????, ?????????????? ? ?????
?????? ???????? [4].
????? ????????????, ??? ?????????????
??????? ? ?????? ????????????????? ??????? ?
??????? ???????????? ???????? ???????? ???????? ??????????? ??????????????? ????????, ?????????????? ????????????? ? ??????????????
??????????? ?????? ??????. ?????????? ????????? ???????????? ? ?????????? ????????????
?????????? ???????? ? ???????? ?????????????? ? ?????????????? ????????? ? ????????, ???????? ??? ?????????????? ??????????? ?, ???
?????????, ? ????????????? ?????????????? ???????? [1, 4].
? ????? ?????? ??? ??????????? ????????????
??????? ?? ???????????? ????????????? ? 75,3%
??????? ???? ???????? ??????????????? ?????????????? (??) ????????? ??????? ????????????.
? ?????? ?????? ??????????? ???????? ? ???????????????? ?????????????? II? ? II? ??. (? = 0,004
? ? = 0,031 ??????????????), ? ?? ????? ??? ?? ?????? ?????? ? ? ?? I ??.
???? ?????? ? ??????? ???????? ? ??????????????? ?????????????? ??????? ?????? ?? ????????????? ????????????????? ??????? ? ?????????
? ?????????????? ???????????? ???????????? ??????? ??????????????????? ????????? ? ?????
?????? ??? ????? ?????? ???????????? ??????
?????? ???????????? ? ????????????? ?????????? ??????? ?????????????? ????????????? ???
?????????? ??????? ??????.
???????? ????????? ?????????????????? ???????????? ? ????????????????? ??????? ?????
???? ?????????? ??????????? ?????????? ?????
?? ???? ???????: 1) ? ????????????? ?????? ?????????? ???????, ??????? ??????? ?????????? ??
???? ????; 2) ?? ?????? ????????????? ?????;
3) ?? ????????? ? ???????????? ?????? ???????
????????? [2, 19].
?????? ??????????? ????, ??? ????????? ?????????? ??????? ????? ????????? ?? ?????? ??????
????????: ?? ????? ???????????????, ????????
??????????????? ?????, ?? ????? ????????
???? [1, 4].
??????????? ???????????? ?????? ????? ?
????????? ???????????? ????? ????? ??????????????????????? ????? ?????? ?? ???????? ????????????? ????????????? ???????????? [6, 7].
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
????? ?? ??????? ????? ??????? ?????????????
????????? ???????? ? ?????? ???????? ? ?????????? ?? ? ?????? ????????????.
?? ?? ??????? ???????????????? ??????? ??
???????? ?????? ????????????????? ??????? ????? ????????, ??? ????? ????????? ?? ?????? ?????????????? ?????????????, ??????? ????????????? ????????????? ????????????? ? ????????, ???? ? ?????? ????????? ? ???????? ?????, ? ?????
???? ?? ???? ?????????? ?? ?????? ????????????????????????? ??? ????????????????????? ??????????, ?????????? ????????? ? ???? ??????????
????????? ????? ? ???????????? ? ?????? ?????
????? ?????????????? ?????????????.
??????????
???????? ?? ????????? ????? ??????? ?????????????? ??????? ? ?????????????? ????????
??????????, ?????????????????? ??????? ??????
???????? ? ?????????? ?????????, ?????????????????? ????????????????? ??????? ???????? ???????????? ???????. ???????? ????? ? ?????? ????????????????? ??????? ????? ?????????????
????????? ?????????? ??????? ?????? ??????????? ???????????? ??????? ? ???? ?? ?????????
??????? ????????????. ??? ?????????? ????? ????? ??????? ? ????? ????????? ?????????????????
???????. ??????????????????? ??????????????
??????????? ? 29% ???????, ????????? ???? ??????????????? ?????????? ? ? 17% ???????, ??-??????? ????????? ???????? ? ? 10%. ????? ???????,
??? ?????????? ?? ? ?????????? ????????? ?????
? ??????????? ??????????? ????? ? ?????? ?????
? ???????? ?????, ? ????? ?????????? ??????????? ????? ????????????????? ????????? ????? ?
??????? ????? ? ???? ? ????, ???????? ???????????? ???????????? ??????? ? ?????? ?????
????? ???????????? ?????????????.
??? ????? ????????? ?????? ???? ?????????
??-, ?????- ? ????????????????? ????????, ????????? ?????? ?? ???????? ??????? ????? ????????????? ????????? ?????????? ??????? ??????,
????????????? ? ???????? ?????????????? ??????????????, ?????????? ?????????? ?????? ????
??????? ????????????? ???????????? ? ????????? ???????? ?????????? ???????????.
? ? ? ? ??? ? ??
1.
2.
3.
??????? ?. ?., ???????? ?. ?., ??? ?. ?. ? ??. ??????????
???????? ????????? ????? ? ????? ??????? ???????? ? ?????? ????? ????? ???????? ??????????? ????????? ???????
????? // ?????? ???????????. 2006. ? 5. ?. 66?74.
??????? ?. ?. ???????????????? ??????? ?????? ? ?????. ??.-???. ????????????. ?.: ????? ??. ?. ?. ???????? ????, 2009. C. 52.
??????????? ?. ?., ???????? ?. ?., ????????? ?. ?. ?
??. ?????????? ??? ????????? ?? ???????? ?????? (?????? ?????????????? ? ??????????????)., ?.: ????????,
1972. C. 304.
?????? ???????????, ? 1, 2012
? ????? ???????????? ? ?????? ? ??????????? ???????? ??????? ?????????????????? ??????? ??????? ????????????? ?????????? ??-??????? II ??????? ????????? 4,5% ???????. ???????????? ??-??????? ???? ???????????????? ?????? ?
?????? ???????? (2,3% ???????) ????? ?????????
?????? ????????? ???????????????????? ??????.
?o ?????? R. Arnold ? ?????. ? ?. ?. ?????? ? ?????., ????????? ?????? ?????????? ?????? ????
????????????? ??????????? ??-???? ?? ????? ???????? (? ???? ?????? ??-??????? ??????? ?????????? ????? ????? ????????? ????????), ???? ???? ?
??????? ??-??????????, ???????????? ? ????? ?
???????????? ??? ???????????? ??????????
??-???? ?????? [5].
????????????? ?????????????? ?????????????? ? ?????????? ? ?????????? ????? ???????? ?
??????????-??????????????? ??????????? ????????, ??????? ??????? ??????????????? ??????????????? ??? ???? ?? ??????????? ???????? ????????????????? ???????. ???? ?????? ? ???? ??????? ??????????? ? ??????? ??????????? ???????
[1, 4, 10, 23], ???????????????????? ??????? ????????????????? ?????????????? ??????????????
? ????????? ????? ?? ???? ???????? ?????????
????? ????? ????????????? ????????? ???.
J. Rekawek ? ?????. ????????? ?? ?????????? ????? ?????? ????????????? ????????????????? ????????? ????? ?????? ??? ?????????? ????????
?????????? ? ?????????????? ??????, ??? ??? ????????????? ????????? ?????????? ??? ??????????? (31,6 ? 15,7% ??????????????; ? = 0,0188)
[23]. ?? ??????? ??????????? ??????? ??????
????????????????? ?????????? ?? ???????? ????????? ????? ? ????????????????? ??????? ?
??????? ??? ???????????? ???? ? ?????????????
??????? ????? ????????? ????????????? ???????? ?????????????? ??????????? ??? ?????? ?????????? ???? 32 ╟? (p < 0,0001). ??? ?????? ?????? ??? ????????????? ????????? ??????? ?????? ?????????? ?? ???????? ?????????????????
??????? ???????? ?? ????.
J. Pfammatter ? ?????. ???????? ? ??????????????? ???????? ?????????? ? ?????????????????
??????? ?????????????? ???????? ???????????,
????????????? ??????? ??????????????? ??????????? ?/??? ???????????? ?????????? ???????????? ???????????????????? ??????? [20]. A. Garson
? ?????. ???????????? ?????????? ??????????
?????????? ???????????????? ????????, ? ????????? ???????????? ?????????? ????????? ??????
??????? ?????????, ? ????????? ??????? ????? ?????????????? ????????????? [13]. ??? ?? ???????
??????????? ??? ???????????? ??????????? ??????? ?????????? ????????? ???????????? ?? ???????? ????????? ????? ? ????????????????? ??-
31
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
32
?????? ???????????, ? 1, 2012
??????? ?. ?. ??????????????? ??????? ???????? ????-
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
????? ????? ?????? ? ????? ??????? ???????? ? ??????
????? ????? ???????? ??????????? ????????? ???????
?????: ???. ? ????. ???. ????. ?., 2007. C. 103.
???????? ?. ?., ???????? ?. ?., ????????? ?. ?. ? ??.
????????? ? ??????? ??????? ??????? c ???????? ????? //
??????? ??????? ?????? ? ???????. 2005. ? 3. ?. 21?26.
????? ?. ?., ???????? ?. ?. ????????????? ????????
?????????? ??????? ??????. ?.: ????????, 1985. C. 272.
??????? ?. ?. ?????????? ??????? ??? ?????????? ???????? ??????????? ??????. ????: ?????????, 1973. C. 236.
Alexiou Ch., Mahmoud H., Al-Khaddour ?. et al. Outcome
after repair of tetralogy of Fallot in the first year of life // Ann.
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Caspi J., Zalstein E., Zusker N. et al. Surgical management of
tetralogy of Fallot in the first year of life // Ann. Thorac. Surg.
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Delaney J., Moltedo J., Dziuraet J. et al. Early postoperative
arrhythmias after pediatric cardiac surgery // J. Thorac.
Cardiovasc. Surg. 2006. Vol. 131. ?. 1296?1300
Dodge-Khatami A., Miller O., Anderson R. et al. Impact of
junctional ectopic tachycardia on postoperative morbidity following repair of congenital heart defects // Eur. J. Cardiothorac.
Surg. 2002. Vol. 21. ?. 255?259.
Fraser Ch. D., McKenzie E. D., Cooley D. A. Tetralogy of
Fallot: surgical management individualized to the patient //
Ann. Thorac. Surg. 2001. Vol. 71. P. 1556?1563.
Garson A. Jr, Gillette P., Titus J. et al. Surgical treatment
of ventricular tachycardia in infants // N. Engl. J. Med. 1984.
Vol. 310. P. 193?195.
Geva T., Ayres N. A., ??? F. A. et al. Quantitative morphometric analysis of progressive infundibular obstruction in tetralogy
of Fallot: a prospective longitudinal echocardiographic study //
Circulation. 1995. Vol. 92. P. 886?892.
15. Ishizaka ?., Ichukawa H., Sawa Y. et al. Prevalence and
optimal management strategy for aortic regurgitation in tetralogy of Fallot // Eur. J. Cardiothorac. Surg. 2004. Vol. 26.
P. 1080?1086.
16. Hennien H. A., Mosca R. S., Ur?elay G. et al. Intermediate
results following complete repair of tetralogy of Fallot in
neonates // J. Thorac. Cardiovasc. Surg. 1995. Vol. 109, ? 2.
P. 332?343.
17. Kaushal S. K., Iyer K. S., Sharma R. et al. Surgical experience with total correction of tetralogy of Fallot in infancy // Int.
J. Cardiol. 1999. Vol. 56, ? 1. P. 35?40.
18. Kirklin J. W., Blackstone E. H., Pacifico A. D. et al. Risk
factors for early and late failure after repair tetralogy of Fallot
and their neutralization // Thorac. Cardiovasc. Surg. 1984.
Vol. 32. P. 208?214.
19. Moss A. J. Risk of mortality in patients with potentially malignant arrhythmias // J. Ambul. Monitor. 1989. Vol. 2. P. 15?19.
20. Pfammatter J.-P., Wagner B., Berdat P. ?t al. Procedural factors associated with early postoperative arrhythmias after repair
of congenital heart defects // J. Thorac. Cardiovasc. Surg. 2002.
Vol. 123. P. 258?262.
21. Pigula F. A., Khalil Ph. N., Mayer J. E. et al. Repair of
tetralogy of Fallot in neonates and young infants // Circulation.
1999. Vol. 100 (Suppl. 2). P. 157?161.
22. Pozzi M., Trivedi D. B., Kitchiner D. et al. Tetralogy of Fallot:
what operation, at which age // Eur. J. Cardiothorac. Surg.
2000. Vol. 17. P. 631?636.
23. Rekawek J., Kansy A., Miszczak-Knecht M. et al. Risk factors for cardiac arrhythmias in children with congenital heart
disease after surgical intervention in the early postoperative period // J. Thorac. Cardiovasc. Surg. 2007. Vol. 133. P. 900?904.
24. Valsangiacomo E., Schmid E., Schupbach R. et al. Early
postoperative arrhythmias after cardiac operation in children //
Ann. Thorac. Surg. 2002. Vol. 74. P. 792?796.
????????? 07.06.2012
╘ ????????? ???????, 2012
??? 616.12-008.46-089.168
?????? ???????????, ? 1, 2012
??????????????? ?????? ??????????? ??????????
??????????? ?????????????????? ???????
? ????????? ? ????????? ????????????????
?. ?. ???????*, ?. ?. ???????, ?. ?. ????????????, ?. ?. ??????????, ?. ?. ????????,
?. ?. ?????????, ?. ?. ??????, ?. ?. ???????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
????. ??????? ????????????? ? ???????????? ????????? ?????????????????? ??????? (???) ? ????????? ? ??????????? ????????? ???????????????? (???).
???????? ? ??????. ? 2007 ?? 2012 ?. ??????? ??????????? ????????? ?????????????????? ??????? (???????????? ??? ? ????????? ? ?????????????-?????????????? ? ???-?) ????????? 60 ?????????, ?????????? ??? ????????? ?????????: 37 (61,6%) ????????? ?????????????? ?????????? ??? ???, 23 (37,4%) ??????? ? ????? ? ???????????? ??????????? ? ????????-???????? ??????????? ? ???????? ? ??? ???-?. ????? ??????? ???? 42 (70%) ???????? ???????? ???? ? 18 (30%) ?
???????? ????. ??????? ????????? ?????????? ?? 2 ?? 75 ??? (??????? ??????? 53,6 ╠ 14,7 ????).
* ????? ??? ?????????: e-mail: leoan@heart-house.ru
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
33
??? ?????? ????????????? ?????????? ??? ??????????????? ??????????? ????????????????????
?????????, ?????? ????????? QRS, ????????? ??????????????? ?????? ??? ?? NYHA ?? ? ?????
????????. ???????????? ?????????? ?????????????????? ??????? ????????? ?? ????? ?????????? ?
????????????????? ???????.
??????????. ?? ???? ???/???-? ?????????? ?????????? ?????? ????????? QRS ?? 17 ╠ 12 ??,
?????????? ??????? ?????? ????????? (????????? ?????????????? ?????? ? ?? 28,6 ╠ 20 ??, ????????? ??????????????? ?????? ? ?? 30,3 ╠ 21 ??), ?????????? ??????? ??????? ?????? ????????? ??
8,5 ╠ 6%.
? 46 (76%) ????????? ?????????? ?????????? ??????? ????????? ??????????????? ?? ???? ?????????????? ?????, ? 7 (11%) ????????? ??????????? ????????? ?????????? ?? ??? ??????????????
??????.
? 51 ???????? ????- ? ??????????????????? ?????????? ?? ???????????. ????????????????? ??????????? ????????? 0%.
??????????. ? ?????????? ??????? ????? ??????????? ?????????????????? ?????? ?????????? ????????????? ???????? ???????????? ?????????, ??????????? ????????????, ????????????? ? ?????????? ????????. ???????? ? ???????????? ?????????? ? ????????? ????????? ???????????????? ??? ??????? ????????? ???????????? ???????? ?????????????? ???????????
??? ????????? ?????????????????? ???????. ????????? ??????????? ????????? ??? ? ???-?
?????? ?????????? ??????? ?????????????? ??????? ????????? ? ?????????? ????????? ???
? ???????? ??????? ?????? ??????? ??? ?????????????? ? ??????????? ??????????????? ???????.
? ? ? ? ? ? ? ? ? ? ? ? ? : ?????????????????? ???????, ????????????-?????????????, ????????? ???????????????.
? ????????? ??????????? ??????????? ???????? ??????????? ???????? ????? ?????????? ??????????? ????????? ??????????????? (???) ? ????? ? ?? ??????? ???????????????????, ???????
??????? ?????????? ? ?????????? ?????? ?????
????? ??????? ???????????. ???, ? ??? ?????
??????? ??????????? ????????? ???????????????? ?????????? ????? 4790 ???. ??? ????????? ????????? ????? 550 ???. ????? ??????? [7]. ???????? ?? ????????? ? ???????? ??????????? ???????? ????????????????? (?????????? ???,
????????? ?????????, ?????????, ????-?????????,
??????????? ???????????? ? ??.) ? ?????????????
(???????? ????????????????, ??????????? ?????????????? ????? Ancor ? ????? ?????????????
??????????? ??????????????? ??????, ??????????? ????????? ???????????????? ??????????????,
?????????????? ??????) ?????? ????????? ???,
????? ????????? ?? ?????? ????????? ????? ???????? ??????? ????? ?????? 5 ??? [111].
??????????? ????????? ??????????????? ???????? ? ???????????? ?????????????? ? ??????????. ?? ?????????????????? ? ???? ?????????? ?????? (????? 22 ??? ???????), ???????? ? ??
(??????????? ? 7% ????????? ? ????? 7,9 ??? ?????????) [1, 2]. ? ???????? ??????? ? ?????? ???????? 2,5% ???????? ???????? ???. ????? ???????, ??????? ??? ???????? ????? ?? ??????? ????? ??????????????? ???? ???????????? ????????
?????.
? ????? ???????? ????????????? ???????????
????????? ???, ???????????? ? ??????????????? ???????, ? ????????? ????? ?????????????
????????? ?????????????????? ??????? (???) ?
??????? ???????????????? ??????????????????????? [5].
?????? ???????????, ? 1, 2012
Objective. The study aimed to evaluate the efficiency and safety of cardiac resynchronization therapy (CRT)
in patients with chronic heart failure (CHF).
Material and methods. Chronic cardiac resynchronization therapy (isolated or combined with cardioversiondefibrillation) was used between 2007 and 2012 in 60 patients with CHF of different origin: 37 (61.6%)
patients underwent implantation of devices for CRT, 23 (37.4%) patients with cardiopulmonary resuscitation
in history underwent CRT-D for ventricular tachycardias. 42 (70%) patients were males and 18 (30%) ?
females. Age varied from 2 to 75 years (mean age ? 53.6 ╠ 14.7 years).
The efficiency of CRT was determined according to standard echocardiographic characteristics, length of QRS
interval, changes of NYHA functional class for CHF before and after surgery. Safety of resynchronization therapy was assessed according to the number of complications in postoperative period.
Results. CRT/CRT-D therapy was associated with reduction of interval in QRS-complex by 17 ╠ 12 ms and
left ventricular volume reduction (end-systolic volume ? by 28.6 ╠ 20 ml, end-diastolic volume ? by 30.3 ╠
21 ml). Left ventricular ejection fraction increased by 8.5 ╠ 6%.
Grade of heart failure reduced by one functional class in 46 (76%) patients. Clinical state of 7 (11%) patients
improves by two functional classes.
51 patients had no peri- and postimplantation complications. Intraoperative mortality was 0%.
Conclusion. Improvement of clinical state, hemodynamic rates, tolerance to physical exercise was noted in a
long-term period after implantation of resynchronization systems. Patients with atrial fibrillation and congestive heart failure in presence of dyssinchrony are considered to be suitable candidates for cardiac resynchronization therapy. Procedure of CRT and CRT-D device implantation is a safe method of surgical treatment in
patients with different grades of CHF and can be the treatment of choice in case of resistance to optimal drug
therapy.
K e y wo r d s : resynchronization therapy, cardioversion-defibrillation, heart failure.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
34
?????? ???????????, ? 1, 2012
?????????????????? ??????? ???????? ??????????? ??????????? ? ?????????? ??????? ??????? ????????? ? ????????? ????????????????,
?????? ??? ? ?????? ??????? ????????? ??????????????? ? ????????? ? ??????? ????????? ???????? ???????, ??????? ?????????? ???????? ??
?????? ? ???????? ?????????????? ?????????????? (?????????? ????????? ????????????????
??????????) [4], ??? ? ? ??????? ??? ? ???? ?????????? ??????????? ?????????????????? ??????? [3, 12].
?????? ?????? ????????? ??????????? ???????????????? ??????? ?????????? ??????????? ?????????????????? ??????? ? ????????? ? ???.
???? ???????????? ? ??????? ????????????? ?
???????????? ????????? ?????????????????? ??????? ? ????????? ? ??????????? ????????? ????????????????.
?????? ???????????, ? 1, 2012
???????? ? ??????
? 2007 ?? 2012 ?. ??????? ??????????? ????????? ?????????????????? ??????? (????????????
??? ? ????????? ? ?????????????-?????????????? ? ???-?) ????????? 60 ???????, ?????????? ??? ? ??????? ???????????? ????????? ???
??????????? ?????????????????? ????????? [6,
8, 10]. ????? ??? ???? 42 (70%) ???????? ???????? ????, 18 (30%) ? ????????. ??????? ?????????
?????????? ?? 2 ?? 75 ??? (??????? ??????? ?
53,6 ╠ 14,7 ????).
? 29 (48,3%) ????????? ????????? ??????????????? ???? ??????????? ??????????? ??????????,
? 29 (48,3%) ? ????????????? (?????????????,
???????????????? ??????????????, ???????????????????? ?????????????, ????????????? ??????
???????? ??????) ? ? 2 (3,4%) ? ?????????. ? 20
(33%) ????????? ??????????? ???????????? ??????????? ????????? ??????? ????????????.
??????? 11 ????????? ?????????? ?? II ??
??? ?? NYHA, 43 ? ? III, 5 ? ? IV.
????????? ???????????? ? ???? ?????? ??????? ????? ????? ????? ???? ??????????? ? 23
(38,3%) ?????????, ??????????????????? ???????
II?III ??????? ? ? 5 (8,3%) ?????????. ????????????? ????????? ????? ?????? ???? ???????????? ????????? ??????? (???. 1): ?????????? ????? ??????????? ?????????? ? 14 (23,3%) ?????????, ?????????????? ????? ???????????
?????????? ? 1 (1,6%) ???????, ???????????????
????? ??????????? ?????????? ? 9 (15%) ???????, ??????????????? ????? ?????????? ?????????? ? 6 (10%) ?????????, ??????????????? ???????????? ?????????? ? 18 (30%).
??? ???????? ???????? ?????????? ???????????????? ????????????????? ??????? ?? ? ?????
????????, ?????????? ?????????? ????????-
???????????????? ???????? (???????????, ??????????), ?-??????????????? (??????????, ??????????, ??????????), ????????? (?????????, ??????????), ????????? ????????? (????????), ???????????? (?????????), ???????, ????????.
?????? ??????????? ???-?????????? ????????? ? ??????? 2007 ?.: 37 (61,6%) ????????? ?????????????? ?????????????????? ???????????????? ??????? Medtronic InSync III 8042, 23
(37,4%) ??????? ? ????? ? ???????????? ??????????? ? ????????-???????? ??????????? ? ???????? ? Medtronic InSync III Protect.
????????? ? ??????????????? ?????? ?????????? ?????????? ? 100% ??????? ???? ?????????
?????????????????????? ???????????? ? ?????????????? ??????? ??????? ??????? ?????????.
??????????? (47,8%) ?? 23 ????????? ? ???????????? ?????????? ????? ??????????? ????????? ???/???-? ???? ????????? ?????????????? ??????? ??-???? ??? ??????????? ?????? ???????????????? ????????? ? ???????? ???????
????????? ??????????. ?????? ???????? ? ?????????? ?????? ??????????? ?????????? ?? ??????????? ?????????? ??? ??????????????????
??????? ???? ????????? ???????? ???????????
??????? c ??????? ??????? Carp?ntier, ????????
???????????????? ??????? ?? de Vega, ??????????????? ???????? ╚????????╩ ? ???????? ??, ?????????? ? ???????????????? ????????????.
?????? ????????????? ?????????? ??????????? ?????????????????? ??????? ???????????
?????? ?? ???????? ????????? ??????????? ??????????????? (??????? ??????? ?????? ????????? ? ?? ??, ???????? ????????????? ?????? ?
???, ???????? ?????????????? ?????? ? ???, ???????? ????????????? ????? ? ???, ????????
?????????????? ????? ? ???), ??????????????????? (?????? ????????? QRS) ?? ? ????? ??????????? ????????? ???/???-?. ????????????
14
18
1
6
?????????? ??
?????????????? ??
??????????????? ??
9
??????????????? ??
??????????????? ??
???. 1. ????????????? ????????? ????? ?????? ?
????????? ? ???
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
?????????? ?????????????????? ??????? ????????? ?? ????? ?????????? ? ????????????????? ???????.
?????????????? ?????? ?????? (?????? ???????
???????, ???????????? ??????????, ???????????? ??????????) ?????????? ? ?????????????? ????????? Excel, ?????????? ?????? ????? ????????????? ? ????????? Meta-analysis Comprehensive
V. 2.0 (???) ??? ??????????????? ??????? ??????????? ??????? (????? ??????? ??????????????????? ??????? ??????? ? 95% ????????????? ??????????).
??????????
????????????? ?????????
?????????????????? ???????
????? ??????????? ????????? 6,6% (4 ????????). ??? ?????? ???? ??????????? ????????????????? ??????????? ????????? ???????????????.
?? ???? ???, ??? ? ?????????, ??? ? ? ?????????? ????? ????? ????????????? (?????? ?????????? ?? ?????????? ????????? ?? 0,5 ?? 59 ???
(? ??????? 25,9 ╠ 17,3 ???), ???????? ????????????? ???????? ????????? ?????- ? ???-???????????, ?? ??? ?? NYHA (??. ???????).
??????? ?????? ????????? QRS ??????????? ??
100 ?? 220 ?? (? ??????? ???? ????? 149,0╠22,4 ??).
????? ?????????? ??? ?????? ????????? QRS
??????????? ? ????????? ? ??????? 132,0╠15,6 ??.
?? ?????? ????? ??????? ??????? ?????? ????????? ??????????? ?? 17 ?? 69% (??????? ?
33,9╠11,0%). ????? ??????????? ?????????
???/???-? ?? ?? ???????? ? ????????? ? ??????? 42,4╠12,2%.
35
? 46 (76%) ????????? ?????????? ??????????
??????? ????????? ??????????????? ?? ???? ??, ?
7 (11%) ????????? ??????????? ????????? ?????????? ?? ??? ??.
???? ????????? ????? ??????????? ?????????? ??? ???? ????????? ?????????????? ?????????
??????. ???? ?? ??? ???? ?? ???? ????????? ????????????????? ????????????? ???????? ???????. ?? ??????????? ???? ???????????? ???????
???????? ?????????? ????? 4 ???.
????? ????, 7 (11,6%) ????????? ???? ????????? ???????? ???????????????? ????????????, 16 (26,6%) ? ???????????????? ?????????
????????????? ?? ?????????????? ??????????
???????.
?????????? ?????????
?????????????????? ???????
? 51 ???????? ?????????? ?? ????? ??? ?????
??????????? ????????? ??? ??????????????????
??????? ?? ??????????? (???. 2). ? 5 ?????????
?????????? ????????? ???? ???????????, ? 2 ????????? ? ?????????? ??????????, ??? ??????????? ????????????? ????????? ???/???-? ???
??????????. ? 1 ???????? ?????????? ??????????????????? ?????????? ? ????????? ??????????????? ???????? ??????????? ? ???????? ?????????????? ??????????????, ?????????? ? ???????????????? ????????????. ? 4 ??????? ??????????
????????? ??????? ???, ????????????? ???????? ?????? ????????? (? 3 ????????? ???? ???????????????? ?????????? ???-?, ? 1 ? ???-??????????). ????????????????? ??????????? ????????? 0%.
???????? ?? ?????? ??????????? ????? ? ???
? ????????? ? ?? II?IV ?? ?? NYHA ?? ? ????? ??????????? ???/???-?
Min
0,727
?0,380
?0,379
?0,402
?0,353
?0,332
0,124
0,104
0,103
0,053
0,095
0,036
0,483
?0,582
?0,581
?0,505
?0,539
?0,402
Max
p
??????????????????? ??????? ??????? ? 95% ??
0,970
?0,177
?0,177
?0,299
?0,168
?0,262
0,0001
0,0001
0,0001
0,0001
0,0001
0,0001
?2
?1
0
1
2
? ? ? ? ? ? ? ? ? ? . ???????? ??????????????????? ??????? ??????? ?? ??, ??? ??, ??? ??, ??? ??, ??? ??
?????? 0 ? ?????? ????????? QRS ?????? 0 ??????????????? ? ????????????? ??????? ?????????? ???/???-?
? ????????? ? ??????????? ????????? ????????????????.
?????? ???????????, ? 1, 2012
?? ??
??? ??
??? ??
??? ??
??? ??
?????? QRS
??????????? ??????
??????? ???????
??????????
????? ? ???
???????????????????
??????? ???????
?????????? ?? ??????? ??????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
36
?????? ???????????, ? 1, 2012
5
2
4
51
?????????, ??????????? ????????????, ????????????? ? ?????????? ????????. ???????? ? ???????????? ?????????? ? ????????? ????????? ???????????????? ??? ??????? ????????? ???????????? ???????? ?????????????? ???????????
??? ????????? ?????????????????? ???????.
????????? ??????????? ????????? ??? ? ???-?
???????? ?????????? ??????? ?????????????? ??????? ????????? ? ?????????? ????????? ??? ?
???????? ??????? ?????? ??????? ??? ?????????????? ? ??????????? ??????????????? ???????.
?????? ?????? ????????????
??? ????????? ?????? ??-2319.2011.7
?????? ???????????, ? 1, 2012
??? ??????????
?????????? ?????????? (????????? ???????)
???????? ? ???????????
????????
? ? ? ? ??? ? ??
???. 2. ?????? ????- ? ??????????????????? ?????????? ??? ?????????? ??????????? ?????????????????? ???????
1.
????? ?. ?., ???????? ?. ?., ????? ?. ?. ? ??. ??????-
??????????
2.
???????????? ??????????? ????????? ??????????????? ?
??????????? ????? ?????????? ????????? ? ??????
????????? // ????. ???????????????. 2006. ? 7 (1).
?. 112?115.
???????? ?. ?., ????? ?. ?., ?????? ?. ?. ? ??. ?????????????????? ??????????? ????????? ???????????????
? ??????????? ????? ?????????? ????????? ? ??????
????????? (????? 2) // ????. ???????????????. 2006.
? 7 (3). C. 3?7.
? ?????????????? ???? ???????????? ??? ?
?????????, ??? ? ? ?????????? ????? ????? ??????????? ?????????????????? ????????? ???????? ????????????? ???????? ???????????? ?????????, ??????????? ?????????????? ???????
?????? ? ????????? ? ??? ?????????? ?? ??????????????? ?????? ??? ?? ????????????? NYHA,
??? ??????????? ? ???????????? ??????????????
???????????? ???????? ??????????? ?? ???????
????????? ? ??? (2010 ?.). ? ?????? ????????? ?
???????????? ?????????? ??? ?????????????
???????????????? ???????? ??????? ???????????? ?????????? ????????????? ????????? ?????????????? ??????? ??-????. ??? ?????? ??????????? ? ???????????? ?????????????? ?????????????????? ???????????? Post AV node ablation
Evaluation (PAVE), ??? ???? ??????? ???????? ????? ??? ??-?????????? ??? ????????????? ?????????? ?????? ?????????. ????? ?? ???? ???????????? ????????? ? ??? ? ???????? ?? ???? ??????????? ??? ???. ?????? 30% ?????????????
????????? ???? ???????? ? III ?? ??? ??
NYHA, ??????? ?? ?? ?? ???? ?????? ?????????
45 ╠ 15%. ?????? ????? 6 ??? ????? ???????? ?
?????? ????????? ? ??? ???? ????????? ????????????? ? ?????????? ????????, ?? ?? ? ????????
?????. ????? ????, ???? ?????????? ?????? ???????????: ??? ???? ?? ??????????? ????????? ??????????????? ????????, ??? ????? ??????? ?????? ???, ???????? ??? ?? ?? ????? 45% [9].
????? ???????, ? ?????????? ??????? ?????
??????????? ?????????????????? ?????? ?????????? ????????????? ???????? ????????????
3.
??????? ?. ?., ??????? ?. ?., ?????? ?. ?., ????????? ?. ?. ?????? ????????????? ???????????????? ???-
??????? ? ??????? ? ????????? ???????????????? // ???.
????? ??. ?. ?. ???????? ???? (????.). 2007.
?. 8, ? 3. ?. 48.
4. ????????? ?. ?. ????????? ???????????????? ?????????? ? ????????? ?????????? ???????? ? ????????? ? ????????? ???????????????? ? ?????? ?????????????????
???????: ???. ? ????. ???. ????. ?., 2009.
5. Abraham W. T., Hayes D. L. Cardiac resynchronization
therapy for heart failure // Circulation. 2003. Vol. 108.
P. 2596?2603.
6. Adams K. F., Lindenfeld J., Arnold J. M. O. et al. HFSA
2006 Comprehensive heart failure practice guideline //
J. Card. Fail. 2006. Vol. 12. P. 1?122.
7. Ansari M., Massie B. M. Heart failure: How big is the problem? Who are the patients? What does the future hold? // Am.
Heart J. 2003. Vol. 146. P. 1?4.
8. Dickstein K., Vardas P., Auricchio A. et al. 2010 Focused
Update of ESC Guidelines on device therapy in heart failure. An
update of the 2008 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure and the 2007 ESC guidelines for cardiac and resynchronization therapy // Eur. Heart J.
2010. Vol. 31. P. 2677?2687.
9. Doshi R. N., Daoud E. G., Fellows C. et al. Left ventricular
based cardiac stimulation Post AV nodal ablation Evaluation
(The PAVE Study) // J. Cardiovasc. Electrophysiol. 2005.
Vol. 16, ? 11. P. 1160?1165.
10. Hunt S. A., Abraham W. T., Chin M. H. et al. ACC/AHA
2005 Guideline Update for the Diagnosis and Management
of Chronic Heart Failure in the Adult ? Summary Article:
A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Writing
Committee to Update the 2001 Guidelines for the Evaluation
and Management of Heart Failure) // J. Am. Coll. Cardiol.
2005. Vol. 46. P. 116?1143.
11. McAlister F. A., Ezekowitz J. A., Wiebe N. et al. Systematic
review: cardiac resynchronization in patients with symptomatic
heart failure // Ann. Intern. Med. 2004. Vol. 141. P. 381?390.
12. Wells G., Parkash R., Healey J. S. et al. Cardiac resynchronization therapy: a meta-analysis of randomized controlled trials //CMAJ. 2011. Vol. 183. P. 421?429.
????????? 21.06.2012
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
37
╘ ????????? ???????, 2012
??? 616.12-089.843-073.432.19
???????? ? ?????? ????????????? ??????????
????????? ??????? ??????????????? ? ??????
???????????? ?? ? ????? ???????????
?????????????????? ?????????
?. ?. ???????*, ?. ?. ???????, ?. ?. ????????????, ?. ?. ??????????, ?. ?. ????????,
?. ?. ?????????, ?. ?. ?????????, ?. ?. ??????, ?. ?. ???????
????. ? ????????? ????? ???????? ????????????? ??????? ????????? ??????????? ????????? ??????????????? ???????? ????????? ?????????????????? ???????. ????? ???????????? ??????? ?????? ????????????? ????????????? ??????????????? ? ???????? ?????????????? ? ??????????? ???????????? ?????? ?? ? ????? ??????????? ????????? ??????????????? ??????.
???????? ? ??????. ???? ??????????? 30 ??????? ? 21 (70%) ??????? ? 9 (30%) ??????. ??????? ????????? ???????? 58 ╠ 7,8 ????. ??? ???????? ???? ?? II?IV ?????????????? ??????? (??)
?? NYHA. ??? ?????????? ???????????? ?????????????? ??????????? ????????? ???????????????
(?????) ? ????????? ?????? ???????? ?????????????? (???????? ?????????????, ???????? ????,
?????????-???????? ????? ????????? ????????). ?? ??????????? ????? ???????????: ??????? ??????? ?????? ?????????, ????????????? ? ?????????????? ??????? ? ?????? ?????? ?????????, ?????????? ????????????, ???????? ???????? ????????, ????? ??????????????????? ????????????,
??????????? ?/?. ?? ?????? ???????? ?????????????? ???????? ??????????? ?????????? 6 ????????? ?????? ?????????, ??????????????? ? ?????????????????? ????????, ???????? ?????????? ?????? ??????????? ???????.
??????????. ????? ???????? ????? ????????? ? III?IV ?? ??????????? ? 23 (76,7%) ?? 3 (10%), ?
?? II ?? ???????? ? 7 (23,3%) ?? 27 (90%). ???????? ????????????? ? ???????? ?????????????? ?????? ?????? ????????? ?????????? ?????????? ?? ? ????? ???????? (?=0,03), ????? ??????? ??????? ?????? ????????? ?? ? ????? ??????????? ??????????????????? ?????????? ????????? ?????????????? 29,4 ╠ 5,8 ? 42 ╠ 9,2% (? = 0,04).
? ????????? ?? ?????????? ?????????????????? ??????? ?????????? ?????? ???????? ????????
????????, ????? ??????????????????? ???????????? ? ??????? ?????????? ????????????.
? ????????????????? ??????? ?????????? ???????? ??????????? ??????- ? ??????????????? ???????????? ? 42,3 ╠ 2,8 ?? 25,3 ╠ 13,2 ?? (? = 0,044) ? ?? 175,2 ╠ 58,9 ?? 119,3 ╠ 40,4 ?? (? = 0,00012)
??????????????.
???????????? ??????????????? ? ?????????????????? ???????????? ?????????????? ????????? ??????? ??????? (r = 0,46, ? = 0,000002).
???????? ?????????????? ? ?????????-???????? ?????? ????????, ??? ??????- ? ??????????????? ???????? ? ????? ???? ??????????? ???? ????????????? ????????????. ? ?????? ?????????
????? ????????, ??? ???????? ??????????? ??????? ?? 2?4 ?? ??????????????? ??????? ???????
????????? ????????? ?????? ????????? ????? 35%.
??????????. ??????- ? ??????????????? ???????? (?????????-???????? ????? ????????? ????????) ???????? ??????????? ?????????? ??????? ??????? ?????? ????????? ? ?????????? ?????????
?????????????? ??????. C????????-??????????? ???????? ????? 65 ??, ??????????? ?????????? 6
????????? ?????? ????????? ? ???? ???????? (?? ???????? ?????????????) ????? ???? ???????????? ???????????? ????????? ??????????????? ?????? ?????????. ?????????? ???????? ??????????? ??????? (?? ????????? ?????) ?????? ????????????? ? ??????????? ??????? ???????.
? ? ? ? ? ? ? ? ? ? ? ? ? : ????????? ?????????????????? ???????, ????????????, ???????? ??????????????, ???????????????.
Obje?tive. Nowadays the most promising method of chronic heart failure correction is cardiac resynchronization therapy. The aim of our study was to define the efficiency of echocardiography in evaluation the signs of
dyssynchrony before and after resynchronization device implantation.
Material and methods. In research were included 30 patients (21 men (70%), 9 women (30%)), mean age
was 58 ╠ 7,8 years. All patients were with II?IV functional class by NYHA. To conduct the study were used
standart echo parameters and modes of tissue Doppler imaging (tissue synchronization imaging, tissue tracking, pulse-wave tissue Doppler). Left ventricular ejection fraction, enddiastolic and endsystolic volumes,
mitral valve regurgitation, velocity time integral, isovolumic relaxation time, E/A have been studied using
* ????? ??? ?????????: e-mail: leoan@heart-house.ru
?????? ???????????, ? 1, 2012
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
38
?????? ???????????, ? 1, 2012
standart echocardiography. By tissue Doppler imaging were measured: standart deviation of left ventricular
6 segments, inter- and intraventricular delay, displacement of mitral valve.
Results. Number of patients with III?IV functional class by NYHA decreased from 23 (76,7%) t? 3 (10%),
and with II functional class increased from 7 (23,3%) t? 27 (90%). Endsystolic and enddiastolic volumes
were significantly reduced after cardiac resynchronization theraphy (? = 0,03), left ventricular ejection fraction before and after resynchronization device implantation appeared respectively 29,4 ╠ 5,8 and 42 ╠ 9,2%
(? = 0,04).
Mitral valve regurgitation, velocity time integral, isovolumic relaxation time, were significantly higher after
cardiac resynchronization theraphy.
There was appeared reducing of intra- and interventricular delay after cardiac resynchronization therapy
from 42,3 ╠ 2,8 ms t? 25,3 ╠ 13,2 ms (? = 0,044) and from 175,2 ╠ 58,9 ms to 119,3 ╠ 40,4 ms (? = 0,00012)
respectively.
By pulse-wave tissue Doppler the decreasing of intra- and interventricular delay and the sum of the above
appeared to be the best predictors of the left ventricular reverse remodeling.
According to tissue Doppler imaging displacement of mitral valve about 2?4 mm correlated with the left ventricular ejection fraction <35%.
Conclusion. According to our study the amount of intra- and interventricular delay appeared to be the best predictor of increasing left ventricular ejection fraction and reducing endsystolic volume (tissue Doppler imaging).
Delay of left ventricular 6 segments also were effective predictors of reverse left ventricular remodeling (by tissue synchronization imaging) and increasing of mitral valve displacement (by tissue tracking) correlated with
improving of the left ventricular ejection fraction.
K e y wo r d s : cardiac resynchronization therapy, dyssynchrony, tissue Doppler imaging, echocardiography.
????????
?????? ???????????, ? 1, 2012
?
????????? ????? ? ???? ?????????????
????? 22 ??? ??????? ? ??????????? ????????? ???????????????? (???). ???????? ?????????????? ????? 2 ??? ????? ??????? ???????????
[4]. ??????????? ????????? ??????????????? ??????????????? ??? ???????, ????????????? ? ?????????? ????????? ?????????????? ?????????
??????, ????????? ???????????????? ?????????,
? ???????????? ????? ???????? ????????????? ??????? ?????????? ????????????? ? ?????????????? ?????????? [2]. ? ????????? ?????????????
???????????? (1970 ?.) ???? ????????, ??? ??????????? ???????????? ? ???????? ????????????
????????? ??????????? ????????? ??????????????? ?????????? 62% ? ?????? ? 42% ? ??????.
?????????? ????????? ? 6?7 ??? ?????? ?? ????????? ? ??????????? ?????????????? [15]. ??????????? ????????? ??????????????? ?????????? ?????????? ???????? ???????? ?????????? ????????? ? ?? ????? ????????? ? ??????????. ?
?????????? ????????? ?????????????????? ? ????????? ??? I?IV ?????????????? ???????
(??) ?? NYHA ?????????? 7% (8,1 ??? ???????),
?????????? ?????????? ??? (II?IV ??) ?????
????? ? 4,5% ????????? (5,1 ??? ???????). ?????????????????? ???????????? ??? (III?IV ??) ????????? 2,1% ??????? (3 ??? ???????) [1]. ?????????????? ?? ?????? 1-??????? ?????????? ????????? ? ??????? 1,2 ?? 1000 ?????????. ?????
????????? ? ??? (I?IV ??) ??????? ???????
?????????? ?????????? 6%, ??? ???? 28,7% ??????? ? ???????, 71,3% ? ???????.
? ????????? ????? ????????? ?????????????????? ??????? (???) ???????? ????? ??
??????? ?????????? ????????? ??????? ? ???
II?IV ?? ?? NYHA, ???????????? ? ??????????????? ???????.
????? ????????? ?? ????????? ?????????????????? ??????? ???????? ????????????? ? ??????? ???????. ???????? ?? ??? ???????????????????????? (???) ? ???????????????????? (?????)
?????????? ??????, ????????????????? ? ???????????? ?????? ? ??????? ?????????? ??????, ? ????? ????????? (20?30%) ?????????????????? ??????? ??????????? ????????????, ??? ? ???? ???????? ?????????? ????????.
???????? ????????????? ????????? ?????????????????? ??????? ????? ???? ??????????
???????????? ????????? QRS ?? ???, ?? ?????
??????? ???????? ?????????? ?????: ???????
??????? ?????? ?????????, ??????? ??????????
???????????????, ??????? ??????????????? ???????? ??????????????? ???????????, ??????- ?
??????????????? ????????. ?????? ????????????
???????????? ??????????? ? ?????? ????????????? ????????????? ??????????? ??????? ????? ?
??????? ???????? ?????????????? ? ???????????
???????????? ?????? ?? ? ????? ???????????
????????? ??????????????? ??????, ? ?????????
???????? ??????????? ??????????? ?????????
??????????????? ???????? ????? ???????????
??????????????????? ?????????? ? ??????? ?
??????????? ????????? ????????????????, ? ????? ?????????? ????????????? ?????? ??????????? ? ?????-??????, ???????????? ? ?????????,
?????????? ????????? ??????????????????
???????.
???????? ? ??????
??? ??????? ???????????? ????? ???? ??????????? 30 ??????? (21 (70%) ??????? ? 9 (30%)
??????), ???????????? ?? ???????????? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
? ???????????? ? ????????? ?????????????? ??????? ????????????? ????????? ? ? ????????? ?????????????? ???????? ?????? ????????-?????????? ???????? ??. ?. ?. ???????? ????. ???????
????????????? ????????? ?????????? ?? 37 ?? 75
??? ? ???????? ? ??????? 58 ╠ 7,8 ????. ??????? ??????????? ????????? ??????????????? ? ??????????? ??????? ?????? (???) ??? ????????? ?? ????????? ??????????? ???????, ????????, ??????
???????????? ???????????? ? ??????????? ???????-???????????????? ??????? ????????????. ?????? ?????????? ???????? ?? 6 ??? ?? 2 ???.
? ???? ????????? ???? ???????? ???????????
??????? ??????????? ????????? ???????????????.
?????????????? ????? ??? ???????????????? ???????? ???-???????? ????????????? ?
NYHA. ?????????? ??? (III?IV ?? ?? NYHA)
???????? 23 (76,7%) ????????, ????? ??????????
???????? ??? (II ?? ?? NYHA) ???????????
? 7 (23,9%) ?????????. ? ?????? ??????????? ??????? ???? ???????? ????????? ????????? ?????
??????: ??????????????? ????? ???????????
?????????? ? ? 5 (16,6%), ?????????? ????? ??????????? ?????????? ? ? 7 (23,3%) ? ???????????? ?????????????? ??????? ???????? ?? ????? ?
? 14 (46,7%) ?????????; ???????????? ??????????
? ???????? ???????? ? 2 (6,6%) ???????. ????????????????? ????????? QRS ?? ???????? ?????
160 ?? ??????????? ? 11 (36,6%), ????? 160 ?? ? ?
19 (63,4%) ?????????, ? ??????? ??? ?????????
157,1 ╠ 15,8 ??.
???? ??????? ?? ???????????? ??????? ??????????? ??????????????? ??????? ? ?????????
??????????? ? ? ????????????? ??????????? ?????. ??????????????? ???????? ???????????, ?????? ????????????? ? ?????????? ???????? ?? ????
?????? ???????????? ??? ??????????, ??????????? ?????????????? ?????????? ??????????
?????????, ?????????? ???, ????? ? ????????
??????????????, ?????? ?????????? ??????? ??????????? ? ???????? ??????????? ??????????????????? ??????????.
??? ?????????? ???????????? ??????????????
??????????? ????????? ????? ? ????????? ?????? ???????? ?????????????? (?????? ????????
?????????????, ????????? ?????, ?????????-????????? ?????? ????????? ????????).
?? ?????? ??????????? ????? ???????????
????????? ?????????: ??????? ??????? ??????
?????????, ????????????? ? ?????????????? ??????? ? ?????? ?????? ?????????, ??????????
????????????, ??????? ?????? ??????????, ???????? ???????? ????????, ????? ??????????????????? ???????????? ?????? ?????????, ??????????? ???????????? ????????? ????? ??????? (E)
? ???????? (A) ??????????????? ?????????? (E/A),
39
??????????, ??????????????? ??????- ? ??????????????? ????????, ? ??.
??????????? ???????? ???????? ? ??????? ??????? ?????? ????????? ? ??????? ? ????????,
??????? ??????? ?????? ????????? ???????????
?? ??????? ????????????? ? ???????????
???????? (????? ??????) ?? ?????????? ???????????? ???????.
?????????? ??????? ???????????????????
???????????? ?????????, ??? ????????, ????????
??????? ???????????? ???????? ??????????
????????? ? ???????????? ????? ???????? ?????
?????????? ?????? ? ???????? ?????? ?????? ????????? ? ??????? ?????? ????? ?????????? ??????. ?? ???????? ?????? ?????????? ? ?????????-???????? ?????? ?? ??????????? ???????????? ???????. ??????????? ????? ???????????? ?
???????? ?????? ?????? ?????????, ????? ? ???????? ??????? ??????????? ???????, ????? ???????, ????? ???????????? ???????????????? ?????? ? ???????? ?????? ?????? ????????? ? ?????
?????????? ?????? [13].
? ??????? ?????????-???????? ?????????????? ??????????? ??????????????? ????????????
???????? (???????? ??????????? ????????????,
?????????? ?? ????? Q ?? ??? ?? ???????? ??????????? ??????? (APE), ? ??????? ?? ????? Q ??
??? ?? ???????? ??????? ???????? ???????
(PPE)). ? ????? ???? ?????????? ?????????? ?????
40 ?? [7], ? ?-?????? ??????????? ?????????????????? ???????????? ?? ????????? ????? ???????????? ????????????? ?????????? ??????????????? ??????????? ? ?????? ?????? ?????? ?????????, ? ????? ??????? ?? ?????? ?????????
130 ?? [16].
??? ????????????? ???????? ??????????????
???????????? 3 ???????? ????? ???????????????
????????? ?????, ??? ?????????? ???????????
?????????? ? ????????? ?????????. ?????? ?????????? ?? 3?6 ?????????????????? ???-??????????. ??? ????????? ????????? ? 3?5 ???????????????? ??????. ????? ? ?????? of line ??????????? ??????????? ?????????.
?? ?????? ?????? ???????? ?????????????
????????? ???????? (????? ???????? ????????????? ??????????? ???????? ?????? ?? ???????
???????? ???? ?????????? ?????????????? ????????? ?? ????????? ? ????????? QRS ?? ???)
[8] ???????????? ??????????? ?????????? 6 ????????? ?????? ????????? ? ???? ???????? ? ?????????????????? ????????????. ????????? ???????????? ????? ??????? ????? ???????? ?????????? ???????????? ????????????? ????????
????????? ?????? ?????? ????????? ? ??????????????? ??????????? (???????? ?? ????? Q ?? ???
?? ??????? ????????????? ???????? ????????
?????? ???????????, ? 1, 2012
???????????? ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
40
?????? ???????????, ? 1, 2012
???????????? ??????? ????????). ?????????? ?????
60 ?? ???????? ????????? ??????????????????
???????????? [11].
? ?????????-???????? ?????? ?????????
???????? ?????????? ????????? ??????????
????? [6]: ?????????-??????????? ???????? (??????? ????? ?????????? ?? ?????? ????? Q ?? ???
?? ?????? ????? S ?? ????????? ???????? ??????
????????? ? ???????? ?? ?????? ????? Q ?? ??? ??
?????? ????? S ?? ????????? ???????? ??????????????? ???????????), ??????????????? ???????? (???????? ?? ?????? ????? Q ?? ??? ?? ??????
????? S ?? ????????? ???????? ???????????????
??????????? ? ?? ?????? ????? Q ?? ??? ?? ??????
????? S ?? ????????? ???????? ????????? ??????
??????? ?????????) ? ????? ???? ???????????.
? ????? ???????????? ????? ????????? ??????????, ?????????? ? ?????? ????????? ????? [5]. ???
?????? ? ?????? ?????? ?????????????? ??????????? 4-???????? ???????? ?? ??????????? ???????.
??? ????????, ?????? ???? ???????? ????????????
????????? ??????????? ???????? ? ??????? ??????????. ?????????????? ?????????? ??????????
???????? ???????? ?????????? ????? ??? ?????????????? ???????????? ?? ????? ???????.
?????????????? ????????? ?????? ???????????
? ????????? Microsoft Excel (??????????? ???????
???????? ???????, ??????????? ??????????, ??????????? ??????????); ?????? ????????????? ?????????????? ? ?????????????? ?????????????????? ?????? Wilkinson ? ????????? GraphPad Prisma,
?????? 5.04 (???).
?????? ???????????, ? 1, 2012
??????????
T?????? ??????????? ????????? ??????????????? ???? ????? ?????????? ?? ??????????? ?????????????????? ?????????. ???, ?? ??????????
???????? ????????? ? ?????????? ??? ???? 23
(76,7%), ? ????????? ? ????? ??????????? ?????????? ??? ? 7 (23,3%), ????? ???????? ?????
????????? ? III?IV ?? ????????? ?? 3 (10%), ? ??
II ?? ? ???????? ?? 27 (90%). ?? ???? ?????????????? ????? ????????? ?????????? ? 80%
(n = 24), ?? ??? ?????????????? ?????? ? ? 20%
(n = 6) ????????? (???. 1).
7
II ?? ?? NYHA
27
23
III?IV ?? ?? NYHA
3
0
5
10
15
20
????? ?????????
?? ???
25
30
????? ???
???. 1. ???????? ?? ?? NYHA ? ????????? ?? ? ????? ???
?????????? ????????????????? ????????????
???????????? ? ??????? 1 ? ??????? 2. ????????
????????????? ? ???????? ?????????????? ?????
?????? ????????? ?????????? ?????????? ?? ? ????? ???????? (? = 0,0003 ? ? = 0,0001 ??????????????). ????? ?? ???????? ?????????? ?????? ????
??????? ???????? ????????? ??????????????? ?
????????? ?????????????? ??????? (? = 0,0016 ?
? = 0,0001 ??????????????). ????? ??????? ??????? ?????? ????????? ?? ? ????? ??????????? ?????????????????? ????????? ????????? ?????????????? 29,4 ╠ 5,8 ? 42 ╠ 9,2% (? = 0,0001).
????? ????, ?? ?????????? ????????? ?????????????????? ??????? ? ????????? ??????????
?????? ???? ?????????? ??????? ??????????????????? ????????????, ??????? ?????? ??????????
? ??????? ?????????? ????????????. ?? ????????
????????? ???????? ???????? ?????? ????? ?????????? ?????????? ? ?? ??? ?? ????? ??????, ???
? ????????????????? ???????.
??????? ???????? ???????? ?? ??, ??? ?????????? ???????????? ?? ?????????? ???????? ? 21
(70%) ???????? ???? ??????????????? ??????? ?
????????? II ? III ??.
?????? ????????? QRS ?? ??? ?? ???????? ?
??????? ????????? 157,1 ╠ 15,8 ??, ????? ?????????? ???????? ? 137,6 ╠ 12,3 ?? (? = 0,004).
? ??????? 2 ???????????? ???????? ???????
???????? ????????? ???????? ???????? (VTI), ????? ? ? ? ? ? 1
?????????????? ????????? ?? ? ??????? ?? ? ????? ???
??????????
?? ???????? (n = 30)
????? ???????? (n = 30)
?
???, ??
???, ??
??, %
???, ??
???, ??
??, ??
293,8 ╠ 80,4
206,9 ╠ 68,4
29,4 ╠ 5,8
7,7 ╠ 1,1
6,6 ╠ 1,3
5,1 ╠ 0,5
234,7 ╠ 79,8
136,1 ╠ 63,3
42 ╠ 9,2
6,7 ╠ 1,2
5,3 ╠ 1,0
4,8 ╠ 0,6
0,0001
0,0003
0,0001
0,0016
0,0001
0,0057
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
300
293,8
234,7
206,9
200
136,1
100
42,0
29,4
0
?? ????????
??? (??)
????? ????????
??? (??)
?? (%)
???. 2. ???????? ?????-??????????? ?? ? ????? ???
???? ??????????????????? ???????????? (IVRT),
??????- (IVMDintra) ? ??????????????? (IVMDinter)
???????????? (?? ??????????? ?????). ?????,
??? ??????? ???????? ????????? ???????? ???????? ? ??????? ??????????????????? ????????????
???????? ????????????? ???????????? ???????????? (? = 0,0001 ? ? = 0,001 ??????????????).
???????? ??????? ???????? ?/? ????????????? ????????????. ????????? ?????????????????? ??????? ????????????? (?? 1?2%) ??????? ????????
?/? ???????????? ???????? ??????. ??? ?????????? ??????? ???????? ???????? ????? ????
????????????? (??????? ???????? ? 1,153 ╠ 0,603 ??
1,102 ╠ 0,702).
? ????????????????? ??????? ?????????? ??????????? ???????? ??????????? ??????????????? ???????? ? ?????????????????? ???????? ?
? 42,3 ╠ 2,8 ?? 25,3 ╠ 13,2 ?? (? = 0,0011) ? ??
175,2 ╠ 58,9 ?? 119,3 ╠ 40,4 ?? (? = 0,0002) ??????????????.
?? ??????????? ???????????? ????????, ???
????????????????? ????????? QRS (> 140 ??) ??????????? ? ??????????? ????????? ?????????????? ?????? ?????? ????????? (? 206,9 ╠ 68,4 ??
136,1 ╠ 63,3 ??) (r = 0,51, p < 0,033).
???????? ??????????? ????????????? ?????????????? ????? (r = 0,34, ? = 0,00001) ????? ???????? ???????????? ? ?????????????? ???????
?? NYHA. ??????? ?? ??????????? ? ???????
? ??????- ? ??????????????? ?????????????, ?
????? ????????? ?????????????????? ???????
??? ??????????? ?????????.
??????????? ???????????? ????????, ??? ???????????? ??????????????? ? ?????????????????? ???????????? ?????????????? ?????????
??????? ??????? ?????? ????????? (r = ?0,46,
?<0,001). ????? ???????? ????????????? ?????????????? ????? ????? ???????? ???????????? ?
????????? ????????? ??????????????? (r = 0,48,
? = 0,0007) ? ????????? ?????????????? (r = 0,47,
? = 0,001) ??????.
???????? ???????????, ?????????? ? ?????????-???????? ?????? ????????? ????????, ??????-,
??????????????? ???????? ? ????? ???? ?????????? ???? ????????????? ???????????? ??????? ?
????????????? ? ???????????? ??????? ???????
?????? ????????? (?? 29,4 ╠ 5,8 ?? 42 ╠ 9,2%), ????????? ??????????????? (?? 293,8 ╠ 80,4 ??
234,7 ╠ 79,8 ??) ? ????????? ?????????????? (??
206,9 ╠68,4 ?? 136,1 ╠ 63,3 ??) ??????.
??????????? ?????????? 6 ????????? ??????
????????? ? ???? ????????, ?????? 33,4 ??, ??????? ???????? ??????????? ????????? ??????????????? ?????? ????????? (r = ?0,61, p < 0,001).
? ?????? ????????? ????? ???? ????????, ???
???????? ??????????? ??????? ?? 2?4 ?? ??????????????? ??????? ??????? ????????? ????????? ?????? ????????? ????? 35%.
??????????
????????? ?????????????????? ??????? ???????? ???????? ??????????????? ??????????,
???????? ??????? ?????? ????????? ? ?????? ?????????? ? ????????? ? ??????????? ????????? ???????????????? ? ? ????????? ????? ??????????????? ??? ???? ?? ?????????? ??????????????? ????????? ??? ??????? ??????? ? ???, ???????????? ?
??????????????? ???????.
????????, ??? ??????? ??????? ?????? ????????? ???????? ???????????? ??????????? ????????????? ??????? ?????? ? ???????? ??? ?????
?????????????? ?????????. ???????? ?????????? ??????, ??????- ? ??????????????? ???????????? ?????????????? ?????? ???????? ???????
?? ? ? ? ? ? 2
?????????? ??????- ? ??????????????? ???????????? ?? ?????? ?????????? ?????
??????????
?? ???????? (n = 30)
????? ???????? (n = 30)
?
APE
PPE
IVMDinter, ??
IVMDintra, ??
VTI
IVRT
171,5 ╠ 30,6
133,4 ╠ 41,6
42,3 ╠ 2,8
175,2 ╠ 58,9
10,0 ╠ 2,9
157,1 ╠ 62,6
143,8 ╠ 20,6
129,5 ╠ 31,2
25,3 ╠ 13,2
119,3 ╠ 40,4
15,2 ╠ 4,9
109,1 ╠ 59,5
0,24
0,2
0,0011
0,0002
0,0001
0,001
?????? ???????????, ? 1, 2012
400
41
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????? ???????????, ? 1, 2012
42
?????? ???????????, ? 1, 2012
?????? ?????????, ????????? ????????? ???????? ????????, ??????????? ?????????????????
??????????????????? ???????????? ????????
?????? ????????? ? ???????? ???????????? ???????????? ??????????? ????????? ???????????????. ??????????? ???????????? ????? ???????????? ?????????? ??????? ?????????? ???????????????.
A. Hamdan ? ?????. ??????????, ??? ????????
????????? ???????? ?????????????? ??????????? ? ?????????????? ??????? ??????????? ????????? ???????????????, ??????????? ? ????????
????????? ?????????????? ? ??????? ?? ????????? ????????????? ???????? (??????? ???????
????? 50%) [14], ???, ? ???? ???????, ?????????
??????? ?? ??????????? ??????? ???????????
????????? ??????????????? ? ???????? ?????????????? ????? ?? NYHA.
??????, ?????????? ? ?????? ???????? ?????????????, ????????? ???????, ??? ??????? ????? ???????? ?????????? ???????????? ????????????? ???????? ????????? ????????? ?????? ????????? ? ??????????????? ??????????? ?????
65 ?? ???? ????????????? ? ???????? ??????- ?
??????????????? ???????????? ? ???????? ????????????? ??????????? ??????????? (???. 3). ????? ????????? ????? ????????? ?????? ???????
????????? ??????????? ???????? ???????? ?????????? ? ?????? ????????? ???????? ?? ??????????? ?? ????????? ?????? ? ??? ???????? ?? ?????
??????? ?????????? [17]. ???? ????? ????? ????? ???????????? ? ??????????? ???????? ??? ??????? ?????? ?????????? ???????????? ? ??????????? ????????? ????????? ??????? ????????.
??? ????????, ? ???????? ??????????????????
???????????? ??????? ???? ?????? ??????? ?????
????? ????? ???? [18], ? ?????????? ????????????
????????? QRS ???????? ????? ?? ???????????
????????? ????????? ?????? ? ?????? ??????????????? ????????? [10]. ??????????? ??????
???????????? ?????? ????????????? ??????
????????? ?????????????????? ??????? ? ??????? ? ????? ?????????? QRS ?? ??? [3], ???????
???????????? ????????????. ????????????????
?????????? ??????????????? ?????? ???, ?????????? ????????? 6-???????? ?????? ? ?????????? ??????? ??????? ?????? ?????????. ???? ????????, ??? ?????????? ??????? ?????? ?????????
?????????? ??? ? ?????? ??? ????? ??????????
???????? ??????????? ??????????????????? ??????????, ? ??????????, ? 3-?? ??????, ??????????? ?????????? ??????? ? ????? ????????.
????????????? ?????? ????????? ?????????????????? ??????? ?? ??????????????? ??????
????????? ? ??? ??????? ? ??????? ?? II ?? ??????????? ????????? ??????????????? ??? ???????
? ???????????? Multicenter InSync Randomized
Clinical Evaluation (MIRACLE ICD II) [12]. ??
????????????? ????? ? ???????????? ??????? ?????? ??????? ? ??????? ? ??????? ??????????
??? ??? ?? ???????.
???????????????? ???????????????? ??????
??????????????? ???? ??? ????????? ???????????
????????? ??????????????? ????? ???????? ???????????????? ????????????, ???????? ?????????
?????? ????????? ??? ??????? ??????????????
????????????.
??????? ????? ?????? ? ????????????? ??????? ????????? ?????????????????? ???????
??? ?????????? ??????? ??????, ????????????? ?
???????????????? ?????????????? ? ?????. ????
? ?????? ????????? ??????? ???? ??? ??????? ??
??????????? ???? ?????? ?? ????????????.
????????????? ???????? ?????????? ? ? ????????? ? ?????????????? (????????????) ??????????????? ? ????????????? ???????????, ?????????? ??????????? ??????????????? ???????.
?????????? ?????????? ??????? ??????? ??????
????????? ? 28 ╠ 4 ?? 46 ╠ 5% (????? ??????????
????????? 50 ╠ 9 ???).
???????? ????????????? ??? ????? ???????
?????????? ???????????? ????????? QRS ?? ???,
?
?
???. 3. ?????????????????? ????????????, ??????????????? ? ?????? ???????? ????????????? ?? (?) ? ?????
(?) ??????????? ??????????????????? ??????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
????????? ???????. ???????? ?????? ? ?????????
?????????? ??????????? ??? ?????? ???????????? ???????? ????? ???? ???????????? ??? ????????? ? ?????????? ????? ????????? ??????????
?? ????????? ?????????????????? ???????.
??? ?????????? ?????????? ???? ????????? ?????????? ???????????? ?????? ??? ??????? ???????? ?????????? ????? ? ????? ????? ??????????
?????. ??? ??????? ???????????? ??????????
????????? ?? ??????? ?????????? ????????????
?????? ????????? ?????????, ??????? ??????? ???????? ???????????? ????????????. ?? ??????
????????? ??????????????, ????????????, ?????????? ??? ?????????? ?????, ???????? ?????
?????? ??????????????? ???????? ?????????????? ?????? ?? ????????? ??????????????????
???????.
????? ????????? ?????-??????? ??????????
???????? ?????????????? ?????????? ????? ??????? ???????????? ????????? ? ????????? ???????? ?????? ?? ???. ???????????????????? ??????????, ????? ??? ???????? ????????????? ?
?????????? ?????? ? ?????????? ?????????? ??????????, ? ????????? ????? ??????? ?????????,
????? ??????? ??????????????? ?????????? ?
????? ???? ????????????? ??? ?????????????
??? ?????? ????????? ?? ????????? ?????????????????? ???????.
??????????
?????????? ???????????? ????????, ??? ?????
??????- ? ??????????????? ???????? ????? 102 ??
(?????????-???????? ????? ????????? ????????)
???? ??????????? ?????????? ??????? ???????
?????? ????????? ? ?????????? ????????? ?????????????? ??????. ???????? ????? 130 ?? (?-?????), ?????????-??????????? ???????? ?????
65 ??, ??????????? ?????????? 6 ????????? ??????
????????? ? ???? ???????? ????? 34 ?? (????? ???????? ?????????????) ????? ??????? ???????????? ???????????? ????????? ???????????????
?????? ?????????, ? ?????????? ???????? ??????????? ??????? (????? ????????? ?????) ??????
????????????? ? ??????????? ??????? ???????
?????? ?????????.
? ? ? ? ??? ? ??
1.
2.
3.
????? ?. ?., ???????? ?. ?., ?????? ?. ?. ? ??. ???????
? ??????????? ????????? ???????????????? ? ??????????
???????????? ????????: ??????????? ???????????, ??????????? ? ???????: ?? ?????????? ???????????? ?????-?-??? // ????. ??????. 2004. ?. 5, ? 1. ?. 4?7.
??????? ?. ?., ??????? ?. ?. ????????-?????????? ????????. ??????? ? ?????????? ???????? ??????? ??????????????. ?.: ????? ??. ?. ?. ???????? ????, 2003. 108 ?.
??????? ?. ?., ????????? ?. ?., ???????? ?. ?. ? ??. ?????????? ?????????? ??????????? ??????????????-??????????????? ? ??????? ? ???????????????? ?????????-
?????? ???????????, ? 1, 2012
?? ????? ??????? ???????? ?????????? ?????:
???????? ??????????? ?????????, ??????? ???????
?????? ?????????, ??????? ?????????? ???????????????, ??????? ??????????????? ???????? ??????????????? ??????????? ? ????????? ??????.
? ????????? ????? ?????????? ????????????
????? ??????, ??? ???????, ??????? ???????????? ??????????? ????????? ???????????????,
??????? ??????? ?????? ????????? ????? 35%,
??????? ????? ????? ????? ???? ? ????????????????? ????????? QRS ?? ??? ????? 150 ??, ???????? ???????????? ??????????? ?? ????????? ?????????????????? ??????? ? ?? ????????? ???????????? ??????????? ????????? ????????????
????????????. ?????? ???? ? ???? ??????? ?????????? ?????????? ????? ??? ?????? ??????? ???????????? ????????????? ??????????, ?????????? ? ??????????????? ????????????, ?????????
????????? ???????????? ?????? ?????????. ??
???? ????????? ??????? (╚?????╩ ???????? QRS,
??????? ????? ????? ????? ????, ?????????? ?????????? ?????? ????????? ? ??????????????
?????????????? ?????????????) ????????? ??????????? ????????? ???????????? ?? ??????
????? ???????????.
?????? ?? ??????????? ?? ????? ??????????
???, ???? ????????, ??? ??? ????????????? ??????????? ????????????????? ????????? ???? ??
???????????? ???????. ?? ?????? ??????, ????????? ??? ?????????? ??????????? ?????? ? ???
???????? ?????????? ? 0,5?2%, ???????? ????????? ? ? 4?6%, ?????????? n. frencicus ? ? 1,6?5%
???????. ??? ???????? ?????????????????? ?????????, ?? ??? ????????? ??????????? ? ????????
??????? ????????? ? ? ??????? ??????? ?????
??????????????? ??????????? ???????? ???????
??????????? ????????? ??????????????? ? ?????????? ??????????? ???????? ?? ????.
??????????? ?????? ???????? ?????????? ????? ??? ???????-???????????????????? ???????????, ??????? ????? ???? ???????????? ??? ??????
??????? ?????? ????????? ?? ????????????.
????????????? ????????? ??????? ?????
????? ???????? ???????? ? ?????? ??????? ????????????. ?????????? ????????? ????????
??????????????? ???????????? ????????? ??????????????? ?????? ????????? ????? ?????????
?????????????????? ???????.
?????????? ????? ????????? ???????? ?????
????????? ???????? ??????? ??????? ?????? ????????? ? ??????? ???????? ? ??????? ? ??????????? ????????? ????????????????, ??????? ?????? ???????????? ???????????? ?????????????
????????? ???????????? ????????? ???????? ?????? ? ??????? ?????????? ?? ??????? ??????????????? ?????? ?? ?????? ?? ???? ???????, ?? ? ??
43
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
44
?????? ???????????, ? 1, 2012
???? ????????? // ??????? ? ????.-?????. ???. 1996. ? 3.
?. 84?87.
4. ??????? ?. ?. ??????????????????? ??????? ??? ????????? ????????? ??????????????? ? ?????? ????????? ?
??????????????? ?????????? ????????? ????????????????? ???????????? // ?????? ???????. 2006. ? 1. ?. 11?20.
5. ??????? ?. ???????????????: ???????????? ??????????? /
??????? ? ????. ?.: ????????-??????, 2010. ?. 141?142.
6. ???????? ?. ?., ?????? ?. ?. ? ??. ???????????? ??????????? ?? ?????????????? ???????????. ???????????????. ?., 2008. ?. 117?119.
7. ?????????? ?. ?. ?????? ????????????? ? ?????????????? ??????? ???????? ?????? ?????????, ??????- ? ??????????????? ?????????? ?? ?????? ???????? ?????????????? ? ??????? ??? ? ??????????? ????????? ????????????????: ???. ? ????. ???. ????. ?., 2008. ?. 58.
8. ?????? ?. ?., ?????? ?. ?. ??????????? ???????????????. 2-? ???. ?.: ????????, 2005. 344 ?.
9. Abraham W. T., Young J. B., Leon A. R. et al. Effects of cardiac resynchronization on disease progression in patients with
left ventricular systolic dysfunction, an indication for an
implantable cardioverter-defibrillator, and midly symptomatic
chronic heart failure. Multicenter InSync ICD II Study
Group // Circulation. 2004. Vol. 110, ? 18. P. 2864?2868.
10. Hamdan A., Shapira Y., Bengal T. et al. Tissue Doppler
imaging in patients with advanced heart failure: relation to functional class and prognosis // J. Heart Lung. Transplant. 2006.
Vol. 25. P. 214?218.
11. Jagdish ?., Siwach S., Rattan A. et al. Echocardiographic and
Doppler Assessment of Cardiac Functions in Patients of Non-
12.
13.
14.
15.
16.
17.
18.
Insulin Dependent Diabetes Mellitus // JIACM. 2002. Vol. 3,
? 2. P. 164?168.
James B., William T. A., Andrew L. S. et al. Combined
Cardiac Resynchronization and Implantable Cardioversion
Defibrillation in Advanced Chronic Heart Failure: The
MIRACLE ICD Trial // J. Am. Med. Ass. 2003. Vol. 289, ? 20.
Jeevanantham V. Metaanalysis on effects of cardiac resynchronization therapy in heart failure patients with narrow QRS complex // Cardiol. J. 2008. Vol. 15, ? 3. ?. 230?236.
Kannel W., Plehn J., Cupples L. et al. Cardiac failure and
sudden death in the Framingham study // Am. Heart J. 1988.
Vol. 115, ? 4. P. 869?875.
Pitzalis M., Lacovello M., Romito R. et al. Cardiac resynchronization therapy tailored by echocardiographic evaluation
of ventricular asynchrony // J. Am. Coll. Cardiol. 2002. Vol. 40.
P. 1615?1622.
Saxon L. A., De Marco ?., Schafer J. et al. Effects of longterm biventricular stimulation for resynchronization on
echocardiographic measures of remodeling // Circulation.
2002. Vol. 105. P. 1304?1310.
Swain R. L., Schwartz R. A., DeLurgio D. B. et al. The
impact of cardiac resynchronization therapy on ventricular
tachycardia/fibrillation: an analysis from the Contak-CD and
InSync-ICD studies // J. Cardiovasc. Electrophys. 2005.
Vol. 16. P. 1168?1171.
Yu ?., Fung W., Lin H. et al. Predictors of left ventricular
reverse remodelling after cardiac resynchronization therapy
for heart failure secondary to idiopathic dilated or ischemic
cardiomyopathy // Am. J. Cardiol. 2003. Vol. 91.
P. 684?688.
????????? 19.07.2012
╘ ????????? ???????, 2012
??? 616.1(023.11)
?????????? ??????????? ??????????? ????????????
? ?????????? ?????????? ??????????
??????????? ?????????????????? ???????
?. ?. ???????*, ?. ?. ???????, ?. ?. ??????
?????? ???????????, ? 1, 2012
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
????. ???????? ?????????????? ????????????????? ?????????????? ???????????? (???) ???????? ??????????? ????? ? 6-???????? ??????? ?? ?????????????? ??????? (??) ??????????? ????????? ??????????????? (??) ?? NYHA, ????????? ?? ?????????? ????????? ? ?????????? ?????????? ??????????? ?????????? ????????? ?????????????????? ??????? (???).
???????? ? ??????. ? ?????????? ?? ?????????? ??????????? ?????????? ??????????????????
??????? ???????? 21 ??? ? ???????? ? ????? ????????? 8875 ?????????. ????????????????? ?????????? ? ????????????????? ??????? ??????????? ?? 4 ??? ?? 40 ???. ???????????? ????? ????
?????? ?? ?????????? ??? ?????????? ? ????????? ????? ?????? ? 1980 ?? 2011 ?.: MEDLINE,
Medscape, Pubmed, ? ????? ?? Web-??????, ??????????? ??????????? ????????????? (Clinical
Center, National Institutes of Health, ClinicalStudyResults.org, ClinicalTrials.gov, www.theheart.org). ?????????????? ?????? ?????? ???????? ? ?????????????? ????????? Excel, ????????? Meta-analysis
Comprehensive V.2.0 (???) (??? ?????????? ??????????? ?????????????? ? ??????????? ??????? ?
?????????? ??????????). ?????? ????????? ?????????? ???????? ?????????? ????? ? 6-????????
??????? ??? ??? ? ????? ?? ?? NYHA ????????????? ? ??????? ??????? ???????? ????????? ? ????? ????????????.
* ????? ??? ?????????: e-mail: leoan@heart-house.ru
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
45
??? ?????????????? ??????? (??????????? ? ?????????????? ?? ?????? ??) ????????????? ?????????? ????????? ?????? (??) ? 95% ????????????? ???????? (95% ??). ?????????? ????????? ?????? ???????????? ?? ?????? ????????????? ????????.
??????????? ?????????? (?????????? ????? ? 6-???????? ???????, ?????????? ????????????? ??????????? ????????? ?????, ?????????? ???????? ?????) ??????????? ?? ?????? ????????? ???????.
??????????. ? ?????? ????????????? ?????????? ??? 8 ?? ??? ?????????? ????????? ?? ????-???
??. ? ????????? ? ????? ?? ?? NYHA ?????????? ???/???-? ?????????? ??????? ??????????
(?? ? ????????? ? I?II ?? ?? NYHA ????????? 0,827 (95% ?? 0,714?0,959), p = 0,012; ?? ? ????????? ? III?IV ?? ?? NYHA ????????? 0,782 (95% ?? 0,668?0,917), p = 0,002). ??? ??????????
???/???-? ? ????????? ? ????? ?? ?? NYHA ?????????? ?????????? ????????????? ? ?????????? ????????, ???????? ?????.
??????????. ????????? ????????? ???????? ????????? ???????? ????????????? ???? ????????????? ?????????? ????????? ?????????????????? ??????? ???????????? ? ? ????????? ? ??????????????-??????????????? ? ????????? ?? ??????????????? ??, ??? ??????????? ? ?????????????
?????????????? ?? ?????????? ?????????????????? ??????? ???????????? ???????? ???????????
ESC 2010. ??????????? ?????????? ?????????? ??????????? ??? ?? ?????????? ??? ? ????? ??????????????? ? ???????????? ? ????????????? ??????? ???? ???????. ? ????? ??????????? ??????????? ???????????? ????????????? ??????????????? ????????????????? ???????????? ????????????? ??????????? ??????? ????? ????????? ? ?????? ????????? ??????????????? ?????????.
? ? ? ? ? ? ? ? ? ? ? ? ? : ??????????? ????????? ???????????????, ???? ? 6-???????? ???????, ?????????????? ?????, ????????? ?????????????????? ???????, ??????????.
????????
?
?????????? ????????? ???????????????
(???) ? ??????? ??????????? ????????-?????????? ???????, ????????????? ???????? ?
2,5% ????????? ????????? ???????? ??????? ? ?????? ? ? 7% ????? ????????? (????? 7,9 ??? ?????????) ?????????? ????????? [1]. ???????????
????????? ??????????????? ??????????? ???????
???????? ?????, ?????????????? ??????? ??????????? ???????????????? ?? ?????? ?????????????????? ????????? ??????????????? ? ???????????,
???, ? ???? ???????, ??????? ????????????? ????????, ???? ???????? ?? ????????? ??????????
??????????? ??????????????? ???????.
?????????? ??????????? ????????, ? ????????? ?????????? ?????????????????? ???????,
??????? ? ????????????? ???????? ??????????,
????????????? ?????????? ????????? ???????????????? [2, 14].
? 1983 ?. ?? 7 ????????? ?????????? ?? ??????????????????????? E. de Teresa ? ?????. [16]
??????? ??????? ????? ????????? ?????????????????? ??????? (???) ? ????????? ? ???????? ????? ????? ????? ???? (?????). ? ??????????
?????????????? ??????????? ????????????, ?
??? ????? ?????????????? ?????????????????,
??????? ????????????? ???? ????????????? ?????????? ????????? ?????????????????? ???????
? ??????? ????????? ? ??????????? ??????????
????????? ??????????????? ? ????? ???????? ?????????????? ? ??????????. ? ???? ????????????
???? ??????? ????????????? ? ????????????
?????????? ??? ???????????? ??? ? ?????????
?????? ???????????, ? 1, 2012
Objective. To standardize functional class of heart failure NYHA according to the results of the 6-minute walk
test, to their further review and meta-analysis of follow-up results of cardiac resynchronization therapy (CRT).
Material and methods. In a meta-analysis of follow-up results of CRT were included 21 trials (8875 patients
in total). The duration of follow-up continued from 4 weeks to 40 months. Literature search of all articles on
the application of the CRT carried out in the following databases from 1980 to 2011: MEDLINE, Medscape,
Pubmed, and Web-sites devoted to clinical trials (Clinical Center, National Institutes of Health,
ClinicalStudyResults.org, ClinicalTrials.gov, www.theheart.org). Statistical analysis was performed using
Excel, Meta-analysis Comprehensive V.2.0 (USA). Calculation of range of test results with a 6-minute walk
from the two trials for the NYHA class was calculated using a system of linear equations with two unknowns.
Risk ratio (RR) and 95% confidence interval (95% CI) were calculated for dichotomous outcomes (mortality and hospitalization for heart failure). Risk ratios were calculated for the fixed effects model.
Continuous indicators (test results with a 6-minute walk test, the maximum rates of consumption of blood oxygen, quality of life) were estimated by the model of random variables.
Results. In a view of proposed revision of the trials, 8 of them were changed to 1?2 functional classes.
Significant reduce of mortality was achieved in patients of any NYHA class when CRT / CRT-D was used (RR
for patients I?II NYHA class was 0.827 (95% CI 0,714?0,959), p = 0,012; RR in patients III?IV NYHA
class was 0.782 (95% CI 0,668?0,917), p = 0,002). In the application of CRT / CRT-D patients each NYHA
class improved indicators of exercise tolerance, quality of life.
Conclusion. This revision increased the capacity of evidence of effectiveness of cardiac resynchronization
therapy alone and in combination with a cardioverter defibrillator in patients with mild heart failure, which
was consistent with existing guidelines for the use of cardiac resynchronization therapy of the European
Society of Cardiology, 2010. Meta-analysis of the follow-up results of CRTs on the use of CRT as a whole,
demonstrates safety and efficacy of this therapy. In order to enable the planning of national multicenter randomized trial is necessary to organize the accounting system of patients under long-term functioning Registries.
K e y wo r d s : heart failure, 6-minute walk test, functional class, cardiac resynchronization therapy, metaanalysis.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
46
?????? ???????????, ? 1, 2012
? ??????????????-??????????????? (???-?) ?
????????? ? ?????????? ????????? ???????????????? [28].
??? ?? ????? ? ????????? ????? ??? ??????
???????? ????????? ????????????? ?? ?????????? ??? ? ????????? ? ????? ???????????
?????????? ??? [7].
????? ????, ? ???? ????????????????? ?????????????? ???????????? (???), ???????????
?????????? ???, ???? ???????? ????????? ??????????? ????? ??????????? ??????????????? ???????? ?? ?? NYHA ? ???????? ???????????? ????? ? 6-???????? ???????, ??? ??????? ?????????? ?????? ??? ? ?????????? ????????????
??????????? ?????????? ??????????? ??????????
??? ? ????????? ? ??? [6].
????????? ???????????? ????????? ??????????? ????????????????? ?????????????? ????????????, ??????????????????? ?? ??????? ????????? ??????????????? ?? ????????? ?????????????
??????????????? ?????? (??) ??? ? ????? ?
6-???????? ???????.
?????? ???????????, ? 1, 2012
???????? ? ??????
????? ???????????? ?????????? ?? ?????????? ??? ?????????? ? ????????? ????? ?????? ?
1980 ?? 2011 ?.: MEDLINE, Medscape, Pubmed, ?
????? ?? Web-??????, ??????????? ???????????
????????????? (Clinical Center, National Institutes
of Health, ClinicalStudyResults.org, ClinicalTrials.gov,
www.theheart.org).
? ????????? ?????? ??????? ????????? ???????? ????? ?? ??????? ? ?????????? ??????: ??????????? ????????? ???????????????, ????????? ?????????????????? ???????, ?????????? ??????
?????????, ????????????????? ??????????????
????????????, heart failure, cardiac resynchronization therapy, ventricular dysfunction, randomized controlled trial, biventricular pacing, single chamber pacing, dual chamber pacing, implantable defibrillators,
meta-analysis, multi-center trial, contraindications,
predict, complications.
??? ?????? ????????????? ?????????? ??????????? ?????????? ??????????? ?????????????????? ??????? ???? ?????????? ?????????
???????? ????????? ???????????? ? ?????? ??????????:
? ??? ? ???????? ????????? ? ??? ? ???????? ??????? ?????? ????????? ????? 40%, ?????????? ?? ????????? ?? ??? ?? NYHA;
? ???, ???????????? ????????????? ???????
? ??????????? ??? ? ??? ???, ? ??????????????
????????????? ????????????????? ??????????,
????????????? ???????????????? ??????????,
????????????? ????????????-????????????? ? ?
????????? ? ???;
? ???, ?????????? ?????? ? ?????????? ?????????????? ?? ?????? ???, ????????? ??????? ??????? ?????? ????????? ??? ?????????? ??????????????? ????????? (???????? ?????, ??????????
????? ? 6-???????? ???????), ????? ??????????;
? ???, ?????????? ????? 30 ?????????.
???????? ????? ????????????:
1) ?????????:
? ????? ???????????;
2) ?????????:
? ?????????????? ?? ?????? ????????? ???????????????,
? ?????????? ????? ? 6-???????? ???????
(6-MWT),
? ?????????? ????????????? ??????????? ?????????,
? ?????????? ???????? ????? (???????? ????????????? ????????? ?????? ???????? ????? ????????? ? ??????????? ????????? ????????????????,
????? ?? 0 ?? 105 ??????; ????? ?????? ????????
??????? ?????????? ????????????????? ? ????? ??????? ???????? ????? ?????????).
???????? ???, ?????????? ? ????????????:
?B-LEFT HF: Biventricular versus Left Univentricular Pacing with ICD Back-up in Heart Failure
Patients (????????? ???????????????? ? ????????????????? ???????????????? ?????????? ? ??????????? ????????????-????????????? ? ????????? ? ????????? ????????????????). ????? ????? ????????? ? 176. ????? ?????????????????
???????????? ? 6 ???.
?BELIEVE: Bi vs Left Ventricular Pacing: An
International Pilot Evaluation on Heart Failure
Patients with Ventricular Arrhythmias (????????????? ???????? ???????????? ?? ?????????? ??- ?
???????????????? ?????????? ? ????????? ? ????????? ???????????????? ? ????????????? ?????????). ????? ????? ????????? ? 74. ????? ????????????????? ???????????? ? 12 ???.
?CARE-HF: Cardiac Resynchronization ? Heart
Failure (????????? ?????????????????? ??????? ?
????????? ???????????????). ????? ????? ????????? ? 813. ????? ????????????????? ???????????? ? 29 ???.
?COMBAT: Conventional Versus Biventricular
Pacing in Heart Failure and Bradyarrhythmia (????????? ??????? ? ???????????????? ?????????? ?
????????? ? ????????? ???????????????? ? ?????????????). ????? ????? ????????? ? 54. ?????
????????????????? ???????????? ? 3 ???.
?COMPANION: Comparison of Medical Therapy,
Pacing, and Defibrillation in Chronic Heart Failure
(????????? ??????????? ??????????????? ???????, ?????????????????? ???????, ? ??? ?????
? ???????? ????????????-????????????? ???
????????? ???????????????). ????? ????? ????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????? ? 1520. ????? ????????????????? ???????????? ? 12 ???.
?DECREASE-HF: Device Evaluation of CONTAK
RENEWAL 2 and EASYTRAK 2: Assessment of Safety
and Effectiveness in Heart Failure (?????? ?????????????? ????????? CONTAK RENEWAL 2 ?
EASYTRAK 2: ?????? ????????????? ? ????????????). ????? ????? ????????? ? 306. ????? ????????????????? ???????????? ? 6 ???.
?Greater-EARTH: Evaluation of Resynchronization Therapy For Heart Failure In Patients With A
QRS Duration Greater Than 120 ms (?????? ????????? ?????????????????? ??????? ? ????????? ?
????????? ?????????????????? ???????? ? ?????
?????????? QRS). ????? ????? ????????? ? 121.
????? ????????????????? ???????????? ? 6 ???.
?HOBIPACE: Homburg Biventricular Pacing
Evaluation (??????????? ???????????? ?? ????????
???????????????? ??????????). ????? ????? ????????? ? 32. ????? ????????????????? ???????????? ? 3 ???.
?MADIT-CRT: Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (?????????????? ???????????? ??
?????????? ??????????????-??????????????? ?
????????? ? ?????????????????? ????????). ????? ????? ????????? ? 1820. ????? ????????????????? ???????????? ? 26 ???.
?MIRACLE: Multicenter InSync Randomized
Clinical Evaluation (?????????????? ????????????????? ??????????? ???????????? ?? ??????????
?????????????????? ???????). ????? ????? ????????? ? 453. ????? ????????????????? ???????????? ? 6 ???.
?MIRACLE ICD: Multicenter InSync Randomized Clinical Evaluation ICD (?????????????? ????????????????? ??????????? ???????????? ??
?????????? ?????????????????? ??????? ? ????????? ? ??????????????-???????????????).
????? ????? ????????? ? 369. ????? ????????????????? ???????????? ? 6 ???.
?MUSTIC AF: Multisite Stimulation in Cardiomyopathies?Atrial Fibrillation (?????????????? ?????????? ??? ??????????????? ? ???????????
??????????). ????? ????? ????????? ? 43. ?????
????????????????? ???????????? ? 3 ???.
?MUSTIC SR: Multisite Stimulation in Cardiomyopathies ? Sinus Rhythm (?????????????? ?????????? ??? ??????????????? ?? ???? ?????????? ?????). ????? ????? ????????? ? 58. ?????
????????????????? ???????????? ? 3 ???.
?PATH-CHF: Pacing Therapies for Congestive
Heart Failure (??????????????????????????? ??????? ??? ?????????? ????????? ???????????????). ????? ????? ????????? ? 41. ????? ????????????????? ???????????? ? 1 ???.
47
?PATH-CHF II: Pacing Therapies for Congestive
Heart Failure II (???????????????????????????
??????? ??? ?????????? ????????? ??????????????? II). ????? ????? ????????? ? 86. ?????
????????????????? ???????????? ? 3 ???.
?RAFT: Resynchronization/Defibrillation for
Ambulatory Heart Failure (?????????????????? ???????/ ????????????-????????????? ??? ??????????? ????????? ???????????????). ????? ?????
????????? ? 1798. ????? ????????????????? ???????????? ? 40 ???.
?RD-CHF: Single Chamber Right Ventricular to
Biventricular Pacing in Permanently Paced Patients
with Worsening Heart Failure (????????? ???????????? ????????????????? ? ????????????????
?????????? ? ????????? ? ??????????? ? ?????????? ??????????????????????? ??? ??????????????? ????????? ???????????????). ????? ????? ????????? ? 44. ????? ????????????????? ???????????? ? 3 ???.
?RethinQ: Cardiac Resynchronization Therapy in
Patients with Heart Failure and Narrow QRS (????????? ?????????????????? ??????? ? ????????? ?
????????? ???????????????? ? ????? QRS). ?????
????? ????????? ? 172. ????? ?????????????????
???????????? ? 6 ???.
?REVERSE: REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction (???????? ??????? ?????????????????? ??????? ?? ???????? ??????????????? ??? ????????????????
????????????? ??????????). ????? ????? ????????? ? 610. ????? ????????????????? ???????????? ? 12 ???.
?RHYTHM ICD: Resynchronization for Hemodynamic Treatment for Heart Failure Management
(?????????? ?????????????????? ??????? ? ??????? ????????? ? ????????? ????????????????).
????? ????? ????????? ? 179. ????? ????????????????? ???????????? ? 6 ???.
?VecTOR: Ventricular Resynchronization Therapy
Randomized Trial (????????????????? ???????????? ?? ?????????? ?????????????????? ???????). ????? ????? ????????? ? 106. ????? ????????????????? ???????????? ? 6 ???.
????? ? ?????????? ???? ???????? 21 ??? ?
???????? ? ????? ????????? 8875 ?????????.
??????? ????????, ??? ??? ??????????????????
??? ???? ????????????, ?????????, ? ?????????, ? ?? ?? ??????????? ?? ?????? ?????????????????? ??????????????? ???????????? ??
?????? ????????????? ?????????? ?????????????????? ???????. ????????????????? ?????????? ? ????????????????? ??????? ??????????? ??
4 ??? ?? 40 ??? [7?15, 17?27, 29, 30].
?????????????? ?????????, ????????????? ? 21
???, ???????? ? ??????? 1 [7?15, 17?27, 29, 30].
?????? ???????????, ? 1, 2012
???????????? ??????
2002
2002
2002
2003
2003
2003
2004
2005
2005
2006
2006
2007
2007
2007
2008
2009
2010
2010
2010
2011
MIRACLE
MUSTIC AF
PATH-CHF
MIRACLE ICD
PATH-CHF II
RHYTHM ICD
COMPANION
CARE-HF
VecTOR
HOBIPACE
BELIEVE
RD-CHF
RethinQ
DECREASE-HF
REVERSE
MADIT-CRT
RAFT
COMBAT
B-LEFT HF
Greater-EARTH
6
6
3
40
26
12
6
6
3
12
3
6
29
12
6
3
6
1
3
6
3
??????
??????????, ???
121
176
54
1798
1820
610
306
172
44
74
32
106
813
1520
179
86
369
41
43
453
58
????? ?????
?????????
0
0
0
15
17,5
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
I ??, %
69,4
0
16,5
80
85
82,5
0
0
0
37,5
0
29
93,5
0
5
0
0
0
0
0
II ??, %
32,5
93,5
52
20
0
0
97,5
100
100
62,5
100
65
6,5
85
87
88,5
85
100
90,5
100
30,6
III ??, %
6,5
31,5
0
0
0
2,5
0
0
0
0
6
0
15
7
67,5
11,5
15
0
9,5
0
IV ??, %
363 ╠ 72,3
304,5 ╠ 119
?
353 ╠ 108
366
390 ╠ 127
?
300 ╠ 97
324
?
?
?
?
264
284 ╠ 136
407 ╠ 81
243 ╠ 124
357 ╠ 20
329 ╠ 85
298 ╠ 136
350 ╠ 109
????????
??????????
6-MWT, ?
104
141
?
271
320
323
?
151
151
?
?
?
?
128
154
49
134
128
151
137
151
6-MWT
min, ?
283
290
?
400
444
447
?
300
300
?
?
?
?
277
302
199
283
277
300
286
300
6-MWT
max, ?
??????????. ?????????? ??????? ???????? ????????????, ??????? ?? ????? ? ???????? ???????????? ??????? ??????????? ????? 6-MWT, ?????? ?? ?????????? ?? ???.
2001
MUSTIC SR
???
?? ? ? ? ? ? 1
48
???????? ???
?????????????? ????????? ? ?????????? ?? ??? ?? NYHA, ?????????? ? ????????? ???
?????? ???????????, ? 1, 2012
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????? ???????????, ? 1, 2012
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
??????????
?????? ? ??????????
?????????????? ???????????? ?? ???????
????????? ???????????????
???????? ?????????? ????? ? 6-???????? ??????? ? ????????? ??? ???????????????? ? ??????? ??????? ???????? ?????????. ? ?????? ?????? ???? ?????? ???????????????? ???????????
?????????? ??????????????? ?? ?? ?? NYHA ?
???????? ??????? ???????? ??????????? ????? ?
6-???????? ???????. ??? ?????????? ????? ???????????? ?????????? ??? ??????? ???????? ???????? 6-MWT ?????????? ??????????? ? ???????????? ?????????? ??????? ?????? ????????
??? ??????? ?????????????????? ????????????
????????????. ?????? ????????? ?????? ????????????????? ???, ??? ??? ?????????????? ? ?????????????? ?????? ??????? ???????????? ????????? ??????????????? ???????????? ????????????
NYHA ?? ?????????? 6-MWT (?? 6 ??? ????????
? ??? I ?? ???????? ?????? ?? 426 ?? 550 ?, ?
??? II ?? ? ?? 300 ?? 425 ?, ? ??? III ?? ? ??
150 ?? 300 ?, ? ? ??? IV ?? ? ????? 150 ?).
???????? ?????? ??????? ?????????? ? ??????????? ?????????? ???????? ??????????? 6-MWT ?
?????????, 85% ??????? ? ???????? ? III ?? ??
?? NYHA ? 15% ? ???????? ? IV ?? ?? ?? NYHA
(???????????? PATH-CHF):
1. ?????? ??????? ??????? ???????? 6-MWT:
85% в 151 ? = 12 835 ?%, ?? ???? 85% ????????? ?
III ?? ???????? ??????? 12 835 ?, ??? ???????,
??? ??? ?? 6 ??? ????? ????????? 151 ? (??????
??????? ???????? ??? ??????? ?? ??).
15% в 0 ? = 0 ?% (?? ?? ????? ??? ????????? ?
IV ?? ?? NYHA).
(12 835+0)/100% = 128,35 ? (??????????? ???????? 6-MWT ??? ??????? ????????????).
2. ?????? ???????? ??????? ???????? 6-MWT:
85% в 300 ? = 25 500 ?%, ?? ???? 85% ????????? ?
III ?? ???????? ??????? 25 500 ?, ??? ???????,
??? ??? ?? 6 ??? ????? ????????? 300 ? (???????
??????? ???????? ??? ??????? ?? ??).
15% в 150 ? = 2250 ?% (?? ?? ????? ??? ????????? ? IV ?? ?? NYHA).
(25 500+2250)/100% = 277,5 ? (????????????
???????? 6-MWT ??? ??????? ????????????).
????? ???????, ?????????? 6-MWT ?????? ??????????? ? ????????? ?? 128,35 ?? 277,5 ?, ?????
??? ? ?????? ?? ??????? ???????????? ????????
??????? ???????? 6-MWT ? 357 ?.
?????????? ??????? ? ??????? 1 ????????
????????????, ??????? ?? ????? ? ???????? ???????????? ??????? ??????????? ????? ? 6-???????? ??????? ?????? ?? ?????????? ?????????????? ??????? ???.
?????? ???????????, ? 1, 2012
????? ? ?????? ??????? ????????? ??????????
????????? ??????????? ????? ? 6-???????? ???????, ???????????? ?????? ?? ?????? ? ?????????????? ????????? ? ??????????? ??????????????? ?????? ?? NYHA ? ?????????? ???????????.
???????? ?????????? ??????????? ????? ? 6-???????? ??????? ??? ??? ? ????? ?? ?? NYHA
????????????? ? ??????? ??????? ????????
????????? ? ????? ????????????.
??? ?????????????? ??????? (??????????? ?
?????????????? ?? ?????? ???) ?????????????
?????????? ????????? ?????? (??) ? 95% ????????????? ???????? (95% ??). ?????????? ????????? ?????? ???????????? ?? ?????? ????????????? ????????.
??????????? ?????????? (?????????? ?????
? 6-???????? ???????, ?????????? ????????????? ??????????? ????????? ?????, ?????????? ???????? ?????) ??????????? ?? ?????? ?????????
???????.
????? ??????????? ??????????? ?????????????? I2. ?????????? I2 ????? 50% ???????????????? ?
?????????????? ?????????????? (??????????????)
??????????? ?????. ????????? ??????????????
?????????????? ?????? ????? ??? ?????????? ?????? ?????? ?????????? ???????????. ?????????? ??? ?????? ?????????? ???????????: ??????
?????????????? ??????? (╚fixed effect╩) ? ??????
?????????? ??????? (╚random effect╩). ???? I2 ????? 50%, ???????????? ?????????? ?????????????
??????????? ? ????? ???? ???????????? ??????
?????????????? ???????. ???? I2 ?????????? 50%
??? ?????, ?? ?????????????? ??????? ?????? ?
?????????? ????????? ?????? ?????????? ??????? ? ???????????. ?????? ?????????????? ??????? ??????????? ??? ???????????, ????? ???????? ????????? ??? ?????????? ????????????,
????? ??? ?????? ?????????? ??????? ?????????,
??? ????? ???????????? ? ?????? ????????????,
????????? ??? ?????? ? ???? ??????????? ??????????, ??? ????????????, ??????? ???????????? ????? ???????? ? ??????????, ?? ?? ????? ?
???? ?????? ?? ?????-???? ????????. ?????????? ????? ?????? ??????????? ???????? ?????
??? ???????? ???????????? (??????????????)
?????????, ??? ??? ? ???? ?????? ?????? ?????????????? ? ?????????? ??????? ????? ?????? ??????????. ??? ??????? ?????????????? (???????????) ????????? ??? ?????? ?????? ???? ??????? ??????????.
????????????? ?????????????? ??????? ???
??????????? ???????? ????????????? NYHA.
????????? Meta-analysis Comprehensive, V.2.0
?????????????? ??? ?????????? ??????????????
??????????? ? ?????????? ????????.
49
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
50
?????? ???????????, ? 1, 2012
?? ? ? ? ? ? 2
???????? ???, ?????????? ?????????? ?? ??????? ???????????? ??????? ????????? ???????????????
???
MUSTIC SR
MIRACLE
MUSTIC AF
PATH-CHF
B-LEFT HF
RD-CHF
PATH-CHF II
Greater-EARTH
??????? ?? ??? ?? NYHA
???????????? ?? ??? ?? NYHA,
???????? ?????????? 6-MWT
III
III?IV
III
III?IV
III?IV
III
II?IV
I?IV
II
III
II
II
II
II
II
II
? ?????? ??????????????? ?????????? ????,
??? ? ?????? ????????????? ???????? ??????????
???????????? ?????????? 6-MWT (?????????????? ??????????) ?? ????????? ? ?? ?? NYHA (???????????? ??????????). ? ????? ? ???? ??????????? ????????????? ?????????? ???? ??? ??
??????? ?? ?? ?? NYHA ? ?????? ?????????
??????? ??????? 6-MWT ? ?????????? ???????????? ??????????? ???.
? ??????? 2 ??????? ???, ??????? ??????? ?????????? ?? ??????????? ??????????? ???? ????????.
????? ???????, ? ??????????? ?? ?????????????? ? ??????????????? ?????? ??? ?? NYHA
???????? ? ??? ???? ???????????? ?????????
???????:
? 5282 ???????? ? ??????????? ?????? ? 3593
???????? ? ??????????? ??????;
? 4797 ????????? ? I/II ?? ?? NYHA;
? 4078 ????????? ? III/IV ?? ?? NYHA.
?????? ???????????, ? 1, 2012
?????????? ??????????? ??????????
???/CP?-? ? ??????? ? ???????????
????????? ????????????????
??? ???????? ?????????? ????? ??????????,
????? ??????????????, ??????????? ????? ? 6-???????? ???????, ??????????? ????????????? ??????????? ????????? ?????, ??????????? ????????
????? (???. 1?3).
? ????? ? ???, ??? ?????? ?????????????? ?????????????? ??? ??????????? ??????????? ?????
??????????? ? ????? ?????????????? ?? ??????
????????? ??????????????? ?? ???????? 50%,
?????? ?????????? ??????????????? ???????
????????????? ????????.
??? ? ???-? ? ????????? ? ????? ?? ??
NYHA ?????????? ??????? ??????????: ?? ? ????????? ? I?II ?? ?? NYHA ????????? 0,827 (95%
?? 0,714?0,959), p = 0,012 (??. ???. 1, ?), ?? ? ????????? ? III?IV ?? ?? NYHA ????????? 0,782
(95% ?? 0,668?0,917), p = 0,002 (??. ???. 1, ?). ????????????? ????????? ???? ????????????? ????????? (?????????? ?????????????? I2 = 0%).
? ????? ???????? ?????????? ??????????????
?????????????? ?????? ????? ?????????????? ????????? ? ?????????? ??????????????? ???????? ?? ??????????? ???????? ??? ??? ? ??????????? ??? (??. ???. 2, ?, ?) ? ? ??????????? ???-?
(??. ???. 2, ?, ?).
?? ?????? ?????????? 2, ??? ?????, ??? ????????????? ????????? ???? ????????????? ????????? (?????? ?????????????? ?? ????????
13,4%), ?????????? ?????????????? ?????????
??? ?????????? ??? ? ????????? ? ?????? ??
??? ?? NYHA ? ??? ?????????? ???-? ? ????????? ?? ??????????????? ???, ?????? ?? ????
???????? ????????????? ???????? ?????????? ?????????????? ????????? ? ??????? ??? ??? ?????????? ???-? ?? ????????? ? ?????????
(p = 0,721).
?????? ??????????? ??????? (??????????? ????? ? 6-???????? ???????, ????????????? ??????????? ????????? ?????, ???????? ?????) ????????????? ??????? ?????????? ??????? ? ????? ?
??????????? 50% ??????? ?????????????? ??????????????.
??? ? ???-? ? ????????? ? ????? ?? ??
NYHA ???????? ????????????? ? ?????????? ???????? (?????????? ????? ? 6-???????? ???????:
??????????????????? ??????? ??????? ? ????????? ????????? 0,420 (95% ?? 0,337?0,503)) ? ???????????? ??????????? ????????? ????? (??????????????????? ??????? ??????? ????????? 0,137
(95% ?? 0,003?0,271)) (???. 3, ?, ?).
????????????? ???????? ??????????????????? ??????? ??????? (???. 3, ?) ??????????????? ?? ????????? ???????? ????? ?????????
????? ?????????? ???/???-?. ? ?????? ??????
???? ?????????? ???????? ?0,370 (95% ??
?0,453... ?0,287).
?????????? ??????????? ?????? ? 6,6% ???????
? ???? ??????? ? ????????????? ????????????
(3,2%), ??????????? ?????????? (1,9%), ?????????? ? ??????????? (6,2%), ?????????? (1,4%), ????????????????? ???????????? (0,3%).
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
51
?????????? ?? ??????? ???
???????? ???
????????? ?????? ???????
??????
??????
??????
p
MUSTIC SR, 2001
MUSTIC AF, 2002
PATH-CHF, 2002
PATH-CHF II, 2003
RD-CHF, 2007
REVERSE, 2008
MADIT-CRT, 2009
RAFT, 2010
B-LEFT HF, 2010
Greater-EARTH, 2011
3,000
2,192
3,600
0,667
0,500
1,368
0,937
0,797
0,106
0,984
0,127
0,094
0,184
0,117
0,102
0,374
0,667
0,673
0,006
0,143
70,736
50,928
70,544
3,793
2,455
4,995
1,317
0,943
1,944
6,758
0,496
0,625
0,399
0,648
0,393
0,636
0,709
0,008
0,131
0,987
??????
0,827
0,714
0,959
0,012
????????? ?????? ? 95% ??
0,01
? ?????????????? I2 = 0%
0,1
1
? ?????? ???/???-?
10
100
? ?????? ????????
?????????? ?? ??????? ???
???????? ???
????????? ?????? ???????
??????
??????
??????
p
MIRACLE, 2002
MIRACLE ICD, 2003
COMPANION (CPT), 2004
CARE-HF, 2005
RHYTHM ICD, 2003
VecTOR, 2005
BELIEVE, 2006
HOBIPACE, 2006
DECREASE-HF, 2007
RethinQ, 2007
COMBAT, 2010
0,740
0,908
0,849
0,675
1,513
0,797
2,000
1,000
0,591
2,443
0,500
0,358
0,451
0,664
0,528
0,315
0,051
0,540
0,068
0,185
0,487
0,100
1,529
1,828
1,086
0,862
7,270
12,401
7,404
14,640
1,891
12,248
2,505
0,416
0,788
0,193
0,002
0,605
0,871
0,299
1,000
0,376
0,278
0,399
??????
0,782
0,668
0,917
0,002
? ?????????????? I2 = 0%
????????? ?????? ? 95% ??
0,01
0,1
? ?????? ???/???-?
1
10
100
? ?????? ????????
???. 1. ??????? ???/???-? ?? ????? ??????????? ? ????????? c I?II ?? (?) ? ? III?IV ?? (?) ??? ?? NYHA:
??????????
???????? ??????????????? ?????? ?? ??
NYHA ???????? ???????????? ???????????, ? ????? ? ??? ????????????? ???????????? ???????????
?????????? ????????????? ? ?????????? ????????
(????????, ???? ? 6-???????? ???????).
? ?????? ????????????? ?????????? ??? ?????? ?? ??? ?????????? ????????? ?? ????-???
??. ?????? ?? ???? ??????? ? ?????? ??? ???????? ????? ????? ?????????? ???????? ??.
????? ???????, ??????????? ????????? ???????? ????????? ???????? ????????????? ???? ????????????? ?????????? ??? ? ????????? ??
??????????????? ?? (???????? ? I?II ?? ??
NYHA), ??? ??????????? ? ????????????? ?????????????? ?? ?????????? ?????????????????? ??????? ???????????? ???????? ??????????? (ESC), 2010.
??????????? ?????????? ?????????? ??????????? ??? ?? ?????????? ??? ? ????? ??????????????? ? ???????????? ??????? ???? ??????? (6,6%
??????????).
??????? ????????, ??? ?? ???? ????????????
???????? ?? ?????????? ?????????????? ????????? ? ??????? ??? ??? ?????????? ???-? ??
????????? ? ?????????.
? ????????? ?????? ?????????? ???????? ???????? ????? ?????????? ? ????? ??????????????, ????????? ????????????? ? ?????????? ???????? ? ???????? ????? ????????? ? ?????????
???????????????? ?????????? ?? ??????? ?? ????????????.
? ?????? ???????? ????? ?????????? ???,
??????????????? ??????? ? ????????????, ? ????? ???????????? ?????????????????? ??????????? ????????? ??????????????? ?????????????
?????????? ????????????? ???, ????????????
?????? ???????????, ? 1, 2012
? ????? ? ?? ???????? 2, 3 ? ????????? ??????
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52
?????? ???????????, ? 1, 2012
?????????? ?? ??????? ???
???????? ???
????????? ?????? ???????
??????
??????
??????
p
MUSTIC SR, 2001
MUSTIC AF, 2002
RD-CHF, 2007
REVERSE, 2008
0,222
0,360
0,143
0,391
0,052
0,035
0,019
0,184
0,941
3,673
1,066
0,829
0,041
0,389
0,058
0,014
??????
0,320
0,174
0,589
0,000
????????? ?????? ? 95% ??
0,01
? ?????????????? I2 = 0%
0,1
1
? ?????? ???
10
100
? ?????? ????????
?????????? ?? ??????? ???
???????? ???
????????? ?????? ? 95% ??
????????? ?????? ???????
??????
??????
??????
p
MIRACLE, 2002
CARE-HF, 2005
COMBAT, 2010
0,522
0,535
0,683
0,304
0,416
0,225
0,897
0,688
2,069
0,019
0,000
0,500
??????
0,538
0,430
0,673
0,000
? ?????????????? I2 = 0%
0,01
0,1
1
? ?????? ???
10
100
? ?????? ????????
?????????? ?? ??????? ???
???????? ???
????????? ?????? ???????
??????
??????
??????
p
MADIT-CRT, 2009
RAFT, 2010
B-LEFT HF, 2010
Creater-EARTH, 2011
0,652
0,746
0,782
1,967
0,525
0,627
0,341
0,625
0,810
0,886
1,793
6,189
0,000
0,001
0,561
0,247
??????
0,719
0,630
0,821
0,000
? ?????????????? I2 = 13,4%
????????? ?????? ? 95% ??
0,01
0,1
? ?????? ???-?
1
10
100
? ?????? ????????
?????????? ?? ??????? ???
???????? ???
p
MIRACLE, 2002
BELIEVE, 2006
1,061
0,714
0,843
0,249
1,335
2,048
0,616
0,531
??????
1,042
0,832
1,304
0,721
? ??????????????
?????? ???????????, ? 1, 2012
????????? ?????? ???????
??????
??????
??????
I2 = 0%
????????? ?????? ? 95% ??
0,01
0,1
? ?????? ???-?
1
10
100
? ?????? ????????
???. 2. ??????? ??? ?? ?????????? ?????????????? ????????? ? I?II ?? (?) ? ? III?IV ?? (?) ??? ?? NYHA.
??????? ???-? ?? ?????????? ?????????????? ????????? ? I?II ?? (?) ? ? III?IV ?? (?) ??? ?? NYHA
?? ?????????? ?????????????????? ??????? ?
????????? ? ???. ?????? ???????????? ????????
?????????? ??????????? ???? ??????? ???? ??????? ????????? ????????? ? ??????? ?????????????
????????.
???????? ? ?????? ???????? ????????? ???????
?????? ????? ?? ????????? ? ???????? ??????????????? ?????????? ????????? ???????????
??????? ??????????, ?????????????? ????????
??????????????, ???????????? ? ??????????.
???????????? ????? ? ??????? ???? ????????
???????? ?????????????? ??????????, ??????????????? ?? ?????????? ????????? ????????
??????????? ? ?????? ??????????? ?????????????????? ???????. ??????????? ????????
????????????? ??????????? ???????????? ?????? ? ?????? ??????????????? ? ????????????? ????????, ??????????, ??????????? ????????????? ?????? ??????? ??? ????????? ?????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????? ??????
53
?????????? ?? ??????? ???
???????? ???
?
???????????????.
?????? ???????
??????
???????
?????? ???????
??????
??????
p
MUSTIC SR, 2001
0,585
0,301
?0,006
1,176
0,052
MUSTIC AF, 2002
0,302
0,311
?0,307
0,911
0,331
PATH-CHF, 2002
0,063
0,317
?0,559
0,684
0,884
REVERSE, 2008
0,048
0,087
?0,123
0,220
0,579
Greater-EARTH, 2011
0,117
0,182
?0,240
0,473
0,521
MIRACLE, 2002
0,462
0,100
0,266
0,658
0,000
COMPANION (CPT), 2004
0,725
0,101
0,527
0,923
0,000
COMPANION (CPT-?), 2004
0,610
0,100
0,414
0,807
0,000
RHYTHM ICD, 2003
0,106
0,188
?0,474
?0,263
0,573
RethinQ, 2007
0,903
0,169
0,571
1,235
0,000
??????
0,420
0,043
0,337
0,503
0,000
??????????????????? ??????? ??????? ? 95% ??
?2,00
?1,00
0,00
? ?????? ????????
1,00
2,00
? ?????? ???/???-?
?????????? ?? ??????? ???
???????? ???
?????? ???????
??????
??????
p
MUSTIC SR, 2001
0,225
0,326
?0,414
0,864
0,490
MUSTIC AF, 2002
0,744
0,319
0,118
1,369
0,020
PATH-CHF, 2002
0,467
0,321
?0,163
1,096
0,146
MIRACLE, 2002
0,301
0,095
0,116
0,486
0,001
HOBIPACE, 2006
0,508
0,359
?0,196
1,212
0,157
RHYTHM ICD, 2003
0,072
0,188
?0,296
0,440
0,702
?0,661
0,164
?0,983
?0,338
0,000
0,137
0,068
0,003
0,271
0,046
RethinQ, 2007
?
???????????????.
?????? ???????
??????
???????
??????
??????????????????? ??????? ??????? ? 95% ??
?2,00
?1,00
0,00
? ?????? ????????
1,00
2,00
? ?????? ???/???-?
?????????? ?? ??????? ???
?????? ???????
??????
??????
p
MUSTIC SR, 2001
?0,455
0,302
?1,047
0,137
0,132
MUSTIC AF, 2002
?0,459
0,313
?1,072
0,155
0,143
PATH-CHF, 2002
?0,857
0,331
?1,506
?0,209
0,010
REVERSE, 2008
?0,209
0,088
?0,381
?0,038
0,017
Greater-EARTH, 2011
?0,074
0,182
?0,282
0,430
0,684
MIRACLE, 2002
?0,450
0,101
?0,647
?0,253
0,000
CARE-HF, 2005
?0,411
0,071
?0,550
?0,272
0,000
HOBIPACE, 2006
?0,303
0,356
?1,000
0,393
0,393
RHYTHM ICD, 2003
?
???????????????.
?????? ???????
??????
???????
0,197
0,188
?0,566
0,172
0,296
RethinQ, 2007
?0,843
0,165
?1,166
?0,521
0,000
??????
?0,370
0,042
?0,453
?0,287
0,000
??????????????????? ??????? ??????? ? 95% ??
?2,00
?1,00
0,00
1,00
2,00
? ?????? ????????
? ?????? ???/???-?
???. 3. ??????? ???/???-? ?? ?????????? ????????????? ? ?????????? ????????? (?????????? ????? ? 6-???????? ??????? (?)), ?? ?????????? ????????????? ??????????? ????????? (?) ? ???????? ????? (?)
?????????? ????????????? ??????? ?????? ?
???????????????? ??????????? ?????????? ????? ??????? ??????? ??? ??????????? ????????
??????????? ? ?????????????? ???????, ????????????????? ???????????? ? ?????????? ????????
??????????? ?????? ?????????. ??? ???????????? ??????????? ??????????? ???, ??????????? ???????, ?????????? ?????????? ?????????
??????, ? ??????? ??????????????? ?? ??????????? ???????? ? ??? ??? ???? ????????? ?????????.
?????? ???????? ???????? ??????????? ?????? ?? ?????? ???????? ??????? ??????????????
??? ?????? ????????? ??????????? ?????????,
?????????? ?????????? ?????? ?????????? ?
?????? ??????????? ? ???????? ???????? ? ╚???????????╩ ?? ??? ?????????? ?????.
?????? ???????????, ? 1, 2012
???????? ???
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????? ???????????, ? 1, 2012
54
?????? ???????????, ? 1, 2012
??????? ????? ????????? ??????? ?????????????, ???????? ???????, ??????, ???????????? ?
?????????? ????????? ???????? ? ???????, ?????????? ?????????????.
? ??????? ?????? ????????-?????????? ???????? ????? ?. ?. ???????? ???? ? ?????? ?????????????? ? ??????? ????????????? ? ??????????????? ??????????? ????? ?? (??????) ??????
?????? ??????? ????????? ? ??????????? ?????
?????? ? ???????????? [3, 4]. ?????? ??????? ???????? ????????:
1) ??????????? ?????????? ??????????? ? ???????? ??????????? ?????? ??????? ? ?????- ?
?????????????;
2) ??????????? ?????? ????????? ???????????
? ??????? ????????? ????? ?????? ? ???????-???????????????? ??????????? ????????? ?????????? ?????????;
3) ????????????????? ?? ?????? ??????????
?????? ??????? ???????? ????????? ? ??????????? ????? ?????? ? ???????????? ????????? ???????? ??????????????????? ??????????? ??????
????????? ??, ? ????????? ??????? ? ?????????? ???????????? ? ?????????? ?????????, ?????????? ?????????????.
????????? ?????????? ?????????? ???????
???????? ? ???????????????? ????????:
1) ??????????? ????????? ??????????? ? ??????????? ?????? ?? ??????????? ? ????????
???????? ??????????? ?????? ??????? ? ??????????? ????? ?????? ?? ?????? ?????????? ?
????? ?????? ???????, ? ????????? ???????????????;
2) ?? ?????? ?????????? ?????????? ??????
?????????? ?????????? ????? ??????????, ?????????? ??????????? ? ??????? ????????? ? ????????? ??????, ????? ????? ??????????? ??????????? ???????????????? ?????? ? ????? ??????;
3) ?????????????? ?????? ??????????? ? ??????? ???????? ??????????? ????????? ????????????? ? ??????????????? ??????????? ?????????????? ????????????????? ???????????? ? ??????
?????????? ?????????.
??????? ???? ???????. ? ????? ??????????? ??????????? ???????????? ????????????? ??????????????? ????????????????? ????????????
????????????? ??????????? ??????? ????? ????????? ? ?????? ????????? ???????????????
?????????.
? ? ? ? ??? ? ??
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
??????????
????????? ????????? ???????? ?????????
???????? ????????????? ???? ?????????????
?????????? ????????? ?????????????????? ??????? ???????????? ? ? ????????? ? ??????????????-??????????????? ? ????????? ?? ??????????????? ??, ??? ??????????? ? ?????????????
?????????????? ?? ?????????? ?????????????????? ??????? ???????????? ???????? ??????????? (2010 ?.). ??????????? ?????????? ?????????? ??????????? ??? ?? ?????????? ??? ? ?????
??????????????? ? ???????????? ? ?????????????
13.
14.
15.
????? ?. ?., ???????? ?. ?., ????? ?. ?. ? ??. ?????????????????? ??????????? ????????? ??????????????? ?
??????????? ????? ?????????? ????????? ? ??????
????????? // ????. ??????. 2006. ? 7 (1). ?. 112?115.
??????? ?. ?., ??????? ?. ?., ????????? ?. ?. ?????????? ????????? ???????????????? ?????????? ? ????????? ? ?????? ????????? ???????????????? ????? ??????????????????? ???????? // ?????? ???????. 2006. ? 1.
?. 27?35.
??????? ?. ?., ??????? ?. ?., ????????? ?. ?. ? ??.
?????? ??????? ????????? ? ??????????? ????? ?????? ?
???????????? (????? ??????????, ???????????? ???????????? ?? ????? ??????) // ?????? ???????. 2011. ? 1.
?. 5?15.
??????? ?. ?., ??????? ?. ?., ????????? ?. ?. ? ??.
????????????? ? ??????????????? ??????????? ?????????
??? ??? ? 2012610478 ?? 10.01.2012.
??????? ?. ?., ???????? ?. ?., ??????????? ?. ?. ????????????? ???????? ? ????????-?????????? ???????????. ?.: ????? ??. ?. ?. ???????? ????, 2006. 256 ?.
??????? ?. ?., ?????? ?. ?. ????? ??????????? ????????????????? ?????????????? ????????? ?? ??????????
?????????????????? ??????? ? ????????? ? ?????????
???????????????? // ?????? ???????. 2011. ? 4. ?. 29?35.
Anthony S. L. Tang, Wells G. A., Talajic M. et al. Cardiacresynchronization therapy for mild-to-moderate heart failure //
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Auricchio A., Stellbrink C., Sack S. et al. Pacing Therapies in
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P. 2026?2033.
Beshai J. F., Grimm R. A., Nagueh S. F. et al. Cardiac-resynchronization therapy in heart failure with narrow QRS complexes // N. Engl. J. Med. 2007. Vol. 357. P. 2461?2471.
Boriani G., Kranig W., Donal E. et al. A randomized doubleblind comparison of biventricular versus left ventricular stimulation for cardiac resynchronization therapy: the Biventricular
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ?????????
16. De Teresa E. An even more physiological pacing: changing the
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(Accessed 25 September 2006).
U. S. Food and Drug Administration. St. Jude Medical╝ Epic?
HF System including the Epic? HF Model V-338 cardiac
resynchronization therapy defibrillator, the Aescula? LV model
1055K lead, the QuickSite? LV model 1056K lead, and the
model 3307, v4.5m programmer software: part 2 ? summary of
safety and effectiveness [VecTOR] [Web Page]. 2005; Available at
http://www.fda.gov/cdrh/pdf3/P030054b.pdf (Accessed 25
September 2006).
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Woo G. W., Petersen-Stejskal S., Johnson J. W. et al.
Ventricular reverse remodeling and 6-month outcomes in
patients receiving cardiac resynchronization therapy: analysis of
the MIRACLE study // J. Interv. Card. Electrophysiol. 2005.
Vol. 12. P. 107?113.
Young J. B., Abraham W. T., Smith A. L. et al. Combined
cardiac resynchronization therapy and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. Multicenter InSync ICD Randomized Clinical
Evaluation (MIRACLE ICD) Trial Investigators // JAMA.
2003. Vol. 289. P. 2685?2694.
????????? 19.07.2012
??????? ?????????
╘ ????????? ???????, 2012
??????????? ?????????? ???????? ????????????
????????? ??????? ????????? ?????? ????? ?????
?. ?. ???????*, ?. ?. ???????, ?. ?. ?????????, ?. ?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ?
???? ?. ?. ???????) ????, ??????
??????????? ??????????? ?????? ???????????? ?????????????? ? ???????????????? ?????????
?????????? ???????? ????? ??????????? ?????? ????? ?????.
?? ?????? ? 2009 ?? 2011 ?. ???? ??????????? ??? ????? ?., 1986, 1988, 1998 ???? ????????. ?????? ???????????? ???????? ???????????????, ????????-??????????? ??????????, ???????????????
* ????? ??? ?????????: e-mail: leoan@heart-house.ru
?????? ???????????, ? 1, 2012
??? 616.124
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
56
?????? ???????????, ? 1, 2012
????????????, ?? ?? ??????????? ????????? ??????? ???????????? ????????? ??????? ?????????.
? ???????? ??????? ??????????? ??????????????? ???????????? ????????? ????????????????,
????????????? ?????????? ??????? ???????????????? ?????????????? ? ??????????? ??????????????? ??????. ? ???????? ??????? ??????????? ?????????? ??????????? ?????????? ????? ? ???????????? ?? ????????? ?????????????? ??????????? ???????? ??????? ?????????, ????????????
??? ??? ????????????? ????????????-?????????????. ??????????? ?????????? ??????????? ? ???????? ??????? ?? ????????.
? ? ? ? ? ? ? ? ? ? ? ? ? : ???????????? ????????? ??????? ?????????, ??????????? ?????????? ???????????, ???????? ???????? ???????????.
We present the clinical case of arrhythmogenic cardiomyopathy and the analysis of different manifestations of this disease within one family.
Three brothers D. born in 1986, 1988 and 1998 were observed between 2009 and 2011. Echocardiography, magnetic resonance imaging, histologic study were used as the methods of examination.
According to their results the arrhythmogenic right ventricular dysplasia was diagnosed.
Elder child had manifestations of end-stage heart failure which required heart transplantation associated with using the assisted circulation system. The second child manifested heart rhythm and conduction
disturbances along with reduction of right ventricular myocardial contractility. He underwent subsequent
implantation of cardioverter-defibrillator. The youngest child had no clinical signs of the disease.
K e y wo r d s : arrhythmogenic right ventricular dysplasia, clinical manifestations of the disease, familial nature of the
disease.
?????? ???????????, ? 1, 2012
?
??????????? ????????? ??????? ?????????
(???????????? ????????????????? ??????????????) ?? ????????????? ???, ???????? ? ????? ?????? ? 1996 ?., ????????? ? ????????? ?????? ?????????????? ? ??????????????? ?????????? ???????? ??????? ????????? (??) ????????? ?
??????? ?????? ? ????????? ???????????????
???????. ? ?????????? ??????? ??????????????
?????? ? ??????? ????????????? ??????????? ?????
?????????: ???????? ????? ??????????, ?????????????????? ???????????? ????????? ??????? ????????? (????) ?????????? 1 ?????? ?? 1000 ?????????, ???????? ?????? ? 1 ?? 5000 ????????? [2, 4,
6, 8]. ????? ?????????????? ????? ???? ??????? ?
?????????? ?????????? ????????, ??? ???????????
????????????? ??????????? ?????????? ???????
(???????????? ???????, ????????? ???????????????, ????? ????????? ????????? ??????) [1, 2, 4,
8]. ??????? ?????? ????, ??????????? ???????
????????????? ??????????? ????? ?????? ? ?????? ? ????????? ?????????? 3:1 [2, 5, 6].
???????????? ????????? ??????? ????????? ?
??????????? ????????????? ???????????, ????? ????? ???????? ????????, ????? ?????????-??????????? ??? ????????????. ? ?????????? ?????
??????? ???????? ?? ?????????-??????????? ???????????? ??????????? [5, 12].
? ????????? ????? ???????? ?? ??????? ????
12 ???????????? ???????, ????????????? ?? ????????????? ????. ??????? ??????????? ??????
???????? (????????????, ????????????, ???????????-2, ???????????-2, ???????????-2) ???????? ?
????????? ?????? ????? ???????????????, ?????? ?????? ? ???????? ????????-??????? ????????? ????????. ? ?????????? ??????? ????? ??????????? ?????????? ?????????? ??????????????? ??????????????, ??? ???????? ? ?????????
??????? ????????? ? ????????? ??? ???????????,
????????, ?????????? ??????????????? ? ???????? ?????????????? ??????????? ???????? ??????? ????????? [12, 15]. ??? ???? ??????????
??? ???? ???????? ??????? ?????????, ?????????
?????????????? ????????-??????? ?????? ?????? ??????? ?????????? ??? ???????? ???????????? ??????? ?? ???? ????????? ??????? [1, 2, 13].
?????????? ???????? ???????????? ??? ????? ??????? ?????? ? ????? ? ??????????? ?????-???? ??????????????? ??????????? ??? ??????????????? ????????, ??? ?????????? ????????????????
??????????? ???? ? ????????? ????????? ????????. ? 1994 ?. ???? ??????????? ???????? ??????????? ????, ?????????? ?? ?????? ??????????? ????????? ???????? ??????? ?????????,
???????????????????????? ?????????, ???????
????????-??????? ????????? ??? ??????????????? ????????????, ????????? ???????? ??????????? [11].
???????????? ??????????? ?????????? ????
?????? ????? ?????.
? 2009 ?. ?? ??????????? ??????? ??????????
???????? ???????? ?. ?., 23 ??? (1986 ?. ?.). ??
???????? ????????, ??? ?. ?. ?????? ??????? ? ?????, ???????? ??????? (?????? ? ????????? ?????
53 ????, ???? 58 ???). ? ???????????? ???? ??? ??????? ?????, ?? ????? ? ?????????? ?? ???????. ??????? ?? ????? 2008 ?. ??????? ??????? ? ????????.
??????? ???? ??????? ? 14 ???, ????? ?????????
?????? ?? ?????? ??? ?????????? ????????, ???????? ????????????? ?????????? ????????, ??????? ????????????, ??????? ? ?????? ??????. ?
????? 2008 ?. ?????????? ???????? ????????????:
????????? ????? ?? ?????, ????????? ??????, ?????????? ????? ??????, ???????? ??????? ???????
? ?????? ??????????, ????? ????????? ????????????? ? ?????????? ????????. ?? ????? ??????????
???? ????????? ??????????????, ? ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ?????????
57
???. 1. ??????????????????? ????????
?. ?., 23 ???. ??????? ?????? ????? ????? ????, ???????? ????? ? ? ??????? ??????????
????? (???) ? 221 ??, ???????? ??????????????
????? (???) ? 236 ??. ????????? ???????????????
???????????????? ???????, ??????? ??? ??????? ?
??, ?? ??????????, ????? ??????????, ????????? ?????? ???????????????? ??????? ?????????
?? 60 ??. ?????????? ?????? ??????????? ???????????????? ? ??????? ??. ??? ???????? ???????? ?????? ????????? (??) ????????? ?? ????????
(???. 3).
?? ?????? ????????????? ???????????????
??? ???????????????? ????????? ???? ? ???????
???????????? ????????????? ???????????????
(??), ? ????? ???????? ??????????? ???????????? ?????????? (??) ? ??????????? ???????
????? ????? ????? ????.
???????? ????????? ???????????????? ???????????? ?????????? (????) ? ???????????
????????? (??????????? ???????? ???????-320) ?
?????????????? ????????? ????????? ????????????, ? ?????????????? ?? ???, ???????? ?????? 3 ??. ?? ??????????? ???? ???? ????????
??????, ????????????????? ? ????????????????
????????? ?????? ??????? ??????: ????? ???????
?????????? ???????? 694 ??, ??? ?? ? 432 ??.
???. 2. ?????????????? ???????? ?. ?., ???????????
?? ??????????? ???
?????? ???????????, ? 1, 2012
╚?????????? ????? ?????? (???): ????????
????????╩ ??????? ??? ????????? ? ?????
??. ?. ?. ???????? ???? ??? ?????????????? ???????.
??? ??????????? ????????? ???????? ???????,
??????????? ??????? ?? ???????? ????? ??????????????. ??? ??????? ? ??????????? ???????,
?????? ????? ???? ???????? 17,99 ??/?2, ????????
?? ???? ???????? ??????????, ?????? ???????
???????, ? ????????? ????????. ?? ??? ???????????? ╚????????????? ?????? ?????╩. ?????
?????? ??????????? ? ????? ??????. ??????? ??????????? ???????? ? 24?28 ? ??????. ??? ??????? ? ????????? ?????? ???????????? ?????????????? ?????????. ?????? ??????? ?????????????
??????? ?????? ??????? ?????? ?? 2,5 ??. ???
???????????? ????????????? ????????????
II ??? ?? ???????? ???????. ???????????? ???????? 85/55 ?? ??. ??. ????? ??????? ??????????, ??????? ????????? ?????????? (???) 98 ??/???.
?????? ??? ????????? ???????? ??????????, ???????? (?? ???????) 16 в 15 в 14 ??. ????? ????????
? ??????, ?????????? ???????????? ??????? ????????? ???????? ? ??????? ???????.
?? ??????????????????? (???) ?????????????
??? ?????? ????? ????????? ??????, QRS 128 ??, ??????? ?????? ????? ????? ????, ??? ? 65 ??/???,
?????? ??????????? ???????????? ??????????????. ? V1?V5 ?????????? ??????????????? ????????????? ????? ? (???. 1).
?? ?????????????? ?????????? ?????????? ???? ??????, ??????????????? ?? ???? ??? ??????
???????. ????????????????? ?????? (???) 68%
(???. 2).
?? ?????? ????????????????????? ???????????? (?????) ???????? ???????????? ??????????
??????? ??????? ????????? ?? ????????? ??? ?????????????? ??????????? (??????? ??????? ??
????????? 6%), ????? ?????????? ?????????? ??????? ??????? ?????????? ?? 8,3 в 9,2 ??. ???????? ????????????? ?????? (???) ??????? ????????? ????????? 6,5 ??, ???????? ??????????????
?????? (???) ? 6,7 ??, ???????? ?????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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?????? ???????????, ? 1, 2012
???. 3. ??????????????? ???????? ?. ?.,
??????????? ?? ??????????? ???
?????? ???????????, ? 1, 2012
???. 4. ?????????? ???? ???????? ?. ?. ?????????? ?????? ???????? ??
???????? ?????????? ??????? ????? ???? ??
28в47 ??, ?????? ????? ???? ????????? ??
45в49 ??. ????? ?????????? ??????? ???????? ?
??????? ????????? ? ??????????? ???????? ? ????? ?????? (???. 4).
?? ?????? ??????? ???????? ??????? ????????? ???????? ????????-??????? ?????????
??????????????, ????? ??????? ????????.
?????????? ???????????? ??????? ????????????: ????? ?????? ????? ? ???? ? ??? ??????????
?? ?????, ???????? ?? ???? ???????? ???????????????? (?? 25 ?/?), ?????????????????? (??
53 ??????/?), ???????? ???????? ?????????? ??
42 ??/???, ??????? ????????? ??????????????????
??????? ???????? ????? ? 12 ??? ? ?????????
1230 ??/??.
????? ???????????? ???????????? ???????????? ??????? ???????????? ????????? ?? ??? ????????? ?? ????????? ???? ??????? ?????????
(???????? QRS ???????? ?? 128 ??, ???????? ?????????????? ??????????? ???????? ??, ????????-??????? ????????? ?? ?? ?????? ???????) ?
???? ????? ????????? (???????? ????? ? ? V1?V3
??????? ??????????, ???????? ?? ?? ??????
????????????? ??????????????? ???).
??????? ??????? ?????????? ??????????? ??????????????? ???????, ???????????? ?? ??????? ????????? ???????????????, ?????????? ??-
???????? ???????????????????????? ????????,
?????????, ????-???????????????, ?????????????,
????????, ??????????????, ? ????????? ? IV ??
?? ????????????? ????????????? NYHA. ???????? ?? ?????????? ???????, ????????????? ???????? ? ????????? ???????? ?? ????, ??????????
?????????? ? ???????????? ??????????, ???????????? ????? ? ????? ???, ? ????? ? ??? ???????? ?????? ????????? ?????????? ????????? ?????????????? ????????? ? ???? 5 ??/??, ??????????? ?
0,05 ???/??. ???????? ????????????? ???????? ?
?????????? ????????????? ?????????? ??????????????? ???????, ??????? ??? ????????? ?
╚???? ????????╩ ?? ?????????????? ??????. ? ???????? ╚?????╩ ? ??????????? ??????????????
?????? ???????? ??? ????????????? ????????????? ?????? ????????? ?????? (???) Berlin Heart
╚EXCOR╩. ?? 65-? ??? ????? ??????????? ???
????????? ???????? ?????????????? ?????????????? ??????.
? ??????? 2011 ?. ?? ??????? ????????? ????
????????, ?. ?., 23 ??? (1988 ?. ?.), ? ???????? ??
????? ????????, ??????????, ?????? ??????????????, ?????????????? ?????????, ??????? ??????
????????. ? ?????? 2011 ?., ?? ???? ??????????????
???????????? ???????? ?????? ????????? ??????????????? ?????? ????????. ? ???????? ???? ?? ????, ?? ???? ????, ??????? ???????? ????, ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ?????????
59
???. 5. ??????????????????? ???????? ?. ?., ??????????? ?? ???????? ?????????????? ??????? ??:
???????????? ?????????
?????
????????? ??????? ???????? ??????? ?????????. ?????? ?????????? ?????? ???????? ??????? ????????? ????????? ??????????????,
??? ?? ???????????? ???????? ???????????? ????????? ??????? ????????? (???. 7).
????? ???????????? ???????????? ???????????? ??????? ???????????? ????????? ?? ???
??????????? ? ????????? ?? ????????? ???????
??????? ????????? (??????????? ????????
???????, ???????? QRS ???????? ?? 128 ??, ???????? ?????????????? ??????????? ????????
??, ????????-??????? ????????? ?? ?? ?????? ???????) ? ???? ????? ????????? (????????
?? ?? ?????? ????????????? ???????????????
???, ????????? ????????? ?? ????????? ?????????????? ??????????? ???????? ??).
?????? ?????? ??????? ???????? ?????????
?????????????? ??????? ???????????? ??????
???????????? ??????????????, ? ????????????? ????????, ??? ?????????? ? ??????????
?????????? ???????????? ????????? ????? ???
??????????? ???????????? ???????????????.
???????? ??????? ???? ????????? ?????????
??????, ???????? ??? ????????????? ??????????????????????? ? ???????? ??????????????
(????). ?? ???? ??????????? ??????? ?????????? ??????????? ????????? ?????????. ??????? ??? ??????? ??? ?????????? ?????????? ??
????? ??????????.
???. 6. ???????-??????????????? ???????? ?. ?.:
?????????? ??????? ??, ???????? ?????? ?????????????? ???????? ?????????. ??? ?? < ??
?????? ???????????, ? 1, 2012
???????? ? ???????? ??????. ???????? ?????????????? ??????? ????????-???????? ??????????
? ??????? 5 ???. ?? ?????? ??????????? ??????????????? ??????? ?? ????????.
??? ??????? ? ?????? ??????? ???????, ?
????????? ????????. ??????? ??????????? ???????? ? 20 ? ??????. ??? ??????? ? ?????????
?????? ???????????? ?????????????? ?????????.
?????? ??????? ????????????? ??????? ??????
??????? ??????, ???????????? ?????????? ?????????? ??????? ??????. ????? ??????????, ??????? ??????????, ??? 58?72 ??/???. ???????
?????? 10. ?????? ?? ?????????.
?? ??????????? ????????????? ??????????????? ??? ? ??????? 38 ? 56 ??? ???????? ??????? ????????? ?????????? ????? ? ????????????. ? 73% ????????? ??????????????? ????
????????????????? ????? ??????????? ??????????, ? ???????????? ???????? ????????????
?????????? 142 ??/???, ? 27% ? ???? ?? ??-???????? ??????????. ???????????? ????????????
?????????? ???????????? 42 935 ????????????
??, ?? ??? 4019 ???????? ????????? ? 2083 ??????? ??????????. ????? ???? ???????? ???????? ???????????? ?? ?? 3 ????????? ? ??????????? ?? ? ??????????? 13 ??????????, ?
??????????? ??????? ????? ????? ????? ???? ?
????????????? ????? 300 ??. ????? ???????????????? 178 ????, ???????????? ????? ??????????
3060 ?? (???. 5).
?? ?????? ????? ???????? ?????????? ??????? ?????? ?????????? ?? 4,7 в 6,3 ??. ????????????? ??????????????? ?? ?????????? ? ??????????????? ???????? ??????????????? 2 ??. ???? ???????? ????????? ???????? ??????????????
??????????? ???????? ????? ?????????? ??????
(?? ?? 47%, ?? ?? 21%), ? ????????????????
??????????? ?????? ??????? (???. 6).
?????????? ???? ? ??????????? ?????????
(??????????? ???????? ???????-320) ????????????????? ? ???????????????? ????????? ??????
??????? ?????? ?? ????????? ?????????????? ??????????? ???????? ?? ?? 15%. ????? ???????
?????????? ???????? 465 ??, ??? ?? ? 398 ??.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
60
?????? ???????????, ? 1, 2012
???. 7. ?????????? ??????? ???????? ???????? ?. ?.
?????????? ?????? ???????? ??, ????????? ???????????????
???? ??? ?????????? ??????? ???? ? ?. ?.,
14 ??? (1998 ?. ?.), ??????? ?????? ? ?????, ?????????? ???????, ? ???????? ?? ??????????? ?? ???????. ????????? ???????????? ???????????????
???: ?????? ?? ????????? ?????????? ????? ?
???????????? ?? ????????. ?? ?????? ????? ?????????? ?? ??????? ????? ? ?????? ???????
?????? ?? ????????. ?????? ??? ???? ? ??????????? ????????? ???????? ?????????????? ?????
??????? ???????? ??????? ?????????. ???????
????????? ?? ????.
?????? ???????????, ? 1, 2012
??????????
??????????? ?????????? ????????? ??? ???????? ???????? ?? ??, ??? ?????????? ???? ????? ??????????? ??-???????. ?????????? ????????? ?????? ???????? ??????????? [5]:
1) ?????????????? ?????? ? ?????-???? ???????? ???????????, ????????????? ????????????
?????????? ???????? ?????? ?/??? ???? ????????? ????????? ???????????;
2) ?????? ????????? ?????????????? ?????????? ? ??????????? ???????????? ???????????????
? ???????????? ??????????? ??????????????? ??
??, ??? ????? ?????????????? ???????? ?? ???????????? ? ???????????? ?????????;
3) ?????? ????????????????? ????????? ???????????????;
4) ?????? ???????????????? ????????? ???????????????.
???????? ??????? ??????????? ???????????
?????? ???????????????, ??? ????????? ???????
????????? ? ???????? ?????????????? ??????????? ???????? ??????? ?????????, ? ????? ????????? ????????? ????????? ? ?????????? ??????
????????. ?? ?????? ????????????????????? ????????????, ? 50% ????????? ? ???? ??????????????? ???????????? ?????????? ??????? ???????
????????? ?? ????????? ??? ?????????????? ???????????. ?????? ???????????????? ??????????????? ?? ??????????? ???? ? 5?10% ??????? [4,
10]. ?????? ??? ?????????? ???????? ????????
??????????? ????????? ???????? ???????????. ??
??? ? 64% ????????? ????? ?????????? ?????????? ????????? QRS ????? 110 ??, ? 85% ???????
???????? ???????? ????? ? ? V1?V3 ??????? ??????????. ???????? ????? ? ? ??????? ??????????,
???????? ?? ??????? ??????? ???????????, ??
???????? ??????????? ????????? ??? ????,
????????? ????? ?? ????????? ????? ???? ???????? ??? ?????? ??? ??????????? ????????
??????? ????????? [2, 10]. ??? ??????????????? ???????????? ???????? ??????? ????????? ?
????? ??????? ???????????? ??????? ?????????
?????????????? ????????? ? ????????-??????? ??????. ? ????????? ????? ?????? ???????????? ????? ????????-??????????? ???????????????? ?????????? ? ?????????????????,
??????? ????????? ??????? ???????????? ?????????????? ????????.
? ??????????? ???????????????? ???????? ??????? ??????????? ??????? ????????? ? ????????
?????????????? ??????????? ???????? ??, ?????????? ? ??????? ??, ??????? ? ???????? ???????? ??. ????????? ?????????? ??????????? ? ??????? ????????? ? ???? ??????? ? ????? ???????? ?????????????? ???? ? ????? ??????
??????????? ????????????? ????????????????
??????? [1, 3, 7, 9, 14].
? ?????? ?????? ? ????? ???????? ????????? ?
????? ??????? ??????? ??????????????? ????.
? ??????? ??????? ??? ??????????????? ???????????? ????????? ????????????????, ??????? ??????????? ?????????? ??????? ????????????????
?????????????? ? ??????????? ???????????????
??????. ? ??????? ??????? ??????????? ??????????
??????????? ?????????? ????? ? ????????????
?? ????????? ?????????????? ??????????? ???????? ??????? ?????????, ???????????? ????????????? ???. ? ???????? ??????? ???????????
?????????? ??????????? ?? ??????????? ???? ??
??????????, ??????, ???????? ??????????? ???????? ???????, ??????? ?????? ?????????? ???
??????????? ? ??????????.
? ? ? ? ??? ? ??
1.
??????? ?. ?. ???????????: ??????????? ? ?????????????
2.
??????? ?. ?., ??????? ?. ?., ????????????? ?. ?.
???????. ?.: ????????, 1989.
3.
4.
5.
???????????? ?????????/?????????????? ??????? ????????? // ?????? ???????. 2010. ? 3. ?. 47?56.
??????? ?. ?., ????????? ?. ?. ?????????? ?????????????? ? ???????????????? ??????? ???????????? ??????????? ? ????????? ? ???????????? ?????????? ???????
????????? // ?????? ???????. 2004. ? 1. ?. 56?63.
???????? ?. ?. ???????????? ?????????/??????????????
??????? ????????? // ?????? ???????. 2008. ? 3.
?. 5?23.
Azaouagh A., Churzidse S., Konorza T., Erbel R. Arrhythmogenic right ventricular cardiomyopathy/dysplasia:
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ?????????
a review and update // Clin. Res. Cardiol. 2011. Vol. 100.
?. 383?394.
6. Calkins H. Arrhythmogenic right-ventricular dysplasia/ cardiomyopathy // Curr. Opin. Cardiol. 2006. Vol. 21. ?. 55?63.
7. Corrado D., Leoni L., Link M. S. Implantable cardioverterdefibrillator therapy for prevention of sudden death in patients
with arrhythmogenic right ventricular cardiomyopathy/ dysplasia // Circulation. 2003. Vol. 108. ?. 3084?3091.
8. Gemayel C., Pelliccia A., Thompson P. Arrhythmogenic
right ventricular cardiomyopathy // J. Am. Coll. Cardiol. 2001.
Vol. 38. ?. 1773?1781.
9. Hulot J. S., Jouven X. X., Empana J. P. Natural history and risk
stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy // Circulation. 2004. Vol. 110. ?. 1879?1884.
10. Marcus F. I., McKenna W. J., Sherrill D. et al. Diagnosis of
arrhythmogenic right ventricular cardiomyopathy/dysplasia:
proposed modification of the task force criteria // Circulation.
2010. Vol. 121, ? 13. P. 1533?1541.
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11. McKenna W. J., Thiene G., Nava A. Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy // Br.
Heart J. 1994. Vol. 71. P. 215?218.
12. Nava A., Thiene G., Canciani B. et al. Familial occurrence
of right ventricular dysplasia: A study involving nine families //
J. Am. Coll. Cardiol. 1988. Vol. 12. ?. 1222?1228.
13. Protonotarios N., Tsatsopoulou A. Arrhythmogenic right ventricular cardiomyopathy/dysplasia and Naxos disease //
Hellenic. J. Cardiol. 2004. Vol. 45. ?. 370?378.
14. Thiene G., Nava A., Corrado D. Right ventricular cardiomyopathy and sudden death in young people // N. Engl. J. Med.
1988. Vol. 318. ?. 129?133.
15. Tsatsopoulou A. A., Protonotarios N. I., McKenna W. J.
Arrhythmogenic right ventricular dysplasia, a cell adhesion cardiomyopathy: insights into disease pathogenesis from preliminary genotype?phenotype assessment // Heart. 2006. Vol. 92.
?. 1720?1723.
????????? 29.06.2012
╘ ????????? ???????, 2012
??? 616.125.2-089.168:616.125-008.318
?????? ????????? ?????????????? ???????
??????????? ?????????? ? ???????
???????? ╚???????? III╩: 18 ??? ??????
?. ?. ???????*, ?. ?. ???????, ?. ?. ??????, ?. ?. ????????????, ?. ?. ?????????,
?. ?. ??????????, ?. ?. ????????
??????????? ?????????? ???????? ????? ?? ???????? ?????? ???? ????????? ????? ?????? ? ????????. ? ????? ???????? ??????????? ??????? ?????????????? ??????? ??????????? ?????????? ????????? ????????????? ???????? ╚???????? III╩, ??????????? ?? ???????? ╚??????-???╩ ? ???????? ????????? ??????????? ? ?????????????? ??????????????. ???????? ?? ?? ??? ????????? ???????? ?????????? ?? ??????????? ????????? ??? ???? ????? ??????????? ? ??????????? ????????, ?????? ??
?????????? ??????????? ?????? ?????????? ??? ?????? ?? ?????? ? ???????????????? ?????????????
????? ??????? ?????????????? ??????? ??????????? ??????????, ??????? ??????????? ? ?????? ???????????????? ????????? ???????????? ????????. ? ?????? ??????????? ??????????? ?????? ????????? ?????????????? ??????? ??????????? ?????????? ? ???????? ?????????? ????? 18 ???.
? ? ? ? ? ? ? ? ? ? ? ? ? : ??????????? ??????????, ╚???????? III╩, ?????????? ??????????.
Atrial fibrillation is one of the most common types of heart rhythm disturbances in humans. ╚Maze III╩ procedure is considered to be the most radical methods of surgical treatment for atrial fibrillation. It is performed
according to the ╚incision-suture╩ technique using median sternotomy and cardiopulmonary bypass. This procedure is less frequently used in clinical practice because of its technical complexity, but the evaluation of longterm results is necessary to answer the question of expediency for using the new methods of surgical treatment
for atrial fibrillation which were developed in view of essential principles of classical surgery. The clinical case
of successful surgical treatment for atrial fibrillation with 18-years of follow-up is presented in the article.
K e y wo r d s : atrial fibrillation, ╚maze III╩, long-term results.
?
????????? ??????????? ??????? ?????????????? ??????? ??????????? ??????????
* ????? ??? ?????????: e-mail: leoan@heart-house.ru
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???? ?. ?. ???????) ????, ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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?????????? ?????, ?????????? ??????????-???????????? ?????????????, ?????????? ???????????? ??????? ?????????? ? ??? ????????? ??????
??????? ??????? ????? ???????? ? ????????????
????? ?????????????????? ??????????. ???????????, ??? ???????? ╚???????? III╩ ???????? ? ???????????? ?????? ???????? ????? ????????? [1?3].
???????? ?? ?? ??? ???????????? ???????? ╚???????? III╩ ?????????? ?? ??????????? ????????? ???
???? ????? ??????????? ? ??????????? ????????,
?????? ?????????? ??????????? ???????? ??????
?????????? ??? ?????? ?? ?????? ? ???????????????? ????????????? ????? ??????? ??????????????
??????? ??, ??????? ??????????? ? ?????? ???????????????? ????????? ???????????? ???????? [2,
4, 5]. ?? ???????????? ??????????? ?????? ?????????????? ??????? ?? ? ??????? ???????? ╚???????? III╩ ? ???????? ?????????? ????? 18 ???.
????????? ?., 59 ???, ?????????? ? ???????????
?????? ?????? ? ??? 2011 ?. ? 1993 ?. (18 ??? ?????) ?
????? ??. ?. ?. ???????? ???? ?? ????????? ????????????? ???????? ?? ?????? ??????? ??????????? ??????????. ????????? ???? ?????????????????,
?????? ?? ????????? ????????? ?????????????
????????. ? ??????? ?????? ??? ??????? ????? ??????????? ???????????? ????????? (???. 1, 2).
?? ??????? ??????? ????? ????????, ??? 17 ???? 1993 ?. ????????? ?. ? ???????? 41 ???? ?????????
? ????????? ????????? ????? ????? ??. ?. ?. ???????? ???? ? ???????? ?? ??????? ? ??????
??????, ?????? ???????? ?????????? ????????????, ???????????????? ????????????? ???????
????????, ???????????????, ???????? ?????? ??
???????? ? ????? ?????????. ?? ???????? ????
????????, ??? ????????? ??????? ???? ??????? ?
1989 ?., ????? ??? ???? ???????? ?????? ????????
(??????????????). ? 1991 ?. ????????? ???????????? ??????? ???????????? ?? ???????????????????. ? ??????????? ???????? ??????????,
????? ?????????? (???????????? 2?3 ???), ??????
???????????? ?????????? ?????????????????
???????????, ????? ?????????????? ??????? ????????. ? ??????? 6 ??? ????????? ?????????
???????? ??? ???????.
?????? ???????????? ???????????? (17 ????
1993 ?.). ????????? ??? ???????? ????????????
??????????????????. ?????? ??????? ? ???????
????????? ??????? ???????, ?? ????????. ???????????????? ????????????. ??????? ?????? ?? ??-
?????? ???????????, ? 1, 2012
???. 1. ?????? ????? ????? ??. ?. ?. ???????? ????. ??????? ? 1956 ?. ? ??????????? ????? 450 000 ??????????? ??????? ???????? ? ??????????? ????????????
???. 2. ??????? ??????? ????????? ?., ?????????? ? 1993 ?.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ?????????
??
??
??
63
???
???
???
???
???
??
???
???
???
??
???
???
??
??????. ???? ??????????. ?????????? ???????
?????? ? ???????? ?????. ??? 66 ??/???, ???? ?????????. ?? 120/85 ?? ??. ??. ?? ????? ?????. ? ?????? ??????? ???????, ?????????? ? ????? ???????? ????. ????? ??????, ??? ????????? ??????????????. ?????? ? ????????? ?? ?????????.
??????? ????????????? ????????????? ? ?????
??????. ?????????????? ?? ????????. ?? ???????
?????? ??????? ? ?????? ????????? ?? ????????.
?????? ???????????? (???? 1993 ?.)
??????????????: ???????? ??????? ???????.
?????? ? ????? ?? ????????.
???????????????????: ????????? ???? ? ???
60 ??/???. ?????????? ????????? ???. P?Q
0,12 ??.
???????????????: ????? ?????????? ? 34 ??.
????? ? 30 ??. ?????????? ??????: ??????? ??????, ??? ???????????, ???????????? ?? 1+. ?????????? ?????? ?? ???????. ???????????????
??????: ??????? ??????, ???????????? ?? 1+. ????? ?????????: ??? ? 5,2 ??, ??? ? 3,7 ??, ?? ?
65%. ??? ?????????? ?? ????????.
?????????????????????? ???????????? ??????:
???????????? ??????????? ?????????? ?? ??????
??????? ?????????????? ???????????. ??????????
??????????. ?????????????? ???????? ?????????
???? (????? 1380 ??).
??????????????: ?????????? ??????? ??? ??????????????? ???????? ????????.
?? ?????? ???????????? ????????? ??????????? ???????: ??????? ???????? ????????? ????.
??????????????? ???????????? ??????????? ??????????. ??????????????? ????? ????????????????????? ??????????. ?? 2? ??????? (?? ????????????? ???????????????????).
???????? ???? 1993 ?. ????????? ?????????
????????????? ???????? ╚???????? III╩ (?????? ?
???????? ???? ?. ?. ???????) (???. 3). ????????
??????????? ? ???????? ????????? ???????????,
?????????????? ?????????????? (??), ?????????? ? ???????????????? ????????????. ?????
????????? ????? ????????? 92 ???, ????? ?? ?
140 ???. ?????????? ? 28 ╟?. ?????????????? ????????? ???????????? ? ????? ??????? ????, ?????????? ? ????????? ? ??? 65 ??/???.
? ?????? ????????????????? ??????? ?????????? ????????? ???????? ????????? ? ??????????? ???????????????, ??? ??????????? ????????????? ????????? ??? ???????????????? ?????????? ? ???????????????? ?????????? ??????.
????????? ???? ????????????? ?? 4-? ????? ?????
???????? ? ?????????? ? ?????????. ?? 17-? ?????
????? ???????? ??????? ???????? ? ?????????????????? ????????? ??? ?????????? ??????????.
?? ???: ????????? ???? ? ??? 72 ??/???. ? ??????? 1993 ?. (????? 3 ??? ????? ????????) ? ????? ?
??????????? ?????????? ????? ???? ???????? ???????????????? ????????? ? ??????????????.
??????????, ??????? ??????? ?????? ? ????????? ??????????? ???? ???????? ?????? 18 ???.
???????????????????: ???? ????????? ?
??? 72 ??/???; P?Q 0,136 ?, QRS 0,079 ?. ???????? ????????? ??????????? ?????? ?????????
(???. 4).
???????????? ??????????????? ???: ?? ?????
???????????? (42 ?) ?????????????? ?????????
???? ?? ??????? ??? 64 ??/???. ???????????
??? ? 49 ??/???, ???????????? ? 94 ??/???.
???? ????? 2,0 ? ?? ????????????????. ????????
27 ????????? ???????????? ? 210 ??????????????? ????????????.
?????? ???????????, ? 1, 2012
???. 3. ????? ?????????? ???????? ╚???????? III╩: ╚????????? ????????????? ????????????? ???????? ?
??????????? ???????? ╚????????╩ ????????? ??????????? ?????????? ???????????????╩ [5]
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
64
?????? ???????????, ? 1, 2012
???. 4. ??????????????????? ????????? ?. (20 ???
2011 ?.)
???????????????: ????? ?????????? 45 в 52 ??,
????? 83 ??. ????? ?????????: ??? ? 3,0 ??,
??? ? 4,8 ??, ??? ? 36 ??, ??? ? 105 ??, ?? ?
66%, ?? ? 69 ??. ?????????? ??????: ??????? ?????????. ?? ? 32 ??. ???????????? I ???????.
?????????? ??????: ??????????????, ???????? ????????. ?? ? 25 ??. ??????? ???????? 7 ?? ??. ??.
???????????? I ???????. ??????????????? ??????
?? ???????. ?? ? 33 ??. ???????????? I ???????.
?????? ???????? ??????? ?? ???????. ????? ??????? ?????????? ? 83 ??. ??????? ??? ? 1,1 ??. ?
?????? ???????? ?????????????? ????? ?????????
????????? ????????? ??????????? ?????????? ?????? ?????????? ? ?????? ?????????. ??????????
???????-??????????????? ????????? ?? ??????????
??????????? ????? E/A = 1,56, ??? ???????????????
? ??????????? ??????? ?????????? (???. 5, 6).
???????????????? ???????????? ??????????
? 3D-??????????????: ???? ??????? ? ??????
?????????? ????????????. ????? ?????? ?????????? 95 ??. ???????????? ?????????? ????????? (???. 7).
?? ?????? ?????? ????????? ????????? ????
?????????????????, ????????? ?????????????
????????? ? ????????? ?????????. ?????????, ???
????? 3 ???? ????? ???????? (? ???????? 44 ???) ????????? ?????? ?????, ??????? ?????? 15 ???.
???? ??????????? ???? ? ????????? ??? ???????????? ??????? ????????????? ??????????????
??????? ?? ? ??????? ???????? ╚???????? III╩
?????? ???????????, ? 1, 2012
???. 5. ???????????????
(?? 20 ??? 2011 ?.): ????????? ????????? ??????????? ?????????? ?????? ?????????? ? ?????? ????????? ?
?????? ???????? ??????????????
???????????
?????
???. 6. ??????????????? (?? 20 ???
2011 ?.): ?????????? ???????-??????????????? ????????? ?? ?????????? ??????????? ????? E/A = 1,56, ??? ??????????????? ? ??????????? ??????? ??????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ?????????
??
65
??
??
??
??
???. 7. ???????????????? ???????????? ?????????? ? 3D-??????????????: ?? ? ????? ?????????, ?? ?
?????? ?????????, ?? ? ????? ??????????, ?? ? ?????? ?????????? (20 ??? 2011 ?.)
? ? ? ? ??? ? ??
1.
2.
3.
4.
5.
??????????? ???????????: ??????????? ? ??????? / ???
???. ?. ?. ???????, ?. ?. ?????????. ? 3 ?. ?. 3. ?.: ?????
??. ?. ?. ???????? ????, 2011. ?. 234?242.
??????? ?. ?., ??????? ?. ?., ????????? ?. ?. ? ??. ????????????? ??????? ??????????? ??????????: ??????????? ????????? ???????? // ?????? ???????????. 2009.
? 2. ?. 5?11.
??????? ?. ?., ????????? ?. ?., ?????????? ?. ?. ????????????? ??????? ??????????? ??????????: ???? ?
??????????? ???????? // ??????? ? ????.-?????. ???. 1998.
? 1. ?. 7?14.
Cox J. L., Ad N. et al. Current status of the Maze procedure for
the treatment of atrial fibrillation // Semin. Thorac. Cardiovasc.
Surg. 2000. Vol. 12. P. 15?19.
Cox, J. L., Shuessler R. B. et al. The development of the Maze
procedure for the treatment atrial fibrillation // Semin. Thorac.
Cardiovasc. Surg. 2000. Vol. 12. P. 2?14.
????????? 27.04.2012
?????? ???????????, ? 1, 2012
? ?????????? ?????. ???? ???????, ??? ?????????
???????? ?????????? ? ????? ???????????? ??????
????, ??????? ???? ????????? ?????? ?? ??????
? ????. ???????? ?? ?? ??? ???????????? ????????
╚???????? III╩ ?????????? ????? ???????????
????????? ??? ???? ??????????? ? ????????????
??????????? ????????, ?? ????????????????
???????? ????? ? ?????? ??????????? ???????
?????????????? ??????? ?? ? ?????????????? ????? ?????????????? ??????? ???????, ????? ??????? ??? ??????? ???????????? ??????????? ?????
???????????????. ?????? ?????????? ????? ????????? ??? ? ?????????? ??????????? ?????????? ???? ??? ?????? ??????????? ????????????
?????????????? ??????? ????? ??????? ???????,
????? ???????? ??????????? ??????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
66
?????? ???????????, ? 1, 2012
???????. ?????? ?? ??????????
XVII ?????????????? ??????
????????-?????????? ????????
╘ ????????? ???????, 2012
??? 616.42-06:616.12-008.313.2]-089
??????? ??????????????? ???????????
?????????? ??? ???????? ???????????
??????? ? ????? ?? ????????? ????????
?. ?. ????????, ?. ?. ???????-?????????, ?. ?. ??????, ?. ?. ???????, ?. ?. ?????????,
?. ?. ???????, ?. ?. ???????, ?. ?. ?????????
?????? ???????????, ? 1, 2012
???? ╚????????????? ??? ????????? ?????????????? ??. ????. ?. ?. ?????????╩
??????????????????? ??
????. ?????? ??????????? ????????? ??????????? ???????? ??? ?????????? ??????????????
??????? ? ????????? ? ??????????????? ???????????? ?????????? (??) ? ?????????? ??????? ??
????????? ?????? ???????????? ??????????? ??????????? ?????.
???????? ? ??????. ?? ?????? 2009?2011 ??. ? ???????????? ???? ???????? 57 ????????? ? ??????? ??????????? ??????? ? ??????????????? ??. ???????? ???? ??????????????? ? ??? ??????:
31 ???????? (1-? ??????) ????????? ?????????????? ??????? ? ?????????? ?????????? ??????,
26 ????????? (2-? ??????) ? ????????????? ????????? ??????. ?????????????? ??????? ??????
?????????? (??) ??????????? ? ?????????????? ?????? ?????????? ?????????. ???? ????????? ????? ????????? ????? ????????????? ??? ????????????? ??????? ??????????? ???????????????
?????????? ?????. ????????, ??????? ????? ???? ?? ????? 0,5% ??? ?????? ?????????? ??????????, ???? ???????? ? ?????????? ?? ??????????? ???????. ?????? ???????????? ??????? ?????????? ???????????? ?? ??????? ???????????????? ??????????????? ?????? (VTI ????? ? ? ?) ?
????????? ? ???????? ?????.
??????????. ??????????? ?? ???????????? ????? ?? ????. ?????????? ?? ???????? ?? ???? ??????? ? ????? ??????? ????? ????????? ????????. ????????? ?? ? ?????? ????????????????? ??????? ?????????? ????????????????? (????????) ??? ????????????? ???????????? ? ? 6 (19,4%) ??????? ? 1-? ? ? 12 (46,2%) ??????? ? ?? 2-? ???????. ??????????? ???????????? ??????????? ????? 3, 6,
12 ???. ??? ?????? ???????????? (????? 3 ???) 18 (58,1%) ??????? 1-? ?????? ? 10 (38,5%) ????????? 2-? ?????? ???? ???????? ?? ??. ????? 12 ??? ????? ???????? 22 (71,0%) ???????? 1-? ??????
? ?????? 8 (30,8%) ??????? 2-? ?????? ?? ????? ????????????????? ??????? (???? ?? ????? 0,5%)
? ???? ???????????????? ??? ?????????? ?? ???????. ?? 2-? ?????? 3 (11,5%) ???????? ????? ???
?????????????? ??. ? 1 (3,2%) ?????? ????? ????????? 1-? ?????? ???????????????? ??????????????? ?????????? ?????????? ? ? 1 (3,9%) ?????? ????? ??????? 2-? ?????? ? ???????? ??????????. ?? ?????? ?????????? ?????????? ??? ???????? ???? ??????????? ?????????? ???????, ?????
???? ?????????? ???? ?????????????. ??????? ?? ?????????????????? ?????????? ? 1-? ?????? ?
100%. ???? (3,9%) ??????? 2-? ?????? ??????? ?????? ????????? ????????? ??????????????.
???????? ????????????? ???????? ???????? ??????? ??????? ?? ? 1-? ?????? ? ? 27,2 ?? 19,3%.
? ????????? 2-? ?????? ? ?????????? ?????? ?? ???????? ???????????? ???????? ?????????????
??????? ??.
??????????. ?????????? ?????????????? ??????? ??????????? ??????????? ??????? ?? ?? ? ????????? ? ??????????????? ???????????? ???????? ?? ???? ??????????? ?????? ?? ???? ??????
??????????, ?????? ?????????? ????????? ????????????? ??????? ?? ????????????? ??????? ?????? ??????????.
? ? ? ? ? ? ? ? ? ? ? ? ? : ??????????? ??????????, ?????????? ??????, ?????????????? ???????.
Objective. The study aimed to analyze the results of different concomitant ablation techniques in
patients with paroxysmal atrial fibrillation (AF) and mitral valve disease according to data of continuous long-term rhythm monitoring.
Material and methods. The study was performed between 2009 and 2011 and included 57 patients with
mitral valve disease and paroxysmal AF. Patients were randomized in two groups: 31 patient (group I)
underwent concomitant ablation with defect correction, 26 patients (group II) underwent isolated correction of defect. Left atrial (LA) radiofrequency ablation was performed using only bipolar devices. All
patients underwent implantation of apparatus for continuous heart rhythm monitoring after the primary
* ????? ??? ?????????: e-mail: meshalkinclinic.ru
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????. ?????? ?? ?????????? XVII ?????????????? ?????? ????????-?????????? ????????
67
stage of intervention. Patients with rate of AF less than 0.5% at every follow-up examination were considered to be responders to treatment. Evaluation of atrial transport function was based on analysis of
transmitral diastolic flow (E-VTI and A-VTI peaks) and pulmonary venous flow.
Results. There were no deaths during in-hospital period. Absence of AF was noted in all cases in both
groups after completion of surgery. AF paroxysm in early postoperative period required pharmacological (cordarone) or electrical cardioversion in 6 patients (19.4%) from group I and in 12 patients
(46.2%) from group II. Control examination was performed in 3, 6 and 12 months. 18 patients (58.1%)
from group I and 10 patients (38.5%) from group II were shown to be free from AF on the first examination. 22 patients (71.0%) from group I and only 8 patients (30.8%) from group II did not have documented arrhythmia (rate of AF less than 0.5%) in 12 months after surgery and were classified as
responsive to treatment. 3 patients (11.5%) from group II already had persistent AF. Left atrial flutter
was noted in 1 patient (3.2%) from group I and 1 patient (3.9%) from group II had typical flutter. Both
patients underwent catheter ablation for atrial flutter, after which the regular rhythm was recovered.
Freedom from thromboembolic complications was 100% in group I. One patient (3.9%) from group II
had acute cerebrovascular accident.
Statistically significant decrease of LA ejection fraction from 27.2 to 19.3% was noted group I. Patients
from group II with regular rhythm did not have significant decrease of LA systolic function.
Conclusion. Concomitant ablation significantly increases freedom from AF at all stages of follow-up in
patients with paroxysmal atrial fibrillation in the setting of mitral valve disease, but this procedure has
adverse effect on left atrial systolic function.
K e y wo r d s : atrial fibrillation, mitral valve disease, radiofrequency ablation.
?????????? ?????????? (??) ????????
????? ???????????????? ? ???????? ?????????? ???????? ????????, ???????? ???????????? ??????? ?? ???????? ????? ?????????, ??????? ??????????? ? ??????????? [8]. ????? 60%
????????? ? ?????????? ??????????? ???????,
?????? ?? ????????, ????? ??????????? ?? [3].
??????? ??????????? ????????????? ?????????
╚????????╩ ????????? ? ??????????? ??????? ???????????? ?????????? ???? ? ????????? ??? ? ????????????????? ??????? ? ??????? ? ?????????
?????????????? ?? [9]. ?????? ??? ????????????????? ???????????? ? ????????????? ?????????? ????????? ??????? ? ????????? ? ??????????????? ???????????? ?????????? ? ?????????? ????????. ????????? ???????????
?????? ???????? ? ???????? ?????????????????? ???????? ? ?????????? ???????? ??????????,
??? ????? ?????????????? ?????????????? ? ???????????? ??????????? ?????. ?????? ????????
??????? ???????? ?????? ?????? ?????????????
?????????????? ??????? ? ????????? ? ??????????????? ??. ?????? ????????? ???????? ????
?????????? ?????? ?????????? ????? ??????????
? ????????? ???????????? ?? [11]. ??????????? ????????? ?????? ????? ????? ?????????????? ????????? ??????? ???????? ??? ? 24-??????? ???????????? ???????????????. ?????? ????????????? ????????????????? ??????????? ?
????????? ? ??????????????? ?? ?? ???? ???????? ????????????? ? ????? ? ?????????? ???????
????? ?????????? ??????? [13]. ????? ???????????? ??????? ?????? ??????????? ????????? ??????????? ???????? ??? ?????????? ?????????????? ??????? ? ????????? ? ???????????????
?? ? ?????????? ??????? ?? ????????? ??????????? ???????????? ??????????? ??????????
?????.
???????? ? ??????
? ?????? 2009 ?? ???? 2011 ?. ? ????????????
???? ???????? 57 ????????? ? ??????? ??????????? ??????? ? ??????????????? ????????????
??????????. ??????? ????????? ??????? ???????? ???? ???????????? ?? ??? ??????: 31 ????????
(1-? ??????) ????????? ?????????????? ???????
? ?????????? ?????????? ??????; 26 ?????????
(2-? ??????) ? ????????????? ????????? ?????????? ??????.
?? ????????? ??????????? ACC/AHA ?? ??????? ????????? ? ?????????? ???????? ?????? ??????????????? ???????? ????????? ???????????
??????? ???? ???????? ?????????? ? ?????????????? ??????? ? ???? ??????? [2]. ???????????
?????????? ???? ???????????????? ??? ??????????????? ???????? ????????????? ???????????
ACC/AHA/ESC [5]. ?? ???? ??????? ??????????????? ?????? ?? ??????????????? ?? ???? ???????? ?????????????. ??????????? ??????????????
????????? ???????????? ? ??????? 1.
?? ? ? ? ? ? 1
?????????????? ???????????
?????????????? ?????????
1-? ??????
(n = 31)
2-? ??????
(n = 26)
???????, ???
51,5 ╠ 6,2
???????/???????,
14/17
n (%)
(45,2/54,8)
??, ?? ?? NYHA, ??? (%)
II
3 (9,7)
III
28 (90,3)
??????? ???????????
??, ???
20,1 ╠ 10,4
???/??????? ? ????????,
n (%)
1 (3,2)
54,7 ╠ 9,3
10/16
(38,5/61,5)
?????? ?????????
2 (7,7)
24 (92,3)
18,8 ╠ 8,1
1 (3,8)
? ? ? ? ? ? ? ? ? ?. ??? ? ???????????? ??????????? ?????.
?????? ???????????, ? 1, 2012
?
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
68
?????? ???????????, ? 1, 2012
?????? ???????????, ? 1, 2012
????????????? ??????????
??? ???????? ???? ??????????? ?????????
???????????? ???????? ? ???????? ??????????
(34 ╟C) ???????????????? ?????????????? ??????????????, ????????? ??????? ????? ???? ??????????? ?-???????? ??????? ??????????? ?????? ?? ??????? ??????????. ??? ?????? ????????
?????????????? ???????????????? ????????????
(Custodiol; Dr Kohler Pharma, Alsbach-Hahnlein,
Germany).
?????????????? ??????? ?????? ?????????? ??????????? ? ?????????????? ?????? ??????????
?????????: ?????????? CardioBlate BP2 (Medtronic
Inc., Minneapolis, MN, USA) ??? ????????????
Isolator Synergy (AtriCure Inc., Cincinnati, OH,
USA). ?????? ???????? ???????????? ???????????????????. ??????? ?????? ????? ? ?????? ???????? ???, ? ????? ???? ?????? ?????????? ????????? ?? ???????????? ????????????? ?????????????? (??? ?????????? ????????????????
???????? ?? ?????? ????????????????? ?????????????? ?????). ?????????? ?????? ??????????? ???????? ??? ????????? ????????????? ??????, ?????? ?????????? ????? ? ???????????????
???????????? ? ??????????? ?????????????????????? ????????? ????? ?????????? (?????????????? ???????? ???????????? ?? ???????? ????? ??
??????????? ??????). ????? ????????? ????? ????????? ????????? ????? ???????: ????? ??
╚?????╩ ? ?????? ????? ?????? ?????? ?? ????????? ??? ???????? ?????? ? ????? ???????? ??? ?
????????????? ╚box lesion╩, ????????????? ????? ?? ????????? ???? ?? ? ??????? ????? ???????? ????. ?? ??????? ???? ???????????????? ??????? ??????????? ??????????? ????? ? ??????????? ???????. ??? ???????????? ??????????
????? ? ????? ???????????? ??????????? ????????? ??????? ?????????????? ??????? ?????? ?????????? ??????? ??, ????????? S. Benussi [1].
???? ?????? ?????????? ??????????? ??????? ?
?????????????? ??????????? ?????????? ???
?????? ? ?????? ?????????????? ???????.
????? ? ???????? ???????????? ?? ?????????
???????? ??? ??????????? ? ?????????? ? ?????
??????? (????. 2).
??????????? ?????????? ?????
? ????? ???????????? ??????????????? ?????????? ????? ????????????? ??????????????
??????? REVEAL XT 9529 (Medtronic Inc.,
Minneapolis, MN, USA). ??????? ???????????????
???? ????????? ? ????? ???????? ? ????? ??????????????? ???????.
?? ???? ???????? ????????? ?????????
REVEAL XT Patient Assistant (Medtronic Inc.,
Minneapolis, MN, USA). ?????????? ???????? ????????????, ? ??????? ???????? ??????? ?????
??????????? ?????????????? ???????.
??? ?????? ??????? ?? ?? ???? ????????????
????? ???????????? ???????? [12]. ????????, ??????? ????? ???? ?? ????? 0,5% ??? ?????? ?????????? ??????????, ???? ???????? ? ?????????? ?? ??????????? ???????.
?????? ???????????? ??????? ??????????
??? ???????????? ???????????????? ??????????????? ?????? ?????????????? ?????????? ??????????????? ??????? ? ?????? ?????????-????????? ???????? ? ??????? ????? ? ? ? ? ?/?, VTI ????? ? ? ? (????????? ???????? ???????? ?????????).
? ????? ???????????? ????????? ? ????????
????? ?????????????? ?????????? ??????????????? ??????? ? ?????? ?????????-????????? ????????, ? ?????????? ???????????? ?????? ? ?????
???????? ?????? ??????? ???????? ???? ? ?????
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(?) ???? ?????? ? ?/?, ? ????? VTI ????? s ? d.
????????????????? ???????
? ??????? ??????????? ?????????? ????? ??????????? ??????? ????????? ? ???? 900 ??/??? ? ??????? 3 ??? ????? ????????. ? ?????????? ????????
?????????? ?????????? ?? 200 ??/??? ?? ????????? ? ? ? ? ? 2
????????????????? ??????
????? ?????????, ???. (%)
??????????
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?????????????
????????? ?????????????? ?????
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???????? ??????????? ???????
???????? ??????????????? ???????
?????????? ????????????
1-? ?????? (n = 31)
2-? ?????? (n = 26)
26 (83,9)
4 (12,9)
1 (3,2)
6 (19,4)
5 (16,1)
1 (3,2)
23 (88,5)
3 (11,5)
?
4 (15,4)
3 (11,5)
2 (7,7)
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?????????????? ?????? ??????
?????????? ???????????? ??? ??????? ? ??????????? ?????????? (? ╠ ?). ??? ??????????????
??????? ?????? ?????????????? ?????? ?????????
??????? (U-???????? ???????????, (??????)
???????? ?????????). ???????? ?????????????
?? ???????????? ?????????????? ? ??????? ???????? ????????????????????. ?????????? ??????? ?? ?? ??????????? ?? ?????? Kaplan?Mayer.
?????????? ????????? ????????????? ?????????
??? ? ? 0,05. ?????????????? ????????? ??????????? ????????? ? ?????????????? ?????? ????????
Statistica 10 (Stat-Soft╝ Inc., USA).
??????????
??????????? ?? ???????????? ????? ?? ????.
? 1 (3,2%) ?????? ????? ????????? 1-? ?????? ???????? ??????????, ????????? ? ??????????, ?
?????????? ????????????? ????? ???????? ???? ?
???? ???????????? ??????????? ????? (??????
???? ?? ???????????? ????????????? ??????????????).
???????? ????? ????? ????????
?????????? ?? ???????? ?? ???? ??????? ?????
????? ????? ????????? ????????. ????????? ??
? ?????? ????????????????? ??????? ??????????
????????????????? (????????) ??? ????????????? ???????????? ? 6 (19,4%) ??????? 1-? ?????? ?
? 12 (46,2%) ????????? 2-? ?????? ????? ?????????? ????????????????? ???????? ?? ?????? ?????????????? ?????. ?? ?????? ?????????? ????????? ???? ? 1 (3,2%) ?????? ????? ????????? 1-?
?????? ????????????? ??????????? ????????????????????????? ? ?????? ??????????? ??????????.
??????????? ???????????? ????????? ??????????? ????? 3, 6 ? 12 ??? ????? ????????. ?? ?????? ??????? ???????????? ???????????? (3 ???
????? ????????) 18 (58,1%) ????????? 1-? ??????
? 10 (38,5%) ????????? 2-? ?????? ???? ????????
?? ?? ???????? ?????? ????????????????? ???????? (???? ?? ????? 0,5%). ????? (8,0%) ????????? 2-? ?????? ????????? ????????????? ???????????? ?? ?????? ?????????????? ?? ? ??????????????? ?????????? ?????.
????? 12 ??? ????? ???????? 22 (71,0%) ???????? 1-? ?????? ? ?????? 8 (30,8%) ??????? 2-?
?????? ?? ????? ????????????????? ???????
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90
80
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70
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60
50
40
38,5
30
34,6
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20
10
0
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9
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??? ?????????? ?? ??????? (??. ???????). ???
(11,5%) ???????? 2-? ?????? ????? ??? ?? ???????????????, ? ?????????????? ??. ? 1 (3,2%)
?????? ????? ????????? 1-? ?????? ???????????????? ??????????????? ?????????? ??????????
(??) ? ? 1 (3,9%) ?????? 2-? ?????? ? ????????
??????????. ?? ?????? ?????????? ?????????? ???
???????? ???? ??????????? ?????????? ???????,
????? ???? ?????????? ???? ?????????????.
???? (3,9%) ??????? 2-? ?????? ?????? ??????? ??????? (4 ? 6 ??? ????? ????????), ??? ???????? 1-? ?????? ???? ???????? ?? ?????????????????? ?????????? ? ??????? 12 ???.
?????? ???????????? ??????? ??????????
??? ???????????? ?????? ???????????? ??????? ?????? ?????????? ???????? ????????????
?????? ? ????? ??????? ? ?????????????? ???????. ??? ???????????? ? ?????????? ??????? ????????, ??? ??????? ?????? ?????????? ????????????? ?????????? ???? ???? ? 1-? ??????. ????? ??????? ????????, ??? ??? ? ???????????? ? 4 (12,9%)
????????? 1-? ??????, ???????? ?? ?????????
????, ? ?? ????? ??? ? ????????? 2-? ?????? ??????????? ??? ???????????? ? 3 ????????? ? ?????????????? ?????? ?? (????. 3).
??????????
????????? ?????? ???????? ?????? ?????????????, ??????????? ??????? ???????????????
?? ? ????????? ? ??????????? ????????, ??????? ????????? ?? ?????? ?????????? ????? ? ?????????????? ???????????? ???????????. ? ????? ???????????? ??????? ?? ??????????? ? ???-
?????? ???????????, ? 1, 2012
??? 3 ???. ? ??????? ?????????? ????????? ????
(????????? ???????????, ??????? ????) ??????????? ??????????? ??????????????????????? ?
???????? ?? ??????????. ? ???? ??????? ???????????????? ??????? ?????????? ????? 3 ??? ?????
????????.
69
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
70
?????? ???????????, ? 1, 2012
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???????? ???????????? ??????? ??????????
?????? ???????????, ? 1, 2012
????????
1-? ??????
2-? ??????
?? ????????:
??????? ??????? ??, %
??????? ???? ?, %
?????? ??, ??
27,2 ╠ 3,4
100
61,5 ╠ 7,2
28,1 ╠ 2,2
100
66,1 ╠ 5,9
?????????? ??????:
??????? ??????? ??, %
??????? ???? ?, %
?????? ??, ??
19,3 ╠ 3,1
87,1
55,4 ╠ 4,9
25,2 ╠ 4,9
88,5
60,2 ╠ 5,3
??????? ?????????? ? ?????? ?????????? ???????
????????? 71,0%, ??? ????????? ???? ??????, ??????????? ??????? ????????. ???, ? ?????? ???????
?? ???????????? ??????? ??????? ?? ?????????
??????? ????????? 84,0% ????? 12 ??? ????? ???????? [6]. ??? ???????????? ????????? ?????? ?? ??????? ???, ??? ????????????? ????????? ? 7-???????? ????????????? ???????????. ??? ???? ??????? ????????, ??? ? ????? ???????????? ???
???????? 1-? ?????? ?? ?????? ??? ?? ??????
12-????????? ???????????? ???????????? ?????
????????? ????, ??? ??????? ? ?????? ??????????????? ??????? ?????? ? ????????? ? ??????????????? ??.
?? ????????? ???????????? ????????????
?????????? ???????? ???????? ??????? ?????
???????? ? ??????? ?? ?? ?? ???? ?????? ?????????????????? ??????????. ?????? ???? ? ????????????? ????, ??? ????????????? ????????? ??????????? ?????? ? ??????????? ???????????
???????? ?????? ?????????? ? ??????????? ???????? ? ??? ?? ????????? ????????? ??????? ??
??????? ??. ????? ????, ???????? ?????????? ???????????, ? ???? ????????? ???????????????
????? ?? ??????? ? ??????????????, ??? ?????????? ????????????? ?????????? ??????? ? ????????? ? ?????????? ??????? ? ????????????
??????????.
?????? ???????? ???????????? Stroke
Prevention in Atrial Fibrillation (SPAF) ??????????,
??? ???? ???????????? ???????? ???????? ? ????????? ? ??????????????? ? ????????? ?????????????? ?? [7].
???????? ??????????? ACC/AHA ?? ???????
????????? ? ?????????? ???????? ?????? ????????? ?????? ??????????????? ? ????????? (???
?????????? ???????? ??????? ??? ???????????
?????????????? ???????) ? ???????? ?????????????? ?????????? ╚maze╩ [2]. ?? ???????, ???
?????? ????????? ?? ? ????? ???????? ???????
?? ?????? ???????????????? ??????? ?? ??????
???? ???????? ?? ?????? ??? ? ??????????????
????????????? ???????????????. ?????????????
p
?
?
?
0,003
> 0,05
> 0,05
??????????? ???????????? ??????????? ?????????? ????? ? ????????? ? ??????????? ????????
???????? (??? ??? ????????? ?????????????
????????) ????? ?????????? ?????????????? ??????? ????? ????? ???????? ????????????, ???????? ????????? ? ?????????? ???????? ???????????????? ???????.
?????? ???????????? ???????? ????????????
???? ?????? ???????????? ??????? ?????? ??????????. ??????? ????? ????????????, ??????????? ?????????????? ??????? ??????????, ????????? ?? ??????????? ??????? ??????? ??? ? ???????????????, ??? ? ? ????????? ??????????????
?? [4, 14]. ???????????? ? ????? ?????? ????????????? ??????? ?????? ?????????? ? ????????? ?
??????????????? ?? ???? ??????????? ?????????? ??????? ??????????? ????? ?? ?????????????? ?????, ??? ?????????? ??????? ? ?????????
? ?????????????? ??????. ? ????? ??????, ??????????? ?? ?????? ???? ?????????????????
?????, ??????? ???????? ?????? ??????? ??????
?????????????? ??????? ?? ???????????? ??????? ?????? ??????????. ?? ???????? ????????????
???????? ????????????? ??????? ?????? ?????????? ?? 2-? ?????? ? ????????? ? ???????????
?????????? ??????.
???????? ????????????? ???????? ????????
??????? ??????? ?????? ?????????? ? ?????? ??????? ? 27,2 ?? 19,3%, ??? ??????????? ? ???????
Stefan LЖnnerholm [10]. ?????????? ?????????????? ? ??? ????, ??? 12,9% ????????? ????? ?????????? ??????? ? ?????????? ??????? ?? ????? ???????? ?????????????? ??????? (?????????? ????
?), ???????? ?? ?????????? ??????????? ????? ?
?????? ????????????.
? ?????????? ?????????? ????????, ??? ?????????? ?????????????? ??????? ???????????
??????????? ??????? ?? ?? ? ????????? ? ??????????????? ???????????? ?????????? ?? ????
??????????? ??????, ?????? ?????????? ?????????
????????????? ??????? ?? ????????????? ??????? ?????? ??????????. ?????????? ??????????
???????????? ? ????????? ? ??????????????? ??
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????. ?????? ?? ?????????? XVII ?????????????? ?????? ????????-?????????? ????????
7.
8.
? ? ? ? ??? ? ??
1.
2.
3.
4.
5.
6.
Benussi S., Nascimbene S., Galanti A. et al. Complete left
atrial ablation with bipolar radiofrequency // Eur. J.
Cardiothorac. Surg. 2008. Vol. 33. P. 590?595.
Bonow R., Carabello B., Chatterjee K. et al. Focused update
incorporated into the ACC/AHA 2006 Guidelines for the management of patients with valvular heart disease // Circulation.
2008. Vol. 118. P. 523?661.
Brodell G., Cosgrove D., Schavone W. et al. Cardiac rhythm
and conduction disturbances in patients undergoing mitral valve
surgery // Clev. Clin. J. Med. 1991. Vol. 58. P. 397?399.
Feinberg M. S., Waggoner A. D., Kater K. M. et al.
Restoration of atrial function after the Maze procedure for
patients with atrial fibrillation // Circulation. 1994. Vol. 90
(Part 2). P. 285?292.
Fuster V., Ryden L., Cannom D. et al. ACC/AHA/ESC 2006
Guidelines for the management of patients with atrial fibrillation ? executive summary. A report of the American College of
Cardiology/American Heart Association task force on practice
guidelines and the European Society of Cardiology committee
for practice guidelines // Circulation. 2006. Vol. 114.
P. 700?752.
Gillinov A., Bakaeen F., McCarthy P. M. et al. Surgery
for paroxysmal atrial fibrillation in the setting of mitral valve
9.
disease: a role for pulmonary vein isolation? // Ann. Thorac.
Surg. 2006. Vol. 81. P. 19?26.
Hart R., Pearce L., Rothbart R. et al. Stroke with intermittent
atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation investigators // J.
Am. Coll. Cardiol. 2000. Vol. 35. P. 183?187.
Kannel W., Abbot R., Savage D., McNamarra P. Epidemiological features of the atrial fibrillation in the Framingham
study // N. Engl. J. Med. 1982. Vol. 306. P. 1018?1022.
Lall S., Melby S., Voeller R. et al. The effect of ablation technology on surgical outcomes after the Cox-maze procedure:
a propensity analysis // J. Thorac. Cardiovasc. Surg. 2007.
Vol. 133. P. 389?396.
10. Lonnerholm S., Blomstrom P., Nilsson L., BlomstromLundqvist C. Atrial size and transport function after the Maze
III procedure for paroxysmal atrial fibrillation // Ann. Thorac.
Surg. 2002. Vol. 73. P. 107?111.
11. Mehall J., Kohut R., Schneeberger W. et al. Absence of
correlation between symptoms and rhythm in symptomatic
atrial fibrillation // Ann. Thorac. Surg. 2007. Vol. 83.
P. 2118?2121.
12. Pokushalov E., Romanov A., Cherniavsky A. et al. Ablation of
paroxysmal atrial fibrillation during coronary artery bypass grafting: 12 months? follow-up through implantable loop recorder //
Eur. J. Cardiothorac. Surg. 2011. Vol. 40. P. 405?411.
13. Stulak J., Sundt T., Dearani J. et al. Ten-year experience with
the Cox-maze procedure for atrial fibrillation: how
do we define success? // Ann. Thorac. Surg. 2007. Vol. 83.
P. 1319?1324.
14. Voeller R., Zierer A., Lall S. et al. The effects of the Cox-maze
procedure on atrial function // J. Thorac. Cardiovasc. Surg.
2008. Vol. 136, ? 5. P. 1257?1264.
????????? 07.06.2012
?????? ???????????, ? 1, 2012
? ?????????? ???????? ???????? ?????????????? ????? ???????, ??????? ???????? ??????
???????????? ???????? ??? ?????????? ????? ??????? ?????????????????????? ?????????????.
71
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
72
?????? ???????????, ? 1, 2012
?????? ???????????, ? 1, 2012
??????? ??? ???????
??????????, ??????????? ???? ????????? ??? ?? ????????? ?????????? ?? ???????????? ?????????
??????????? ???????????? ????????? ??????? ╚?????? ???????????╩ ????????? ????? ??????????.
?????????? ?????????? (???????? ? ??????????? ?????): 121552, ??????, ?????????? ?., ?. 135,
????? ??. ?. ?. ???????? ????; annali_aritmologii@mail.ru.
?????? ???????????? ??????? ?????????? ?????? ??????????, ?????????? ? ??????????, ??????????? ?? ????????????? ?? ????????????? ??????? ? ???????????? ????????????? ????? ??????? ????????? ? ??????? ?????????? ??? ?????????? ???????????? ? ????????????? ????????????.
??? ?????????, ???????????? ? ??????, ???????? ???????????? ?????????. ??????? ? ???????????
????????????? ???????? ??????????? ???????????? ????????? ? ???????????? ??????? ??????? ?? ????????? ??????? ???????????? ? ??????? ?????????? ????????????, ??? ??????? ? ????????????? ?????????? ???????????, ? ?????? ?????? ???? ??? ????? ???????????, ? ??? ????????????? ? ??????????? ?? ?????????????? ??????????. ???????? ????????? ?? ????? ????? ???????????? ?????? ??????, ???????? ? ??????????, ??? ????????? ?? ??????????.
???????? ?? ????????????? ????????, ?????????????? ????? ? ??? ??? ???? ????????????? ????????. ?????????? ???????, ??? ?????????, ?????????? ????????:
1. ??????? ??????????? ????????.
2. ?????? ?????????? ?????????? ? ???????? ??????????.
3. ???????????? ???????????.
4. ???????????? ???????????.
5. ?????????? ???????? ?????????? ?????????? ??? ??????? ?? ?????? ?????.
6. ?????????? ??????? ????????????.
???????? ????????? ??????????? ??? ???????????? ?? ?????????? ???? ????? ?????????????
??????? ????????????. ?????? ???? ???????? ??????? ??? ??????????????? ?????? ? ??????????. ??
???????? ? ?????? ???????? ??????? ?? ????????????.
?????????? ????????????????? ?????????????? ???????????? ?????? ???? ????????? ? ???????????? ? ????????????? ??????????? ??? ???????????? ??????? ??????? (http://www.consort-statement.org/).
???????? ?????????? ?????????? ????????????? ?? ????????? ??????, ??????? ?????? ??????
????? ? ???????????????? ??????????? ????????????. ????????? ??????????????? ?? ????????? ???? ????????? ?????????:
1. ????????? ???? ???????????? ????? ? ?????????? ????????? ??????? ?????? ? ????? ?/??? ? ????
??????, ?/??? ? ?? ?????? ? ?????????????.
2. ????????? ?????????? ? ?????????? ?????????? ? ?????????? ??? ???? ???????????? ???????????
????????? ?? ?????? ?? ??????????.
3. ????????? ??? ???????? ?? ?????????? ???????? ? ????????????????? ?????? ??????.
????? ?????? ???????? ? ?????????? ?? ???? ????? ?? ????? ???? ???????? ?? ?????????? ?????????? ??? ???????? ? ????, ??? ?? ??? ?? ????? ???? ??????? ? ??????? ??????? ??? ??????????? ????????
???? ?????????? ??????.
?????? ??????? ???????????? ???????? ?????? ?????? ? ?????? ??????????? ???????????? ??? ??
??????????? ??????, ?? ????????? ??????? ????? ??????? ??????? ? ??????????? ??????????. ??? ????????, ?????????? ?????????????? ??????, ?????? ?????? ???????????????? ????????????????? ??????
??????? ????????????, ???????, ????????????? ? ????????????? ??????????? ?? ??????????? ? ????????.
???????????? ???????????? ? ???????? ???????? ???????? ??????? ?????????????? ???? ???????????? ??????????. ? ?????? ?????????? ????????????? ?? ???????? ?????? ????????? ? ??????? ╚???????? ? ??????╩ ?????? ??????????? ?????????? ????????? ????????? ????????? ? ?????????, ????????????? ??????????? ?????????? ?? ???????? ??????????? ?????? ????????. ??? ???? ??????
???????????? ?????? ???? ???????? ????????? ?????????.
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??? ???? ???????????? ?????? ???? ??????? ?? ????????? ????? ????????. ? ?????? ????? ?????????????? (????????????????, ??????????? ????????????? ??? ?????? ???? ??????? ?????????????, ????????-???????????? ??????????) ??????? ???????? ? ???????? ? ???????????????? ??????. ?????? ?????????? ????? ??????????? ????????? ?????????? ? ???????????? ??? ?????????? ?? ????????????? ????????? ?????????. ??????, ???????????? ???????? ???????? ? ????? ????????????? ?????????, ?????
?????? ????? ?????????? ?????????? ? ??????? ╚?????? ???????????╩ ?????? ?? ???? ???.
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? ??? ??????????? ? ???????? ? ??????????? ??????;
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?????? ? ?????????????. ? ?????? ?????????? ??????? ??? ??????, ??????? ???????????? ? ???????????? ? ???????? ? ??????? ???????????. ???????????????? ?????? ?????? ????? ???? ???????? ????????????. ?????? ??????????? ????? ??. ?. ?. ???????? ???? ?????????????? ??????? ??????????? ??????????????? ??????????.
?????????? ??????
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* ????????????? ?????????????? ????????????, ???????????? ? ?????? ??????? ?????????? ? ?????, ????? ???????? ?????????? ???????? ?? ?????????? ????? ??????? ??????. ? ????? ?????? ? ???????????????? ?????? ?????????? ?????????????? ????? ??????? ?????? ? ???????????????? ??????????? ????????????.
** ? ??????????, ??????????? ??????? ???????????? ? ??????????????, ??????????? ????????????? ????????????? ???? ??????????????? ????????? ? ???????.
????????????? ???????? ??????????? ??????? ??????? ??????? ?? ???????????? ? ???????????? ????????????? ???????? ? ??????????. ??????, ?? ??????????????? ???????????? ? ??????? ???????????, ????? ?????????.
╚??????? ?????????╩ ??????????????? ????????? ?????? ? ?????? ?? ???????????? ? ??????????????? ???????? ??? ?????????. ?????? ? ??????? ╚?????? ? ????????╩ ?????? ???????????? ????? ??????????? ? ?????????? ??????????? ??????? ╚?????? ???????????╩. ?????????? ????? ? ????????
╚???????????? ???????╩ ? ╚?????????? ?? ?????????? ????????, ?????????????? ?? ??????? ???????╩
?????????????? ?????? ?? ???????????? ? ????????? ???????.
?????? ???????????, ? 1, 2012
????????? ?????? (?? ?????)
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
74
?????? ???????????, ? 1, 2012
?????? ?????? ???? ???????????? ? ???? ???????????, ? ??? ?????????????? ??????????? ????????.
?????? ?? ??????????? ???????? ?????? ???? ????????? ????????? ?? ??????. ???????? ??????????????
?? ???????? ???????? ?? ????? ??????? ?????.
???? ????????? ? ???????. ? ??????? ???????????? ?????????? ? ??????????? ???????. ??????
???????? ? ?4; ?????????? ? ???????; ???????????? ? ?? ??????; ???????? ?????? ? 1,25 ??. ????? ???????????????? ?????????? ? ?????? ?????? ???? ?????? ??????????? ??????? Times New Roman 14-??
??????? ??????? ?????. ????????????? ???????? ? ??????????, ???? ? 2,5 ?? ?? ???? ??????. ?????????
??????? ? ????????? ??????? ? ?????? ?????? ????. ?? ????????? ????? ????? ???????? ?? ???????????.
? ???????????? ??????? (??. ???????) ???????? ?????? ????? ????????? ????????? ?????:
1. ????????? ????.
2. ??????? ? ???????? ?????.
3. ?????, ????????? ?? ????????: ╚????????╩, ╚???????? ? ??????╩, ╚??????????╩, ╚??????????╩,
╚??????╩ ??? ╚??????????╩.
4. ???????.
5. ??????? ? ??????? ? ???.
6. ?????? ?????????????? ??????????.
????????? ????
????????? ???? ?????? ???????? ? ???? ?????? ???????? ?????? (???????????? ?? ???????????), ???????? ? ??????? ???????, ???????? ? ??????????????? ??????????, ? ??????? ??????????? ????????????.
???????? ? ??????????? ?????, ? ????? ????? ???????? (?????) ?????? (??????????? ????) ??????
???? ?????????? ? ?????? ????? ?????????? ?????. ???? ?????????? ????????????, ?????????? ? ??????,
????? ?????????????? ?? ??????? ???????, ?? ???????? ?????????? ????????, ????? ? ???? ?????????? ??????. ????? ????, ?? ????????? ????? ?????????? ??????? ?????? ?????????? ???? ? ???????? ? ?????? ?????? (?? ?????? ????????, ?????? ? ???????????? ??????). ? ?????????? ?????????? ??? ????????? ?????????????? ????????????.
???????
??????? ? ???????? ? ???????? ???????? ????? ??????, ?????????? ?? ??????. ????? ???????? ?? ?????? ????????? ??????????? ? ??????????, ?? ??????????? ?????? ?????????.
????????????????? ??????? ?????? ???????? ?? ??????? ????????:
1. ╚????╩ ? ?????? ???????????? ????????, ??????????????? ? ?????? ????????????, ? ???????????? ????????.
2. ╚???????? ? ??????╩ ? ???????? ??????? ????????????, ?????????? ?????????, ??????????????
???????????, ????????????????, ?????????????????, ?????????????? ? ?????? ???????.
3. ╚??????????╩ ? ????????? ???????? ?????????? ??????????? ? ?? ?????????????? ??????????.
4. ╚??????????╩ ? ???????? ????? ????????????.
??? ??????????? ??????????? ?????????????? ??????????? ??????? ?????????????? ? ??????????? ????????????? ??????? ????? ??????? ???????????? ?????? ? ?????????? ?? ?????????? ????????
??????? ??????? ?????????? ??????????? ??????????? ????????????????? ???????, ?. ?. ????????????????? ??????? ?? ??????? ? ?????????? ????? ??????? ?? 650 ?? 700 ????.
??????? ??????????????? ?? ????????? ?????.
???????? ?????
?????? ???????????, ? 1, 2012
? ?????? ???????? ??????????? ?? 3 ?? 6 ???????? ???? ?? ??????? ? ?????????? ????? ?? ??????
??????????? ?????????? ?????????? Index Medicus. ??????????? ??????????? ???????? ???? ?? ???????? ? ???????? ???????? ?????????? ? Index Medicus.
?????
?????????? ???? ? ?????? ????? ?????? ?????? ?????????? ?? 300 ?? 3500 (??. ???????).
Microsoft Office Word 2003
????? ?????????? ?????????? ???? ? ?????-???? ????????? ??????, ???????? ???. ??? ??????????
????????? ????? ?????????? ?????????? ???? ?? ???? ?????????. ? ???? ?????? ???????? ??????? ??????????. ????? ?????????? ?????????? ????, ???????, ????? ? ??????. ???? ?????????? ?????? ??????? ?
???????? ??????, ?????????? ?????? ╚????????? ??? ??????╩; ? ????????? ?????? ??????? ???.
Microsoft Office Word 2007
? Microsoft Office Word 2007 ??????? ??????? ??????? ?????????? ???? ??? ????? ?????? ? ????????.
? Office Word 2007, ?????? ?????, ?????????????? ????????, ??????, ??????, ????? (? ?????? ????????
? ??? ?? ?????). ????? ? ??????? ? ???????? ?? ????????? ?? ???????????, ?????? ??? ???????????????
????????? Office Word 2007 ?? ????? ??????? ? ???????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??? ???????
75
??????? ??????? ?????????? ????
? ????????? Office Word 2007 ??? ????? ?????? ? ???????? ? ??? ????????????? ?????????????? ?????
??????? ? ????, ??????? ???????????? ? ?????? ????????? ? ?????? ????? ??????? ???????.
??????? ???? ? ?????????? ??????????
??????? ???? ?????????????? ?? ???? ?????????, ? ????? ? ????? ??? ?????????? ??????????. ?????????????, ????? ????????? ????????? ???? ?? ??????. ???????? ?????, ? ??????? ????????? ?????????? ?????. ?
?????? ????????? ??????????? ?????????? ???? ? ?????? ?????????. ????????: 100/1440 ????????, ??? ?????????? ???????? ???????? 100 ????, ? ???? ???????? ? 1440. ??? ?????? ?????????? ?????? ?? ?????? ???????? ????????? ???????? ?????? ????????, ? ?????, ????????? ??????? ??????? CTRL, ???????? ?????????.
? ?????? ?????? ? ???????? ??????????????? ?? ??????????? ???????? ??????? ? ??????????, ?? ??????? ????? ????????. ??????? ????????????? ?????? ?????????? ????????? ? ??????????, ???????
??????????? ??????? ? ? ??????????, ?? ? ???????????? (?????? ??????????) ????????????.
????? ???????? ?????? ???????? ?? ????????? ????????, ???? ?? ??????? ???????? ?????????????:
1. ╚????????╩. ?????? ?????????? ???????????? ???????????? ? ??? ???????? (???? ????????????) ??
????????? ??????? ???????????? ???????.
2. ╚???????? ? ??????╩. ?????? ???????? ?????????? ? ?????????? ? ???????????? ????????? ???
????????????????? ????????, ??????? ????????????, ?????????????? ???????????, ????????????, ????????????????, ????????????????? ? ?????? ?????????. ????????? ??????????? ????? ??????? ??????????? ?????????????? ???????????, ????? ???????????? ???????? ??????????? ??? ?????????????
??????? ?? ????????????.
????????????? ??????????? ?????? ???? ?????????? ????????? ?????????, ??????????????????? ???????? ?? (?????????? ????? ?????????? ???????????, ??????????? ? ╟?, ? ????????, ?????????????? ?
?? ??. ??.), ? ???????? ????? ????????????? ????????????, ?????? ??? ???, ???, ???, ?? ? ?. ?. ??????????????? ????????????? ????????????? ??????????????? ???????? ???????? ? ??????????. ? ???????
?????????? ????? ??????????? ???????? ???????? ? ????????? (? ???????) ????? ? ??????-?????????????.
3. ╚??????????╩ ? ???????? ????? ????????. ?????????? ????? ???? ???????????? ? ???? ?????? ???
??????? ??????????????? ????????? ? ?????? ????????????????? ? ?????? ??? ??????? ?????? ? ??????.
4. ╚??????????╩. ?????? ???????? ? ???? ????????????? ??????????? ? ?? ?????????? ?? ??????? ??
??????????????? ?????? ?????? ???????. ?????????? ??????? ?????? ???? ?????? ? ???????. ????? ??
?????????? ???????? ??????????? ???????????? ? ??? ???????????? ??????????.
5. ╚??????????╩. ?????? ???????? ???????? ?????? ? ?????? ????????????.
6. ????????????? ?? ?????????? ??? ?????? ?????? ??????????? ? ????? ??????. ????, ??????? ???????????? ????? ? ???????????????? ??????????? ????????????, ?? ?? ?????????? ???????? ?????????????? ??????????, ????? ???? ???????? ? ???? ???????.
???????
??????? ?????? ???? ??????, ????????????, ?? ?? ???????????? ?????. ?????? ??????? ?????? ????? ?????????? ????? ? ??????? ?????????. ??? ???????????? ? ???????? ???????????? ????????????????.
?????? ??????? ? ?????????? ??????????????? ?? ????????? ?????.
???????
???? ??????????? ???????? ? ??????? ? ???? ?????? ??????????????? ???????????? ??????????
(Index Medicus). ??????????? ????????????? ??????? ????????, ???? ??? ????? ?????????????? ???????
?????? ???????????, ? 1, 2012
???????? ?????????? ???????, ?????? ? ?????
???????????? ????? ?????????? ?????????? ???????, ???????, ????? ? ?????? (? ????????? ??? ???
???) ? ?????????. ?? ??????? ?????????????? ? ?????? ???????????? ???????? ??????? ??????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
76
?????? ???????????, ? 1, 2012
?????????? ?????????? ??????????. ??????????? ????????????? ??????? ????????. ?? ??????? ?????
???? ????????? ?????????? ?????????? ?????????, ?????? ? ?. ?. ? ?????-????? ???????, ?? ??? ????????? ???????????. ????????????? ???????? ????????????? ?????????? ????????. ??????????? ?????
???? ???????????? ? ???? ?????????? ??? ? ???????? ???????? ? ???????? TIF ??? EPS ? ????????????
?? ???????????.
?????????? ??????????? ?????? ???? ?? ????? 300 ????? ?? ???? ??? ??????? ??? ?????-????? ??????????? ??? 1200 ????? ?? ???? ??? ?????-????? ????????? ????????. ??????????? ??????????
????????????? ? ???????????? ? ?? ????????????? ? ?????? ??????. ??????? ? ???????? ?????? ????????? ????????????? ??????????? ? ???????????, ? ??? ????? ???????? ?? ?????????????? ?????? ???????????? ? ?????????????? ???????? ??? ???????????? ??????????? ???????????????? ??????????????? ???????. ??? ???????? ??????????? ? ???????????? ??????? ????????. ? ???????? ? ???????????????? ?????????? ????????? ????? ??????? ????????? ? ?????????? ??????? ? ?????????.
??????? ? ??????? ? ??? ??????????????? ?? ????????? ?????.
??????
??????? ????????????? ??????? ? ?????? ?????? ?????????????? ??????????? ? ??????????, ???????
??????????? ??????? ? ????? ? ??????????, ?? ? ???????????? (?????? ??????????) ????????????.
?????? ?? ???????????? ????????? ????????????? ? ?????????? ??????? ? ????????? ??????? ?????????????, ? ????? ??????????? ???????. ??? ????????? ?????????? ?? 4 ??????? ???????????? ??????????? ??? ??????, ??? ??????? ? ??????????? ??? ?????? ?????? ? ??????????? ╚? ??.╩ (? ??????????? ?????????? ╚et al.╩). ? ?????? ?????? ?????? ???? ?????????? ???????? ? ?????????? ???????. ?????? ????????, ???-????? ? ???????????????? ?????? ?? ?????? ?????????? ? ?????? ??????. ????????????
???????? ?????? ???? ??????? ? ???????????? ? Index Medicus.
??????? ????????????? ??????
?????? ???????????, ? 1, 2012
?? ?????? ?? ???????:
1. ????????? ?. ?., ????? ?. ?., ???????? ?. ?. ? ??. ??????????? ???????????????????? ?????????
? ?????? ????????????????? ??????? ? ????? ??????? ???? ????? ? ??????????? ???????? ?????? //
????????? ????? ??. ?. ?. ???????? ????. 2008. ?. 9, ? 6. ?. 247?254.
2. Rubens F. D., Labow R. S., Lavallee G. R. et al. Hematologic evaluation of cardiopulmonary bypass circuits
prepared with a novel block copolymer // Ann. Thorac. Surg. 1999. Vol. 67. P. 689?698.
?? ?????:
3. ???????? ?. ?. ?????????????? ????????. ???.: ??????, 2000. 227 ?.
4. Ferraris V. A., Ferraris S. P. Fibrinolytic activation in cardiopulmonary bypass: impact on the management
of bleeding // Management of bleeding in cardiovascular surgery / Ed. R. Piffare. Philadelphia: Hanley & Belfus
Inc., 2000. 502 ?.
?? ???????????:
5. ??????? ?. ?. ??????????? ???????? ? ????? ? ?????? ???? ?? 5 ??: ???. ? ????. ???. ????. ?.,
2010. 208 ?.
?? ??????-?????????? (???????? ????????: doi ? ??????????? ???????? ???????????):
6. Kazaz M., Celkan M. A., Ustunsoy H., Baspinar O. Mitral annuloplasty with biodegradable ring for infective endocarditis: a new tool for the surgeon for valve repair in childhood // Interact. Cardiovasc. Thorac. Surg.
doi: 10.1510/icvts.2005.105833.
al valve disease, radiofrequency ablation.
?????????? ?????????? (??) ????????
????? ???????????????? ? ???????? ?????????? ???????? ????????, ???????? ???????????? ??????? ?? ???????? ????? ?????????, ??????? ??????????? ? ??????????? [8]. ????? 60%
????????? ? ?????????? ??????????? ???????,
?????? ?? ????????, ????? ??????????? ?? [3].
??????? ??????????? ????????????? ?????????
╚????????╩ ????????? ? ??????????? ??????? ???????????? ?????????? ???? ? ????????? ??? ? ????????????????? ??????? ? ??????? ? ?????????
?????????????? ?? [9]. ?????? ??? ????????????????? ???????????? ? ????????????? ?????????? ????????? ??????? ? ????????? ? ??????????????? ???????????? ?????????? ? ?????????? ????????. ????????? ???????????
?????? ???????? ? ???????? ?????????????????? ???????? ? ?????????? ???????? ??????????,
??? ????? ?????????????? ?????????????? ? ???????????? ??????????? ?????. ?????? ????????
??????? ???????? ?????? ?????? ?????????????
?????????????? ??????? ? ????????? ? ??????????????? ??. ?????? ????????? ???????? ????
?????????? ?????? ?????????? ????? ??????????
? ????????? ???????????? ?? [11]. ??????????? ????????? ?????? ????? ????? ?????????????? ????????? ??????? ???????? ??? ? 24-??????? ???????????? ???????????????. ?????? ????????????? ????????????????? ??????????? ?
????????? ? ??????????????? ?? ?? ???? ???????? ????????????? ? ????? ? ?????????? ???????
????? ?????????? ??????? [13]. ????? ???????????? ??????? ?????? ??????????? ????????? ??????????? ???????? ??? ?????????? ?????????????? ??????? ? ????????? ? ???????????????
?? ? ?????????? ??????? ?? ????????? ??????????? ???????????? ??????????? ??????????
?????.
???????? ? ??????
? ?????? 2009 ?? ???? 2011 ?. ? ????????????
???? ???????? 57 ????????? ? ??????? ??????????? ??????? ? ??????????????? ????????????
??????????. ??????? ????????? ??????? ???????? ???? ???????????? ?? ??? ??????: 31 ????????
(1-? ??????) ????????? ?????????????? ???????
? ?????????? ?????????? ??????; 26 ?????????
(2-? ??????) ? ????????????? ????????? ?????????? ??????.
?? ????????? ??????????? ACC/AHA ?? ??????? ????????? ? ?????????? ???????? ?????? ??????????????? ???????? ????????? ???????????
??????? ???? ???????? ?????????? ? ?????????????? ??????? ? ???? ??????? [2]. ???????????
?????????? ???? ???????????????? ??? ??????????????? ???????? ????????????? ???????????
ACC/AHA/ESC [5]. ?? ???? ??????? ??????????????? ?????? ?? ??????????????? ?? ???? ???????? ?????????????. ??????????? ??????????????
????????? ???????????? ? ??????? 1.
?? ? ? ? ? ? 1
?????????????? ???????????
?????????????? ?????????
1-? ??????
(n = 31)
2-? ??????
(n = 26)
???????, ???
51,5 ╠ 6,2
???????/???????,
14/17
n (%)
(45,2/54,8)
??, ?? ?? NYHA, ??? (%)
II
3 (9,7)
III
28 (90,3)
??????? ???????????
??, ???
20,1 ╠ 10,4
???/??????? ? ????????,
n (%)
1 (3,2)
54,7 ╠ 9,3
10/16
(38,5/61,5)
?????? ?????????
2 (7,7)
24 (92,3)
18,8 ╠ 8,1
1 (3,8)
? ? ? ? ? ? ? ? ? ?. ??? ? ???????????? ??????????? ?????.
?????? ???????????, ? 1, 2012
?
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
68
?????? ???????????, ? 1, 2012
?????? ???????????, ? 1, 2012
????????????? ??????????
??? ???????? ???? ??????????? ?????????
???????????? ???????? ? ???????? ??????????
(34 ╟C) ???????????????? ?????????????? ??????????????, ????????? ??????? ????? ???? ??????????? ?-???????? ??????? ??????????? ?????? ?? ??????? ??????????. ??? ?????? ????????
?????????????? ???????????????? ????????????
(Custodiol; Dr Kohler Pharma, Alsbach-Hahnlein,
Germany).
?????????????? ??????? ?????? ?????????? ??????????? ? ?????????????? ?????? ??????????
?????????: ?????????? CardioBlate BP2 (Medtronic
Inc., Minneapolis, MN, USA) ??? ????????????
Isolator Synergy (AtriCure Inc., Cincinnati, OH,
USA). ?????? ???????? ???????????? ???????????????????. ??????? ?????? ????? ? ?????? ???????? ???, ? ????? ???? ?????? ?????????? ????????? ?? ???????????? ????????????? ?????????????? (??? ?????????? ????????????????
???????? ?? ?????? ????????????????? ?????????????? ?????). ?????????? ?????? ??????????? ???????? ??? ????????? ????????????? ??????, ?????? ?????????? ????? ? ???????????????
???????????? ? ??????????? ?????????????????????? ????????? ????? ?????????? (?????????????? ???????? ???????????? ?? ???????? ????? ??
??????????? ??????). ????? ????????? ????? ????????? ????????? ????? ???????: ????? ??
╚?????╩ ? ?????? ????? ?????? ?????? ?? ????????? ??? ???????? ?????? ? ????? ???????? ??? ?
????????????? ╚box lesion╩, ????????????? ????? ?? ????????? ???? ?? ? ??????? ????? ???????? ????. ?? ??????? ???? ???????????????? ??????? ??????????? ??????????? ????? ? ??????????? ???????. ??? ???????????? ??????????
????? ? ????? ???????????? ??????????? ????????? ??????? ?????????????? ??????? ?????? ?????????? ??????? ??, ????????? S. Benussi [1].
???? ?????? ?????????? ??????????? ??????? ?
?????????????? ??????????? ?????????? ???
?????? ? ?????? ?????????????? ???????.
????? ? ???????? ???????????? ?? ?????????
???????? ??? ??????????? ? ?????????? ? ?????
??????? (????. 2).
??????????? ?????????? ?????
? ????? ???????????? ??????????????? ?????????? ????? ????????????? ??????????????
??????? REVEAL XT 9529 (Medtronic Inc.,
Minneapolis, MN, USA). ??????? ???????????????
???? ????????? ? ????? ???????? ? ????? ??????????????? ???????.
?? ???? ???????? ????????? ?????????
REVEAL XT Patient Assistant (Medtronic Inc.,
Minneapolis, MN, USA). ?????????? ???????? ????????????, ? ??????? ???????? ??????? ?????
??????????? ?????????????? ???????.
??? ?????? ??????? ?? ?? ???? ????????????
????? ???????????? ???????? [12]. ????????, ??????? ????? ???? ?? ????? 0,5% ??? ?????? ?????????? ??????????, ???? ???????? ? ?????????? ?? ??????????? ???????.
?????? ???????????? ??????? ??????????
??? ???????????? ???????????????? ??????????????? ?????? ?????????????? ?????????? ??????????????? ??????? ? ?????? ?????????-????????? ???????? ? ??????? ????? ? ? ? ? ?/?, VTI ????? ? ? ? (????????? ???????? ???????? ?????????).
? ????? ???????????? ????????? ? ????????
????? ?????????????? ?????????? ??????????????? ??????? ? ?????? ?????????-????????? ????????, ? ?????????? ???????????? ?????? ? ?????
???????? ?????? ??????? ???????? ???? ? ?????
??????????. ???????????????? ? ??????????? ????????????? (s), ?????????????? (d) ? ???????????
(?) ???? ?????? ? ?/?, ? ????? VTI ????? s ? d.
????????????????? ???????
? ??????? ??????????? ?????????? ????? ??????????? ??????? ????????? ? ???? 900 ??/??? ? ??????? 3 ??? ????? ????????. ? ?????????? ????????
?????????? ?????????? ?? 200 ??/??? ?? ????????? ? ? ? ? ? 2
????????????????? ??????
????? ?????????, ???. (%)
??????????
????????? ??????????? ???????:
?????????????
????????? ?????????????? ?????
???????????? ??????????
???????? ??????????? ???????
???????? ??????????????? ???????
?????????? ????????????
1-? ?????? (n = 31)
2-? ?????? (n = 26)
26 (83,9)
4 (12,9)
1 (3,2)
6 (19,4)
5 (16,1)
1 (3,2)
23 (88,5)
3 (11,5)
?
4 (15,4)
3 (11,5)
2 (7,7)
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????. ?????? ?? ?????????? XVII ?????????????? ?????? ????????-?????????? ????????
?????????????? ?????? ??????
?????????? ???????????? ??? ??????? ? ??????????? ?????????? (? ╠ ?). ??? ??????????????
??????? ?????? ?????????????? ?????? ?????????
??????? (U-???????? ???????????, (??????)
???????? ?????????). ???????? ?????????????
?? ???????????? ?????????????? ? ??????? ???????? ????????????????????. ?????????? ??????? ?? ?? ??????????? ?? ?????? Kaplan?Mayer.
?????????? ????????? ????????????? ?????????
??? ? ? 0,05. ?????????????? ????????? ??????????? ????????? ? ?????????????? ?????? ????????
Statistica 10 (Stat-Soft╝ Inc., USA).
??????????
??????????? ?? ???????????? ????? ?? ????.
? 1 (3,2%) ?????? ????? ????????? 1-? ?????? ???????? ??????????, ????????? ? ??????????, ?
?????????? ????????????? ????? ???????? ???? ?
???? ???????????? ??????????? ????? (??????
???? ?? ???????????? ????????????? ??????????????).
???????? ????? ????? ????????
?????????? ?? ???????? ?? ???? ??????? ?????
????? ????? ????????? ????????. ????????? ??
? ?????? ????????????????? ??????? ??????????
????????????????? (????????) ??? ????????????? ???????????? ? 6 (19,4%) ??????? 1-? ?????? ?
? 12 (46,2%) ????????? 2-? ?????? ????? ?????????? ????????????????? ???????? ?? ?????? ?????????????? ?????. ?? ?????? ?????????? ????????? ???? ? 1 (3,2%) ?????? ????? ????????? 1-?
?????? ????????????? ??????????? ?????????????
Документ
Категория
Информационные технологии
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2012, аритмологии, 205, анналы
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