Implantacja ICD w profilaktyce pierwotnej – EPS nowym pomysłem na trafną kwalifikację

Marzec 17, 2014  |  Udostępnij  | 

Większość implantowalnych kardiowerterów-defibrylatorów (ICD), urządzeń mających za zadanie przerywanie groźnych dla życia arytmii komorowych, wszczepia się w profilaktyce pierwotnej, czyli zanim wystąpi pierwszy epizod wspomnianych zaburzeń rytmu. Randomizowane badania, takie jak MADIT, czy SCD HeFT potwierdziły słuszność takiego postępowania u pacjentów z niską frakcją wyrzutową (EF), stąd wiodąca rola właśnie tego wskaźnika w algorytmach decyzyjnych zawartych w wytycznych. Standardy ESC dotyczące postępowania u chorych z przewlekłą niewydolnością serca (CHF) sugerują implantację ICD w prewencji pierwotnej nagłego zgonu sercowego (SCD) w przypadku pacjentów w II-III klasie hemodynamicznej wg NYHA, z EF≤35%, mimo co najmniej trzymiesięcznej, optymalnej farmakoterapii. Należy jednak zastanowić się, czy sama frakcja wyrzutowa może być wystarczającym predyktorem wystąpienia SCD z przyczyn arytmicznych. W praktyce klinicznej obserwuje się wielu chorych, u których, mimo skrajnie niskiej EF, nigdy nie dochodzi do wyzwolenia częstoskurczu komorowego, czy migotania komór. Jednocześnie groźne komorowe zaburzenia rytmu pojawiają się u pacjentów z niewydolnością serca, ale frakcją wyrzutową nie kwalifikującą do implantacji ICD. Rozwiązaniem tego problemu postanowili zająć się naukowcy z Australii, którzy wyniki swojego badania opublikowali niedawno na łamach pisma Circulation[1].

Protokół eksperymentu zakładał przeprowadzenie badania elektrofizjologicznego (EPS) z próbą wyzwolenia częstoskurczu komorowego (VT), jako elementu kwalifikacji do implantacji ICD. Kolejnych pacjentów po przebytym zawale z uniesieniem odcinka ST (STEMI) początkowo oceniano pod względem frakcji wyrzutowej. Osoby z EF≤30% oraz te z EF≤35% i CHF w II lub III klasie NYHA były następnie kwalifikowane do EPS. Defibrylator implantowano jedynie tym, u których w trakcie badania elektrofizjologicznego wyzwolono epizod VT.  Pacjenci z EF>40% stanowili grupę kontrolną, liczącą 1286 osób. EPS wykonano u 128 osób. Okazał się on negatywny (bez wyzwolenia arytmii) u 63% chorych (80 osób). Arytmię wyzwolono u pozostałych 37% chorych (48 osób). ICD implantowano ostatecznie u <0,1% pacjentów z grupy kontrolnej, 4% pacjentów z grupy bez VT (wbrew protokołowi) i 90% z grupy VT. Pierwszorzędowym punktem końcowym był czas wolny od zgonu lub arytmii (VF/VT nie prowadzące do śmierci). Okres ten nie różnił się istotnie między grupą kontrolą i grupą bez VT (p>0,5), natomiast w obu grupach był w sposób istotnie statystycznie dłuższy niż w grupie pacjentów z VT indukowanym w trakcie EPS (p<0,001). W trakcie całej 3-letniej obserwacji odsetek chorych wolnych od groźnych arytmii wyniósł w przybliżeniu 92% w grupie kontrolnej, 93% wśród pacjentów z negatywnym EPS i tylko 63% wśród chorych z VT wyzwalanym w trakcie badania elektrofizjologicznego. Można więc stwierdzić, że pacjenci z niewydolnością serca ze znacznie obniżoną frakcją wyrzutową, u których nie indukuje się VT w trakcie EPS, mają dobrą perspektywę przeżycia wolnego od arytmii, a więc nie wymagają zabezpieczenia ICD.

Do wyników powyższego badania należy podchodzić z ostrożnością ze względu na relatywnie niewielką liczbę przebadanych chorych, a co za tym idzie niewielką ilość obserwowanych zdarzeń. Niemniej jednak, jeśli znajdą one potwierdzenie w kolejnych badaniach, EPS może stać się wartościową częścią procesu stratyfikacji ryzyka SCD i kwalifikacji do implantacji ICD. Być może wykonanie badania elektrofizjologicznego pozwoliłoby na wyłonienie grupy naprawdę wysokiego ryzyka arytmii, pozwalając zaoszczędzić pacjentom bez indukowanego VT możliwych powikłań związanych z zabiegiem wszczepienia defibrylatora i późniejszym działaniem tego urządzenia.

1. Zaman S. et al., Long-Term Arrhythmia-Free Survival in Patients with Severe Left Ventricular Dysfunction and No Inducible Ventricular Tachycardia Post Myocardial Infarction. Circulation. 31 Dec 2013 [Epub ahead of print]



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