#46
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Öèòàòà:
2. Äàæå â ìûñëÿõ íå äîïóñêàë èäåþ î íåíóæíîñòè ÿäåðíîé ìåäèöèíû. 3. Âîïðîñîì íà âîïðîñ. À ÷òî ÿäåðíàÿ ìåäèöèíà çàíèìàåòñÿ òîëüêî äèàãíîñòèêîé æèçíåñïîñîáíîãî ìèîêàðäà? |
#47
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Òåïåðü î ñóòè âîïðîñà - î æèçíåñïîñîáíîì ìèîêàðäå.
1.  ãàéäå ïî ÀÊØ íàïèñàíî, ÷òî ÷åì íèæå ÔÂ, òåì áîëüøå ïîëüçà îò ÀÊØ.  ðÿäå èññëåäîâàíèé óñòàíîâëåíî, ÷òî "patients with an EF less than 0.35 from the CASS registry showed 5-year survival rates of 73%, 70%, and 62% in patients with an EF from 0.31 to 0.35, 0.26 to 0.30, and less than 0.25, respectively (554). A comparison between surgically treated and medically treated groups revealed the greatest surgical benefit in patients with an EF of 0.25 or less. The medically treated patients had a 5-year survival rate of 43% compared with 63% for those treated with coronary bypass surgery. A comparison study of 5824 patients who underwent medical or surgical therapy for ischemic heart disease in the Duke University Cardiovascular Database showd that patients with the worst LV function (EF less than 0.35) had the greatest 10-year survival benefit from bypass surgery (46% versus 27%). Patients with an EF of 0.35 to 0.50 had a 10-year survival rate of 62% in the surgical group versus 50% in the medical group (87)" ñòð. å393. 2. Íà ýòîé æå ñòðàíèöå íàïèñàíî, ÷òî ÀÊØ ïîêàçàíî ïàöèåíòàì ñ òÿæåëûì ïîðàæåíèåì êîðîíàðíûõ àðòåðèé è íèçêîé Ô òîëüêî ïðè óñëîâèè íàëè÷èÿ æèçíåñïîñîáíîãî ìèîêàðäà. È ÷òî îòäåëüíî ýòà ïðîáëåìà îáñóæäàåòñÿ â ðàçäåëå 9. 3. Ïåðåõîäèì ê ðàçäåëó 9. Òàì ñêàçàíî, ÷òî"if the patient has prominent signs and symptoms of CHF with minimal angina, the decision to operate should be based on objective evidence of hibernating myocardium (755)". Ññûëêà 755. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] 318 ïàöèåíòàì ñ ÔÂ<35% ñäåëàëè ñòðåññ-ÝõîÊà ñ äîáóòàìèíîì, äàëåå èõ âðà÷è íà îñíîâàíèè ðàçëè÷íûõ ïðèçíàêîâ ðåêîìåíäîâàëè ðåâàñêóëÿðèçàöèþ è â ñòàòüå îòêðûòî îá ýòîì íàïèñàíî - "The decision for revascularization was not randomized and was made by the patients’ physicians" è â çàâèñèìîñòè îò ðåçóëüòàòîâ ðàçäåëèëè èõ íà 4 ãðóïïû: åñòü æèâîé ìèîêàðä è âûïîëíåíà ðåâàñêóëÿðèçàöèÿ (1), åñòü æèâîé ìèîêàðä è íå âûïîëíåíà ðåâàñêóëÿðèçàöèÿ (2), íåò æèâîãî ìèîêàðäà+ðåâàñêóëÿðèçàöèÿ (3) è íåò æèâîãî ìèîêàðäà+íåò ðåâàñêóëÿðèçàöèè (4). Ïîñëå ýòîãî ìåñòà ÿ áû óæå äàëüøå ñòàòüþ íå ÷èòàë, ïîòîìó ÷òî ñëèøêîì ìíîãî ñáúåêòèâèçìà è ñëó÷àéíîñòåé ïðè òàêîì äèçàéíå ïðèäåòñÿ ó÷èòûâàòü. Íî ÷èòàåì äàëüøå - òàáëèöó èñõîäíîé õàðàêòåðèñòèêè âêëþ÷åííûõ ïàöèåíòîâ. Òàì íå óêàçàí õàðàêòåð ïîðàæåíèÿ êîðîíàðíûõ ñîñóäîâ. Òàêèì îáðàçîì, âðà÷è, óâèäåâ ñòâîë ËÊÀ ìîãëè âñåì ñîâåòîâàòü ðåâàñêóëÿðèçàöèþ è òàêèå ïàöèåíòû ïðîñòî äîëüøå æèëè. Ýòîò äåôåêò äèçàéíà ïðîñòî ñïðÿòàëè îò ÷èòàòåëÿ. Êîñâåííî, íà ýòî óêàçûâàåò ÿêîáû íåäîñòîâåðíûé ðîñò îò 1 ê 4 ãðóïïå ðîñò ÷èñëà ïàöèåíòîâ ñ 3-õ ñîñóäèñòûì ïîðàæåíèåì: îò 39% â 1 ãðóïïå äî 54% â 4. Äàëüøå, â ãðóïïå 1 äîñòîâåðíî ÷àùå îòìå÷àëàñü ñòåíîêàðäèÿ (54% ïðîòèâ 20% â ãðóïïå 4). Ìîæåò áûòü ðåøåíèå î ðåâàñêóëÿðèçàöèè ïðîñòî íàäî îñíîâûâàòü íà æàëîáàõ ïàöèåíòà è íå òðàòèòüñÿ íà PET? È íàêîíåö ñåé÷àñ ìíîãèìè ýêñïåðòàìè ïðèçíàåòñÿ íåçíà÷èòåëüíàÿ ðîëü ñòðåññ-ÝõîÊà â îïðåäåëåíèè "æèâîãî" ìèîêàðäà. Âûâîä: ÿ áû íå ñòàë ïðèìåíÿòü â ðåàëüíîé êëèíè÷åñêîé ïðàòèêå ðåçóëüòàòû ñòîëü ñïîðíî ñïëàíèðîâàííîãî èññëåäîâàíèÿ. 4. Ñëåäóþùàÿ ôðàçà/öèòàòà èç ãàéäà "There should be demonstration of substantial regions of myocardial viability that would benefit from revascularization (756)" Ññûëêà 756. Î÷åíü ïîõîæåå íà ïðåäûäóùåå èñëëåäîâàíèå èç ×åõèè - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] 5. È íàêîíåö - "Such areas must be perfused by coronary arteries of sufficient size and location to be reasonable targets for bypass surgery (757)" Ññûëêà 757. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] "Clinical data were collected retrospectively by chart review by use of predetermined definitions and a standardized data collection form". Ïðè âñåì óâàæåíèè ê àâòîðàì ðåòðîñïåêòèâíûå èññëåäîâàíèÿ íå ñîâñåì íàäåæíûé (ñîâñåì íå íàäåæíûé) èñòî÷íèê èíôîðìàöèè. PS: âñå, ÷òî õîòåë ñêàçàòü, ñêàçàë. Ïðîäîëæåíèå äèñêóññèè ñ÷èòàþ îïàñíûì äëÿ ôîðóìà. Áåðó íà ñåáÿ îáÿçàòåëüñòâà íå ïèñàòü áîëüøå ñîîáùåíèé â ýòîé òåìå. Ó âñåõ, êîãî îáèäåë åùå ðàç ïðîøó ïðîùåíèÿ. |
#48
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Óâàæàåìûé äîêòîð Ïàíêîâ!
ÈÌÕÎ, íåò ñìûñëà ïðèäèðàòüñÿ ê ñëîâàì. ß ëè÷íî íå âèæó áîëüøîãî ïðîòèâîðå÷èÿ â ïðèâåäåííûõ Âàìè öèòàòàõ Èãîðÿ. Ïîêàçàíèÿ ê ðåâàñêóëÿðèçàöèè îïðåäåëÿþòñÿ íå òîëüêî (è ê ñòàòè, íå ñòîëüêî) êîëè÷åñòâîì æèçíåñïîñîáíîãî ìèîêàðäà, à ñêîðåå îáúåìîì ñàìîé çîíû èøåìèè. Ñîãëàñèòåñü, ó äîâîëüíî áîëüøîãî ÷èñëà áîëüíûõ, êîòîðûì îñóùåñòâëÿþò ðåâàñêóëÿðèçàöèè âåñü ìèîêàðä, ê ñ÷àñòüþ, æèçíåñïîñîáåí. Ñöèíòèãðàôèÿ - ãîðàçäî ìåíåå operator-depending ìåòîä, ÷åì ñòðåññ-Ýõî è, ñëåäîâàòåëüíî, áîëåå îáúåêòèâíûé. Îòòóäà è ðîñò ïîïóëÿðíîñòè. |
#49
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Öèòàòà:
Öèòàòà:
Öèòàòà:
Íà ñàìîì äåëå ïðè ïóáëèêàöèè ýòîãî ñëó÷àÿ ó ìåíÿ áûëà è åùå îäíà öåëü - ïîêàçàòü Âàì, êàê îòëè÷àþòñÿ ðåçóëüòàòû èññëåäîâàíèÿ ìèîêàðäà â ýòîé âûïèñêå îò äåéñòâèòåëüíîãî ñîñòîÿíèÿ ìèîêàðäà ó ýòîãî áîëüíîãî. Ïî÷åìó åìó âñå-òàêè âûïîëíèëè îïåðàöèþ? Íî, áîþñü, ñ Âàìè äî ýòîãî íå äîéäó. Íå äîæèâó. |
#50
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Åâãåíèé Íèêîëàåâè÷, Âû íàì äîðîãè ñî âñåõ òî÷åê çðåíèÿ, òàê ÷òî óæ, ïîæàëóéñòà, äîæèâèòå .
Äóìàþ, äåéñòâèòåëüíî, íåîáõîäèì íåáîëüøîé òàéì-àóò äëÿ ñíèæåíèÿ ãðàäóñà äèñêóññèè. Ãëàâíîå, ÷òî â öåëîì ìû âñå ãîâîðèëè îá îäíîì è òîì æå, ïðîñòî êòî-òî - áîëåå ïðîôåññèîíàëüíî, à êòî-òî - áîëåå èçäàëåêà. |
#51
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Öèòàòà:
Êðîìå òîãî, ÷òî ýòîò ìåòîä ìåíåå çàâèñèì îò îïåðàòîðà, îí ïîçâîëÿåò âèçóàëèçèðîâàòü èìåííî òå êëåòêè ìèîêàðäà, êîòîðûå ìåòÿòñÿ. Êëåòêè, à íå ñòåíêó â öåëîì! Åñëè ýòî ïåðôóçèîííàÿ ñöèíòèãðàôèÿ - òî îáÿçàòåëüíî êëåòêè ñ ñîõðàííîé ìåìáðàíîé è íàëè÷èåì îáìåíà âåùåñòâ, ïîñêîëüêó ñàìè àãåíòû â ýòîì îáìåíå ó÷àñòâóþò è çàäåîæèâàþòñÿ èìåííî â "æèâûõ" êëåòêàõ. Âñå äðóãèå, íåèçîòîïíûå ìåòîäû, ïðè âñåé èõ çàìå÷àòåëüíîé ðàçðåøàþùåé ñïîñîáíîñòè íå ìîãóò äèôôåðåíöèðîâàòü ïîãèáøóþ òêàíü îò "æèâûõ" êëåòîê. Ïîýòîìó, êîãäà ãðàìîòíûé àìåðèêàíñêèé êàðäèîëîã òîëüêî ãëÿíåò íà ñöèíòèðãàììó âûñîêîãî ðèñêà -ðåøåíèå ïðèíèìàåò áåç ïðîìåäëåíèÿ. |
#52
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#53
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Öèòàòà:
ß õîòåëà íàïèñàòü, ÷òî, íåñîìíåííî, ýòî òàê. Ïðîñòî â Ðîññèè ìåòîä ñöèíòèãðàôèè, ê âåëèêîìó ñîæàëåíèþ, äîñòóïåí íå âåçäå (ïðè÷èíû íåäîñòóïíîñòè ìîãóò áûòü ðàçíûå). |
#54
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Öèòàòà:
Nuclear cardiology is not widely performed in other Asian countries. This is unfortunate, especially when the large population bases of the region are considered... Most cardiologists in these countries prefer echocardiography as a screening test and coronary angiography as a final diagnostic test. Coronary angiography remains relatively inexpensive compared with radionuclide imaging. Nuclear medicine and specifically nuclear cardiology procedures are considered to be special tests and are performed in only a few large centers. Similar situations are seen in a number of other countries in Asia....Other problems facing nuclear cardiology in Asia are limited training opportunities and the fact that general cardiologists currently have a greater interest in intervention and echocardiography than in nuclear medicine techniques... |
#55
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To Igor73.
À Âû âèäåëè òàêóþ ñòàòüþ: Rizzello V - Heart - 01-FEB-2006 Long term prognostic value of myocardial viability and ischaemia during dobutamine stress echocardiography in patients with ischaemic cardiomyopathy undergoing coronary revascularisation [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Â çàùèòó îïðåäåëåíèÿ æèçíåñïîñîáíîñòè è, ãëàâíîå, äîáóòàìèí-ñòðåññ-ÝÕÎ. |
#56
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 îæèäàíèè îòâåòîâ Èãîðÿ è åãî åäèíîìûøëåííèêîâ íà âîïðîñû, çàäàííûå ìíîþ â ïîñòå ¹ 49, â ñâÿçè ñ ïîæåëàíèÿìè êîëëåã ïðîäîëæèì ðàññìàòðèâàòü ñèòóàöèþ ñ íàøèì ïàöèåíòîì, âûïèñêà êîòîðîãî ïðåäñòàâëåíà â ïîñòå ¹ 30. Äëÿ òîãî, ÷òîáû ÷èòàòåëè â äàëüíåéøåì íå ïèñàëè î ñåáå «Êðàéíå ìàëî ïîíèìàþ â ÿäåðíîé ìåäèöèíå.» íà÷íåì ñ ãàéäîâ ïî ðàäèîèçîòîïíîé äèàãíîñòèêå â êàðäèîëîãèè. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
 ðàçäåëå 2. General Principles of Assessing Myocardial Viability by Radionuclide Techniques íà ñòðàíèöå 30 ìîæíî íàéòè âîò ýòî The radionuclide tracers and techniques most often used in this situation have been evaluated for their relation to preserved tissue viability directly, by correlating tracer uptake (of the single-photon tracers Tl-201 and sestamibi, and the metabolic tracer FDG) with histologically confirmed extent of tissue viability obtained by a biopsy of the relevant myocardial regions at the time of coronary artery bypass surgery. In these studies, it has been demonstrated that quantitative analysis of tracer uptake correlates directly with the magnitude of preservation of tissue viability (372,378-380). Many studies in the literature evaluate the techniques for assessing viability by assigning a specific threshold or cutpoint, often 50 or 60% of maximum tracer uptake, to create dichotomous performance characteristics (sensitivity, specificity, and positive and negative predictive values). An important principle illustrated by the biopsy studies is that tracer uptake represents a continuous variable, with the magnitude of tracer uptake directly reflecting the magnitude of preserved viability. In turn, the magnitude of tracer uptake is linked to the probability of regional functional recovery after revascularization (381,382).Ñ òåõ ïîð, êàê âûøëè ýòè ãàéäû îñíîâíûå ïðèíöèïû èíòåðïðåòàöèè ðåçóëüòàòîâ ñöèíòèãðàôèè íå èçìåíèëècü. Íà íèõ-òî ìû è îñòàíîâèìñÿ. 1- åñëè íàêîïëåíèå èíäèêàòîðà â ìèîêàðäå íå ìíååå 50 % - ìèîêàðä (ó áîëüíûõ ÈÁÑ!) àáñîëþòíî æèçíåñïîñîáåí. 2- Ïðè ñíèæåíèè äî 60% (à ñåé÷àñ íåêîòîðûå àâòîðû ñ÷èòàþò è äî 69%) îò ìàêñèìóìà – óñëîâíî æèçíåñïîñîáåí 3- Ïðè ñíèæåíèè äî 70% è áîëåå ìèîêàðä íå æèçíåñïîñîáåí. Ïîýòîìó, åñëè âàì ãîâîðÿò îá îöåíêå æèçíåñïîñîáíîãî ìèîêàðäà ïðè íàãðóçêå â ñëó÷àå ñöèíòèãðàôèè Öèòàòà:
Íèêàêîé íàãðóçêè çäåñü íå íàäî.  íàøåì ñëó÷àå õèðóðãè òðåáîâàëè ïîäòâåðäèòü èëè îïðîâåðãíóòü çàêëþ÷åíèå ÌÐÒ ñ êîíòðàñòîì: «ðóáöîâûå èçìåíåíèÿ íà âåðõóøêå, ïåðåäíåé, áîêîâîé íèæíåé ñòåíêàõ, òðàíñìóðàëüíîå ðàñïðîñòðàíåíèå äî 70%." Ñõåìàòè÷åñêè ó íàøåãî áîëüíîãî ïðè àâòîìàòè÷åñêîé ïîëóêîëè÷åñòâåííîé îöåíêå ýòî âûãëÿäåëî âîò òàê: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Êàêèå áóäóò ìíåíèÿ? |
#57
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Åñëè äðóãèõ ìíåíèé íå áóäåò, ðàçðåøèòå ïðîäîëæèòü èçëîæåíèå ñèòóàöèè. Íà ïðåäñòàâëåííîì ðèñóíêå ÿ îáâåë áåëûì ïóíêòèðîì î÷àãè, êîòîðûå ìîæíî îòíåñòè ê íåæèçíåñïîñîáíûì ïî ïðèíöèïàì, èçëîæåííûì â ãàéäàõ è öèòèðîâàííûì ðàíåå.
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Âèäíû äâà òàêèõ î÷àãà. Îäèí - íà âåðõóøêå ñ ðàñïðîñòðàíåíèåì íà ïåðåäíþþ ñòåíêó ìåíåå ÷åì íà åå àïèêàëüíóþ òðåòü. Âòîðîé – çàäíåáàçàëüíûå îòäåëû ñ ïåðåõîäîì íà çàäíåáîêîâóþ ñòåíêó. Ñðàâíèì ýòî ñ òåì, ÷òî íàïèñàíî â âûïèñêå ïî ðåçóëüòàòàì ÌÐÒ …Èøåìè÷åñêèå èçìåíåíèÿ ËÆ: ðóáöîâûå èçìåíåíèÿ íà âåðõóøêå ïåðåäíåé áîêîâîé íèæíåé ñòåíêàõ, òðàíñìóðàëüíîå ïîðàæåíèå äî 70%… Ñ îäíîé ñòîðîíû, óïîìÿíóòû âðîäå òå æå ñòåíêè è ïðîöåíòû íàðóøåíèé ïåðôóçèè ïî ïîëóêîëè÷åñòâåííîé îöåíêå ñîâïàäàþò ( íå îáÿçàòåëüíî ýòî òðàíñìóðàëüíûå ïîðàæåíèÿ!). Íî, ïîñìîòðèòå íà ðàäèîíóêëèäíûå èçîáðàæåíèÿ ïåðôóçèè: 1- ðàçâå çîíû îòìå÷åííûå áåëûì ïóíêòèðîì (òî åñòü íåæèçíåñïîñîáíûé ìèîêàðä) çàíèìàþò 70% ïëîùàäè âñåãî ìèîêàðäà? 2 - Ðàçâå áόëüøàÿ (óäàðåíèå íà î) ÷àñòü ïåðåäíåé ñòåíêè íå ðåäñòàâëåíà æèçíåñïîñîáíûì ìèîêàðäîì? 3- Ðàçâå âñÿ ïåðåäíåáîêîâàÿ ñòåíêà íå ïðåäñòàâëåíà æèçíåñïîñîáíûì ìèîêàðäîì? 4- Ðàçâå ÌÆÏ è ïåðåäíåïåðåãîðîäî÷íûå îòäåëû íå ïðåäñòàâëåíû æèçíåñïîñîáíûì ìèîêàðäîì? |
#58
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â ëþáîì ñëó÷àå ÿ áû ïîñìîòðåë ãëóáèíó (severity) äåôåêòîâ ïåðôóçèè - ýòî 1.
à 2 - íàäî ñìîòðåòü íà ñîêðàòèìîñòü! èìõî òóò íå âñå â ïîðÿäêå ñ íèæíå - ïåðåãîðîäî÷íûì ñåãìåíòîì (ñðåäíÿÿ ñòåïåíü íàðóøåíèé ïåðôóçèè) è âåðõóøå÷íî-íèæíèì! è êñòàòè êàêîé òèï êîðîíàðíîãî êðîâîòîêà ó ïàöèåíòà ëåâûé èëè ïðàâûé? |
#59
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Öèòàòà:
Èìåííî äëÿ ýòîãî ÿ è ïðèâåë ãàéäû, è íåïîñðåäñòâåííî öèòèðîâàë îñíîâíûå ïðèíöèïû èíòåðïðåòàöèè ñöèíòèãðàìì ïðè îöåíêå æèçíåñïîñîáíîñòè. Ãäå â ãàéäàõ Âû óâèäåëè îöåíêó ñîêðàòèìîñòè ïðè âûÿâëåíèè æèçíåñïîñîáíîñòè ïî ïåðôóçèîííûì ñöèíòèãðàììàì? Ïðåäëàãàåòå AHA, ACC è ASCN âíåñòè èçìåíåíèÿ â ãàéäû? Öèòàòà:
Èìåííî äëÿ òîãî, ÷òîáû Âû óâèäåëè çîíû íåæèçíåñïîñîáíîãî ìèîêàðäà ÿ è îáâåë áåëûì ïóíêòèðîì çîíû ñîîòâåòñòâóþùèå íåæèçíåñïîñîáíîìó ìèîêàðäó ñîîòâåòñòâåííî èíòåðïðåòàöèè ïî ãàéäàì. Ê ñîæàëåíèþ, ýòî, ïîêà ÷òî, íå êñòàòè, ïîñêîëüêó ðå÷ü èäåò îá îöåíêå æèçíåñïîñîáíîñòè ïî ïåðôóçèîííûì ñöèíòèãðàììàì. Èçâèíèòå. |
#60
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Öèòàòà:
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