Heart transplantation in patients with dilated cardiomyopathy caused by myocarditis or other reasons: predictors of ineffectiveness of drug therapy and selection criteria for an operation
Abstract
Aim – to identify predictors of the ineffectiveness of drug therapy for dilated cardiomyopathy syndrome (DCM), taking into account the etiology of the disease, to compare patients with poor response to treatment, those who died and those who underwent heart transplantation (HT), to specify criteria and timing of selection for HT.
Material and methods. 331 patients with DCM syndrome were included in the study, 103 women and 228 men (31.1 and 68.9%), average age was 48 (37; 58) years old (16 to 77 y.o.). The inclusion criteria were age >16 years, the left ventricle end diastolic size (LV EDS) more than >5.5 cm, left ventricle ejection fraction (LV EF) <50%. In addition to the standard examination, we assessed the level of anticardial antibodies (90.6%) and PCR-diagnostics of the viral genome in the blood/ myocardium (79.8%), coronary angiography (43.2%), cardiac multispiral computed tomography, MSCT (62.8%), magnetic resonance imaging, MRI (32.0%), scintigraphy with 99mTc-MIBI (29.6%), and DNA diagnostics if indicated. Myocardial morphological examination was performed in 115 (34.7%) patients (life-time in 92% of cases). The average follow-up was 13 (5; 42) months, up to 12 years.
Results. Almost all patients had chronic heart failure (CHF), stage IIB–III disease – 50.8% patients. The mean LV EDS was 6.4 (6; 7) cm, LV EF 32 (25; 39)%. 14 (4.2%) patients underwent HT on the average in 8.5 (2; 13.5) months. By the time of the operation, 11 patients had UNOS1 status; 3 died. 58 (18.3%) patients without HT died on the average after 12 (2.75; 26.0) months, the death + transplantation rate was 18.4%. The main predictors of the ineffectiveness of conservative therapy and the reason for urgency in HT issue were the genetic origins of DCM (especially in combination with myocarditis), a poor direct response to treatment (the absence of an increase in EF for at least 5%) both in the first and subsequent months of treatment, low voltage of QRS complex on the ECG, the presence of pathological waves Q/QS complex, as well as IIB–III stage of CHF, severe restrictive dysfunction (E/A over 2.0), tricuspid regurgitation II degree. LVEF was significantly lower in those who died/underwent HT compared with survivors without HT (33.3±8.9 vs 25.5±10.4%, p<0.001), but did not have independent prognostic value.
Conclusion. Mortality rate of the patients with DCM is still significantly higher than HT rate. The key clinical predictor of adverse outcomes (death/HF) is insufficient increase in EF as a result of complex treatment during the first six months and longer. In case of the good direct response to treatment indications for HT should be reevaluated at different stages of observation, even in patients with good direct response to treatment.
Keywords:dilated cardiomyopathy, myocarditis, heart transplantation, myocardial biopsy, mortality, prognosis
For citation: Blagova O.V., Alieva I.N., Solovyova E.A., Sedov A.V., Kogan E.A., Zaitsev A.Yu., Sedov V.P., Sarkisova N.D., Nedostup A.V. Heart transplantation in patients with dilated cardiomyopathy caused by myocarditis or other reasons: predictors of ineffectiveness of drug therapy and selection criteria for an operation. Clin Experiment Surg. Petrovsky J. 2019; 7 (3): 15–30. doi: 10.24411/2308-1198-2019-13002 (in Russian)
Received 17.06.2019. Accepted 25.07.2019.
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