6 курс / Кардиология / Джон_Кэмм_Болезни_сердца_и_сосудов_2011

ЗАКЛЮЧИТЕЛЬНЫЕ КОММЕНТАРИИ

Быстрое развитие биомедицины и микроэлектроники и введение в практику дистанционных беспроводных, независимых от пациента, систем мониторинга привело к значительному улучшению диагностических и терапевтических возможностей. Устройства для кардиостимуляции становятся все меньших размеров, более надежными, с большим сроком службы, предлагают множество алгоритмов высокого уровня и возможностей программирования и диагностики. Однако роль кардиолога остается решающей и фундаментальной. Клиническое понимание и мышление, дополненное адекватными диагностическими методами, приведет к правильному диагностическому подходу к брадикардии, выбору подходящего метода лечения, наиболее подходящего устройства и типа стимуляции, если она показана. Неоценимы в данной связи и результаты рандомизированных клинических исследований, а также опубликованные руководства по электрокардиостимуляции. Однако ключевые факторы для успеха лечения - опыт, знания и навыки врача, занимающегося кардиостимуляцией [181], которые определяют удовлетворенность и благополучие пациента на всех этапах лечения и последующего наблюдения.

ДАЛЬНЕЙШИЕ ПЕРСПЕКТИВЫ

Имплантируемые электрокардиостимуляторы служат в настоящее время "золотым стандартом" в лечении брадикардии с выраженными клиническими проявлениями. Полвека клинических и технологических инноваций привели к появлению в последние годы высокотехнологичных устройств. Доказательная база для практики кардиостимуляции была усилена результатами многочисленных рандомизированных исследований. Вместе с тем результаты исследований часто отличались от ожидаемых и показывали несоответствие технологических улучшений и клинического прогноза. Исследования также подчеркнули тот факт, что физиологическая стимуляция требует сохранения и восстановления не только предсердно-желудочкового, но и меж-

ивнутрижелудочкового синхронизма. В следующее десятилетие скорее всего внимание будет сосредоточено на минимизации диссинхронии путем отказа от ненужной стимуляции и улучшения последовательности сердечной активации при стимуляции с использованием альтернативных очагов стимуляции, таких как межпредсердная перегородка и септальная часть выносящего тракта ПЖ. В некоторых случаях стимуляция множественных очагов желудочков может быть необходимой для подтверждения сердечной синхронизации, что будет требовать разработки более специализированных эндокардиальных электродов и возможного использования эпикардиального подхода при применении торакоскопических методов. Новейшие технологии могут представлять собой альтернативу стандартным электродам, и уже имеются предварительные данные по использованию ультразвуковой энергии для кардиостимуляции [182]. Интеграция анатомических данных, полученных с помощью различных визуализирующих методов с картами электрической активации, может способствовать прицельному расположению электрода для достижения оптимальной функции сердца при стимуляции. Наиболее ближайшие разработки, вероятно, будут включать применение систем стимуляции, совместимых с МРТ [163], и более частого использования программирования и мониторинга функции стимулятора на расстоянии, наряду с множеством гемодинамических и клинических параметров. Включение гемодинамических

идругих биосенсоров в систему для стимуляции также может способствовать автоматической и динамической оптимизации программируемых параметров. В более длительной перспективе при использовании генной терапии и методов, связанных со стволовыми клетками, возможна разработка биологических стимуляторов, которые могут полностью заменить системы, используемые в настоящее время [183]. Каким бы ни было направление будущих разработок, главными при отборе пациентов и выборе варианта электрокардиотерапии для улучшения клинических результатов лечения останутся компетентность и наблюдение кардиолога, информированного о результатах клинических исследований, проводимых в соответствии с требованиями качественной клинической практики.

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