Funkcionalni oporavak bolesnika sa ishemijskom kardiomiopatijom lečenih implantacijom mononuklearnih ćelija koštane srži tokom aortokoronarne bajpas hirurgije
Sažetak
Uvod/Cilj. Intramiokardna implantacija mononuklearnih ćelija koštane srži (MNĆKS) tokom hirurške revaskularizacije miokarda aortokoronarnim premošćivanjem (HRMAKP), kao pokušaj regenerativne terapije u lečenju hronične ishemijske srčane slabosti, testirana je u manjem broju kliničkih studija sa nekonzistentnim zaključcima po pitanju popravljanja funkcije leve komore i sa periodom praćenja najčešće od šest meseci do godinu dana. Primarni cilj studije bio je da pokaže bolji i dugotrajniji funkcionalni kapacitet za vežbanje bolesnika sa ishemijskom kardiomiopatijom (IK) operisanih kombinacijom implantacije MNĆKS i HRMAKP u odnosu na bolesnike operisane samo HRMAKP. Sekundarni cilj bio je da pokaže njihovo duže preživljavanje i kvalitetniji život u nižoj NYHA klasi u dugoročnom praćenju, prosečno pet godina posle operacije. Metode. Trideset bolesnika sa IK i srednjom ejekcionom frakcijom leve komore od 35,9 ± 4,7% bili su prospektivno i nasumično uključeni u otvorenu interventnu kliničku studiju jednog centra i podeljeni u dve grupe: prva grupa od 15 bolesnika označena kao studijska grupa i predviđena da dobije uz HRMAKP i implantaciju MNĆKS i druga grupa od 15 bolesnika, označena kao kontrolna grupa, kojoj je rađena samo HRMAKP. Rezultati. Svi bolesnici obe grupe dobili su prosečno 3,4 ± 0,7 aortokoronarnih graftova, i to svi po graft leve unutrašnje torakalne arterije na prednju silaznu međukomorsku granu leve koronarne arterije (LIMA-LAD) i po potrebi autovenske graftove na druge koronarne arterije. Grupa kojoj je rađena i implantacija MNĆKS imala je u proseku 17,5 ± 3,8 injekcija rastvora MNĆKS sa prosečnim brojem ubrizganih mononuklearnih ćelija od 70,7 ± 32,4 × 106 u totalnom prosečno ubrizganom volumenu od 5,7 ± 1,5 mL. Izračunato je da je prosečno ugrađeno 3,96 ± 2,77 × 106 CD34+ ćelija i 2,65 ± 1,71 × 106 CD133+ ćelija. Svi bolesnici su postoperativno praćeni od 2,5 do 7,5 godina (prosečno 5 godina). U vreme poslednje postoperativne kontrole statistički značajno veći broj bolesnika iz grupe HRMAKP uz intramiokardnu implantaciju MNĆKS nalazio se u NYHA I funkcionalnoj klasi u poređenju sa bolesnicima iz grupe kojoj je rađena samo hirurška revaskularizacija (14/15 vs 5/15; p = 0.002). Pređeno rastojanje izmereno šestominutnim testom hoda pokazalo je statistički značajnu razliku već na postoperativnoj kontroli posle šest meseci (435 m u grupi MNĆKS i HRMAKP u odnosu na 315 m u grupi HRMAKP; p = 0,001) i održavala se sve vreme praćenja i neznatno povećavala do poslednje kontrole (520 m u odnosu na 343 m; p < 0,001). Kardiovaskularni mortalitet bio je takođe statistički značajno manji u grupi lečenoj implantacijom MNĆKS uz HRMAKP nego u grupi tretiranoj HRMAKP (p = 0,049). Zaključak. Implantacija mononuklearnih ćelija koštane srži uz hirurške revaskularizacije miokarda aortokoronarnim premošćivanjem bezbedna je i izvodljiva procedura kojom se postiže bolji funkcionalni oporavak bolesnika i smanjuje kardiovaskularni mortalitet.
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