Механизмы нарушений вариабельности сердечного ритма у пациентов с врожденными пороками сердца

В результате анализа данных литературы были изучены патогенетические механизмы нарушений вариабельности сердечного ритма (ВСР) у пациентов с врожденными пороками сердца (ВПС). Показано, что изменения ВСР начинаются еще внутриутробно и определяются типом порока и гемодинамическими нарушениями. Доминирующий паттерн изменений ВСР включает снижение временных показателей (SDNN, rMSSD, pNN50) и общей мощности спектра, что свидетельствует о снижении общей вариабельности. Характерен симпато-вагусный дисбаланс с преобладанием симпатических влияний (повышение LF/HF) и снижением парасимпатического тонуса (уменьшение HF-компонента). При цианотических ВПС (СГЛС, ТФ, ТМС) наблюдается более выраженная симпатикотония (LF/HF>3,0) и снижение как временных показателей (SDNN, rMSSD), так и частотных параметров (общая мощность спектра, HF-компонент) до 40–60 % от нормы, тогда как при ацианотических дефектах изменения умереннее. Пациенты с легочной гипертензией демонстрируют снижение LF-компонента, а при системно-легочных шунтах возможно транзиторное повышение HF в рамках компенсаторной реакции. В редких случаях, преимущественно у пациентов с хронической перегрузкой правого желудочка, может наблюдаться повышение нелинейных показателей ВСР (SampEn), что отражает дезорганизацию регуляторных процессов. Хирургическая коррекция, особенно в условиях искусственного кровообращения, вызывает дополнительное снижение ВСР из-за повреждения автономных нервов и системной воспалительной реакции. Более выраженные изменения наблюдаются при открытых вмешательствах по сравнению с эндоваскулярными методами. В отдаленном послеоперационном периоде часто сохраняется вегетативный дисбаланс с преобладанием симпатических влияний, что может быть связано как с остаточными структурными изменениями, так и с последствиями хирургического повреждения автономной иннервации.

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