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Kardiyak resenkronizasyon tedavisinde ekokardiyografinin rolü

Yıl 2009, Cilt: 31 Sayı: 3, 316 - 330, 24.03.2009

Gökhan Bektaşoğlu Mehmet Yılmaz İzzet Tandoğan

Öz

Özet

Randomize klinik çalışmalarda, orta ve ileri derecede kalp yetersizliğinin tedavisinde kardiyak resenkronizasyon tedavisinin (KRT) yararlı etkileri gösterilmiştir. Ancak KRT' ye verilen cevap kişiler arasında farklılıklar göstermektedir. Klinik takipte KRT uygulanan hastaların %30-50' sinde tedaviye yanıt gözlenememektedir. KRT den fayda görecek hastaları belirleyecek özgül tekniklere ihtiyaç duyulmaktadır. Bu teknikler içerisinden ekokardiyografi, son yıllarda, KRT implantasyonu öncesi mekanik dissenkroninin varolduğu hastaların belirlenebilmesi için tercih edilen yöntem olmuştur. Mekanik dissenkroniyi tespit edebilmesine rağmen, ekokardyografinin kullanımı yönünde tartışmalar halen devam etmektedir. Günümüzde hasta seçimi için rutin kullanımı önerilmemesine rağmen, önümüzdeki yıllarda KRT uygulanacak hastaların seçiminde ekokardiyografinin tercih edilecek yöntem olabileceği düşünülmektedir.

Anahtar sözcükler: Ekokardiyografi, kardiyak resenkronizasyon tedavisi, kalp yetersizliği, kardiyomiyopati, mekanik dissenkroni

 

Abstract

Numerous randomized clinical trials demonstrated the beneficial effects of cardiac resynchronization therapy (CRT) in the treatment of moderate to severe heart failure. However, response to CRT may vary significantly among individuals. 30-50 % of patients still do not respond to CRT in clinical practice. Specific techniques in order to determine the patients who will benefit from CRT are required. Among these techniques, echocardiography has emerged over recent years as the technique of choice to identify patients for the presence of mechanical dyssynchrony before CRT implantation. Despite its usefulness in detecting mechanical dyssynchrony, this issue is still a matter of debate. Although its routine use in patient selection is not recommended today, it seems echocardiography will be the method of choice in patient selection to CRT for the next years.

Keywords: Echocardiography, cardiac resynchronization therapy, heart failure, cardiomyopathy, mechanical dyssynchrony

Anahtar Kelimeler

-

Kaynakça

  • Xiao HB, Roy C, Fujimoto S, Gibson DG. Natural history of abnormal conduction and its relation to prognosis in patients with dilated cardiomyopathy. Int J Cardiol 1996; 53: 163- 70.
  • Murkofsky RL, Dangas G, Diamond JA, Mehta D, Schaffer A, Ambrose JA. A prolonged QRS duration on surface electrocardiogram is a specific indicator of left ventricular dysfunction. J Am Coll Cardiol 1998; 32: 476-82.
  • Hamby RI, Weissman RH, Prakash MN, Hoffman I. Left bundle branch block: a predictor of poor left ventricular function in coronary artery disease. Am Heart J 1983; 106: 471-7.
  • Iuliano S, Fisher SG, Karasik PE, Fletcher RD, Singh SN; Department of Veterans Affairs Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. QRS duration and mortality in patients with congestive heart failure. Am Heart J 2002; 143: 1085-91.
  • Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L; Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539-49.
  • Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C, Garrigue S, Kappenberger L, Haywood GA, Santini M, Bailleul C, Daubert JC; Multisite Stimulation in Cardiomyopathies (MUSTIC) Study Investigators. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med
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  • Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, Kocovic DZ, Packer M, Clavell AL, Hayes DL, Ellestad M, Trupp RJ, Underwood J, Pickering F, Truex C, McAtee P, Messenger J; MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346: 1845-53.
  • St John Sutton MG, Plappert T, Abraham WT, Smith AL, DeLurgio DB, Leon AR, Loh E, Kocovic DZ, Fisher WG, Ellestad M, Messenger J, Kruger K, Hilpisch KE, Hill MR; Multicenter InSync Randomized Clinical Evaluation (MIRACLE) Study Group. Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure. Circulation 2003; 107: 1985-90.
  • Auricchio A, Stellbrink C, Sack S, Block M, Vogt J, Bakker P, Huth C, Schöndube F, Wolfhard U, Böcker D, Krahnefeld O, Kirkels H; Pacing Therapies in Congestive Heart Failure (PATH-CHF) Study Group.Long-term clinical effect of hemodynamically optimised cardiac resynchronization therapy in patients with heart failure and ventricular conduction delay. J Am Coll Cardiol 2002; 39: 2026-33.
  • Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, DeVries DW, Feldman AM; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140-50.
  • Linde C, Leclercq C, Rex S, Garrigue S, Lavergne T, Cazeau S, McKenna W, Fitzgerald M, Deharo JC, Alonso C, Walker S, Braunschweig F, Bailleul C, Daubert JC. Long-term benefits of biventricular pacing in congestive heart failure: results from the MUltisite STImulation in Cardiomyopathy (MUSTIC) study. J Am Coll Cardiol 2002; 40: 111-8.
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  • Woo GW, Petersen-Stejskal S, Johnson JW, Conti JB, Aranda JA Jr, Curtis AB. Ventricular reverse remodeling and 6-month outcomes in patients receiving cardiac resynchronization therapy: analysis of the MIRACLE study. J Interv Card Electrophysiol 2005; 12: 107-13.
  • Bleeker GB, Kaandorp TA, Lamb HJ, Boersma E, Steendijk P, de Roos A, van der Wall EE, Schalij MJ, Bax JJ. Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy. Circulation 2006; 113: 969-76.
  • Ypenburg C, Schalij MJ, Bleeker GB, Steendijk P, Boersma E, Dibbets-Schneider P, Stokkel MP, van der Wall EE, Bax JJ. Impact of viability and scar tissue on response to cardiac resynchronization therapy in ischaemic heart failure patients. Eur Heart J 2007; 28: 33-41.
  • Ansalone G, Giannantoni P, Ricci R, Trambaiolo P, Fedele F, Santini M. Biventricular pacing in heart failure: back to basics in the pathophysiology of left bundle branch block to reduce the number of nonresponders. Am J Cardiol 2003; 91 (Suppl): 55F-61F.
  • Alonso C, Leclercq C, Victor F, Mansour H, de Place C, Pavin D, Carré F, Mabo P, Daubert JC. Electrocardiographic predictive factors of long-term clinical improvement with multisite biventricular pacing in advanced heart failure. Am J Cardiol 1999; 84 : 1417-21.
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  • Bleeker GB, Holman ER, Steendijk P, Boersma E, van der Wall EE, Schalij MJ, Bax JJ. Cardiac resynchronization therapy in patients with a narrow QRS complex. J Am Coll Cardiol 2006; 48: 2243-50.
  • Yu CM, Chan YS, Zhang Q, Yip GW, Chan CK, Kum LC, Wu L, Lee AP, Lam YY, Fung JW. Benefits of cardiac resynchronization therapy for heart failure patients with narrow QRS complexes and coexisting systolic asynchrony by echocardiography. J Am Coll Cardiol 2006; 48: 2251-7.
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  • Rouleau F, Merheb M, Geffroy S, Berthelot J, Chaleil D, Dupuis JM, Victor J, Geslin P. Echocardiographic assessment of the interventricular delay of activation and correlation to the QRS width in dilated cardiomyopathy. Pacing Clin Electrophysiol 2001; 24: 1500- 06.
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  • Bordachar P, Lafitte S, Reuter S, Sanders P, Jaïs P, Haïssaguerre M, Roudaut R, Garrigue S, Clementy J. Echocardiographic parameters of ventricular dyssynchrony validation in patients with heart failure using sequential biventricular pacing. J Am Coll Cardiol 2004; 44: 2157-65.
  • Mortensen PT, Sogaard P, Mansour H, Ponsonaille J, Gras D, Lazarus A, Reiser W, Alonso C, Linde CM, Lunati M, Kramm B, Harrison EM. Sequential biventricular pacing: evaluation of safety and efficacy. Pacing Clin Electrophysiol 2004; 27: 339-45.
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Kardiyak resenkronizasyon tedavisinde ekokardiyografinin rolü

Yıl 2009, Cilt: 31 Sayı: 3, 316 - 330, 24.03.2009

Gökhan Bektaşoğlu Mehmet Yılmaz İzzet Tandoğan

Öz

Randomize klinik çalışmalarda, orta ve ileri derecede kalp yetersizliğinin tedavisinde kardiyak resenkronizasyon tedavisinin (KRT) yararlı etkileri gösterilmiştir. Ancak KRT’ ye verilen cevap kişiler arasında farklılıklar göstermektedir. Klinik takipte KRT uygulanan hastaların %30-50’ sinde tedaviye yanıt gözlenememektedir. KRT den fayda görecek hastaları belirleyecek özgül tekniklere ihtiyaç duyulmaktadır. Bu teknikler içerisinden ekokardiyografi, son yıllarda, KRT implantasyonu öncesi mekanik dissenkroninin varolduğu hastaların belirlenebilmesi için tercih edilen yöntem olmuştur. Mekanik dissenkroniyi tespit edebilmesine rağmen, ekokardyografinin kullanımı yönünde tartışmalar halen devam etmektedir. Günümüzde hasta seçimi için rutin kullanımı önerilmemesine rağmen, önümüzdeki yıllarda KRT uygulanacak hastaların seçiminde ekokardiyografinin tercih edilecek yöntem olabileceği düşünülmektedir

Anahtar Kelimeler

Ekokardiyografi kardiyak resenkronizasyon tedavisi kalp yetersizliği kardiyomiyopati mekanik dissenkroni

Kaynakça

  • Xiao HB, Roy C, Fujimoto S, Gibson DG. Natural history of abnormal conduction and its relation to prognosis in patients with dilated cardiomyopathy. Int J Cardiol 1996; 53: 163- 70.
  • Murkofsky RL, Dangas G, Diamond JA, Mehta D, Schaffer A, Ambrose JA. A prolonged QRS duration on surface electrocardiogram is a specific indicator of left ventricular dysfunction. J Am Coll Cardiol 1998; 32: 476-82.
  • Hamby RI, Weissman RH, Prakash MN, Hoffman I. Left bundle branch block: a predictor of poor left ventricular function in coronary artery disease. Am Heart J 1983; 106: 471-7.
  • Iuliano S, Fisher SG, Karasik PE, Fletcher RD, Singh SN; Department of Veterans Affairs Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. QRS duration and mortality in patients with congestive heart failure. Am Heart J 2002; 143: 1085-91.
  • Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L; Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539-49.
  • Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C, Garrigue S, Kappenberger L, Haywood GA, Santini M, Bailleul C, Daubert JC; Multisite Stimulation in Cardiomyopathies (MUSTIC) Study Investigators. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med
  • Linde C, Leclercq C, Rex S, Garrigue S, Lavergne T, Cazeau S, McKenna W, Fitzgerald M, Deharo JC, Alonso C, Walker S, Braunschweig F, Bailleul C, Daubert JC. Long-term benefits of biventricular pacing in congestive heart failure: results from the Multisite Stimulation in Cardiomyopathy (MUSTIC) Study. J Am Coll Cardiol 2002; 40: 111-8.
  • Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, Kocovic DZ, Packer M, Clavell AL, Hayes DL, Ellestad M, Trupp RJ, Underwood J, Pickering F, Truex C, McAtee P, Messenger J; MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346: 1845-53.
  • St John Sutton MG, Plappert T, Abraham WT, Smith AL, DeLurgio DB, Leon AR, Loh E, Kocovic DZ, Fisher WG, Ellestad M, Messenger J, Kruger K, Hilpisch KE, Hill MR; Multicenter InSync Randomized Clinical Evaluation (MIRACLE) Study Group. Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure. Circulation 2003; 107: 1985-90.
  • Auricchio A, Stellbrink C, Sack S, Block M, Vogt J, Bakker P, Huth C, Schöndube F, Wolfhard U, Böcker D, Krahnefeld O, Kirkels H; Pacing Therapies in Congestive Heart Failure (PATH-CHF) Study Group.Long-term clinical effect of hemodynamically optimised cardiac resynchronization therapy in patients with heart failure and ventricular conduction delay. J Am Coll Cardiol 2002; 39: 2026-33.
  • Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, DeVries DW, Feldman AM; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140-50.
  • Linde C, Leclercq C, Rex S, Garrigue S, Lavergne T, Cazeau S, McKenna W, Fitzgerald M, Deharo JC, Alonso C, Walker S, Braunschweig F, Bailleul C, Daubert JC. Long-term benefits of biventricular pacing in congestive heart failure: results from the MUltisite STImulation in Cardiomyopathy (MUSTIC) study. J Am Coll Cardiol 2002; 40: 111-8.
  • Leclercq C, Kass DA. Retiming the failing heart: principles and current clinical status of cardiac resynchronization. J Am Coll Cardiol 2002; 39: 194-201.
  • Woo GW, Petersen-Stejskal S, Johnson JW, Conti JB, Aranda JA Jr, Curtis AB. Ventricular reverse remodeling and 6-month outcomes in patients receiving cardiac resynchronization therapy: analysis of the MIRACLE study. J Interv Card Electrophysiol 2005; 12: 107-13.
  • Bleeker GB, Kaandorp TA, Lamb HJ, Boersma E, Steendijk P, de Roos A, van der Wall EE, Schalij MJ, Bax JJ. Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy. Circulation 2006; 113: 969-76.
  • Ypenburg C, Schalij MJ, Bleeker GB, Steendijk P, Boersma E, Dibbets-Schneider P, Stokkel MP, van der Wall EE, Bax JJ. Impact of viability and scar tissue on response to cardiac resynchronization therapy in ischaemic heart failure patients. Eur Heart J 2007; 28: 33-41.
  • Ansalone G, Giannantoni P, Ricci R, Trambaiolo P, Fedele F, Santini M. Biventricular pacing in heart failure: back to basics in the pathophysiology of left bundle branch block to reduce the number of nonresponders. Am J Cardiol 2003; 91 (Suppl): 55F-61F.
  • Alonso C, Leclercq C, Victor F, Mansour H, de Place C, Pavin D, Carré F, Mabo P, Daubert JC. Electrocardiographic predictive factors of long-term clinical improvement with multisite biventricular pacing in advanced heart failure. Am J Cardiol 1999; 84 : 1417-21.
  • Sogaard P, Kim WY, Jensen HK, Mortensen P, Pedersen AK, Kristensen BØ, Egeblad H. Impact of acute biventricular pacing on left ventricular performance and volumes in patients with severe heart failure. A tissue Doppler and three-dimensional echocardiographic study. Cardiology 2001; 95: 173-82.
  • Nelson GS, Curry CW, Wyman BT, Kramer A, Declerck J, Talbot M, Douglas MR, Berger RD, McVeigh ER, Kass DA. Predictors of systolic augmentation from left ventricular preexcitation in patients with dilated cardiomyopathy and intraventricular conduction delay. Circulation 2000; 101: 2703-9.
  • Fauchier L, Marie O, Casset-Senon D, Babuty D, Cosnay P, Fauchier JP. Reliability of QRS duration and morphology on surface electrocardiogram to identify ventricular dyssynchrony in patients with idiopathic dilated cardiomyopathy. Am J Cardiol 2003; 92: 341-4.
  • Bleeker GB, Holman ER, Steendijk P, Boersma E, van der Wall EE, Schalij MJ, Bax JJ. Cardiac resynchronization therapy in patients with a narrow QRS complex. J Am Coll Cardiol 2006; 48: 2243-50.
  • Yu CM, Chan YS, Zhang Q, Yip GW, Chan CK, Kum LC, Wu L, Lee AP, Lam YY, Fung JW. Benefits of cardiac resynchronization therapy for heart failure patients with narrow QRS complexes and coexisting systolic asynchrony by echocardiography. J Am Coll Cardiol 2006; 48: 2251-7.
  • Pitzalis MV, Iacoviello M, Romito R, Massari F, Rizzon B, Luzzi G, Guida P, Andriani A, Mastropasqua F, Rizzon P. Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony. J Am Coll Cardiol 2002; 40: 1615-22
  • Marcus G, Rose E, Viloria EM, Schafer J, De Marco T, Saxon LA, Foster E; VENTAK CHF/CONTAK-CD Biventricular Pacing Study Investigators. Septal to posterior wall motion delay fails to predict reverse remodeling or clinical improvement in patients undergoing cardiac resynchronization therapy. J Am Coll Cardiol 2005; 46: 2208-14.
  • Rouleau F, Merheb M, Geffroy S, Berthelot J, Chaleil D, Dupuis JM, Victor J, Geslin P. Echocardiographic assessment of the interventricular delay of activation and correlation to the QRS width in dilated cardiomyopathy. Pacing Clin Electrophysiol 2001; 24: 1500- 06.
  • Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L; Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539-49.
  • Adamson PB, St John Sutton M, Plappert T. Echo-defined ventricular dyssynchrony predicts magnitude of response to cardiac resynchronization. Circulation 2002; 106: 381.
  • St John Sutton M, Plappert T, Hilpisch KE. Baseline aortic preejection interval (bAPEI) as a predictor of response to cardiac resynchronization therapy. Circulation 2002; 106: 380.
  • Penicka M, Bartunek J, De Bruyne B, Vanderheyden M, Goethals M, De Zutter M, Brugada P, Geelen P. Improvement of left ventricular function after cardiac resynchronization therapy is predicted by tissue Doppler imaging echocardiography. Circulation 2004; 109: 978-83.
  • Yu CM, Lin H, Ho PC, Yang H. Assessment of left and right ventricular systolic and diastolic synchronicity in normal subjects by tissue Doppler echocardiography and the effects of age and heart rate. Echocardiography 2003; 20: 19-27.
  • Ansalone G, Giannantoni P, Ricci R, Trambaiolo P, Laurenti A, Fedele F, Santini M. Doppler myocardial imaging in patients with heart failure receiving biventricular pacing treatment. Am Heart J 2001; 142: 881-96.
  • Yu CM, Chau E, Sanderson JE, Fan K, Tang MO, Fung WH, Lin H, Kong SL, Lam YM, Hill MR, Lau CP. Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation 2002; 105: 438-45.
  • Garrigue S, Jaïs P, Espil G, Labeque JN, Hocini M, Shah DC, Haïssaguerre M, Clementy J. Comparison of chronic biventricular pacing between epicardial and endocardial left ventricular stimulation using Doppler tissue imaging in patients with heart failure. Am J Cardiol 2001; 88: 858-62.
  • Bordachar P, Lafitte S, Reuter S, Sanders P, Jaïs P, Haïssaguerre M, Roudaut R, Garrigue S, Clementy J. Echocardiographic parameters of ventricular dyssynchrony validation in patients with heart failure using sequential biventricular pacing. J Am Coll Cardiol 2004; 44: 2157-65.
  • Ansalone G, Giannantoni P, Ricci R, Trambaiolo P, Fedele F, Santini M. Doppler myocardial imaging to evaluate the effectiveness of pacing sites in patients receiving biventricular pacing. J Am Coll Cardiol 2002; 39: 489-99.
  • Mele D, Aggio S, Pesanisi G. Quantitative tissue Doppler can measure and localize improvement of ventricular dyssynchrony, in dilated cardiomyopathy after biventricular pacing. Eur Heart J 2002; 4: 651.
  • Yu CM, Fung WH, Lin H, Zhang Q, Sanderson JE, Lau CP. Predictors of left ventricular reverse remodeling after cardiac resynchronization therapy for heart failure secondary to idiopathic dilated or ischemic cardiomyopathy. Am J Cardiol 2003; 91: 684-8.
  • Bax JJ, Marwick TH, Molhoek SG, Bleeker GB, van Erven L, Boersma E, Steendijk P, van der Wall EE, Schalij MJ. Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation. Am J Cardiol 2003; 92: 1238-40.
  • Bax JJ, Bleeker GB, Marwick TH, Molhoek SG, Boersma E, Steendijk P, van der Wall EE, Schalij MJ. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol 2004; 44: 1834- 40.
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  • Kedia N, Ng K, Apperson-Hansen C, Wang C, Tchou P, Wilkoff BL, Grimm RA. Usefulness of atrioventricular delay optimization using Doppler assessment of mitral inflow in patients undergoing cardiac resynchronization therapy. Am J Cardiol 2006; 98: 780-5.
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  • Mortensen PT, Sogaard P, Mansour H, Ponsonaille J, Gras D, Lazarus A, Reiser W, Alonso C, Linde CM, Lunati M, Kramm B, Harrison EM. Sequential biventricular pacing: evaluation of safety and efficacy. Pacing Clin Electrophysiol 2004; 27: 339-45.
  • Vanderheyden M, De Backer T, Rivero-Ayerza M, Geelen P, Bartunek J, Verstreken S, De Zutter M, Goethals M. Tailored echocardiographic interventricular delay programming further resynchronization therapy. Heart Rhythm 2005; 2: 1066-72. optimizes left ventricular performance after cardiac
Toplam 59 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Bölüm Derlemeler
Yazarlar

Gökhan Bektaşoğlu

Mehmet Yılmaz

İzzet Tandoğan

Yayımlanma Tarihi 24 Mart 2009
Yayımlandığı Sayı Yıl 2009Cilt: 31 Sayı: 3

Kaynak Göster

AMA Bektaşoğlu G, Yılmaz M, Tandoğan İ. Kardiyak resenkronizasyon tedavisinde ekokardiyografinin rolü. CMJ. Eylül 2009;31(3):316-330.