ЭНДОВАСКУЛЯРНАЯ ВАЛЬВУЛОПЛАСТИКА У ПАЦИЕНТКИ С КРИТИЧЕСКИМ МИТРАЛЬНЫМ СТЕНОЗОМ И МАССИВНЫМ ТРОМБОЗОМ ЛЕВОГО ПРЕДСЕРДИЯ

We are presenting a case of endovascular repair of critical mitral stenosis of rheumatic genesis complicated by decompensated congestive heart failure and massive thrombosis of the left atrium. According to the clinical status of the patient, the patient was found to be inoperable. Despite the extremely high risk of endovascular intervention, the patient underwent balloon mitral valvuloplasty using intracardial and transthoracic echocardiography. The analysis of technical and clinical aspects of the intervention and its results during the in-hospital period and a 9-month follow-up was performed. We concluded on the appropriateness of the chosen treatment strategy.Представлен случай эндоваскулярной коррекции критического митрального стеноза ревматического генеза, осложненного декомпенсированной застойной сердечной недостаточностью и массивным тромбозом левого предсердия. С учетом клинического статуса больной пациентка была признана неоперабельной. Несмотря на крайне высокий риск эндоваскулярного вмешательства, больной по жизненным показаниям с использованием интракардиальной и трансторакальной эхокардиографии выполнена баллонная митральная вальвулопластика. Проведен анализ технических и клинических аспектов вмешательства и его результатов в течение госпитального периода наблюдения и спустя 9 месяцев после операции. Сделано заключение о целесообразности выбранной тактики лечения

Эффекты когнитивной реабилитации с применением двойной задачи у пациентов в раннем послеоперационном периоде прямой реваскуляризации миокарда

Aim. To assess the effects of cognitive rehabilitation with dual-task training that involves a cognitive task combined with postural and walking control, as well as electroencephalogram indices in patients in the early postoperative period after direct myocardial revascularization.Methods. The study enrolled 48 patients scheduled for coronary artery bypass graft surgery. Subjects in this prospective, randomized study were randomized using envelopes to a postoperative cognitive training group (n = 23) and non-training group (n = 25). The cognitive training was carried out daily, starting 3-4 days after the procedure and until the discharge order. Dual tasks training (a cognitive task combined with postural and walking control) lasted 15-20 minutes. All patients were submitted to an extended neurophysiological assessment (psychometric tests and electroencephalogram study) and stabilography 3-5 days before and 8-11 days after coronary artery bypass grafting.Results. The patients who underwent cognitive training experienced postoperative cognitive dysfunction (POCD) in 39% cases in the early postoperative period after intervention, while the non-training group - in 64%. The relative risk of developing POCD in the non-training group was 2.77 (95% CI: 0.86-8.91, Z = 1.704, p = 0.08). The patients in cognitive training exhibited better cognitive state compared to the preoperative state (Z = 2.58; p = 0.01) in the absence of statistically significant differences in the non-training group. Moreover, type-1 theta power values increased in the non-training group in comparison to the preoperative values, while the cognitive training group did not have a statistically significant difference in theta power.Conclusion. Positive effects of dual task rehabilitation on the neurophysiological parameters of patients undergoing direct myocardial revascularization were demonstrated. Positive effects include lower frequency of POCD, improved cognitive state and less pronounced cortical dysfunction. The dual task training had proved a suitable training method for this category of patients. Additional studies are required to test the possibility of increasing the duration and intensity of dual task training for stronger recovery effect and improved cognitive and walking performance of patients in the postoperative period after direct myocardial revascularization.Цель. Оценить влияние когнитивной реабилитации с применением двойной задачи на когнитивные, постуральные функции и показатели электроэнцефалограммы у пациентов в раннем послеоперационном периоде прямой реваскуляризации миокарда.Материалы и методы. В проспективном рандомизированном исследовании участвовали 48 пациентов, подвергнутых коронарному шунтированию. Путем простой рандомизации (метод конвертов) сформированы группы послеоперационного когнитивного тренинга (n = 23) и сравнения (n = 25). Основной группе когнитивный тренинг проводили ежедневно, с 3-4-го дня после операции и до выписки из стационара в виде 15-20-минутных сессий с выполнением двойных заданий (постуральный тренинг и когнитивная задача). Всем больным оценены нейрофизиологический статус (психометрическое тестирование и электроэнцефалографическое исследование) и стабилография за 3-5 дней до и на 8-11-е сут после вмешательства.Результаты. В раннем послеоперационном периоде кардиохирургических вмешательств у пациентов, прошедших когнитивный тренинг, число случаев послеоперационной когнитивной дисфункции (ПОКД) составило 39%, тогда как в группе сравнения - 64%. Относительный риск развития ПОКД в группе без когнитивного тренинга - 2,77 (95% доверительный интервал 0,86-8,91; Z = 1,704; p = 0,08). В группе когнитивного тренинга наблюдалось увеличение                интегрального показателя когнитивного статуса по сравнению с предоперационным уровнем (Z = 2,58; p = 0,01) при отсутствии статистически значимых различий в группе сравнения. Также обнаружено, что мощность биопотенциалов тета-1-ритма увеличилась по сравнению с дооперационными показателями только у больных группы сравнения, тогда как у участников, прошедших программу когнитивного тренинга, не выявлено статистически значимого послеоперационного увеличения тета-активности.Заключение. Показано положительное влияние когнитивной реабилитации с применением двойной задачи на нейрофизиологические показатели пациентов, перенесших прямую реваскуляризацию миокарда, в виде меньшей частоты ПОКД, улучшения когнитивного статуса и менее выраженной корковой дисфункции, что позволяет говорить об эффективности этого когнитивного тренинга для анализируемой выборки. Необходимо дополнительно рассмотреть вопросы продолжительности и интенсивности тренинга с использованием двойных задач для повышения восстановительного эффекта на интеллектуальные ресурсы и постуральные функции больных в послеоперационном периоде прямой реваскуляризации миокарда

ВЛИЯНИЕ ПУЛЬМОНАЛЬНОЙ ДЕНЕРВАЦИИ НА МЕХАНИЧЕСКУЮ ФУНКЦИЮ ПРАВЫХ ОТДЕЛОВ СЕРДЦА У БОЛЬНЫХ ЛЕГОЧНОЙ ГИПЕРТЕНЗИЕЙ

Aim. To estimate mechanical function of the right heart chambers after the pulmonary denervation in comparison with the sham procedure using right heart catheterization (RHC) and echocardiography.Methods. Twelve patients with different clinical types of pulmonary hypertension were included in the study. All patients were randomized into two groups: Group I patients (n = 6) underwent the pulmonary denervation, Group II patients (n = 6) had sham procedure. All the patients had functional class 3 pulmonary hypertension. The patient screening was performed using echocardiography findings, and the final decision was made after RHC. After including in the study the RHC was done three times: before the procedure, immediately after it, and on the 12th months of the follow-up. Echocardiographic measurement of the right heart parameters was performed four times: a day before the procedure, immediately after it, on the 5th day and on the 12th months of the follow-up.Results. No complications during the procedure and the follow-up were registered. There were no statistically significant differences in any of the RHC parameters between groups at the second and the third control points. The same findings were determined after echocardiographic analysis.Conclusion. Pulmonary denervation does not have statistically significant effect on the mechanical function of the right heart chambers within the 12-months follow-up.Цель. Изучение механической функции правых отделов сердца после пульмональной денервации в сравнении с ложной процедурой по данным катетеризации правых отделов сердца и эхокардиографии.Материалы и методы. В исследование было включено 12 пациентов с различными клиническими формами легочной гипертензии, которые были рандомизированы на две группы. В группе I (6 пациентов) выполнялась пульмональная денервация, в группе II (6 пациентов) – ложная процедура. Все пациенты соответствовали III функциональному классу. Скрининг пациентов осуществлялся на основании данных эхокардиографии, окончательное решение принималось после проведения катетеризации правых отделов сердца (КПОС). После включения пациентов в исследование КПОС выполнялась трижды: непосредственно перед выполнением процедуры, тотчас после ее выполнения и через 12 месяцев после ее выполнения. Эхокардиография с регистрацией показателей, характеризующих функциональное состояние правых отделов сердца, выполнялась четыре раза: за сутки до выполнения процедуры, тотчас после ее выполнения, на пятые сутки и через 12 месяцев после ее выполнения.Результаты. Осложнений во время процедуры и в течение последующего 12-месячного наблюдения не зарегистрировано. При оценке результатов процедур по данным КПОС во второй и третьей контрольных точках по всем измеренным показателям отсутствовали статистически значимые различия при сравнениях между группами в любой из контрольных точек. Такое же заключение следует из анализа эхокардиографических показателей.Заключение. Денервация легочной артерии в сроки 12 месяцев после процедуры не приводит к статистически значимым различиям в показателях, характеризующих механическую функцию правых отделов сердца

Main predictors of in-hospital adverse outcomes in non-ST elevation acute coronary syndrome patients with multivessel disease

Aim. To evaluate the range of risk factors associated with adverse cardiovascular events onset in hospital period of follow-up in patients with non-ST elevation acute coronary syndrome (NSTEACS) with multivessel disease (MD).Material and methods. To the study, under the framework of prospective, single-center registry, the NSTEACS and MD patients were included. Depending on the strategy of revascularization, three groups were selected: staged PCI, coronary bypass (CBG) and PCI as the first with CBG as the second stage. As adverse cardiovascular events, the following were taken: death, myocardial infarction, stroke or transient cerebral ishemia, clinically significant bleeding by BARC, repeat nonscheduled revascularization of target vessel. Results. Analysis revealed the groups of factors increasing the probability of adverse cardiovascular events. Those are: (1) clinical and demographic  — older age, diabetes, postinfarction cardiosclerosis, multifocal atherosclerosis, chronic renal failure; (2) coronary and surgical — left main stem lesion, severe atherosclerosis by SYNTAX Score, high surgical risk by EuroScore II, revascularization strategy;  (3) predominance of low or moderate risk by GRACE comparing with high risk.Conclusion. The results have confirmed high predictional significance of clinical and demography and coronary factors for development of adverse cardiovascular diseases. A significant finding of the study was the fact that in a hospital with surgery and endovascular treatment available 24/7, the intermediate and low GRACE risk in NSTEACS and MD is a factor of adverse cardiovascular events development due to revascularization delays if the risk is not high

THE PREVALENCE OF INTACT CORONARY ARTERIES IN RELATION WITH INDICATIONS FOR SCHEDULED CORONARY ARTERIOGRAPHY

Aim. To evaluate the prevalence and possible reasons for intact coronary arteries (CA) diagnostics in patients with different indications for scheduled coronary arteriography (CAG).Material and methods. The selection studied, consisted of 711 case histories of patients, underwent scheduled CAG at SRI CICVP during 1 April — 31 may 2014. Taken the indications for CAG, 5 groups were selected: 1 — patients with coronary heart disease (CHD) suspicious (n=288), 2 — patients with myocardial infarction (MI) in anamnesis (n=277), 3 — atherosclerosis of peripheral arterial pools (PAP) (n=18), 4 — patients with acquired valve defects (AVD) (n=43), 5 — patients with cardiac rhythm disorders (CRD) (n=85).Results. In intergroup comparison it is marked that men were predominant among patients with MI in anamnesis and having PAP atherosclerosis, but women predominated among AVD patients (p<0,01). The age of groups was comparable (p=0,266). Typical angina clinical picture was more common significantly in suspected CHD group and previous MI (p<0,001). Also, the atypical angina and cardialgia were less common in MI anamnesis group (p=0,003) and p<0,001). Cardialgia was more common in AVD (p<0,001). Mean value of pretest probability of CHD was higher in groups with MI anamnesis and PAP lesion, and lesser — in AVD (p=0,015). Rhythm disorders were more common in AVD patients and those who actually was being investigated for CRD (p<0,001). also, ischemic strokes dominated among PAP and AVD (p=0,019). Analysis of CAG data showed that the absence of coronary lesion with higher prevalence is in groups with AVD and CRD (p<0,001). No significant stenoses of CA were less common in MI anamnesis group and AVD (p=0,004). However, hemodynamically significant stenoses of CA were significantly more common in those after MI and in PAP lesion (p<0,001).Conclusion. Among studied patients, in 32,9% there were no stenoses of CA in planned CAG. Highest number of intact CA was found in preoperation investigation of AVD patients (76,7%) and CRD (67,1%), least — in MI anamnesis (11,6%) and PAP lesion (16,7%). In investigation of suspected CHD, intact CA were found in 37,9% cases

ASSOCIATION OF A LYMPHOTOXIN-α VARIABLE SITE rs1041981 WITH DEVELOPMENT OF LONG-TERM UNFAVORABLE OUTCOMES IN PATIENTS WITH ACUTE CORONARY SYNDROME WITHOUT ST-SEGMENT ELEVATION

Lymphotoxin-α (LTA) is a major pro-inflammatory cytokine produced at the early stages of vascular inflammation, taking part in the formation of arterial atherosclerosis and development of coronary heart disease. Functional changes in the gene encoding LTA production may influence the development of coronary heart disease with unfavorable progression. However, studies for associations between rs1041981 (C-804A) LTA gene variant and development of acute cerebrovascular accidents, myocardial infarction, and severity of coronary atherosclerosis have yielded contradictory results. The purpose of our study was to investigate an association of rs1041981 gene LTA with risk of adverse events within five years of follow-up in the patients with acute coronary syndrome without ST elevation ST (nonST-ACS). 178 patients with nonST-ACS from the Kemerovo Cardiology Center Registry were included into the study. Genotyping of rs1041981 site variable LTA gene was performed by TaqMan technique using an “iCycler iQ” device (BIO-RAD, USA). Results: we have found that the A allele and A/A genotype polymorphism in LTA gene (rs1041981) have been associated with development of adverse cardiovascular events over five years of observation (respective p levels were 0.02 and 0.036). In patients with A/A genotype, the rs1041981 polymorphism in LTA gene was associated with 3.8-fold increase in adverse cardiovascular events, compared to patients having A/C or C/C genotype. Carriage of A allele in LTA gene (rs1041981) doubles the risk of adverse cardiovascular events in patients with nonST-ACS at long observation terms. By means of Kaplan-Meier method, we have determined that survival to the first endpoint occurred more often in carriers of the genotype A/A of LTA gene (rs1041981). The A/A genotype of LTA gene (rs1041981) proved to be more significant (p = 0.016) for development of adverse outcomes, when combining the patients with A/C and C/C genotypes. One may draw a conclusion that A allele and A/A genotype of rs1041981 LTA polymorphism is associated with development of adverse cardiovascular events during the five-year period following the index event in patients with nonST-ACS

THE RESULTS OF MYOCARDIAL REVASCULARIZATION IN NON-ST-ELEVATION ACUTE CORONARY SYNDROME PATIENTS AND MULTIVESSEL DISEASE

Aim. To evaluate in-hospital and long-term outcomes of treatment in non-ST-elevation acute coronary syndrome (NSTEACS) according to the revascularization strategy.Material and methods. In the study under the framework of singlecenter registry, in 2012-2015, 400 patients included, with NSTEACS and multivessel disease (MD). According to the revascularization strategy, all patients were selected to three groups: staged percutaneous intervention (PCI) — PCI-PCI, for 265 (66,5%) patients, bypass grafting (CBG) — 84 (20,2%), and PCI at first step and then CBG (PCI-CBG) in 34 (8,75%). Remaining patients were treated conservatively — 17 (4,5%). Endpoints were such adverse cardiovascular events as death, myocardial infarction, stroke or transient ischemia, repeated revascularization.Results. The highest GRACE values up to 138,1±25,7 were in PCI-PCI group (p=0,00001), but the most severe coronary lesion by SYNTAX 28,7±10 was in CBG group (p=0,00001). The highest surgical risk by EuroScore II was in CBG group — 4,32±2 (p=0,003). The group PCI-PCI showed the highest mortality, reached 7,5% by 12 months (5,3% inhospital and 2,2% further), and long-term mortality in PCI-CBG and CBG groups was 2,9% and 2,4%, respectively (p>0,05) (all fatal cases in these groups were in-hospital). The leading by MI prevalence in 12 months was PCI-PCI group (6,8%), and in PCI-CBG and CBG groups all MI cases were 5,9% and 1,2% in-hospital, respectively (p>0,05). Minimal levels of repeated revascularization had the groups PCI-CBG and CBG — 5,88% and 0%, resp., and in PCI-PCI group this level reached 9,81%.Conclusion. The most complete myocardial revascularization in NSTEACS patients can be achieved with such strategies as PCI-CBG and CBG, regardless the highest grade of coronary lesion. Revascularization strategy as the staged PCI, is applicable with in the highest GRACE patients and requiring revascularization as soon as possible. The development needed, of algorithms of optimal strategy of revascularization in NSTEACS, with MD, based upon objective criteria, and meaning the higher rate of CBG approach fulfilling the most complete revascularization