Management of patients with acquired valvular heart disease in noncardiac surgery

Valvular heart disease is widespread among general population, mainly in older age groups, who often require noncardiac surgery. As the population ages, the significance of this problem will only increase. The basic principles of perioperative managing such patients by a multidisciplinary team, necessarily including a cardiologist, are systematized and set out in international clinical guidelines, which are regularly updated. Currently, the Russian Society of Cardiology guidelines on management of valvular heart diseases are being prepared for publication. However, specifics of assessment and management of patients when planning noncardiac surgery require more detailed presentation for a cardiology practitioner

THE SIGNIFICANCE OF OSTEOPONTINE AND MATRIX METALLOPROTEASE-9 IN THORACAL AORTA ANEURYSM DEVELOPMENT

Aim. To evaluate the significance of osteopontine and MMP-9 in the development of thoracal aorta aneurysm in patients with tricuspid (TAV) and bicuspid (BAV) aorta valve. Material and methods. Totally 94 patients included with the dilation of thoracal aorta for more than 40 mm, and 50 patients without aorta pathology, that were the comparison group. All patients underwent echocardiographic study by Vivid 7 (GE, USA) device by standard protocol. The osteopontine concentration and MMP-9 were measured in blood serum with manual plate immune-enzyme assay. Results. The concentration of MMP-9 in blood serum of the patients with aorta pathology and TAV did not differ significantly with the value in comparison group. Otherwise, in IHD the concentration of MMP-9 was significantly higher than in patients without aorta pathology (164,9±76,6 ng/ml and 106,8±82,7 ng/ml, respectively, p<0,01) and closely correlated with the Valsalva sinuses diameters (r=0,302, р=0,007). Comparative analysis of the osteopontine serum concentration did not show differences in the subgroups studied.Conclusion. The positive correlation revealed of the aorta diameter and concentration of MMP-9 in blood serum of the patients with BAV confirms not only the differences in the pathogenesis of thoracal aorta aneurysm in TAV and BAV, but makes it possible to think on the usage of MMP-9 as biomarker of thoracal aorta dilatation

2020 Clinical practice guidelines for Hypertrophic cardiomyopathy

Russian Society of Cardiology (RSC)With the participation: Russian Association of Cardiovascular SurgeonsEndorsed by: Research and Practical Council of the Ministry of Health of the Russian Federation Task Force: Gabrusenko S.A. (Chairman), Gudkova A.Ya.* (Chairman), Koziolova N.A. (Chairman), Alexandrova S.A., Berseneva M.I., Gordeev M.L., Dzemeshkevich S.L., Zaklyazminskaya E.V., Irtyuga O.B., Kaplunova V.Yu., Kostareva A.A., Krutikov A.N., Malenkov D.A., Novikova T.N., Saidova M.A., Sanakoev M.K., Stukalova O.V

Russian consensus statement on the diagnosis and treatment of patients with carotid stenosis

Carotid stenosis is a multidisciplinary problem that requires the involvement of a specialists’ team, including cardiovascular surgeons, neurosurgeons, endovascular surgeons, cardiologists, neurologists, and internists. In this consensus statement, a group of experts considered the main stages of diagnosing carotid stenosis, as well as discussed, the necessary prevention methods and features of choosing the optimal treatment approach. The aim was to provide concise and structured information on the management of patients with carotid stenosis. This document was developed based on the updated clinical guidelines of the European Society for Vascular Surgery and the American Association for Vascular Surgery, taking into account the consensus opinion of Russian experts

Influence of socioeconomic factors on pregnancy outcome in women with structural heart disease

OBJECTIVE: Cardiac disease is the leading cause of indirect maternal mortality. The aim of this study was to analyse to what extent socioeconomic factors influence the outcome of pregnancy in women with heart disease.  METHODS: The Registry of Pregnancy and Cardiac disease is a global prospective registry. For this analysis, countries that enrolled ≥10 patients were included. A combined cardiac endpoint included maternal cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, hospitalisation for cardiac reason or intervention. Associations between patient characteristics, country characteristics (income inequality expressed as Gini coefficient, health expenditure, schooling, gross domestic product, birth rate and hospital beds) and cardiac endpoints were checked in a three-level model (patient-centre-country).  RESULTS: A total of 30 countries enrolled 2924 patients from 89 centres. At least one endpoint occurred in 645 women (22.1%). Maternal age, New York Heart Association classification and modified WHO risk classification were associated with the combined endpoint and explained 37% of variance in outcome. Gini coefficient and country-specific birth rate explained an additional 4%. There were large differences between the individual countries, but the need for multilevel modelling to account for these differences disappeared after adjustment for patient characteristics, Gini and country-specific birth rate.  CONCLUSION: While there are definite interregional differences in pregnancy outcome in women with cardiac disease, these differences seem to be mainly driven by individual patient characteristics. Adjustment for country characteristics refined the results to a limited extent, but maternal condition seems to be the main determinant of outcome

PREGNANCY AND DELIVERY MANAGEMENT OF WOMEN WITH AORTA AND AORTIC VALVE PATHOLOGY

Aim. To analyze the specifics of clinical course of pregnancy, delivery and postnatal period in women with disorders of aortic valve (AV) and aorta.Material and methods. During the period from January 2012 to December 2014, under conditions of specialized perinatal center of FSBI Almazov Center in Saint-Petersburg, into prospective cohort study, 56 patients included, with structural pathology of aorta and AV. Mean age 29±4,5 y.o. (18-38 y.o.). All patients underwent echocardiographic study (EchoCG) on Vivid 7 GE equipment by standard protocol. The level of N-terminal brain natriuretic peptide (NT-proBNP) was measured by electrochemiluminiscent analyzer Cobas e411 (Roche, Swiss) at 34±6 week of pregnancy.Results. The most common pathology in the analyzed group were aortic stenosis and aortic coarctation. The main cause of AV pathology was inborn defect (IHD) — bicuspid AV (BAV). Complications in cardiovascular functioning developed in 9 cases (16%) and were related to ventricular rhythm disorders of high grades and signs of heart failure with need of medication treatment (10,7%, n=6). Level of NT-proBNP was higher than 125 pg/mL in 12 patients (21,4%) and its mean value was 330,3±54,7 pg/mL; in women with increased NT-proBNP complications in cardiovascular system developed 3 times more often. In 25 patients (44,6%) various obstetric complications were found, mostly in the 3rd trimester of pregnancy. Regardless the clinically significant cardial pathology, women delivered in mature term, 38,6±1,5 weeks. After delivery there were no cases of heart failure progression or other cardiovascular complications development.Conclusion. For women with aortic and AV pathology there is benign prognosis of pregnancy and delivery taken they are managed in specialized centers

Pathogenetic mechanisms of ascending aortic aneurysm of varied aetiology

Aim. To assess the impact of disturbed extracellural matrix protein balance and matrix metalloproteinase (MMP) activity on the development of ascending aortic aneurysm (AAA) of varied aetiology. Material and methods. The study included 38 patients with AAA and 17 controls without any aortic pathology. In intra-surgery biopsy samples, the levels and activity of MMP-2, MMP-9, fibrillin, elastin, and collagen were measured. Results. Elevated levels of latent MMP-9 and MMP-2 forms were observed in patients with atherosclerosis and tricuspid aortic valve, compared to controls. In participants with bicuspid aortic valve, the levels of both latent and active MMP-9 forms were higher than in controls. In biopsy samples, the elastin-to-collagen ratio values were elevated in patients with atherosclerosis (1:1,7) and bicuspid aortic valve (1:1,6). Conclusion. The difference in the MMP levels and activity and the increased collagen-to-elastin ratio could be related to the underlying mechanisms of the AAA development in patients with bi- and tricuspid aortic valve

POLYMORPHISMS OF MATRIX METALLOPROTEASES 2 AND 9 GENES IN ASCENDING AORTA ANEURISM PATIENTS

Aim. To study the role of mononucleotide polymorphisms of the matrix metalloproteases genes MMP2 and MMP9 in the development of ascending aorta aneurism (AOA).Material and methods. Totally 287 patients included with AOA and 227 persons of control group. All patients underwent echocardiography and assessment of mononucleotide gene polymorphisms of MMP2 (rs2285053) and MMP9 (rs11697325, rs2274755, rs17577) real-time, by PCR.Results. The association of MMP9 (rs11697325) is confirmed for the formation of AOA. AA genotype was significantly more prevalent among AOA patients (c2 =7,2; p=0,01). AA genotype carriers had higher ascending aorta diameter comparing to other persons with different variants (p=0,02). The relation is shown of the polymorphism ММР2 (rs2285053) and AOA development. Persons with CC genotype were more prevalent in the group of the aorta pathology patients (c2 =7,0; р=0,03).Conclusion. Genetic variants ММР9 and ММР2 can be additional risk factors of ascending aorta aneurism development. Therefore the assessment of different polymorphisms of matrix metalloproteases genes is useful for the risk stratification of the patients with ascending aorta dilation

¹⁸F-sodium fluoride and ¹⁸F-fluorodeoxyglucose positron emission tomography for assessment of aortic valve inflammation and calcification in patients with aortic stenosis

Aim. To determine the inflammation and calcification activity in aortic stenosis (AS) by assessing the accumulation of 18F-FDG and 18F-NaF in the aortic valve; to study the relationship of the AS severity, aortic calcification and the accumulation of 18F-FDG and 18F-NaF. Material and methods. The study included 62 patients with asymptomatic AS (29 patients with tricuspid (TAV) and 33 with bicuspid (BAV) aortic valve), aged 40 to 70 years. The maximum flow rate at the aortic valve (Vmax) differs from 2,4 m/s to 4,5 m/s. The mean age of patients was 59,44±7,33 years, M:W 1:1. Patients with infective endocarditis and chronic rheumatic heart disease were excluded. The AS severity was assessed according to the standard protocol of transthoracic echocardiography with the use of Vivid 7 ultrasound system (GE,USA). All patients underwent combined positron emission tomography/computed tomography (PET/CT) of the aortic valve using the Discovery 710 system. Evaluation of calcification and inflammation activity of the aortic valve was performed using 8F-NaF and 18F-FDG PET/CT. A quantitative assessment of radiopharmaceuticals accumulation was carried out using uptake ratio indices. The calcium score was calculated using SmartScore 4.0 software.Results. Patients with TAV and BAV were comparable in severity of AS, the median Vmax was 2,9 [2,6; 3,4] m/s and 2,9 [2,3; 3,3] m/s, respectively. Also, TAV and BAV patients did not differ in calcification values (Agatston score 1088 [465; 2192] and 1128 [442; 2391] HU, respectively). The association of 18F-FDG accumulation and AS severity has not been established. At the same time, the association was found between the aortic valve peak velocity and the calcium score (r=0,57, p< 0,0001), as well as the 18F-NaF accumulation values — maximum, mean and maximum to mean (r=0,37, p=0,002; r=0,46, p=0,0001 and r=0,41, p=0,0008, respectively). No association between the accumulation of 18F-FDG and 18F-NaF (r=0,098, p=0,49) was found.Conclusion. It was found that the inflammation according to 18F-FDG PET/CT does not play a significant role in AS pathogenesis. At this time, 18F-NaF PET/CT is a reliable method for the AS diagnosis and valve calcification assessment. It can be used to evaluate the prognosis and effectiveness of therapy in TAV and BAV patients