Possibilities of treatment of patients with resistant arterial hypertension

The literature review provides an analysis of various modern invasive methods of treatment of patients with resistant arterial hypertension. Future of the method is sketched, as well as their efficacy and safety

Dilation of the Infarct-Related Coronary Artery to Reduce the Incidence of the No-Reflow Phenomenon in STEMI Patients

Background: The pathogenesis of slow/no-reflow phenomena is a critical socio-medical problem due to high mortality and work disability rates in patients with ST-segment elevation myocardial infarction (STEMI). Slow/no-reflow phenomena are multifactorial involving 4 key elements: 1) distal embolization of the coronary bed of the infarct-related coronary artery; 2) ischemic damage to the myocardium; 3) reperfusion injury of the heart muscle; 4) individual (genetic) susceptibility of the microcirculation to injury.   Objective: To analyze the outcomes of percutaneous coronary interventions (PCI) in patients with STEMI and TIMI 0 blood flow of an infarct-related coronary artery based on the strategy to restore antegrade blood flow (balloon predilation or dilation of an infarctrelated artery).   Materials and methods: We analyzed treatment outcomes of 209 patients with STEMI and TIMI 0 blood flow. The patients were grouped based on the PCI strategy: group 1 included 147 patients who underwent balloon angioplasty to restore antegrade blood flow, and group 2 included 62 patients who underwent dilation of an infarct-related coronary artery.   Results: Our study found that direct stenting in STEMI patients was associated with statistically significantly lower risk of slow/noreflow phenomena (P = 0.001, Pearson’s χ2) and, as a result, better functional outcomes of treatment (chronic heart failure grade classified according to Strazhesko-Vasilenko and by left ventricular ejection fraction) that were also statistically significant (P = 0.001, Pearson’s χ2).   Conclusions: Our study demonstrated that the risk of slow/no-reflow phenomena in patients with TIMI 0 blood flow of an infarctrelated coronary artery was statistically significantly lower (P = .001, Pearson’s χ2) in the group of patients who underwent dilation of an infarct-related coronary artery to restore antegrade blood flow. Functional outcomes (chronic heart failure grade and overall survival) were also better in this group of patients (P = .001, Pearson’s Chi-square). Moreover, dilation of an infarct-related coronary artery was associated with preserved left ventricular ejection fraction compared with the group of patients who underwent balloon angioplasty to restore antegrade blood flow (P < 0.001, Pearson’s χ2)

The role of intravascular methods of examination of coronary arteries in the selection of patients with diffuse and multivessel lesions for myocardial revascularization

Objective Assessment of the role of intravascular imaging methods in choosing the surgical strategy of myocardial revascularization.Material and Methods The study included 62 patients with diffuse and multivessel coronary artery disease, who underwent percutaneous coronary infervention (PCI) using intravascular imaging methods. Measurement of fractional flow reserve (FFR) in diffusely altered arteries was performed under conditions of maximum hyperemia, sequentially between stenoses, using the sensor, starting from the distal segment. Initially, the most distal hemodynamically significant stenosis was stented. Then, a repeated measurement of FFR was performed, and the issue of the need for stenting of other stenoses was solved. The results of stenting, as well as determination of the area of stent implantation were carried out by the method of optical coherence tomography (OCT).Results After FFR measurement the number of arteries with hemodynamically significant stenoses decreased by 24.7% (from 93 to 70). It was also noted that in patients with two-vessel lesions, the average number of such stenoses decreased from 2.95 ± 0.65 to 1.82 ± 0.88, and in patients with three-vessel lesions – from 2.96 ± 0.6 to 2.24 ± 0.76 respectively (p = 0.0024). Complete (functionally adequate according to FFR measurements) myocardial revascularization was achieved in 88.7% of patients. The second-generation drug eluting stents were implanted in 82 (47.1%) patients, and the third generation stents – in 92 (52.9%) patients. At the same time, the success rate of recanalization of occlusions was 100%. Overall, optimal stent implantation was achieved in all patients. Major cardiovascular complications were observed in 1 (1.6%) patient, which required additional interventions.Conclusion Complex use of intravascular imaging methods (OCT and FFR measurements) allows a differentiated approach to the assessment of each stenosis of the affected artery in patients with diffuse and multivessel coronary lesions, to achieve a high frequency of complete myocardial revascularization, as well as to reduce the number of unnecessary interventions and intraoperative complications

Pre- and postoperative left atrial appendage visualization: selecting the optimal method

Background: Atrial fibrillation (AF) is reported to be one of the main etiological factors of ischemic stroke. Transcatheter occlusion of the left atrial appendage (LAAO) is an alternative to anticoagulant therapy in the thromboembolism prevention in atrial fibrillation patients with a high bleeding risk. The role of contrast-enhanced cardiac computed tomography (CT) for preoperative assessment and postoperative control has not been sufficiently studied to the present moment.Objective: Comparison of the possibilities of transesophageal echocardiography (TEE) and computed tomography in pre- and postoperative imaging in the context of LAAO interventions.Material and methods: This retrospective cohort study included 38 patients divided into 2 groups: in the first group TEE was used for intervention planning and postoperative control, patients of the second group were examined with CT. The indicators obtained during LAA measurements were assessed, as well as the result of the intervention – according to the risk of peripheral leakage into the left atrial appendage.Results: The average left atrial appendage depth and orifice diameter according to transesophageal echocardiography were significantly smaller compared to computed tomography data (25.58 ± 4.65 versus 31.05 ± 6.41, p = 0.011; 17.21 ± 2.70 versus 18.55 ± 3.05 p = 0,006, respectively). In the computed tomography group, there was a not statistically significant trend towards a lower risk of leakage for 4–5 mm leaks (RR = 0.500; 95% CI 0.060–3.710) and for 2–3 mm leaks (RR = 0.500; 95% CI 0.150–1.540). In addition, 45 days after the intervention computed tomography revealed 5 cases of incomplete endothelialization of the device with the contrast agent leak into the LAA in the absence of peripheral leakage.Conclusion: Contrast-enhanced cardiac computed tomography, unlike transesophageal echocardiography, allows to detect incomplete occlusive device endothelialization, which may influence the choice of postoperative antithrombotic therapy. The use of computed tomography in an intervention planning for the LAAO may reduce the risk of peripheral leakage, however, this hypothesis needs to be confirmed in studies with a larger number of patients

Непосредственные и отдаленные результаты стентирования позвоночных артерий у пациентов с бессимптомным течением хронической ишемии головного мозга

Highlights. The efficiency of the endovascular treatment combined with medical therapy versus medical therapy has been proven to prevent strokes in patients with vertebral artery atherosclerotic lesions and asymptomatic chronic cerebral ischemia.Aim. To assess the efficiency of endovascular treatment in patients with asymptomatic vertebral artery atherosclerotic lesions as an approach for secondary prevention of strokes.Methods. Group 1 patients (n = 44) underwent stenting of the vertebral arteries combined with the medical therapy to prevent strokes, whereas group 2 patients (n = 56) received the medical therapy alone. Group 1 was then subdivided into two subgroups -subgroups 1a and 1b. Subgroup 1a patients underwent (n = 22) stenting using the embolic protection devices, while Subgroup 1b patients (n = 22) - embolic protection devices were not used. The follow-up was up to 36 months with regular visits at 12, 24, and 36 months. The inclusion criteria were as follows: asymptomatic vertebral artery stenosis of 50-95%; the diameter of the vertebral arteries of less than 3.0 and not more than 5 mm; the presence of cerebral and focal symptoms corresponding to asymptomatic chronic brain ischemia (according to E.V. Schmidt).Results. The overall incidence of spasm and dissection during endovascular intervention was 20% and 4.5% in Subgroup 1a and 1b, respectively (p = 0.0367). 2 (4.5%) patients had transient ischemic attack in Subgroup 1a. There were no perioperative strokes in Subgroup 1b. The overall rate of major cerebral complications over 36 months was 4.5% in Group 1 versus 37.5% in Group 2 (x2 = 15.101; p <0.0001). The rate of adverse cardiac events was 9.1% and 19.6%, in Groups 1 and 2, respectively (x2 = 14.784; p <0.0001). In-stent restenosis occurred in 38.67% of patients in Group I, who underwent stenting using various generations of stents. In-stent restenosis did not affect the incidence of major cerebral complications in the long-term period (x2 = 0.1643; p = 0.735).Conclusion. Endovascular treatment combined with medical therapy allowed preventing cerebral complications associated with the instability of atherosclerotic plaques in patients with asymptomatic vertebral artery stenosis. It has proved to be an effective method for the secondary prevention of strokes. Основные положения. Впервые у пациентов с атеросклеротическими стенозами позвоночных артерий и бессимптомным течением хронической ишемии головного мозга доказана высокая эффективность комбинированного (эндоваскулярного и медикаментозного) подхода при вторичной профилактике нарушений мозгового кровообращения с учетом приверженности пациента лечению по сравнению с только лекарственной терапией.Цель. Определить целесообразность эндоваскулярных вмешательств у асимптомных пациентов с атеросклеротическими стенозами позвоночных артерий как метода вторичной профилактики нарушений мозгового кровообращения (НМК).Материалы и методы. В I группе (n = 44) вторичная профилактика НМК проведена комбинированным способом - стентирование позвоночных артерий в сочетании с медикаментозной терапией, во II группе (n = 56) выполнено только медикаментозное лечение. В I группе дополнительно проведена «слепая» рандомизация на две подгруппы - 1а и Ib. В подгруппе 1а (п = 22) эндоваскулярное вмешательство выполняли с использованием устройств защиты от эмболии, в подгруппе Ib (n = 22) данные устройства не применяли. Отдаленные сроки наблюдения составили 12, 24 и 36 мес. Критерии включения пациентов в исследование: асимптомные больные со стенозами позвоночных артерий 50-95%; диаметр позвоночных артерий 3,0-5,0 мм; общемозговые и очаговые симптомы, соответствующие начальной (асимптомной) стадии хронической ишемии мозга (по Е.В. Шмидту).Результаты. Суммарная частота развития спазма и диссекций во время эндоваскулярного вмешательства в подгруппе Ia составила 20%, в подгруппе Ib - 4,5% (р = 0,0367). Также в подгруппе Ia у 2 (4,5%) пациентов возникли преходящие НМК, в подгруппе Ib периоперационных НМК не наблюдалось. Общая частота серьезных мозговых осложнений за 36 мес. наблюдения составила 4,5% в I группе и 37,5% во II группе (х2 = 15,101; р<0,0001). Частота кардиальных событий - 9,1 и 19,6% в I и II группах соответственно (х2 = 14,784; р<0,0001). Рестеноз имплантированных стентов отмечен у 38,67% больных I группы, которым выполнено стентирование позвоночных артерий различными генерациями стентов. При этом сам по себе рестеноз не влиял на частоту значительных мозговых осложнений в отдаленном периоде (х2 = 0,1643; р = 0,735).Заключение. Эндоваскулярное вмешательство в сочетании с медикаментозной терапией помогает избежать развития значительных мозговых осложнений, возникающих вследствие нестабильности атеросклеротической бляшки у асимптомных пациентов со стенозами позвоночных артерий, и является эффективным методом вторичной профилактики НМК

Отдаленные результаты чрескожных коронарных вмешательств у пациентов с диффузным и многососудистым поражением коронарных артерий

Highlights. Two-year results of stenting in patients with diffuse and multivessel coronary artery lesions performed using intravascular research and control methods (optical coherence tomography, blood flow fractional reserve) are presented. A low incidence of myocardial infarction, repeated interventions and a high level of survival, free from significant cardiovascular complications, were noted when using intravascular research methods in patients during percutaneous coronary intervention in comparison with the patients who did not undergo intravascular methods.Aim. To evaluate the two-year results of percutaneous coronary interventions (PCI) in patients with diffuse and multivessel coronary lesions.Methods. 128 patients were included in the study and divided into two groups. In group I (n = 62) PCI was performed using intravascular imaging methods, in group II (n = 66) no intravascular imaging methods (retrospectively) were used. The measurement of fractional flow reserve (FFR) in diffusely altered arteries was performed against the background of maximum hyperemia between stenoses by pulling the sensor starting from the distal segment. Initially, the most distal hemodynamically significant stenosis underwent the stenting. Then, a repeated measurement of FFR was performed and it showed if the further stenting was needed. The results of stenting, as well as the determination of the stent implantation area were carried out by the method of optical coherence tomography.Results. 12 months after PCI the results of treatment were checked in all patients and after 24 months – in 106 patients (56 and 50, respectively, in groups I and II). The achievement of complete (functionally adequate, according to FFR measurements) myocardial revascularization was achieved in 93.5% of patients from group I, while the result in the control group was only 56% of patients. The average number of stenoses in the target non-occluded artery according to angiography and after FFR measurement was the following: in patients with two-vessel lesions – 2.95±0.65 and 1.82±0.88, respectively, and in patients with three-vessel lesions – 2.96±0.6 and 2.24±0.76, respectively (p = 0.0024). After 12 months of follow-up, significant differences were observed between groups I and II in the frequency of myocardial infarction (1.8 and 4.0%, respectively; χ2 = 5.172) and repeated interventions (3.6 and 16.0%, respectively; χ2 = 8.114). By the 24th month of follow-up, among the observed patients, the total frequency of myocardial infarction, repeated interventions and cardiac death were significantly higher in patients of group II compared with group I and they were 45.5 and 9.6%, respectively (χ2 = 14.784; p<0,0001).Conclusion. Long-term results of PCI in patients with diffuse and multivessel coronary lesions using intravascular imaging methods (optical coherence tomography and FFR measurements) are characterized by low cardiac complications, compared with patients operated without imaging methods. Основные положения. Представлены двухлетние результаты стентирования пациентов с диффузным и многососудистым поражением коронарных артерий, выполненного при использовании внутрисосудистых методов исследования и контроля (оптическая когерентная томография, фракционный резерв кровотока). Отмечены низкая частота инфаркта миокарда, повторных вмешательств и высокий уровень выживаемости, свободной от значимых сердечно-сосудистых осложнений, при использовании внутрисосудистых методов исследования у пациентов во время чрескожного коронарного вмешательства в сравнении с больными, которым внутрисосудистые методы не применяли.Цель. Оценить двухлетние результаты чрескожных коронарных вмешательств (ЧКВ) у больных с диффузным и многососудистым поражением коронарного русла.Материалы и методы. В исследование включены 128 пациентов, распределенных в две группы. В I группе (n = 62) ЧКВ выполняли с использованием внутрисосудистых методов исследования, во II группе (n = 66) – без внутрисосудистых методов исследования (ретроспективно). Измеряли фракционный резерв кровотока (ФРК) в диффузно измененных артериях на фоне максимальной гиперемии последовательно, между стенозами, путем протяжки датчика начиная с дистального сегмента. Стентировали первоначально самый дистальный гемодинамически значимый стеноз. Далее выполняли повторное измерение ФРК, при необходимости – стентирование других стенозов. Определение зоны имплантации стента, а также оценку непосредственных результатов стентирования осуществляли методом оптической когерентной томографии.Результаты. Через 12 мес. после ЧКВ результаты лечения прослежены у всех пациентов, через 24 мес. – у 106 больных (56 и 50 в I и II группах соответственно). Достичь полной (функционально адекватной по данным измерения ФРК) реваскуляризации миокарда удалось у 93,5% пациентов I группы и лишь у 56% участников контрольной группы. Среднее количество стенозов в целевой неокклюзированной артерии по данным ангиографии и после измерения ФРК составило: у пациентов с двухсосудистым поражением – 2,95±0,65 и 1,82±0,88, у больных с трехсосудистым поражением – 2,96±0,6 и 2,24±0,76 (p = 0,0024). Через 12 мес. наблюдения отмечены достоверные различия между I и II группами по частоте инфаркта миокарда (1,8 и 4,0%; χ2 = 5,172) и повторных вмешательств (3,6 и 16,0%; χ2 = 8,114). К 24 мес. наблюдения суммарная частота инфаркта миокарда, повторных вмешательств и кардиальной смерти была достоверно выше у пациентов II группы, составив 45,5 против 9,6% в I группе (χ2 = 14,784; р<0,0001).Заключение. Отдаленные результаты эндоваскулярного лечения больных с диффузным и многососудистым поражением коронарного русла с использованием внутрисосудистых методов исследования (оптическая когерентная томография и измерение ФРК) отличаются низкой частотой кардиальных осложнений в сравнении с таковыми у пациентов, оперированных без визуализирующих методов.

THE ROLE OF INTRAVASCULAR METHODS OF RESEARCH TO VERIFY THE DIAGNOSIS OF CORONARY HEART DISEASE IN WORKERS OF JSC “RUSSIAN RAILWAYS” RELATED TO THE SAFETY OF TRAIN TRAFFIC

The purpose of the study was to determine the role of the complex use of FFR and IVUS to verify the diagnosis of coronary heart disease in the examination of the professional suitability of Russian Railways employees, related to safety of train traffic. The study showed that survival rates free of major adverse cardiac events, transient rhythm disturbances, syncopal conditions and repeated hospitalizations for the angina pectoris, in groups with “unchanged” coronary arteries and intermediate stenoses of the coro-nary arteries with FFR negative result were not significantly different in the long-term period and amounted to 100 and 95.2%, respectively (p > 0.05), which makes to consider them as professionally suitable workers and return to work. When comparing this indicator in the subgroups of patients with FFR positive result undergoing stenting under the control of IVUS and patients with FFR negative result receiving optimal medical therapy, there were also no significant differences (97.3 and 95.2%, respectively, p > 0.05), which makes it possible to swich workers who have undergone stenting to "light" work, not related to the safety of train traffic

Different tactics of single-stent endovascular treatment among coronary heart disease patients with coronary artery bifurcation lesions

Aim. To analyze the results of different tactics of single-stent endovascular treatment among patients with coronary heart disease (CHD) and coronary artery bifurcation lesions (CABL). Material and methods. The study included 135 CHD patients with CABL. All participants were divided into 2 groups: Group I (n=77; 58,3 %) consisted of patients who underwent coronary artery (CA) main branch (MB) stenting and subsequent kissing balloon angioplasty of a CA side branch (SB). Group II (n=55) included patients with “genuine” CABL, who underwent only MB stenting with SB protection, but without SB balloon angioplasty. Results. In all 132 CABL patients, drug-eluting stents were successfully implanted, with technical effectiveness of 100 % and in-hospital survival of 100 %. Clinical outcomes were similar in both groups, with no major cardiovascular events registered. At the same time, such an important angiographic index as SB diameter was significantly higher in Group I, compared to Group II. At later stages, Group II patients required SB angioplasty and demonstrated habitual angina symptoms, ischemic electrocardiographic (ECG) changes, and slow SB blood flow (TIMI grade <III) after CA MB stenting. Conclusion. MB stenting of CA bifurcation without SB kissing balloon angioplasty cannot be recommended to all CABL patients. Development of habitual angina symptoms, ischemic ECG changes, and slow SB blood flow (TIMI grade <III) often requires subsequent SB kissing balloon angioplasty

IMMEDIATE AND LONG-TERM RESULTS OF THE LEFT ATRIUM AURICLE OCCLUDER IMPLANTING IN ATRIAL FIBRILLATION

Aim. To evaluate the safety and efficacy of the “WATCHMAN” occluder (OW) in atrial fibrillation patients (AF) during hospital period and in 12 months after the procedure.Material and methods. Frоm 2013 to 2015 years, in the N. A. Semashko Central clinical hospital № 2 of “RZD”, 15 OW were implanted to patients with persistent AF of non-rheumatic origin, admitted for electro cardioversion, or electrophysiological study and radiofrequency ablation, pacemaker implantation. Indications for endovascular intervention were the threat of repeated embolism, high bleeding risk, severe comorbidities, and inefficacy of antithrombotic therapy. From the study were excluded those with stenosis of the left atrioventricular space and thrombi in the left atrium auricle (LAA). During pre-surgery period, all patients underwent standard transthoracal and transesophageal echocardiography for assessment of the LAA anatomy, its size in four points of view and its position to the left upper pulmonary vein. For stroke risk assessment and of thromboemolic complications the score CHA2 DS2 was used and its new edition CHA2 DS2 -VASc. Before the discharge from clinic, all patients underwent transesophageal echocardiography, repeated in 6 weeks, 6 and 12 months.Results. Mean age of patients was 52 year old. All patients had successful OW implanting. Interventions were done without general anesthesia, under local anesthesia. Mean duration of surgery was 42±11,3 min. To every patient one device was utilized. There were no replacements of OW for wrong sizing or other reasons. In 5 patients (anatomy as “chicken wing”) under angles 90-135º there was protrusion of lower border of OW found by 1/3 of the length. In patients with LAA OW sizes 33 and 27, there was residual flow registered under the lower border, of5 mmand2 mmdiameter, respectively. There were no complications during operation and nearest post-operation period. In 12 months after the study there was not dislocation, embolization or position changes among the devices. The residual flow diameter in33 mmimplant patient decreased in 6 months from 5 to2 mm, in the other — remained2 mm. No patients had brain circulation disorders and other embolies.Conclusion. The method of OW implanting into LA of non-rheumatic origin is effective method of embolic complications prevention, not followed by bleedings and making to prognosis improvement of this kind of patients, as to quit entire life anticoagulatio

SYMPATHIC DENERVATION OF RENAL ARTERIES: PAST, PRESENT AND FUTURE

The analysis presented of recent studies that show efficacy of the procedure of sympathic renal denervation in arterial hypertension. Future of the method is sketched, including diabetic patients, pulmonary hypertension patients and cardiac rhythm disorders