Predictors of Atrial Fibrillation Developing in Hospital Stage After Coronary Artery Bypass Surgery.

Aim    To identify independent predictors associated with in-hospital atrial fibrillation (AF) following coronary artery bypass grafting (CABG).Material and methods     The study included 80 patients (88.75 % men) who had elective CABG surgery at the Sklifosovsky Research Institute of Emergency Medicine. Based on the development of AF during the hospital stage of treatment (up to 10 days after CABG surgery), patients were divided into two groups. The group with AF consisted of 19 patients, and the group without AF consisted of 61 patients. All patients underwent electrocardiography (ECG), transthoracic echocardiography (EchoCG) with calculation of the left ventricular (LV) geometry type, and assessment of operational indexes. During surgery, biopsy of a part of the right atrial (RA) appendage was taken from 61 patients to verify the severity of myocardial fibrosis on a four-score scale where 0 is no interstitial fibrosis, 1 is slight fibrosis, 2 is moderate fibrosis, and 3 is severe fibrosis.Results    All included patients had a low risk of developing postoperative complications according to the EuroSCORE II scale. According to EchoCG data, patients with AF had significantly higher ratios of left ventricular myocardial mass to body surface area (LVMM / BSA) (p = 0.0006) and of left atrial volume to body surface area (LA volume / BSA), p = 0.008). The distribution of patients by type of LV geometry was as follows: in the group with AF, 52.63 % (n=10) of patients were diagnosed with concentric LV hypertrophy (LVH) whereas in the group without AF, the majority of patients (83.60 %, n=51) had normal LV geometry and concentric LV remodeling (LVR) (p<0.0001). According to the results of histological study, patients of the AF group more frequently had moderate and severe interstitial fibrosis in the AF appendage (p = 0.003). After multivariate regression and ROC analysis, the predictive value remained for concentric LVH (p=0.002), LVMM / BSA ratio ≥97 g / m2 (p=0.006), LA volume / BSA ratio ≥ 34.4 ml / m2 (p=0.04), and for RA appendage interstitial fibrosis score ≥2 (p=0.004). Based on the identified predictors, a regression model was developed to predict the development of AF at the hospital stage after CABG (p<0.0001). The sensitivity and specificity of the model were 86.67 % and 78.26 %, respectively.Conclusion    In patients at low perioperative risk, the LVMM / BSA ratio ≥97 g / m2, the LA volume ratio / BSA ≥34.4 ml / m2, a RA appendage interstitial fibrosis score ≥2, and the presence of LVH were independent predictors of the development of AF at the hospital stage after CABG operation.Conclusion In patients at low perioperative risk, a LVMM / BSA ratio ≥97 g / m2, a LA volume / BSA ratio ≥34.4 ml / m2, a RA appendage interstitial fibrosis score ≥2, and the presence of LVH were independent predictors of the development of AF at the hospital stage after CABG.

[PECULIARITIES OF DIAGNOSTICS AND TREATMENT OF PATIENTS WITH RECURRENT MYOCARDIAL INFARCTION].

The aim of the study was to evaluate the efficiency of invasive strategies for the treatment of 306 patients with recurrent myocardial infarction (IM) admitted to our clinic in 2003-2007. We compared the results of three approaches: various forms of transdermal coronary interventions (TDI) including delayed (24-72 hr) ones (n = 30), surgical myocardial revascularization within 8-12 weeks after the onset of recurrent myocardial infarction (n = 25), and conservative therapy (n = 251). Overall cardiovascular lethality was estimated during 5 years in 101 patients. It was shown that recurrent myocardial infarction is a predictor of high risk of death associated, in the absence of reperfusion therapy, with high intra-hospital and long-term lethality. TD1 soon after recurrent IM does not exclude possibility of its application in a later period. Various interventions including delayed ones markedly decrease the frequency of complications and lethal outcome that remains high in their absence. At the same time, severe lesions of the coronary bed in many patients with recurrent MI limit the possibility of using TDI and should be regarded as indications for planned surgical myocardial revascularization. Coronary bypass surgery after myocardial scarring prevents progress of left ventricle dysfunction, improves its contractility and increases life expectancy. Enhanced availability of reperfusion strategies in the form of TDI and/or delayed surgical myocardial revascularization opens up new possibilities for effective treatment of recurrent Ml.

[Esophageal stenting complications].

The aim of the study was to analyze esophageal stenting complications in case of cancer and benign diseases. It was investigated complications in 8 patients in terms from 7 days to 1 year after intervention. In 4 patients esophageal stenting was performed for constrictive esophageal cancer and compression with pulmonary cancer metastases into mediastinal lymphatic nodes. 2 patients had esophageal stenting for post-tracheostomy tracheo-esophageal fistula, 1 patient - for spontaneous esophageal rupture, 1 patient - for post-burn scar narrowing of esophagus and output part of the stomach. Severe patients' condition with tumor was determined by intensive esophageal bleeding in 2 cases, bilateral abscessed aspiration pneumonia, tumor bleeding, blood aspiration (1 case), posterior mediastinitis (1 case). Severe patients' condition with benign disease was associated with decompensated esophageal narrowing about proximal part of stent (1 case), increase of tracheo-esophageal fistula size complicated by aspiration pneumonia (1 case), stent migration into stomach with recurrence of esophago-mediastino-pleural fistula and pleural empyema (1 case), decompensated narrowing of esophagus and output part of the stomach (1 case). Patients with cancer died. And patients with benign diseases underwent multi-stage surgical treatment and recovered. Stenting is palliative method for patients with esophageal cancer. Patients after stenting should be under outpatient observation for early diagnosis of possible complications. Esophageal stenting in patients with benign diseases should be performed only by life-saving indications, in case of inability of other treatment and for the minimum necessary period.

[Efficacy of reperfusion therapy in syndrome of predominant right ventricular dysfunction associated with inferior myocardial infarction].

Aim of the study was choice of optimal tactics of treatment of patients with syndrome of predominant right ventricular (RV) dysfunction, associated with inferior myocardial infarction. We compared immediate and remote results of 3 strategies of treatment of 100 patients admitted to N.V. Sklifosovsky Research Institute for Critical Care in 2003-2007: various methods of percutaneous coronary intervention (PCI), including delayed PCI in the acute period (n=48), thrombolytic therapy without subsequent PCI (n=20), conservative therapy without reperfusion therapy (n=32). Indications to delayed interventions were based on high risk of death due to RV infarction. It follows from the data obtained that optimal tactics of treatment of RV infarction is provision of availability of reperfusion therapy in the form of various types of PCI. Preferable are primary PCIs in the absence of which delayed PCIs acquire practical value. Thrombolytic therapy can be used as a component of combined reperfusion. Absence of signs of its efficacy on electrocardiogram during first 90 minutes serves as absolute indication for rescue PCI. Inaccessibility of the latter is a reason for provision of delayed interventions. Electrocardiographic signs of achieved pharmacological reperfusion do not exclude high probability of early recurrences of ischemia, expediency of application of PCI during the time preceding these recurrences. In the absence of PCI hospital and remote mortality have been very high. Optimization of accessibility of mechanical reperfusion including delayed allows to achieve efficacy of treatment of RV infarction, prevent development of complications and lethal outcomes.

[Cytomegalovirus infection and pneumocystis pneumonia after coronary stenting and cardiac transplantation for acute myocardial infarction].

The paper presents the clinical and anatomic data of combination treatment for acute myocardial infarction, by stenting the infarct-related artery, followed by cardiac transplantation, which have provided the optimal result of surgery and caused no severe rejection reaction. The immediate causes of death have been infectious complications (cytomegalovirus infection and pneumocystis pneumonia) developing in the presence of immunodeficiency state. The following diagnosis formulation is pathogenetically warranted: the underlying disease is "Secondary immunodeficiency due to immunosuppressive therapy" and infectious complications may be assigned to the individual rubric "Secondary disease" (i.e. occurring in immunodeficiency).

[Features of tanatogenesis and extensiveness of myocardial infarction depending on severity of atherosclerotic stenosis of the coronary arteries]. / Osobennosti tanatogeneza i obshirnost' infarkta miokarda v zavisimosti ot rasprostranennosti ateroskleroticheskogo stenozirovaniia koronarnykh arterii.

142 fatal cases of acute myocardial infarction (AMI) are analyzed. In 56% cases the surface of AMI exceeded 50% of the working surface of the left ventricle and patients died, as a rule, during the first week of the disease of cardiogenic shock or progressing heart failure. In cases of a small AMI (up to 30% of working surface of the left ventricle, 25% cases) the frequent cause of death was external cardiorrhexis. It is emphasized that the size of AMI is not always determined by severity of stenosing atherosclerosis in the coronary arteries since isolated stenosis of one branch can also provoke a large AMI. The results are in favour of more active use of prophylactic surgical (including endovascular) treatment of ishemic heart disease before the development of a large AMI.

[Profuse gastric bleeding in a female with Dieulafois syndrome]. / Profuznoe zheludochnoe krovotechenie u bol'noi s sindromom D'elafua.

Dieulafois syndrome is a rare congenital pathology with profuse gastric bleeding due to the damage to arterial wall in the submucosa layer. The case illustrates difficulties encountered in the treatment of such patients.

[Energy expenditures in patients with insulin-dependent diabetes mellitus in a hospital and ambulatory environment (computer analysis)]. / Energotraty u bol'nykh insulinzavisimym sakharnym diabetom v statsionarnykh i ambulatornykh usloviiakh (komp'iuternyi analiz).

Original computer programs for assessment of energetic value of nutrition and daily energy expenditures of man based on physical activity protocols have been developed. The programs were tried in 16 patients with insulin-dependent diabetes, and essential individual differences from tentative table estimations of energy expenditures were detected. Correlations between treatment efficacy and individual energy expenditures of patients were observed; a moderate deficit of nutrition calories was found more detrimental for metabolic control than their moderate excess. The regularities detected even in such a nonrepresentative sample permit us evaluate high the potentialities and significance of the suggested method for assessment of energy expenditures.

[Computer-automated calculation of allowed human body weight]. / Komp'iuternyi avtomatizirovannyi raschet dopustimoi massy tela cheloveka.

A body weight (BW) classification has been proposed. It has been used in a PC program which compared BW of the patient with the current international criteria for "optimal" and "normal" BW depending on the sex, age, height, complexion, and estimated the level of obesity. The program has been tested on a group of students. The studies demonstrated that most men and women had average BW. Excessive BW was found in 29% women and 5% men. Besides, fat women are psychologically predisposed to have excessive BW, and thin ones, insufficient BW. The complexion of the patient significantly influences the allowed BW.

[Characteristics of rate and time parameters in secondary changes in the ventricular repolarization period]. / Osobennosti skorostnykh i vremennýkh parametrov pri vtorichnykh izmeneniiakh perioda repoliarizatsii zheludochkov.

An analysis of the first electrocardiographic derivative in 48 patients with left-ventricular hypertrophy and complete block of the left limb of His bundle demonstrated a prolongation of myocardial excitation spread and increased rate of change in the difference of potentials during repolarization, the changes being more marked in patients with left-ventricular hypertrophy. In cases where left-ventricular hypertrophy was combined with coronary disease, the rate of change in the difference of potentials was reduced dramatically during repolarization.

[Automated design of a diet for a patient with diabetes mellitus and obesity]. / Avtomatizirovannyi raschet diety bol'nomu sakharnym diabetom i ozhireniem.

A program of automated calculation of an individual diet for patients with diabetes mellitus and obesity has been worked out for the Elektronika HMC-80 PC. During a 15-20 min. interactive dialogue with the PC the caloric value and balance of a diet of 160 food items are assessed. Indices like sex, age, height, body mass, physical activity and diet are taken into account in dietary calculation. The testing of the program under clinical conditions has shown its multifunctional nature: it permits the detection of disturbed quantitative (caloric value) and qualitative (the ratio of proteins, fats and carbohydrates) indices of a diet, errors of an inpatient dietetic service and helps to form habits of nutritional culture in patients and medical staff.

[Use of the microcomputer in teaching clinical endocrinology]. / Ispol'zovanie mikro-EVM v obuchenii klinicheskoi éndokrinologii.

The paper is concerned with the results of the use of the Electronika NMS 01900.1 microcomputer manufactured in the USSR for teaching clinical endocrinology. Owing to its small dimensions, simple maintenance and sufficiently vast computing potentialities it can be widely used for teaching. A program with broad functional possibilities was prepared permitting students to objectivize their knowledge in clinical endocrinology. Fast automated test control of knowledge raises the efficacy of teaching many times.