[Practical aspects of anticoagulant therapy in patients with atrial fibrillation and arterial hypertension].

Atrial fibrillation (AF) represents the most frequent sustained cardiac arrhythmia, the prevalence of AF is 1-2 % in the general population and up to 6 % for population over 80 years. Arterial hypertension (AH) is the commonest background comorbidity in patients with AF. Patients with AF have 3-6­fold increased risk of ischemic stroke in comparison to that in general population, additionally the presence of AH leads an 2-3­fold increase in risk of subsequent stroke. Current clinical guidelines recommend long-time anticoagulant treatment for prevention of stroke and thromboembolic complications in majority of patients with confirmed AF. Not only does uncontrolled high blood pressure contribute to developing new-onset AF or AF progression but also can increase a bleeding risk related to oral anticoagulants. Patients with AF and concomitant AH resulting in target organ damage need for more favorable safety profile of oral anticoagulants. Instruction label dabigatran treatment in two doses can individualize approach to choice of long-term anticoagulation with lower risk of major bleeding in AF patients.

[A New Insight on Anti-Ischemic Action of Ivabradine in Patients With Stable Angina].

Increase in heart rate triggers most ischemic episodes due to disbalance between myocardial oxygen delivery and consumption. Furthermore, increased heart rate is a modifiable risk factor in patients with chronic heart failure. Ivabradine reduces heart rate by selectively inhibiting the If current of sinoatrial node cells. Recent studies have shown that ivabradine may reduce myocardial ischaemia and its consequences not only through heart rate reduction, but also because of additional pleiotropic effects. This review summarizes last findings that demonstrate variety of ivabradine actions on coronary blood flow and left ventricular function in patients with ischemic heart disease.

[Left Atrial Remodeling and Thromboembolic Risk in Patients With Recurrent Atrial Fibrillation].

PURPOSE: To assess the relationship between left ventricular and left atrial (LA) structural and functional characteristics and thromboembolic (TE) risk in patients (pts) with recurrent atrial fibrillation (AF). MATERIAL AND METHODS: Sixty pts (mean age 65 [61; 72] years, 42% men) with nonvalvular paroxysmal and persistent AF during sinus rhythm were divided into three groups based on CHA2DS2-VASc score: 1, 2, and ≥ 3. All pts underwent conventional and speckle tracking echocardiography. Apical four- and two-chamber views images of 6 myocardial segments in the filling phase were obtained to assess global peak left atrial longitudinal strain (PALS) in the reservoir (r) and contractile (c) phase. RESULTS. Patients with paroxysmal AF had significantly higher PALSr compared with patients with persistent AF (15.1 vs 11.2%, p = 0.0002) and PALSc (-15.0 vs -12.0%; p = 0.0002]. In logistic regression analyses, only higher PALSr was significantly associated with lower CHA2DS2-VASc score (OR 0.61; 95% Cl 0.38-0.97; p = 0.03). In order to distinguish patients with moderate and high TE risk we performed ROC curve analysis. Effective PALSr cut-off point was 16.7% with sensitivity of 62.5%, specificity of 39.0% and an area under the curve of 0.85 (95% Cl 0.72-0.98; p = 0.002). CONCLUSIONS: In patients with AF PALSr was independently associated with CHA2DS2-VASc score. Use of a PALSr threshold allows to detect patients with moderate and high TE risk and can be considered in the process of decision making on initiation of anticoagulation treatment in patients with AF and CHA2DS2-VASc score of 1.

[Giant abdominal urate tumor-like mass with multiple crystalline deposits in the bowel and lung walls in a patent with terminal heart failure].

The paper describes a unique case of a large abdominal urate mass with a peculiar inflammatory process with giant cells and smaller urate deposits in the lung and small bowel without articular changes and kidney injury in a patient with terminal heart failure.

[Achievement of goal resting heart rate in patients with stable angina and hypertension at the background of therapy with -adrenoblockers in real clinical practice].

ß-Adrenoblockers improve quality of life and in a number of cases life prognosis in patients with stable angina (SA). Dose of -adrenoblockers is considered optimal if at the background of treatment resting heart rate (rHR) is persistently decreased down to 55-60 bpm. But according to data of international registries rate of achievement of target rHR (trHR) in real clinical practice does not exceed 22%. Aim of this study was to determine what portion of patients with SA and arterial hypertension (AH) achieves trHR at the background of therapy with -adrenoblockers in routine practice in this country. Twenty centers in 6 towns in Russian Federation recruited 399 patients (mean age 64+/-10 years) with class I-III angina and concomitant primary AH. These patients for at least 2 months received any -adrenoblocker and did not change its dose during 4 weeks before inclusion into the program. Portion of patients with trHR was 15.5%. There were no significant differences between average daily doses of most frequently used -adrenoblockers (metoprolol, bisoprolol, carvediolol) in groups of patients who achieved and did not achieve trHR. Quality of life of patients who achieved was comparable with that of those who did not achieve trHR. Attainment of trHR was associated with significant decrease of short acting requirement nitrates. There was a significant direct correlation between attainment of trHR and target arterial pressure.

[A possibility to interchange heart rate-slowing therapy with ivabradine and atenolol in patients with stable angina pectoris].

AIM: To evaluate the efficiency and safety of an interchange of atenolol and ivabradine in patients who had stable angina pectoris without myocardial infarction in the history and left ventricular (LV) systolic dysfunction. SUBJECTS AND METHODS: The trial enrolled 31 patients less than 70 years of age who had sinus rhythm, functional classes II-I angina on exertion without clinical signs of LV systolic dysfunction. At the first stage, 15 patients were randomized to ivabradine with its dose titration during 2 weeks; the other 16 patients were to atenolol. At the second stage, 10 patients were switched from ivabradine used at Stage 1 to atenolol 100 mg/day, other 10 patients who were on atenolol were switched to ivabradine 15 mg/day, and 11 patients received combination therapy with ivabradine + atenolol in half doses. All the patients underwent treadmill exercise testing and applanation tonometry. RESULTS: Atenolol, unlike ivabradine, lowered brachial blood pressure and unchanged the central index of its increment, which was associated with LV systolic elongation. On the contrary, ivabradine decreased the central increment index and exerted no significant effect on the duration of LV systole. By comparatively lowering heart rate, ivabradine as well as atenolol reduced pulse wave propagation velocity. CONCLUSION: If ivabradine or atenolol is insufficiently effective or poorly tolerated, there may be an interchange of the drugs, as well as their combination in half doses without substantially affecting their therapeutic action in patients with stable angina pectoris without LV systolic dysfunction.

[Prognosis of hospital mortality in patients with acute decompensation of chronic heart failure].

We assessed prognostic value of clinical-laboratory and instrumental parameters in 100 patients with acute decompensation of chronic heart failure (CHF) in relation to hospital mortality. Independent predictors of lethal outcome in patients with acute decompensation of CHF were low systolic arterial pressure at admission (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01 to 1.05 per each 1 mm Hg of blood pressure lowering), elevation of urea content (OR 1.29, 95%CI 1.11 to 1.47 per each 1 mmol/L of elevation), potassium (OR 2.09, 95%CI 1.08 to 4.38 per 1 mmol/L of elevation) and creatinine (OR 1.01, 95%CI 1.01 to 1.03 per 1 mmol/L of elevation), lowering of glomerular filtration rate (OR 1.29, 95%CI 1.18 to 1.41 per 1 ml/min/1,73 m2 of lowering), left ventricular dilatation (OR 9.53, 95%CI 1.44 to 38.17; =0.043), pulmonary hypertension according to echocardiography data (=0.007), scarry changes according to electrocardiography data (OR 3.00, 95%CI 1.00 to 10.58; p=0.05), lack of therapy with acetylsalicylic acid (OR 6.21, 95%CI 1.62 to 22.73; =0.009) and -adrenoblockers (OR 6.99, 95%CI 1.39 to 14.49; =0,005) at ambulatory stage.

[Remote clinical results of treatment of atrioventricular nodal reciprocated with the use of novel and traditional methods of radiofrequency catheter ablation of slow part pathway of atrioventricular junction].

Remote results of radiofrequency catheter ablation (RFCA) - modification of "slow" part pathway of atrioventricular junction (AVJ) in patients with typical form of atrioventricular nodal reciprocal reciprocated tachycardia (AVNRT), carried out on the basis bi and monopolar recording of electrical activity of fibers of slow" part pathway of AVJ. Study participants were 104 patients (44 women) aged 21-86 years with typical form of AVNRT who had been subjected to primary RFCA procedure - modification of slow part pathway of AVJ. In group 1 (n=51) RCA RFCA was conducted on the basis of simultaneous monoand bipolar endocardial registration recording of new potential of "slow" part pathway of AVJ. In group 2 (n=53) RCA RFCA was done on the basis of bipolar registration of traditional potentials of "slow" part pathway of AVJ. Total period of follow up of patients was 32+/-11 months. According to data of control visits 1, 3, 6, 12, and 24 months after RCA RFCA for AVNRT based on collection of anamnesis, physical examination, registration of electrocardiogram and Holter monitoring none of the patients had recurrences of AVNRT in indicated periods of follow up. Method of mapping of fibers of "slow" part pathway of AVJ based on redislocation of destructive electrode in the zone of novel potential located at significant distance from compact part of AVJ differs from common approach and allows to carry out catheter RCA RFCA with minimal risk of impairment of atrioventricular conduction. Long term results of radiofrequency modification of "slow" part pathway of AVJ performed on the basis of registration recording of novel potential are comparable with results of traditional RCA RFCA technique in patients with AVNRT.

[Typical atrial flutter: classification, clinical manifestations, diagnosis, and treatment].

Main etiological factors, mechanisms of arrhythmogenesis and classification of atrial flutter (AFl) are presented. Clinical electrocardiographical and electrophysiological features of typical AFl are described. Main diagnostic measures are delineated and principles of tactical approach to management of patients with typical AFl presented. Indications to radiofrequency catheter ablation, and physical characteristics of radiofrequency interventions in lower isthmus of the right atrium are discussed. Data of analysis of comparative efficacy of pharmacological and interventional approaches to management of patients with typical AFl as well as spectrum of possible complications associated with surgery are also presented.

[Comparison of transthoracic, transesophageal, and intracardiac echocardiography sensitivity for guiding transseptal puncture during radiofrequency ablation in the left atrium].

The paper contains comparison of sensitivity and rates of false negative results of transthoracic (TT), transesophageal (TE), and intracardiac (IC) echocardiography (echoCG) during transseptal puncture in the run of the procedure of radiofrequency ablation of atrial fibrillation. In the work fulfilled we analyzed results of 208 echocardiographical intraprocedural investigations conducted with the aim of visualization of interatrial septum (IAS) during transseptal puncture. TT, TE and IC echoCG were carried out in 32, 26, and 150 cases, respectively. Phenomenon of IAS stretching was visualized by TT echoCG in 2 (6%) cases (sensitivity 6.7%). At TE tenting phenomenon was verified in 20 patients (20%) (sensitivity 86.9%). Puncture of IAS was carried out under IC echoCG control in 127 patients. Puncture was made in the center of thin portion of IAS (in the region of fossa ovalis), in its upper and lower portions in 65, 28, and 15.7% of cases, respectively. Sensitivity of IC echoCG was 98.4%. Rate of false positive results reached 92.8, 13.04 and 1.5% for TT, TE and IC echoCG, respectively. At present IC echoCG is most sensitive and safe ultrasound technique for verification of optimal positioning of the system for conduct of transseptal puncture in the region of IAS in comparison with TT and TE echoCG.

[Wolff--Parkinson--White syndrome: classification, clinical manifestations, diagnosis, and treatment].

Main etiological factors, mechanisms of arrhythmogenesis, and classification of Wolff-Parkinson-White (WPW) syndrome are presented and clinico-electrocardiographical and electrophysiological peculiarities of atrioventricular reciprocal tachycardia in this syndrome are described. Main diagnostic measures, principles of their correct interpretation are specified and principles of tactical approach to management of patients are presented. Indications to electrophysiological investigation and radiofrequency catheter ablation, physical characteristics of radiofrequency action in regions of optimal mapping of supplementary atrioventricular junction are discussed. Data of analysis of efficacy of pharmacological and interventional approaches to the treatment of patients with WPW syndrome are also presented.

[Alcohol septal ablation and prevention of sudden cardiac death in patients with hypertrophic cardiomyopathy. A case report].

We discuss approaches to the treatment of patients with hypertrophic cardiomyopathy, problems of prevention of sudden cardiac death in subjects with this pathology, and present results of multicenter study assessing efficacy of cardioverter defibrillator implantation in patients with hypertrophic cardiomyopathy. Special attention is devoted to the method of alcohol septal ablation in patient with obstructive form of hypertrophic cardiomyopathy and discussion of indications to this intervention. Clinical case is presented demonstrating early and long time results of alcohol septal ablation of pronounced obstruction of left ventricular outflow tract in a woman with high risk of sudden cardiac death.

[Quality of life of patients with Wolff-Parkinson-White syndrome before and during one year after radiofrequency catheter ablation of accessory pathways].

The paper contains presentation of complex analysis of quality of life (QL) of 140 patients with Wolff-Parkinson-White (WPW) syndrome before and during one year after radiofrequency catheter ablation (RFCA) of accessory pathways (AP) . Assessment of QL was based on the use of nonspecific and specific questionnaires. Parameters of QL were analyzed in dependence on localization of AP and its electrophysiological properties (concealed, manifested). It was shown that before intervention parameters of QL in patients with WPW syndrome were significantly lower than in the group of clinical comparison (practically healthy persons). Complex study of criteria of QL allows to assert that just after 2 months after RFCA there occurs considerable improvement of the general condition of patients with WPW syndrome. 6 and 12 months after operation complete restoration of both physical and mental working capacity was noted. This is confirmed by absence of significant differences between QL criteria in patients with WPW syndrome and in the group of healthy volunteers.

[Echocardiographic evaluation in patients with idiopathic ventricular arrhythmias originating from right ventricular outflow tract before and one year after radiofrequency catheter ablation].

PURPOSE: To estimate echocardiographic measurements in patients with idiopathic ventricular arrhythmias originating from right ventricular outflow tract (RVOT) before and one year after radiofrequency ablation (RFA) comparing with healthy volunteers. MATERIALS AND METHODS: The study consisted of 30 patients (7 women, 34.9+/-15.2 years of age) with predominantly repetitive monomorphic ventricular ectopy and nonsustained ventricular tachycardias. Arrhythmia history was 4.6+/-3.5 years. The control group consisted of 20 healthy unselected subjects (5 women, 41.9+/-5.3 years of age) without left ventricular (LV) dysfunction. All consecutive patients with idiopathic ventricular arrhythmias underwent electrophysiology study and RFA. Transthoracic echocardiography was performed before, 2, 6 and 12 months after RFA. RESULTS: Significantly higher LV end diastolic volume and lower LV ejection fraction were observed in study group patients to compare with control group patients. LV function significantly improved in postablative patients during 1 year follow up. There were no found complications associated with RFA. CONCLUSIONS: Idiopathic ventricular arrhythmias originating from right ventricular outflow tract (RVOT) could be a cause of arrhythmogenic LV remodeling. Successful ablation of the focal source of right ventricular ectopy resulted in normalization of LV function during follow up period.

[Initial experience in Russia of excimer laser extraction of endocardial leads].

PURPOSE: To assess effectiveness and safety of excimer laser extraction of chronically implanted transvenous pacing leads using countertraction technique. We operated upon 10 patients (female 2), mean age 56.1+/-11.7 years. Average time of lead placement was 7.7+/-4.2 years. Indications included erosion of device pocket in 4 patients, abscess of pocket in 2 patients, high grade of tricuspid valve insufficiency in 1 patient with 2 ventricular leads, lead related induction of life-threatening ventricular tachycardia in 3 ICD patients. We used xenon-chloride laser with excimer laser sheath SLS n KIT 14-16 Fr and locking stylet LLD KIT (Spectranetics, USA). Endotracheal anesthesia was applied in all cases. Leads removal was a success for 3 atrial and 12 ventricular leads. All endocardial leads were extracted with countertraction after near-the-complete progression of the laser sheath. Postoperative follow-up period was 16.3+/-5.7 months. There were no procedure-related complications. CONCLUSION: Laser lead extraction is a safe and effective approach to removal of long-term leads including those with active fixation.

[First experience of the use of rotational coronary atherectomy in patients surviving myocardial infarction].

An experience of the use of rotational atherectomy during interventions on calcified stenoses of coronary arteries in survivors of myocardial infarction is presented. The article contains consideration of potential advantages of the use of rotablation, indications to its application and possible complications, as well as discussion of results of clinical studies of assessment of efficacy and safety of this procedure in patients with ischemic heart disease.