[Assessment of the results of left ventricular reconstruction in combination of coronary atherosclerosis and diabetes mellitus]. / Otsenka rezul'tatov rekonstruktsii levogo zheludochka pri sochetanii koronarnogo ateroskleroza i sakharnogo diabeta.

AIM: To study the effect of type 2 diabetes mellitus on changes of intracardiac haemodynamics and myocardial morphology in patients with ischaemic heart disease and a postinfarction aneurysm of the left ventricle before and after corrective operations on the heart. PATIENTS AND METHODS: The study included 79 patients with ischaemic heart disease and a chronic aneurysm of the left ventricle (Group I - patients with type 2 diabetes mellitus (n=27), mean age 57.5±3.9 years, average number of shunts 2.9±0.6; Group II - patients without diabetes mellitus (n=52), mean age 55,3 ±7.1 years, average number of shunts - 2.7±0.3). In the preoperative period all patients were examined taking into account the functional class of angina pectoris, with the assessment of the left ventricular ejection fraction, end-diastolic index, end-systolic index, sphericity index. All patients underwent coronary artery bypass grafting and surgical restoration of the normal geometry of the left ventricle according to the Menicanty technique with the target end-systolic index of 60 ml/m2, during which 39 patients from both groups were subjected to intraoperative biopsy of the left ventricular myocardium and right atrial auricle. RESULTS: The intergroup analysis revealed no statistically significant differences in age, angina pectoris class, level of arterial pressure between the groups. Neither were there statistically significant differences in the echocardiographic parameters at the preoperative stage. In the postoperative period, we detected a significant decrease in the end-systolic and end-diastolic volumes of the left ventricle in both groups, with a statistically significant increase of the left ventricular ejection fraction observed only in non-diabetic patients. One year after the operation, such patients still continued to demonstrate more favourable parameters of the systolic and diastolic functions of the left ventricle. A detailed analysis with determining the delta of the alterations in the parameters revealed more significant positive dynamics in the postoperative period in patients with ischaemic heart disease not associated with type 2 diabetes mellitus. CONCLUSION: The obtained findings are indicative of negative dynamics of the course of chronic ischaemic heart disease aggravated by type 2 diabetes mellitus after reconstruction of the left ventricle. Macro- and microangiopathy in type 2 diabetes mellitus significantly deteriorated the myocardial trophism. Subsequent bleedings draw phagocytic cells into the myocardial stroma, thus adversely affecting the further prognosis and course of the disease, since we demonstrated that the presence of inflammatory infiltrate in the myocardial stroma is a key factor of unfavourable outcomes of surgical treatment of patients with ischaemic cardiomyopathy.

[Typical errors pulmonary artery verification on the example of a clinical case].

The difficulties of verification of pulmonary embolism (PE) are well known and have not been overcome to date, despite significant progress in approaches to managing patients with this pathology over the past 1015 years. Due to the nonspecific clinical picture, cases of a long and difficult journey to this diagnosis are not exclusive. In large studies have shown that the most frequent symptom of pulmonary embolism shortness of breath. However, it is not always associated with doctors of different specialties with the need to exclude this diagnosis, purposefully collect anamnesis, identify risk factors. Modern low-dose oral contraceptives are considered quite prosperous in terms of the development of thrombotic complications and cause a slight (1020%) increase in fibrinogen concentration, factors VII, VIII and X, as well as a decrease in the content of active protein S by 1020%. But in the case of the presence of diseases and conditions that increase the risk of venous embolism, this effect may be sufficient for the realization of life-threatening pulmonary embolism. In this regard, it is important to provide a combined effect on the prognosis of the pathology of the patients and the chosen method of contraception.

[The Importance of the Type of Heart Circulation for the Prognosis of Pulmonary Embolism].

AIM: To study the distribution of the type of heart circulation (left- dominant, right- dominant, and mixed (balanced) in patients with pulmonary thromboembolism of fatal and non-fatal outcome. MATERIALS AND METHODS: More than 36,000 case histories, protocols and findings of post-mortem examinations of patients hospitalized in 2003-2012 were subjected to analysis. (ten year period). Statistical processing of the actual material was carried out using the SAS 9 and SPSS 21 software packages. The critical level of significance p for all used procedures of statistical analysis was assumed to be 0.05. Results of the study. The study included 893 cases of pulmonary embolism registered in the data of the case histories and materials of the pathoanatomical studies. Data on the type of heart circulation and a detailed description of the coronary artery atherosclerosis were present in 264 cases: in 171 patients with pulmonary embolism and fatal outcome, and in 93 patients with pulmonary embolism and non-fatal outcome. A clear predominance was found in the group with pulmonary embolism and non-fatal outcome of patients with the right type of heart circulation - 78.5% versus 7% in the group of people who died with pulmonary embolism (p<0.0001). Accordingly, persons with "non-right type of heart circulation" (left and balanced) predominantly prevailed among patients with pulmonary embolism and fatal outcome. At the same time, the dead with the right type of heart circulation in all cases had a stenosis of the right coronary artery (RCA) more than 60%. RCA dominance in the heart circulation with absence its significant stenosis creates more favorable hemodynamic conditions for survival in patients with pulmonary embolism. Owners of other types of organization of coronary blood flow ("non-right type of heart circulation") have a worse prognosis both in the absence of coronary atherosclerosis and, moreover, in its presence, especially in the case of significant atherosclerotic lesion of the RCA pool. At the same time, in patients with the right type of heart circulation and hemodynamically significant atherosclerosis RCA in conditions of pulmonary embolism the prognosis is also unfavorable. In view of the above, in patients with coronary atherosclerosis, timely restoration of blood flow in RCA (coronary artery stenting) is great importance in relation to the prognosis associated not only with coronary heart disease, but also with PE.

[Ultrasonographic control of cerebral blood flow in patients with stenosis of brachiocephalic arteries before and after carotid endarterectomy]. / Ul'trazvukovoi kontrol' mozgovogo krovotoka u bol'nykh so stenozom brakhiotsefal'nykh arterii do i posle karotidnoi éndarteréktomii.

The authors studied the parameters of arterial and venous blood flow in patients presenting with haemodynamically significant atherosclerosis of the carotid arteries before and after carotid endarterectomy, as well as while carrying out functional tests. Comparing the indices of arterial blood flow in the Study Group consisting of 52 patients and the Control Group comprising 15 apparently healthy volunteers at rest prior to the operation revealed statistically significant differences of volumetric parameters of blood flow in the internal carotid artery. The obtained results showed that the breath-holding test was accompanied and followed by increased velocity of blood flow in the middle cerebral artery (MCA) on the side contralateral to stenosis, with the reactivity index (RI) amounting to 0.98±0.20, which statistically significantly differed from the RI in the Control Group patients (1.28±0.13). The forced respiration test demonstrated a decrease in the volumetric indices of blood flow in the MCA on the side of stenosis, as well as an increase of the maximum end-diastolic velocity of blood flow on the side contralateral to stenosis. The test with sublingual administration of nitroglycerin appeared to result in reduced blood flow in the MCA. The supratrochlear test demonstrated decreased velocity of blood flow in the supratrochlear artery. Studying the venous link of cerebral vessels after the operation showed that statistically significant differences were revealed only on the side contralateral to stenosis as compared with the values prior to revascularization. An increase of blood flow in the internal jugular veins after the operation on the side contralateral to the operation was apparently suggestive of an adequate distribution of blood flow through the main vessels of the brain.

[Estimation of poor prognostic factors in patients with pulmonary artery thromboembolism]. / Otsenka faktorov neblagopriyatnogo prognoza u patsientov s tromboemboliei legochnoi arterii.

AIM: To identify predictors of fatal outcome in hospitalized patients with risk factors (RF) for pulmonary artery thromboembolism (PATE) during its occurrence. SUBJECTS AND METHODS: To determine predictors of fatal outcome in patients with PATE, the data of a 10-year city hospital pulmonary embolism registry were used to analyze RF for PATE (according to European and Russian guidelines), complaints, medical histories, and laboratory and instrumental data, which can be identified at general surgery or general therapy hospital, as well as a nosological entity existing in the patients. RESULTS: According to the existing idea on thrombogenesis, RF for PATE and its fatal outcome, information about used treatment, and autopsy data, 137 parameters were selected in patients with PATE. For estimating the risk of death in patients with PATE, a logistic regression analysis was employed to make a mathematical model encompassing 10 indicators: bed rest; the presence/absence of lung diseases; chronic venous insufficiency; obesity; the symptom complex of cor pulmonale; postinfarction cardiosclerosis of the left ventricle, pericardial effusion; right atrial dilatation; right ventricular dilation; right ventricular systolic pressure >36 mm Hg as evidenced by echocardiography. CONCLUSION: The mathematical model built during the study allows the calculation of a risk for fatal outcome in the development of PATE for a specific patient in terms of its individual characteristics.

[Inhospital thrombolism of right cardiac chambers].

Veins of lower extremities are classic sources of pulmonary artery thromboembolism (PATE). But one should not underestimate presence of thrombi in other potential sources - veins of small pelvis, superior vena cava, and chambers of the heart. We analyzed 652 case histories and autopsy data of patients in whom PATE had been revealed at pathological anatomical investigation and selected 157 cases in which right heart chambers were sources of emboli (right atrium in 83.5% and right ventricle - in 13.7% of cases). According to autopsy data average mass of the heart was 512.5+/-36.1 g. In most patients it exceeded norm. Thrombi in both right and left cardiac chambers were found in 52.3% of cases. Eighty three patients had history of myocardial infarction or were treated for MI during last hospitalization; 52.3% of patients had atrial fibrillation. After detailed study of all anamnestic, clinical, instrumental, and pathologic-anatomic data we selected 69 factors which according to contemporary views could facilitate formation of thrombus in the right cardiac chambers. Using these factors and method of logistic regression we created a mathematical model for assessment of probability of the presence of thrombi in right cardiac chambers.

[Thromboembolism of pulmonary artery branches from the right cardiac chambers].

AIM: To reveal possible predictors of thrombosis in the right cardiac chambers and to build a mathematical model to estimate the probability of thrombi in them in patients with thromboembolism of the pulmonary artery branches. MATERIALS AND METHODS: The data of autopsy protocols and case histories were analyzed in'157 patients in whom the source of thromboembolism had been right cardiac chambers according to postmortem evidence. A logistic regression method was used to create a probability model. RESULTS: The findings were used to select 69 indicators--possible provokers of thrombosis and accordingly predictors of thrombi in the right cardiac chambers. A mathematical model--a formula to estimate the probability of thrombi in the right cardiac chambers--was made. It comprised 8 indicators: weight, height, pericardial fluid, right atrial dilatation, right ventricular wall thickness, a left or right ventricular apical scar, a concomitant inflammatory process, and concurrent diabetes mellitus. CONCLUSION; The application of the developed formula may assist in identifying a group of patients who have the highest probability of thrombi in the right cardiac chambers and accordingly must undergo a more in-depth examination.

[Thromboembolism of pulmonary artery branches based on the registry data of Tomsk hospitals].

The aim of this work was to study dynamics of new cases of hospital thromboembolism of pulmonary artery branches (TEPA) based on the registry data of Tomsk hospitals for 2003-2010 and to estimate applicability of recommendations of European Society of Cardiologists (2008) on diagnostics and treatment of TEPA. Case records and autopsy protocols were available for analysis. The data were treated using Statistica for Windows 6.0 package. 5.04% of the deceased patients had TEPA according to autopsy data. The discrepancy between clinical and pathoanatomical findings averaged 57.6%. In 2010, TEPA was not diagnosed in 35.6% patients. The number of new cases of submassive TEPA and TEPA of small branches with the fatal outcome decreased to 40.7 and 48% since 2007 while the incidence of lethal massive thromboembolism amounted to 68%. Its increase was especially notable among men after 2008. In 2003, 73.3% of the patients who died from TEPA were women while it was the cause of death in 54.8% of men in 2010. The duration of hospital stay was 0-16 (mean 8/1 +- 7.8) bed-days. Most patients (60.3%) had 3 or more risk factors. The frequency of TRPA relapses correlated with the presence of pericardial fluid (p = 0.039) and acute myocardial infarction (p = 0.023). In 24.2% of the cases. TEPA originated in heart chambers.

[Cerebral perfusion and tractography in obese children]. / Rezul'taty izucheniya tserebral'noi perfuzii i traktografii u detei s ozhireniem.

OBJECTIVE: To study the relationship of the structure of the white matter of the brain, neurovascularization and cognitive functions in obese children and adolescents. MATERIAL AND METHODS: The study included 64 obese patients, aged 12-17 years, and 54 children without excess body weight. A general clinical examination, neuropsychological testing (the Raven's test with the calculation of IQ, MoCA, the Rey 15-Item Memory Test (RMT), 1 and 2), magnetic resonance imaging (MR) tractography and contrast-free perfusion of the brain were conducted. RESULTS: Obese children and adolescents had both a decrease in scores on MoCA and the Raven's test, and in terms of IQ, while according to RMT-1, there were significant differences in the two groups, and in RMT-2 the results were comparable. Perfusion analysis showed a decrease in vascularization in the white matter area of the occipital lobe on the left and its increase in the temporal lobe area also on the left. When assessing the white matter according to MR tractography, a decrease in fractional anisotropy was noted in the area of the hook-shaped beam on the right and left, anterior and posterior commissural tracts. These changes were correlated with neuropsychological results. CONCLUSION: In obese children and adolescents, there was a destruction of the integrity of the white matter and neurovascularization of the brain associated with a deficit of cognitive functions.

[Diagnosis of thromboembolism of the pulmonary artery branches according to autopsy data in Tomsk hospitals in 2003-2007].

AIM: To study the frequency and structure of new cases of thromboembolism of the pulmonary artery branches among those who died at Tomsk hospitals in 2003 to 2007. MATERIALS AND METHODS: The autopsy protocols and case histories of all patients (n = 442) with the lifetime and/or postmortem diagnosis of pulmonary thromboembolism (PTE) who had died at Tomsk hospitals on January 1, 2003 to December 31, 2007 were analyzed. A systemic postmortem study applied the complete organ evacuation method (complete evisceration after Shore). The variance analysis was employed to calculate variability in all values; the correlation analysis was used to estimate statistical correlations. RESULTS: Out of the 442 patients, 217 (50.9%) patients had thromboembolism as being a direct cause of death and it worsened the course of the underlying disease in 225 (49.1%) patients. According to the number of dead patients with PTE, therapeutic (60.6%), surgical (26.6%), and cancer (9.1%) ones ranked first, second, and third, respectively. In addition to the most common inferior vena cava thrombosis (65.1%), right cardiac thrombosis was the main source of PTE in 25.6% of cases. CONCLUSION: The detected specific features of the occurrence of new cases of PTE at Tomsk hospitals in 2003-2007 may become the basis for planning measures by health administrators to improve the diagnosis of PTE and to improve medical and preventive care to patients with this condition in therapeutic-and-prophylactic institutions.

[Function of the brain venous system and a 24-h profile of arterial pressure in hypertensive patients].

AIM: To study blood flow along the internal jugular veins (IJV) in the initial state and under the action of nitroglycerin in patients with essential arterial hypertension (EAH) with reference to characteristics of a 24-h profile of blood pressure. MATERIAL AND METHODS: A 24-h monitoring of blood pressure (MBP), duplex scanning of IJV, venous IJV outflow were studied in 26 patients with EAH stage 2 (mean age 39 +/- 5.0) before and after sublingual intake of nitroglycerin (0.5 mg). RESULTS: By 24-h MBP findings, two groups of patients were identified: with unaffected blood pressure profile (group 1) and affected profile (group 2). Nitroglycerin produced a unidirectional reaction of IJV (increased outflow) in group 1 and multidirectional changes of venous outflow along the IJV in patients of group 2. CONCLUSION: Nitroglycerin test showed different venous cerebral hemodynamics in EAH patients with different variants of 24-h MBP.

[Prognostication of hemodynamic efficacy of surgical correction of chronic coronary insufficiency based on stress test with nitroglycerine]. / Prognozirovanie gemodinamicheskoi éffektivnosti khirurgicheskoi korrektsii khronicheskoi koronarnoi nedostatochnosti na osnovanii dannykh nagruzochnogo testirovaniia s nitroglitserinom.

In our previous studies we demonstrated possibility of the use of stress echocardiography with sublingual administration of nitroglycerine for detection of viable myocardium. Basing on data about myocardial and cerebrovascular reserves obtained during nitroglycerine tests we created mathematical model for prediction of hemodynamic effectiveness of coronary bypass surgery. Stress echocardiography, Doppler echography of middle cerebral and internal carotid arteries with nitroglycerine were carried out in 80 patients with coronary artery disease before myocardial revascularization. Quantitative equivalent characterizing degree of myocardial reserve preservation in early postoperative period was used as basis for discrimination of patients into groups with positive and negative result of surgery, and coefficients and constants of discriminant function were calculated for these groups. According to results of clinical testing sensitivity, specificity and diagnostic effectiveness of the model were 76.9, 75 and 76%, respectively.

[The cerebral hemodynamics of patients with ischemic heart disease during transesophageal electrical stimulation of the left atrium]. / Sostoianie tserebral'noi gemodinamiki u bol'nykh ishemicheskoi bolezn'iu serdtsa vo vremia chrespishchevodnoi élektricheskoi stimuliatsii levogo predserdiia.

In 26 patients with coronary heart disease, transesophageal atrial pacing was used to study cerebral hemodynamics from brain tomoscintigraphic findings as compared to the severity of induced of myocardial ischemia, echocardiographic parameters of left ventricular function and prostacyclin-thromboxane balance. In angina pectoris, the lower rate of cerebral blood flow was found to be correlated with the integral parameter of myocardial ischemia, deteriorated cardiac contractile and pump function, and higher plasma thromboxane A2 levels.

[Effect of antiischemic therapy in immediate period after mammary coronary bypass surgery on left ventricular contractility and conduit blood flow. Randomized controlled study]. / Vliianie antiishemicheskoi terapii v blizhaishem periode posle mammarno-koronarnogo shuntirovaniia na sokratitel'nuiu funktsiiu levogo zheludochka i krovotok po mammarno-koronarnym shuntam: randomizirovannoe platsebo-kontroliruemoe issledovanie.

AIM: To assess influence of 2-week course therapy with atenolol, nebivolol, and verapamil on systolic and diastolic left ventricular function and mammary coronary blood flow in early period after revascularization. MATERIAL: Patients (n=113) after mammary coronary bypass grafting. METHODS: Echocardiographic characteristics of systolic and diastolic left ventricular function, and blood flow through mammary coronary grafts were measured before and after treatment with study drugs. RESULTS: In placebo treated patients isovolumic relaxation time (IVRT) and late diastolic filling phase (A) increased, while velocity characteristics of mammary-coronary blood flow decreased. Administration of atenolol, nebivolol, and verapamil was associated with significant increases of left ventricular ejection fraction, stroke volume, cardiac output, IVRT, peak diastolic velocity, flow through mammary coronary grafts and their lumen diameter, and decrease of E/A ratio. CONCLUSION: Administration of atenolol, nebivolol, and verapamil in early postoperative period after mammary coronary bypass grafting improved systolic and diastolic function of the left ventricle, and blood flow through mammary coronary grafts. None of the studied drugs had significant advantage over others.

[A decrease in left ventricular hypertrophy and the dynamics of the parameters of circadian BP monitoring under the influence of ramipril in patients with essential arterial hypertension]. / Umen'shenie gipertrofii levogo zheludochka i dinamika parametrov sutochnogo monitorirovaniia AD pod vliianiem ramiprila u bol'nykh éssentsial'noi arterial'noi gipertoniei.

To evaluate factors of action of ramipril, an inhibitor of angiotensin-converting enzyme, which may induce a decrease in left ventricular hypertrophy (LVH), 45 LVH patients aged 21-53 years with mild and moderate essential hypertension have underwent echo-CG determination of left ventricular mass and 24-h monitoring of arterial pressure (AP). Multiple regression was used to examine prognostic significance of such parameters as age, sex, height, weight, duration of the disease, mean 24-h AP, its variability and the degree of nocturnal fall. It was found that ramipril reduced LVH irrespective of the hypotensive effect.

[Carotid atherosclerosis detectability in patients with coronary heart disease and arterial hypertension]. / Chastota vyiavleniia u bol'nykh ishemicheskoi bolezn'iu serdtsa i arterial'noi gipertoniei.

AIM: To assess detectability of carotid atherosclerosis in patients with coronary heart disease (CHD) and arterial hypertension (AH) by the data of ultrasonic screening, to study location and detectability of atherosclerotic lesion of common carotid arteries, internal carotid arteries, external carotid arteries in correlation with basic disease. MATERIAL AND METHODS: Ultrasonic screening of brachyocephalic arteries was made in 469 patients: with CHD (n = 239), AH (n = 230) including patients with concomitant postinfarction cardiosclerosis (PICS) and moderate chronic cerebrovascular failure (CCVF). RESULTS: Ultrasonic angiography detected atherosclerotic carotid artery lesion in patients with CHD and PICS (81.6%) or CCVF (76.9%) or angina pectoris (64.2%). In hypertension subjects carotid artery atherosclerosis was encountered in 28.1%. CONCLUSION: It is justified to make ultrasonography of carotid arteries in all patients with CHD and AH irrespective of age, gender, underlying clinical diagnosis.

[Diagnosis of structural changes] of the brain in patients with coronary and asymptomatic carotid atherosclerosis]. / Daignostika strukturnykh izmenenii golovnogo mozga u bol'nykh koronarnym i bessimptomnym karotidnym aterosklerozom.

AIM: To compare echomorphostructure of atherosclerotic plaques and vascular stenosis degree with structural changes of the brain according to MR image in patients with combined atherosclerotic affection of coronary and carotid arteries in an asymptomatic course of carotid atherosclerosis. MATERIAL AND METHODS: MR imaging was made in 53 men aged 44 to 78 years with stenosing atherosclerotic affection of the internal carotid arteries. Vascular obstruction reached 30-80%. Neurological examination detected no signs of focal brain lesions. Hypertension, myocardial infarction, permanent atrial fibrillation were diagnosed in 19 (36%), 20 (38%) and 12 (23%) patients, respectively. RESULTS: Ultrasound investigation has established that carotid arteries contain more frequently spongy and heterogenic plaques than dense and calcinated. MRI registered structural alterations of cerebral tissue of various degree in 96% cases. CONCLUSION: Significant correlations were established between ischemic affection of the brain with myocardial infarction, arterial hypertension, cardiac fibrillation, type of atherosclerotic plaque.

[Abnormal cerebrovascular reactivity in patients with asymptomatic atherosclerosis of the carotid arteries]. / Narusheniia tserebrovaskuliarnoi reaktivnosti u bol'nykh s asimptomnym ateroskleroticheskim porazheniem sonnykh arterii.

The study included 53 patients (males at the age of 44-78 years) with ischemic heart disease and arterial hypertension with asymptomatic unilateral atherosclerotic affection of carotid arteries (CA). Ultrasonic investigation registered 30-80% stenosis of carotid arteries in the absence of neurological deficit. Cerebrovascular reactivity was assessed by means of the hypercapnic hypoxic test (HHT) including breathing via additional "dead space" for 3 min. Initial and peak linear velocity of the blood flow in the middle cerebral artery was measured with ultrasonic transcranial dopplerography. By HHT results, three types of cerebral vascular reactions in patients with combined atherosclerosis of coronary and carotid arteries were identified: subnormal dilatation on the side of stenosed internal carotid artery, increased dilatation and paradoxical vasoconstriction on the affected side. Cerebrovascular reactivity and the type of atherosclerotic plaques did not collerate.

[Minor stenosis of carotid arteries: differential approach in diagnosis and surgical treatment]. / Malye stenozy sonnykh arterii: differentsial'nyi podkhod v diagnostike i khirurgicheskom lechenii.

The results of treatment of 161 patients with atherosclerotic small degree stenoses of carotid arteries (up to 50% of diameter) were analyzed. From them 67 patients underwent operations for chronic cerebro-vascular failure and 11 patients--for acute cerebro-vascular failure. 31 patients, who had contraindications for surgery or refused it, plasmapheresis procedures were carried on, 52 patients with asymptomatic carotid arteries' disease underwent conservative treatment. On the base of the results of examination and late results of treatment it is shown valid to recommend carotid endarterectomy as a prophylactic measure in acute cerebrovascular failure in asymptomatic patients who have morphologically unstable plaques of carotid arteries. If there are general contraindications for carotid endarterectomy, with the aim of prophylaxis of cerebrovascular failure the procedures of plasmapheresis for alteration of morphologic structure of plaques are advisable.