["Guiding lights" for the diagnosis of chronic thromboembolic pulmonary hypertension in the flow of patients with pulmonary embolism].

On December 13, 2021, an expert council was held to determine the position of experts of different specialties regarding the reasons for the low level of diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) in real clinical practice in a pandemic of a new coronavirus infection and possible ways to improve detection in patients with pulmonary embolism (PE) ) in history. The reasons for the low level of diagnosis of CTEPH are the insufficient level of knowledge of specialists, especially primary care physicians; lack of clear regulatory documents and expert centers for the management of this category of patients. Primary diagnosis of CTEPH in a pandemic can be strengthened through the widespread use of telemedicine for consultations of primary care physicians with specialists from expert centers; to maximize the role of echocardiography and computed tomography (CT) as differential diagnostic tools for dyspnea, in particular in patients with COVID-19. To increase the detection rate of CTEPH, diagnostic vigilance is required in patients with risk factors and episodes of venous thromboembolism. To improve the screening of CTEPH, it is necessary to create an algorithm for monitoring patients who have had PE; provide educational activities, including through the media; create materials for patients with accessible information. The regulatory documents should designate the circle of responsible specialists who will be engaged in long-term monitoring of patients with PE. Educational programs are needed for primary care physicians, cardiologists, and other physicians who come into the field of view of patients with CTEPH; introduction of a program to create expert centers for monitoring and managing patients with the possibility of performing ventilation-perfusion lung scintigraphy, cardiopulmonary stress test, CT, right heart catheterization. It seems important to build cooperation with the Ministry of Health of Russia in order to create special protocols, procedures for managing patients with PE and CTEPH.

[Problematic aspects of pulmonary hypertension due to left heart disease: focus on combined postcapillary and precapillary pulmonary hypertension].

Рulmonary hypertension (PH) is a common complication of left heart diseases. In addition to a passive increase of pressure in the venous bed of the pulmonary circulation, leading to an increase of mean pulmonary pressure, signs of precapillary PH could be detected in some patients. Since 2013, a hemodynamic subtype of PH due to left heart diseases combined post/precapillary PH has been identified, with a more unfavorable prognosis and high mortality.

[The possibilities of using levosimendan in medical preparation to Coronary Artery Bypass Grafting in coronary artery disease patients with low left ventricular ejection fraction].

AIM: to work out an approach of preoperative drug preparation for CAD patients with low LVEF and varying degrees of compensation for CHF, to study the possibility of using levosimendan (L) in this preparation. MATERIALS AND METHODS: We studied 82 patients with severe angina pectoris, multivascular coronary disease, extensive postinfarction zone, LVEF ≤35%, chronic heart failure and proven viable myocardium, which performed CABG. All patients received long - term standard CHF therapy before surgery: loop diuretic, ACE/ARA, beta - blocker, aldosterone antagonist. In the first, retrospective part of the study (39 pts), it was determined which factors could be associated with perioperative AHF. In the second, prospective part (43 pts), the course of the operation and the early postoperative period in patients with compensated and uncompensated heart failure were compared; uncompensated pts received L 2 days before surgery in addition to standard therapy. The third, retro - prospective part of the study (37 pts) was the assessment of operation outcome in patients only with uncompensated pre - operative CHF, but with different preoperative drug preparation. RESULTS: Statistically significant direct influence on the perioperative AHF development was provided by the combined clinical sign - venous pulmonary congestion+orthopnea (p.

[Possibility of complex medicamental and endovascular treatment of pulmonary hypertension in Takayasu arteritis with predominant pulmonary arteries' lesion].

Takayasu arteritis (TA) is a systemic vasculitis with predominatly lesions of aorta and its large branches. In some cases pulmonary arteries (PA) are involved in the pathological inflammatory process and lead to the formation of pulmonary hypertension and significantly worse the prognosis. Timely development of lesion of PA, appointment of adequate therapy and surgical treatment can prevent irreversible damage of blood vessels and improve the prognosis. Perioperative administration of interleukin-6 inhibitor inhibitor (tocilizumab) in at patients with indications for vascular surgery, including angioplasty PA, should be considered as a promising approach to control the inflammatory activity of TA, reduce the dose of glucocorticoids and the risk of postoperative complications. We present the clinical experience of significant improvement in the patients condition was achieved by using two-stage balloon angioplasty on the background of control of the disease activity with interleukin-6 tocilizumab intravenously and specific therapy with riociguat and iloprost.

[Complications of the Catheter Treatment of Atrial Fibrillation: Stenosis of All Pulmonary Veins after Radiofrequency Ablation].

Radiofrequency ablation is the "gold standard" in atrial fibrillation treatment. The frequency of complications is about 3.5-3.9 %. The symptomatic pulmonary vein stenosis is one of the most severe complications. In this report we present a clinical case of stenosis of all four pulmonary veins after redo catheter ablation of atrial fibrillation in 61year-old patient, and discussion of possible causes, specific features of diagnosis, and possible approaches to treatment of this complication.

[Atrial myocarditis in a patient with Takayasu arteritis].

Takayasu arteritis belongs to the group of systemic vasculitis with a predominant lesion of large - caliber vessels and the development of stenosis of their lumen. In world practice, to establish the diagnosis of arteritis Takayasu apply the criteria proposed by the American College of rheumatologists. Currently, there are no randomized clinical trials related to the disease, and the diagnosis and treatment of patients are based on a number of small studies, a series of clinical cases and expert opinion. The described clinical observation of a patient with Takayasu arteritis is of interest in connection with the detected atrial myocarditis during MRI diagnosis of the heart with contrast, which allows us to discuss the feasibility of this imaging technique in complex and doubtful cases.

[Metilin Improves Сardiac Function in Rabbits With Chronic Heart Failure].

AIM: To study effects of intravenous infusion of a cardioprotective drug metilin, developed at the "National Medical Research Center of Cardiology" on indices of cardiac function in rabbits in vivo after prolonged administration of doxorubicin. MATERIALS AND METHODS: Animals of the experimental group were intravenously injected with doxorubicin (2 mg / kg once a week) for 8 weeks, animals of the control group received the same volume of saline. Myocardial damage was characterized by an increase in concentration of malondialdehyde (MDA), troponin (TnI) and MB-fraction of creatine kinase (CK-MB) in venous blood and by disturbances in the left ventricle (LV) structure at morphological examination. Metilin effects on cardiac function were assessed by echocardiography and LV catheterization by the Millar catheter tip pressure transducer. RESULTS: Doxorubicin administration led to a decrease of the body mass of animals, an increase of the plasma concentration of cardiac markers CK-MB and TnI, lipid peroxidation (LPO) product MDA in venous blood, and pronounced disturbances in the structure of LV fibers and microvessels. At the same time, a significant decrease of myocardial contractility indices was observed. Manifestations of this decrease were increase of the end-diastolic and end-systolic dimensions (EDD and ESD, respectively), and decreases in the shortening fraction and ejection fraction (SF and EF, respectively) compared to baseline values. These changes indicated development of chronic heart failure (CHF) in animals of the experimental group. Against this background, intravenous infusion of metilin significantly increased SF and EF, but did not affect the heart rate. Beneficial effects of metilin on the indices of cardiac contractility and relaxation were maintained after the infusion was stopped. Noteworthy, metilin exerted greater influence on cardiac function of rabbits with CHF compared to control animals that did not receive doxorubicin. CONCLUSION: The obtained results indicate the potential of metilin to reduce LV dysfunction during chemotherapy with doxorubicin.

[Contractile Function of Isolated Hearts With Preserved and Reduced Ejection Fraction In Vivo].

The aim of the study was comparison of contractile function of isolated hearts of rats with doxorubicin-induced myocardial injury which were tentatively divided according to the level of ejection fraction determined by echocardiography in vivo. After 4 weeks of doxorubicin administration (2 mg/kg subcutaneously once a week) about half of animals had normal (86±1 %) and the other half reduced (61±4 %) ejection fraction. The first group was defined as diastolic heart failure (DHF) and the other as systolic (SHF). The maximal pressure developed by the isolated heart in isovolumic mode was reduced in DHF by 13 %, and in SHF by 34 %. The relaxation index in both groups was lowed by 22-24 %. Both groups were characterized by a decline in the ability to raise developed pressure while increasing coronary perfusion pressure, as well as by the loss of the ability of coronary vessels to maintain a stable flow rate while increasing perfusion pressure. The hearts of control animals were able to raise the cardiac work index (the product of developed pressure and heart rate) during prolonged high frequency (7-9 Hz) stimulation, while the two groups treated with doxorubicin reduced the level of this index. The content of basic energy metabolites (ATP, phosphocreatine, creatine) in both groups was reduced by 20-38 %. The results showed that the hearts in DHF and SHF groups showed approximately the same level of reduction of the contractile function and energy metabolism, and hence their difference in vivo was probably due to varying degrees of mobilization of compensatory mechanisms.

Contractile Function of Isolated Hearts With Preserved and Reduced Ejection Fraction In Vivo.

The aim of the study was comparison of contractile function of isolated hearts of rats with doxorubicin-induced myocardial injury which were tentatively divided according to the level of ejection fraction determined by echocardiography in vivo. After 4 weeks of doxorubicin administration (2 mg/kg subcutaneously once a week) about half of animals had normal (86±1%) and the other half reduced (61±4%) ejection fraction. The first group was defined as diastolic heart failure (DHF) and the other as systolic (SHF). The maximal pressure developed by the isolated heart in isovolumic mode was reduced in DHF by 13%, and in SHF by 34%. The relaxation index in both groups was lowed by 22-24%. Both groups were characterized by a decline in the ability to raise developed pressure while increasing coronary perfusion pressure, as well as by the loss of the ability of coronary vessels to maintain a stable flow rate while increasing perfusion pressure. The hearts of control animals were able to raise the cardiac work index (the product of developed pressure and heart rate) during prolonged high frequency (7-9 Hz) stimulation, while the two groups treated with doxorubicin reduced the level of this index. The content of basic energy metabolites (ATP, phosphocreatine, creatine) in both groups was reduced by 20-38%. The results showed that the hearts in DHF and SHF groups showed approximately the same level of reduction of the contractile function and energy metabolism, and hence their difference in vivo was probably due to varying degrees of mobilization of compensatory mechanisms.

[Comparison of Diagnostic Values of Instantaneous Wave-Free R atio and Fractional Flow R eserve With Noninvasive Methods for Evaluating Myocardial Ischemia in Assessment of the Functional Significance of Intermediate Coronary Stenoses in Patients With Chronic Ischemic Heart Disease].

OBJECTIVE: To compare the diagnostic accuracy of instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) with noninvasive methods in assessment of the functional significance of moderate coronary stenoses in patients with chronic ischemic heart disease (IHD). METHODS: We included in this study 50 patients with chronic or suspected IHD and moderate coronary stenoses (50-70%; 74 stenoses). Values of iFR and FFR were determined within 10 days after noninvasive stress tests (combination of stress-echo and SPECT). The values of iFR and FFR were compared with the results of noninvasive methods by ROC-analysis. Coronary artery stenosis was considered functionally important if at least one of noninvasive tests (stress-echo or SPECT) demonstrated positive result. RESULTS: The results of noninvasive stress-tests were positive in 14 patients (28%). ROC area under the curve (AUC) for iFR - 0.961±0.019 (95%CI 0.888-0.992). The best cut-off point for iFR is 0.92 (sensitivity 100, specificity 84%). ROC AUC for FFR - 0.893±0.041 (95%CI 0.79-0.96). The best cut-off point for FFR is 0.81 (sensitivity 100% and specificity 69%). There was no significant difference between iFR and FFR ROC-curves (р=0.0845). CONCLUSION: The values of iFR and FFR have equivalent agreement with the results of noninvasive tests commonly used to detect myocardial ischemia in patients with moderate coronary stenoses.

[The diagnostic value of measuring the momentary blood flow reserve versus non-invasive methods to detect myocardial ischemia in assessing the functional significance of borderline coronary artery stenoses]. / Diagnosticheskaia tsennost' izmereniia momental'nogo rezerva krovotoka po sravneniiu s neinvazivnymi metodami vyiavleniia ishemii miokarda pri otsenke funktsional'noi znachimosti pogranichnykh stenozov koronarnykh arterii.

AIM: To estimate the diagnostic value of measuring the momentary blood flow reserve (MBFR) versus the surrogate non-invasive standard (SNS) for myocardial ischemia verification (MIV) (a combination of stress echocardiography and single-photon emission computed tomography). SUBJECTS AND METHODS: The investigation enrolled 50 patients with stable angina in the presence of chronic coronary heart disease (CHD) or suspected CHD, in whom coronary angiography (CA) revealed borderline coronary stenoses (50-70% lumen diameters). The examination algorithm had two options. In one option, when included in the study, patients had already CA results not older than 1 month, and MBFR was measured 4-7 days after non-invasive stress tests. In the other option, MBFR in the area of borderline coronary artery stenosis was measured simultaneously with CA; and the noninvasive stress tests were carried out in the following week. A total of 74 coronary stenoses were examined. RESULTS: SNS for MIV was positive in 14 (28%) patients. When comparing with the non-invasive methods of myocardial ischemia verification, the area under the ROC curve for MBFR was 0.961±0.019 (95% confidence interval, 0.888-0.992). The optimal cut-point was 0.92, which is corresponded by a sensitivity of 100% and a specificity of 84%. CONCLUSION: When compared with SNS for MIV, the method for measuring MBFR has a high diagnostic accuracy.

[The Time Course of Formation Of Systolic Dysfunction of the Heart in Doxorubicin Cardiomyopathy].

The anthracycline-induced cardiomyopathy is a frequent and menacing complication of antitumor therapy leading to chronic heart failure. A study of the formation of heart failure can reveal early signs of the development of systolic dysfunction of the heart. In this work in rats we studied cardiac function at different duration of doxorubicin treatment, the most effective anthracycline antibiotic. Cumulative doses of doxorubicin were 8-20 mg/kg, and the term of study lasted from 6 to 20 weeks. The echocardiography and catheterization of the left ventricle (LV) have been use. The ejection fraction and other indicators of LV contractility decreased steadily with increasing dose and duration of the study, in parallel with rat survival. However, the cardiac output related to the unit of body weight, as well as diastolic LV size, remained at a level close to control within 8-10 weeks. Only after 20 weeks when the ejection fraction decreased from 81+/-1 to 49+/-4%, diastolic LV volume increased by 59%. Invasive indicators of myocardial contractility and relaxability significantly decreased by 11 and 19% after doxorubicin dose of 8 mg/kg, while time of preejection and time of systole increased by 18 and 10%. These changes progressed with increasing doses of doxorubicin. At each dose, the relaxation constant declined relatively deeper than contractility index by 8-25%. The results show that: 1) the gradual formation of cardiac insufficiency mobilizes a variety of compensatory mechanisms that retard cardiac dilatation; 2) the development of systolic dysfunction takes place with a predominantly violation of relaxation process; 3) an elongation of the preejection period and duration of systole may serve as noninvasive criteria for the formation of the systolic dysfunction.

[The Action of Apelin-12 and Its Analog on Hemodynamics and Cardiac Contractile Function of Rats With Isoproterenol-Induced Myocardial Lesion].

Introduction of isoproterenol (beta-adrenoreceptor agonist) into rats is one of the widespread experimental models of heart failure. It is caused by diffuse ischemic damage of cardiomyocytes, followed by development of substitutive fibrosis. Apelin is a natural regulator of the myocardial contractility. The effects of apelin molecule fragment, apelin-12 and its more stable synthetic analogue, apelin-12-2 on cardiac contractile function of rats with isoproterenol-induced myocardial lesion (IML) and control animals has been studied in this work using invasive (catheterization of the left ventricle) and non-invasive (echocardiography and impedansometry) methods. Infusion of both peptides was made by sequentially increasing rate from 0.5 to 50 µg/kg/min. In the control group, efficacy of apelin-12 was low while apelin-12-2 moderately but significantly increased indices of myocardial contractility and relaxability. These changes were more pronounced in rats with IML and, in addition, the heart rate and LV systolic pressure increased in this group. These results correlate well with echocardiographic studies which showed increases of LV end diastolic volume, stroke volume and ejection fraction by 17-38%. These alterations are probably due to improved Ca2+ transport in cardiomyocytes, as in experiments on isolated cardiomyocytes both apelins have facilitated and improved Ca2+ removal from myoplasma. The results allow to conclude that apelin-12-2 seems to be a promising candidate for further development as a therapeutic agent in heart failure.

[Complex study of the rat heart at isoproterenol damage].

Introduction of isoproterenol (an agonist of beta-adrenoreceptors) to rats is one of the widespread experimental models of cardiac failure. It is caused by damage of cardiomyocytes with the subsequent development of substitutive fibrosis. The purpose of the given work was the complex characteristic of cardiac function by means of invasive and noninvasive (echocardiography and impedansometry) methods of research. Isoproterenol was injected twice with a daily interval in dozes 85, 120, 150 or 180 mg/kg. Echocardiographic study of the heart in 2 weeks revealed obvious attributes of cardiac failure (left ventricular dilatation, lowered ejection fraction) in the groups which have received high cumulative dozes of isoproterenol (300-360 mg/kg). The catheterization of the left ventricle in these groups has shown raised enddiastolic pressure, decreased maximal rate of pressure development and fall, and also lowered indices of myocardial contractility and relaxability. In the groups which have received smaller isoproterenol dozes, apparent decrease in relaxability parameters (constants of isovolumic and auxovolumic relaxation) has been revealed at only slightly changed parameters of contractility. A strong correlation between echocardiographic and invasive parameters of myocardial contractility has been found. The phase analysis of the cardiac cycle has shown a lengthening of isometric phases of contraction and relaxation, as well as duration of ejection due to shortening duration of filling of both ventricles. Cardiomyocytes isolated from hearts with obvious cardiac failure responded to electrostimulation by arrhythmic contractions and also by much slowed and incomplete removal of free Ca++ from the myoplasm. Results allow to conclude that relatively smaller extent of myocardial damage is accompanied by decreased relaxability at slightly changed contractility, while at greater degree of damage both processes fail, but delay of relaxation still prevails.

[The study of hypotensive action of dinitrosyl-iron complex with glutathione containing drug oxacom in healthy volunteers].

On the basis of earlier executed studies of hypotensive effect of dinitrosyl iron complexes (DNIC) with glutathione, the drug has been created in industrial conditions named oxacom. Preliminary pharmacological studies of oxacom have not revealed negative qualities. The drug has been now tested in 14 healthy men in whom at single intravenous introduction it caused typical response - a decrease of diastolic as well as systolic arterial pressure on 24-27 mmHg through 3-4 min with subsequent very slow restoration in 8-10 hours. The heart rate after initial rise was quickly normalized. Echocardiography revealed unaltered cardiac output in spite of reduced cardiac filling by 28%. The multilateral analysis of clinical and biochemical data has revealed an absence of essential alterations which could lead to pathological consequences. The drug is recommended for carrying out of the second phase of clinical trial. The comparative study of the efficiency of hypotensive action of oxacom, S-nitrosoglutathione (GS-NO) and sodium nitrite (NO2) in rats has shown that the duration of effect was the greatest at oxacom action.

[Quantitative myocardial perfusion assessment with magnetic resonance imaging in patients with coronary artery disease]. / Kolichestvennaia otsenka perfuzii miokarda s pomoshch'iu magnitno-rezonansnoi tomografii u bol'nykh khronicheskoi ishemicheskoi bolezn'iu serdtsa.

AIM: To elucidate feasibility of the absolute myocardial blood flow (MBF), total coronary resistance (TCR), and myocardial blood flow reserve (MBFR) quantification using MRI in patients with coronary artery disease (CAD). MATERIAL AND METHODS: A total of 19 patients with angiographically documented CAD and 9 healthy subjects were studied by MRI using double-slice saturation-recovery Turbo-FLASH sequence for monitoring myocardial first pass kinetics of Gd-DTPA-BMA at rest and during hyperemia (dipyridamole 0.56 mg/kg). The signal intensity curves were acquired within ROI for perfusion beds of the three main coronary arteries (LAD, LCX and RCA) and left ventricle cavity. Eighty five myocardial segments were included in final analysis (group 1 - supplied by <> coronary arteries, n=26; group 2 - supplied by arteries with non-significant diameter stenoses <50%, n=27; group 3 - supplied by arteries with significant stenoses >/=50%, n=32). Sixteen segments were revascularized subsequently (PCI or CABG). One-compartment model and slope-method were used for flow calculation. Myocardial and blood signal intensities were converted to concentration of Gd-DTPA-BMA according to the <> calibration curve. RESULTS: MBF was similar in groups at baseline (group 1 - 0.98+/-0.54, group 2 - 1.24+/-0.53 and group 3 - 1.28+/-0.48 ml/g/min) but significantly lower in group 3 during hyperemia (2.57+/-1.23, 2.99+/-1.14 vs. 1,79+/-0.94 ml/g/min, p<0.05). MBFR (the ratio of flow during hyperemia to flow at baseline) was significantly lower in group 3 than in groups 2 and 1 (1.4+/-0.7 vs. 2.7+/-1.3 vs. 2.9+/-1.2, respectively, p<0.01). Receiver-operator characteristic analysis of MBFR (value /=50%). TCR (mean arterial pressure divided by flow) significantly decreased (78.8+/-42.2 vs. 41.3+/-17.3 mm Hg ґ min ґ g/ml, p<0.01), MBF accordingly increased (1.61+/-0.77 vs. 2.58+/-0.91 ml/g/min, p<0.01) during hyperemia and MBFR <> (1.3+/-0.6 vs. 3.0+/-1.3, p<0.00l) in myocardial segments after revascularization. CONCLUSION: Absolute MBF and MBFR calculation by first-pass contrast perfusion MRI are feasible in patients with CAD before and after revascularization.

[Comparative assessment of resting myocardial perfusion in patients with postinfarct cardiosclerosis by electron-beam tomography and 99mTc-MIBI myocardial single-photon tomography]. / Sravnitel'naia otsenka perfuzii miokarda v pokoe u bol'nykh s postinfarktnym kardiosklerozom s pomoshch'iu élektronno-luchevoi tomografii i odnofotonnoi émissionnoi komp'iuternoi tomografii miokarda c 99mTc-MIBI.

The purpose of the study was to compare myocardial perfusion assessed by electron beam computed tomography (EBCT) with that obtained by 99mTc-sestamibi single photon emission computed tomography (SPECT) in patients with old myocardial infarction and control subjects at rest. A total of 42 patients with suspected and known ischaemic heart disease (IHD) were included in the study. 20 pts had a history of Q-wave myocardial infarction (MI), 12 pts had an old non-Q-wave MI and 10 served as controls (without perfusion defects on SPECT images at rest). Assessment of the myocardial perfusion by EBCT was performed using the short axis view and multislice mode (MSM) during injection of 50 ml of the nonionic contrast medium at 4 ml/s via cubital vein. Perfusion defects were localized by SPECT according to 6-segment model of the LV (septal, anterior, lateral, posterior, inferior and apical). Overall concordance between EBCT and SPECT was 67% for normal versus abnormal perfusion. Agreement between the 2 methods for each of the 6 segments was 81% (K = 0.62) for the anterior segment, 71% (K = 0.42) for the septal segment, 71% (K = 0.43) for the apical, 69% (K = 0.3) for the lateral segment, 48% (K = 0.13) for the posterior segment and 60% (K = -0.13) for the inferior segment. Discrepancies between the two of techniques were most notable in the posterior region. Beam hardening during passage of the contrast medium through the heart chambers and descending aorta is possible explanation of the artifacts on EBCT images. This study demonstrates that nowadays EBCT is not yet alternative to SPECT in the assessment of the myocardial perfusion in patients and further improvements of scanning techniques are necessary.