Randomized Clinical Trial of Hybrid vs. Surgical vs. Percutaneous Multivessel Coronary Revascularization: 5­year Follow-up of HREVS Trial.

Aim      To evaluate 5-year results of the HREVS (Hybrid REvascularization Versus Standarts) study.Material and methods  The study included 155 consecutive patients with multivessel coronary artery disease who were randomized into 3 groups: coronary artery bypass grafting (CABG) (n=50), hybrid coronary revascularization (HCR) (n=52) and percutaneous coronary intervention (PCI) (n=53) according to the consensus of the cardiology team on the technical and clinical feasibility of each of the three coronary revascularization strategies. The primary endpoint of the study was residual ischemia 12 months after revascularization according to data of single-photon emission computed tomography (SPECT). Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) over 5 years of follow-up, which included all-cause death, myocardial infarction, stroke, and clinically determined repeat myocardial revascularization.Results Baseline characteristics of patients did not differ between study groups. Median residual ischemia determined by SPECT data after 12 months was not statistically significantly different in the CABG, HCR and PCI groups: 6.7 [4.6; 8.8]%, 6.4 [4.3; 8.5]% and 7.9 [5.9; 9.8]%, respectively (p=0.45). Mean follow-up period was 76.5 months (at least 60 months). There were no statistically significant differences in all-cause mortality between the CABG, HCR and PCI groups, 10.6, 12.8 and 8.2 %, respectively (p=0.23). Statistically significant differences between the groups of CABG, HCR and PCI in the incidence of myocardial infarction (12.8; 8.5 and 16.3 %; p=0.12), stroke (4.2; 6.4 and 10.2 % ; p=0.13), repeat revascularization for clinical indications (23.4; 23.4 and 34.7 %; p=0.11) were not observed either. However, the cumulative 5-year MACCE value was similar in the HCR group and the CABG group but significantly lower than in the PCI group (51.1, 51.1 and 69.4 %, respectively; p = 0.03).Conclusion      HCR that combines advantages of PCI and CABG is a promising strategy for coronary revascularization in multivessel coronary artery disease. HCR demonstrates satisfactory long-term results comparable to those of CABG but superior to PCI. To confirm the safety and efficacy of HCR, a large multicenter study is required that would have a sufficient power to evaluate clinical endpoints.

[Computer modeling of the area of carotid endarterectomy with patches of various forms]. / Sposob komp'yuternogo modelirovaniya zony klassicheskoi karotidnoi endarterektomii s primeneniem zaplat razlichnoi formy.

OBJECTIVE: To describe geometric models of carotid artery bifurcation and computer modeling of carotid endarterectomy (CEA) with patches of various configurations. MATERIAL AND METHODS: The method was demonstrated on a reconstructed model of intact vessel based on preoperative CT of the affected vessel in a certain patient. Blood flow is modeled by computational fluid dynamics using Doppler ultrasound data. Risk factors were assessed considering hemodynamic parameters of vascular wall associated with WSS. RESULTS: We studied hemodynamic results of 10 virtual CEA with patches of various shapes on the example of a reconstructed intact artery in a particular patient. Patch implantation is aimed at prevention of carotid artery narrowing since simple suture without a patch can reduce circumference of the artery by 4-5 mm. This result adversely affects blood flow. On the other hand, too wide a patch creates aneurysm-like deformation of internal carotid artery bulb. It is not optimal due to a large recirculation zone. It was found that patch width approximately equal to 3 mm ensures an optimal hemodynamic result. Deviations from this median value, both upward and downward, impair hemodynamics while the absence of a patch results the worst result. CONCLUSION: The proposed computer modeling technique is able to provide a personalized patch selection for CEA with low risk of restenosis in long-term follow-up period.

[Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: in-hospital outcomes. Part 2]. / Koronarnoe shuntirovanie pri infarkte miokarda i nestabil'noi stenokardii: gospital'nye iskhody. Chast' 2.

AIM: To assess in-hospital outcomes of coronary artery bypass grafting in patients with acute coronary syndrome, depending on the presence or absence of myocardial infarction. PATIENTS AND METHODS: Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and subjected to coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction, who underwent surgery at an average of 16 (11; 20) days after manifestation of the clinical signs of myocardial infarction. The endpoints of the study were major adverse cardiovascular events during the in-hospital period: death, myocardial infarction, acute cerebral circulation impairment/transitory ischaemic attack, repeat revascularization, septic complications, multiple organ failure syndrome, wound infectious complications, requirement for repeated surgical debridement, remediastinotomy due to haemorrhage, the frequency of extracorporeal membrane oxygenation and renal replacement therapy. RESULTS: The mortality rate in the compared groups was similar: 3% (n=3) and 3% (n=2), respectively. Perioperative myocardial infarction occurred in 1 (1%) patient of the first group, with no cases of this complication observed in the second group. The frequency of reoperations due to haemorrhage in the early postoperative period in the group of unstable angina pectoris amounted to 3% (n=3) and was associated with administration of dual antithrombotic therapy, with no cases of this complication in the group of myocardial infarction. Wound complication in the second group were observed in 7.6% (n=5) and in the first group in 4% (n=4) (p=0.33). The differences turned out to be statistically insignificant for such postoperative complications as multiple organ failure syndrome, requirement for repeated surgical debridement, renal replacement therapy, and extracorporeal membrane oxygenation. The residual SYNTAX Score in the group of myocardial infarction amounted to 2.3±2.8, whereas in the group of unstable angina pectoris to 2.3±3, thus suggesting complete revascularization in the total sample of patients with acute coronary syndrome. The average length of hospital stay (including the postoperative period) in the first group amounted to 26.3±6.6 days and in the second group to 27.4±7.2 days (p=0.53). The postoperative bed-day in the group with unstable angina pectoris was 12.6±3.2 and in the myocardial infarction group - 14.9±5.3 (p=0.06). CONCLUSION: The obtained in-hospital outcomes suggest that coronary artery bypass grafting may be an efficient and safe method of complete revascularization for patients with non-ST-elevation acute coronary syndrome, including that resulting in myocardial infarction, performed averagely on day 16 (11; 20) after the onset of clinical manifestations of myocardial infarction.

First Experience of Sutureless Redo on Mitral Valve Using Valve-in-Valve Technique: Two-Stage Implantation on a Large Animal.

Sutureless implantation of the mitral valve bioprosthesis using the valve-in-valve method was performed on a large animal (sheep). According to the results of a two-stage implantation (primary implantation of a xenopericardial 26-mm framed bioprosthesis and reimplantation of the developed 23-mm bioprosthesis), minor changes in quantitative indicators were revealed: an increase in the transprosthetic gradient by 1.3 mm Hg and a decrease in the area of the mitral orifice by 21.6%. Considerable reduction in the intervention time by 18 min was achieved (by 40% in comparison with the primary prosthesis). The absence of adverse events in the animal and complications in the post-operative period, as well as physiological hemodynamic indicators indicate the safety of the developed medical device.

[Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: analysis of perioperative factors. Part 1]. / Koronarnoe shuntirovanie pri infarkte miokarda i nestabil'noi stenokardii: analiz perioperatsionnykh faktorov. Chast' 1.

AIM: The purpose of this study was to assess the perioperative clinical, demographic and anatomo-angiographic factors in patients presenting with non-ST-segment elevation acute coronary syndrome and being candidates for coronary artery bypass grafting, depending on the presence or absence of myocardial infarction. PATIENTS AND METHODS: Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and recommended by the cardiosurgical team to undergo coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction. A lethal outcome occurred in 2 (3%) Group Two patients prior to revascularization, hence they were not included into the analysis comparing the results of surgery in both groups, however these data were taken into consideration, being analysed separately. RESULTS: The group of patients with myocardial infarction appeared to include significantly more female patients (20 (30.3%) versus 15 (15.3%) in the group of patients with unstable angina pectoris, p=0.02). However, by such parameters as the average age, left ventricular ejection fraction, and the frequency of diabetes mellitus the compared groups did not differ. The group with myocardial infarction was characterised by a severe clinico-angiographic status: more frequently encountered was stage II obesity (3%, n=3 in the first group and 10.6% n=7 in the second group, p=0.04). On the whole, the majority of patients were at intermediate and high risk (44.7% in the group with unstable angina pectoris versus 81.8% in the group of myocardial infarction, p<0.05). Group Two patients significantly more often presented with three-vessel lesions of the coronary bed (40 (40.8%) and 39 (59%), p=0.02). The level of low-density lipoproteins appeared to be significantly higher in patients with myocardial infarction (3.3±1 mmol/l and 2.9±0.9, p=0.04). In the same group more often encountered were peripheral artery lesions (28 (21%) and 12 (11.3%), p=0.04). In its turn, in the group of unstable angina pectoris, there were significantly more patients having received dual antithrombotic therapy prior to surgery (44 (44.9%) and 17 (25%), p=0.01). Approximately half of the patients in the first group (53%, n=52) had a history of myocardial infarction (p=0.001). CONCLUSION: The obtained findings suggested that amongst the patients with non-ST-elevation acute coronary syndrome resulting in myocardial infarction prevailing were those of female gender, with obesity, as a consequence, hyperholesterolaemia and triple-vessel disease. At the same time, postinfarction cardiosclerosis, renal dysfunction, and haemodynamically significant lesions of lower-extremity arteries were encountered in the group of unstable angina pectoris.

[Peculiarities of the development of acute coronary syndrome in patients after coronary artery bypass grafting]. / Osobennosti razvitiia ostrogo koronarnogo sindroma u patsientov posle koronarnogo shuntirovaniia.

AIM: The purpose of the study was to analyse clinical peculiarities of the development of acute coronary syndrome in patients after coronary artery bypass grafting procedures and to evaluate the in-hospital results of treatment PATIENTS AND METHODS: Within the frameworks of a single-centre register over the period from 2006 to 2016 the study included 81 patients (with a total of more than 5000 coronary artery bypass grafting operations performed during this period). We examined the preoperative, intraoperative, and in-hospital periods, as well as the patients' status at the moment of the development of the clinical course of acute coronary syndrome, its structure and terms of manifestation, the dynamics of the coronary bed condition, also carrying out the analysis of treatment strategies and the in-hospital outcomes thereof. RESULTS: The development of acute coronary syndrome after coronary artery bypass grafting procedures was revealed in patients with a mean age of 58 (52; 63) years, with a history of postinfarction cardiosclerosis (70.37%), arterial hypertension (92.59%), dyslipidemia (51.83%), obesity (77.78%) and a multiple-vessel lesion of the coronary bed (67.90%) of intermediate risk according to the SYNTAX score estimated as an average of 26 (22; 32) points. In the structure of acute coronary syndrome having developed in patients with previously endured coronary artery bypass grafting operations, prevailing was its form of non-ST-segment elevation (87.65%), predominantly of a low risk (61.73%) which manifested itself averagely 24 (12; 35) months after the operation. The main factor of the development of acute coronary syndrome was progression of atherosclerosis (60.49%). The dominating strategy of treatment was medicamentous therapy (55.56%). The in-hospital mortality rate amounted to 2.47%. In the dynamics of the clinical status of the patients prior to coronary artery bypass grafting by the moment of the manifestation of acute cardiac ischaemia there took place a significant decrease in the left ventricular ejection fraction (p=0.01) and progression of atherosclerosis to the multifocal status (p=0.004). CONCLUSION: Patients with acute coronary syndrome, having previously endured coronary artery bypass grafting procedures appear to belong to a special cohort presenting with a series of clinical peculiarities and despite satisfactory in-hospital results do require special attention, with the development of appropriate algorithms for risk stratification and optimal therapeutic decision-making.

[The experience of development of partnership between science and health care institutions in resolving issues of circulatory system diseases].

In Russia, the process of clustering institutions at the regional level is evolved. The analysis of scientific publications revealed only several examples of efficiently functioning medical clusters. As a rule, the publications present problems or projects and perspectives of development of medical clusters. At that, no information is available concerning organizational mechanisms integration of institutions. Purpose of the study is to evaluate the results of partnership between institutions of science and practice in resolving strategic health problems related to diseases of blood circulatory system. Materials and methods. The study applied such methods as monographic approach, data derivation, statistical technique, logical and system analysis. Results. The partnership between scientific and educational institutions and practical health care organizations was analyzed on the example of the system of medical care of circulatory system diseases organized in the Kemerovo region. The effective functioning of such a partnership is based on seven integration principles. Thus, the number of treated patients increased by 7.1% from 2011 to 2018. At the same time, the number of beds decreased by 9.2%. As a result, bed turnover increased by 18.1% over this period. The work of X-ray surgery service almost doubled the rate of percutaneous coronary interventions in case of acute coronary syndrome (from 22.0% in 2011 to 42.7% in 2018). The main organizational basics of successful cooperation of institutions are succession and interdependency in work of physians and departments, joint environments of quality management, knowledge management and personnel training, shared management of research and medical activity, common production and information environment, corporate culture and traditions.

[The cellular composition of explanted bioprosthetic heart valves in infective endocarditis]. / Kletochnyi sostav éksplantirovannykh bioprotezov klapanov serdtsa pri infektsionnom éndokardite.

OBJECTIVE: To perform immunohistochemical typing of cells as a component of bioprosthetic (BP) heart valves explanted during reoperations for prosthetic valve endocarditis. MATERIAL AND METHODS: The authors investigated 8 models of KemCor and PeriCor artificial heart valves produced by NeoCor Company (Kemerovo, Russia), which were explanted from the mitral position due to infection of xenogeneic implanted material. The following markers: CD3 (T-lymphocytes), CD20 (B-lymphocytes), CD34 and VEGFR2 (endotheliocytes), CD68 (monocytes/macrophages), vimentin (fibroblasts), and α-smooth muscle actin (smooth muscle cells), were used for immunohistochemical typing of cells as a component of the analyzed samples. RESULTS: Recipient cells were found to colonize devitalized BP tissues in infective endocarditis. This process simultaneously involved several types of cells performing their functions in infectious lesion and its initiation of BP remodeling. Macrophages contributed to the sanitation of the foci of infection and destruction of BP xenotissue; endotheliocytes ensured neovascularization and resistance of the implanted valve surface to infection; fibroblasts played a role in the neoplastic transformation of collagen, and smooth muscle cells were likely to take on the role in forming the elastic framework of a leaflet and in ensuring the mechanical properties of the bioprosthesis. CONCLUSION: In the time course of development of prosthetic endocarditis, the recipient cells populate xenovalve leaflets that are a modified extracellular matrix obtained from the porcine aortic valve complex. This process is a consequence of the destruction of the BP surface and deep components. The observed cellular reactions are likely to be adaptive and to be aimed at eliminating microorganisms and regenerating structural damages.

[In-hospital outcomes of transcutaneous coronary intervention and carotid endarterectomy in hybrid and staged regimens]. / Gospital'nye rezul'taty chreskozhnogo koronarnogo vmeshatel'stva i karotidnoi éndarteréktomii v gibridnom i poétapnom rezhimakh.

The aim of this study was comparative assessment of in-hospital outcomes after hybrid and staged surgical management of patients presenting with haemodynamically significant lesions of the coronary (CA) and brachiocephalic arteries (BCA) treated by means of either endovascular or surgical techniques. Over the period from 2010 to 2017, we operated on a total of 197 patients with stenotic lesions of the carotid and coronary arteries. The strategy of revascularization included transcutaneous coronary intervention (TCI) and carotid endarterectomy (CEA). Of these, 73 (37%) patients underwent staged revascularization of the brain and myocardium in various sequence (TCI-CEA or CEA-TCI), with a mean interval between the operations amounting to 9.89±7.36 months. Unfavourable outcomes were regarded as the development of such significant cardiovascular events as myocardial infarction (MI), acute impairment of cerebral circulation, death, repeat unplanned revascularization. For hybrid strategy (TCI+CEA) the index period of assessing the outcomes was the single in-hospital period, whereas for the staged strategy it was the time period beginning from the in-hospital period of the primary operation and ending by the in-hospital period of the second stage. The groups were comparable by the absolute majority of the parameters. More than half of the patients were elderly males. One third had a history of MI. The findings of coronary angiography most often revealed lesions of 1-2 CAs. The average parameters of carotid artery stenosis, according to the BCA angiography varied from 74.9 to 82.6%, with bilateral occlusive stenotic lesions being revealed in every third patient. In connection with more frequent involvement of 1-2 CAs the patients underwent implantation of 1-2 stents. In our sample we used a total of 247 stents. Of these, 119 were uncoated and 128 were drug-eluting stents. No between-group significant differences in the development of unfavourable cardiovascular events during the in-hospital postoperative period were revealed. However, despite this, a pronounced negative tendency of the complication rate was noted in the group of staged revascularization. Non-optimal time intervals between the stages of the operations in a third of cases exceeded one year on the patient's own initiative. Nearly a quarter of patients did not come for the second stage of revascularization. An important finding of our study was no increase in the risk of stent thrombosis in hybrid operations compared with the staged approach, despite administration of a loading dose of clopidogrel after CEA, but not before TCI. Another significant result was the fact of greater availability of revascularization of the myocardium and the brain within the framework of the hybrid strategy as compared with the staged one, which may play an important role in prevention of ischaemic unfavourable events in the remote period of follow up.

Endothelialization of Polycaprolactone Vascular Graft under the Action of Locally Applied Vascular Endothelial Growth Factor.

We have previously developed a polycaprolactone (PCL) vascular graft with incorporated vascular endothelial growth factor (VEGF). Functioning of the PCL/VEGF graft in rat circulatory system over 1, 3 and 6 months after implantation into abdominal aorta was tested. Graft patency and formation of vascular wall elements were assessed histologically and by immunofluorescence staining for von Willebrand factor, CD31, CD34, and collagens I and IV and DAPI staining. Local application of VEGF promoted endothelialization and improved patency of the graft. The wall of the PCL/VEGF graft underwent remodeling due to active cellular infiltration and the extracellular matrix deposition.

[Prediction of Risk of Calcification of Heart Valve Bioprostheses on the Basis of Comprehensive Assessment of Recipients Clinical Factors and Their Compliance With Therapy].

PURPOSE: The development of the prediction methods of calcification risk of heart valve bioprostheses (BP) based on comprehensive assessment of the impact of clinical factors of the recipients and their adherence to medication. MATERIALS AND METHODS: We performed a retrospective study of clinical status and adherence to drug therapy of 170 recipients of heart valve BP with (n=63) and without (n=109) calcification. We used the method of comprehensive assessment of the analyzed parameters with estimation of prognostic coefficients for each of them, followed by calculation of integral indicators and construction on their basis of prognostic models for the various intervals of BP functioning. RESULTS: The most important risk factors of calcium-associated BP dysfunctions at any duration of observation were heart failure decompensation, as well as the discontinuation of ACE inhibitors and ß-blockers. At duration of BP functioning up to four years negative effect on prognosis produced the presence of concomitant multifocal atherosclerosis, during additional 4 (from 4 to 8) years - diabetes mellitus, and afterwards (over 8 years) - coronary artery disease. Lowering of probability of BP calcium degeneration was related to regular use of aldosterone antagonists during first 4 years after BP implantation and regular subsequent use of statins. CONCLUSIONS: Based on the comprehensive assessment of clinical status of patients and their compliance to medication it is possible to make adequate prediction models for assessment of the risk of structural dysfunctions due to BP calcification at various time intervals of remote postoperative period.

[Five-year outcomes of aorto-femoral vascular reconstructions in patients with multifocal atherosclerosis]. / Rezul'taty rekonstruktivnykh vmeshatel'stv na aortobedrennom segmente u patsientov s mul'tifokal'nym aterosklerozom.

AIM: To analyze long-term results of surgical treatment of atherosclerotic occlusive-stenotic lesion of aorto-femoral segment within the single-center prospective register. MATERIAL AND METHODS: The study included 275 patients who underwent aorto-femoral reconstructive interventions for the period 2011-2014. Inclusion criterion was indications for aorto-femoral surgery due to severe atherosclerotic lesions of the infrarenal aorta and/or ilio-femoral arteries. Mean follow-up was 54±11.6 months. RESULTS: Prognostic significance of various clinical-instrumental, anatomical-angiographic and perioperative variables has been comprehensively analyzed. Five-year outcomes and cardiovascular morbidity were assessed in consecutive patients after reconstructive procedures on the aorto-femoral segment. Multidisciplinary approach to determine optimal revascularization strategy and certain tactical and technical algorithms are necessary to improve the outcomes in these severe patients.

[Comparative assessment of in-hospital outcomes of transcatheter implantation and «open¼ prosthetic repair of the aortic valve]. / Sravnitel'naia otsenka gospital'nykh rezul'tatov transkateternoi implantatsii i "otkrytogo" protezirovaniia aortal'nogo klapana.

The authors carried out comparative assessment of in-hospital outcomes of transcatheter aortic valve implantation (TAVI) and «open¼ prosthetic repair of the aortic valve. The main criterion for inclusion into the study was the presence of indications for surgical correction of an isolated defect of the aortic valve (AV). Group One comprised 11 patients subjected to TAVI and Group Two (comparison group) consisted of 23 patients undergoing «open¼ prosthetic repair of the AV. There were no statistically significant between-group differences by the main parameters evaluated. In the Comparison Group, there was one lethal outcome; one patient developed significant haemorrhage requiring emergency mediastinotomy; more frequently revealed were pneumonia and hydrothorax, as well as wound complications. Analyzing the obtained results demonstrated comparable in-hospital outcomes of TAVI and «open¼ prosthetic repair of the AV in patients at intermediate surgical risk, despite older age of patients in the TAVI group.

[In-hospital outcomes of carotid endarterectomy depending on severity of contralateral lesion]. / Gospital'nye rezul'taty karotidnoi éndarteréktomii v zavisimosti ot razlichnoi vyrazhennosti kontralateral'nogo porazheniia.

AIM: To compare in-hospital outcomes of carotid endarterectomy (CEE) in patients with different lesion of contralateral internal carotid artery (ICA). MATERIAL AND METHODS: There were 730 CEE procedures in patients with bilateral ICA lesion for the period 2011-2016. All patients were divided into 4 groups depending on contralateral ICA stenosis grade: group 1 - stenosis up to 60% (42.6%, n=311); group 2 - 60-90% (18.7%, n=137); group 3 - 90-99% (25.9%, n=189); group 4 - occlusion (12.7%, n=93). Endpoints were unfavorable cardiovascular events including death, myocardial infarction (MI), stroke/TIA, significant hemorrhage by BARC scale (Bleeding Academic Research Consortium). RESULTS: In-hospital mortality and incidence of MI, stroke/TIA were similar in all groups. However, there were no cardiovascular complications in patients with critical contralateral stenosis or occlusion. Bleeding followed by redo surgery was the most frequent complication. Overall incidence of adverse cardiovascular events did not exceed 1.23%. CONCLUSION: There was no correlation between contralateral ICA stenosis and incidence of in-hospital adverse events including death, MI, stroke/TIA. Currently, technique of CEE is well developed that is associated with low incidence of postoperative complications.

[The Social Economic Factors and Models of Forecasting Mortality Because of Cardiovascular Diseases].

The purpose of the study is modeling and analysis of effect of social economic characteristics of regions on population mortality of cardiovascular diseases. The official data of the Federal service of state statistics of the Russian Federation were used concerning social economic indices and mortality of cardiovascular diseases in the regions of Russia in 2012. The selection of social economic indices included percentage of males in population structure, percentage of individuals of retirement age, percentage of urban population, percentage of individuals with income lower that living wage, percentage of the unemployed individuals, Gini coefficient, percentage of individuals with university education, atmosphere air pollution with emissions of permanent sources, average per capita consumption of vodka and liqueurs, criminality, percentage of regional budget for social cultural expenses, percentage of workers involved in unhealthy labor conditions from total number of population of region. The selection of indices of mortality of cardiovascular diseases included class of diseases of blood circulation system in general, ischemic heart disease and class of cerebrovascular diseases. The mortality was evaluated in overall by population and separately on able-bodied age. The modeling of dependence of mortality from social economic indices was implemented using regression analysis. The calculated ?-coefficients and coefficients of determination were applied to determine approximate input of each predictor into alteration of levels of mortality. The statistically significant mathematical models of dependence of mortality on number of social economic indices were derived. The values explain on 40-75% spreading of regional indices of mortality. The percentage of input of age factor into regional differences of mortality reaches 13-35% in various classes of cardiovascular mortality. Besides, in able-bodied age the average per capita consumption of hard alcoholic beverages (vodka and liqueurs) can be considered as a stable predictor of cardiovascular mortality with corresponding input of 5-7% in the regional differences. The other social economic indices demonstrate a statistically significant relationship only in certain indices of mortality that permits to surmise about only supposed cause-and-effect relationships.

[The Problem of Minimally Changed Coronary Arteries at Elective Coronary Angiography].

AIM: to study rates and possible causes of detecting "clean" coronary arteries at elective coronary angiography. MATERIAL AND METHODS: Medical records of 711 patients who had undergone elective coronary angiography (ECAG) between 01/04 and 31/05 2014 were retrospectively reviewed. Four groups were distinguished: group 1 - patients with normal coronary arteries (n=234), group 2 - patients with coronary artery stenoses (CAS) <60% (n=94), group 3 - patients with 60-69% CAS (n=22), group 4 - patients with CAS more or equal 70% (n=361). RESULTS: Most patients were men (p<0.001), except group 1, where women prevailed (p<0.05). Patients in groups 3 and 4 were older than in groups 1 and 2 (p=0.019). Symptoms of angina were less likely to be found in group 1 (p<0.001). History of myocardial infarction (MI) prevailed in group 4 (p<0.001). Arrhythmias were detected more frequently in group 1 (p<0.001); there were less diabetics in this group (p=0.010). Group 1 contained more patients examined before cardiac valve surgery (p<0.001). Typical angina was more often found in group 4, whereas atypical angina - in group 1 (p<0.001). Cardialgia prevailed in groups 1 and 2 (p<0.001). Holter ECG monitoring was used more frequently in group 1 (p<0.001). Symptoms of latent coronary insufficiency were mainly reported in group 1 (p=0.006). The pretest probability of ischemic heart disease (IHD) was higher in groups 2 and 4 compared to group 1 (p<0.001). CONCLUSION: Among patients who had undergone ECAG 32.9% had no CAS. Younger females without history of MI and diabetes as well as patients with atypical angina or cardialgia prevailed in this group. This group of patients had the lowest pretest probability of IHD (58%). Patients without CAS were more often scheduled for EGAG before valvular heart surgery and because of cardiac arrhythmias.

[Results of a Randomized Study: Multivessel Stenting and Staged Revascularization in Patients With ST-Elevation Myocardial Infarction Using Second Generation Drug Covered Stents].

Lack of evidence base on the use of 2-nd generation drug covered stents in patients with ST-elevation myocardial infarction (STEMI) with multivessel lesions in coronary vascular bed makes it important to conduct studies of new devices in a framework of multivessel stenting in primary percutaneous coronary intervention (PPCI) and staged revascularization. Controversial data on outcomes of the strategy of multiple revascularization in STEMI might be related to the use of previous generation coronary stents in this category of patients. Aim of this study was assessment of one year outcomes of multivessel stenting in a framework of PPCI and staged revascularization (8.6+/-4.2 days between stages) with the use of 2-nd generation drug covered stents. We showed that both multivessel stenting and staged revascularuzation might be effective options of revascularization in STEMI with the use of 2-nd generation drug covered stents and maintenance of limited time interval between PCI on infarct related artery and PCI on other coronary vessels with significant stenotic lesions. This strategy was associated with low rate of adverse cardiovascular events.

[Investigation of the structure of a functionally intact xenopericardial bioconduit after long-term implantation]. / Issledovanie struktury funktsional'no sokhrannogo ksenoperikardial'nogo bioproteza posle prodolzhitel'nogo perioda implantatsii.

AIM: to investigate the cellular composition of a functionally intact xenopericardial valve in a recipient with acquired mitral defect after long-term implantation. MATERIAL AND METHODS: A Uniline bioconduit (BC) ('Neocor', Kemerovo) removed from the heart in the mitral position at 7.2 years after implantation was investigated. Heart valve leaflets were fixed in a buffered 4% paraformaldehyde solution and imbedded in paraffin or epoxy resin. Slices made from the paraffin samples were stained with hematoxylin and eosin or underwent immunohistochemical (IHC) examination for typing endothelial cells, smooth muscle cells, macrophages, fibroblasts, and T and B lymphocytes. The epoxy resin-embedded samples were examined using light and scanning electron microscopy according to the original procedure. For this, the samples were ground and polished, then stained with toluidine blue and basic fuchsin or contrasted with uranyl acetate and lead citrate. RESULTS: Different cell types were found in the outer layers of heart valve leaflets. IHC showed that endothelial cells, macrophages, smooth muscle cells, and fibroblasts were present in the samples. A relationship was found between the degree of degenerative changes in the BC surface and the magnitude of cellular infiltration in xenotissue. This paper debates whether impaired integrity of the surface leaflet layers plays a trigger role in structural dysfunctions of the implanted valves and whether BC endothelialization has a protective effect, which can considerably reduce the immunogenicity of xenotussie and prevent the penetration of recipient cells. CONCLUSION: The paper shows that it is expedient to modify the surface of the heart valve leaflets in order to create favorable conditions for the attachment and function of endothelial progenitor cells.

[Long-term results of different approaches to revascularization in non-ST-segment elevation acute coronary syndrome and multiple coronary atherosclerosis]. / Otdalennye rezul'taty razlichnykh podkhodov k revaskuliarizatsii pri ostrom koronarnom sindrome bez pod''ema segmenta ST i mnozhestvennom koronarnom ateroskleroze.

AIM: To assess the long-term results of different approaches to treating patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS) and multivessel coronary artery disease (MVCAD). SUBJECTS AND METHODS: A total of 150 patients with NSTE ACS, in whom coronary angiography revealed MVCAD, were examined. The patients were divided into 3 groups according to the selected treatment policy: 1) percutaneous coronary intervention (PCI) (n=91 (60.6%)); 2) coronary artery bypass grafting (CABG) (n=40 (26.6%)); and 3) only medical treatment (n=9 (6%)). The mean follow-up was 27.6±3.5 months. RESULTS: The medical treatment policy in this patient sample demonstrates the worst results, with the majority of cardiovascular events developing in the hospital period. PCI in patients with NSTE ACS and multiple coronary atherosclerosis has a number of objective limitations in this patient sample, leading to suboptimal treatment outcome. CONCLUSION: The use of CABG or PCI as a myocardial revascularization technique in patients with NSTE ACS and MVCAD is characterized by a comparable satisfactory survival in the hospital and long-term follow-up periods. 12% of patients do not receive revascularization due to the extremely high risk from any of coronary blood restoring methods, which results in very many deaths largely occurring during the hospital period.

[Factors for the development of persistent postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery under extracorporeal circulation]. / Faktory razvitiia stoikoi posleoperatsionnoi kognitivnoi disfunktsii u patsientov, perenesshikh koronarnoe shuntirovanie v usloviiakh iskusstvennogo krovo-obrashcheniia.

AIM: To analyze the factors contributing to the increased risk of persistent postoperative cognitive dysfunction (POCD) in patients undergoing coronary artery bypass surgery (CABS) under extracorporeal circulation (EC). SUBJECTS AND METHODS: 257 male patients aged 45 to 69 years with coronary heart disease (CHD) undergoing elective CABS under EC were examined. In addition to conventional clinical examination, all the patients underwent neuropsychological testing 3-5 days before, 7-14 days and 1 year after CABS. Persistent POCD was diagnosed if there was a 20% decline in cognitive domains at 1-year postoperatively versus preoperatively in 20% of the tests of an entire neuropsychological battery. Binary logistic regression analysis was applied to identify the factors supposedly increasing the risk of persistent POCD. RESULTS: It was found that high baseline cognitive status, early POCD after CABG under EC, low adherence to the prescribed treatment regimen, as well as progressive carotid artery (CA) stenosis could predict with a high (85%) probability that persistent POCD might develop at 1 year after surgery. CONCLUSION: The findings are suggestive of the multifactorial origin of persistent POCD, a significant role in the development of which is played by not only the preoperative cognitive status, but also by postoperative factors, such as the degree of adherence to the prescribed treatment regimen, early POCD, and progressive CA stenosis.