[Comparative Clinical Biochemical Assesment of the State of Mycardium After Coronary Artery Bypass Surgery Performed Using Various Techniques].

We compared parameters of the state of myocardium after coronary artery bypass surgery (CABS) performed according to the following techniques--with complete cardiopulmonary bypass (CABS-CBP), beating heart bypass grafting with parallel normothermic perfusion (CABS- BH-NP), and beating heart bypass grafting (CABS-BH). Patients (n = 100, 86% men, 14% women, age 56-69 years) were divided into 3 groups with comparable sex, age, state of the myocardium, and EUROSCORE surgical risk. In group 1 patients (n = 35) we used CABS-CHB, in group 2 (n = 32)--CABS-BH-NP, in group 3 (n = 33)--CABS-BH. The following parameters were obtained on day 1 after surgery: left ventricular ejection fraction (EF, echocardiography), blood plasma levels of creatine phosphokinase (CPK), CPK-MB, and cardiac troponin I (TnI). There was no significant difference in parameters studied between groups 1 and 2 with a tendency to their more pronounced positive dynamics in group 2. In group 3 compared with groups 1 and 2 we observed significant lowering of levels of CPK (by 21.2-30.9%, p < 0.05), CPK-MB (by 9.1-13.1%, p <0.05), Tnl (by 0.6-0.7%, p < 0.05), and elevation of EF (by 9.8-11.6%, p < 0.05). Rate of development of myocardial infarction in group 3 (6.8%) was lower than in groups 1 and 2 (14.2 and 9.8%, respectively). In all groups we observed close correlation between biochemical parameters and left ventricular EF (r = 0.74-0.82, p < 0.01).

[Comparative Clinical Biochemical Assessment of the State of Myocardium After Coronary Artery Bypass Surgery Performed Using Various Techniques].

We compared parameters of the state of myocardium after coronary artery bypass surgery (CABS) performed according to the following techniques - with complete cardiopulmonary bypass (CABS-CBP), beating heart bypass grafting with parallel normothermic perfusion (CABS-BH-NP), and beating heart bypass grafting (CABS-BH). Patients (n=100, 86% men, 14% women, age 56-69 years) were divided into 3 groups with comparable sex, age, state of the myocardium, and EUROSCORE surgical risk. In group 1 patients (n=35) we used CABS-CHB, in group 2 (n=32) - CABS-BH-NP, in group 3 (n=33) - CABS-BH. The following parameters were obtained on day 1 after surgery: left ventricular ejection fraction (EF, echocardiography), blood plasma levels of creatine phosphokinase (CPK), CPK-MB, and cardiac troponin I (TnI). There was no significant difference in parameters studied between groups 1 and 2 with a tendency to their more pronounced positive dynamics in group 2. In group 3 compared with groups 1 and 2 we observed significant lowering of levels of CPK (by 21.2-30.9%, p<0.05), CPK-MB (by 9.1-13.1%, p<0.05), TnI (by 0.6-0.7%, p<0.05), and elevation of EF (by 9.8-11.6%, p<0.05). Rate of development of myocardial infarction in group 3 (6.8%) was lower than in groups 1 and 2 (14.2 and 9.8%, respectively). In all groups we observed close correlation between biochemical parameters and left ventricular EF (r=0.74-0.82, p<0.01).

[The use of computer pulse oximetry monitoring for screening of sleep apnea in patients of a hospital cardiology department].

In order to assess the overall prevalence of sleep apnea of obstructive and central origin in of patients hospital cardiology department we performed continuous pulse oximetry monitoring during sleep in all patients admitted over 2 months. Of the 139 patients reliable results were obtained in 125 (89.9%). In 72% of patients desaturation index was 5 or more, indicating probability of sleep apnea. In 36% of patients oxygen desaturation index was > or = 15, which corresponded to moderate forms of sleep apnea. And only 28% of patients had no pathological changes in the nocturnal oxygen saturation curve. Thus, in patients hospital cardiology department we revealed extremely high prevalence of sleep apnea of various origins. Showed the technical feasibility of the continuous pulse oximetry monitoring for mass screening of apnea during sleep.

[Detection of risk factors and early manifestations of cardiovascular diseases during ambulatory examination of working age persons].

We have studied prevalence of risk factors (RF) of cardiovascular diseases (CVD) recorded for statistical purposes in subjects of able bodied age during 10 year period of observation in a policlinic as well as prevalence of early and/or oligosymptomatic CVD manifestations in 11762 subjects of working age with RF of CVD development according to results of complex noninvasive examination of cardiovascular system in ambulatory conditions during the period from 2000 to 2009 year. Numbers of men and women were 45.3 and 54.7%, respectively. The program of examination included analysis of ECG, echocardiography (EchoCG), ultrasound examination of brachiocephalic vessels, 24-hour Holter ECG monitoring, exercise test on treadmill. In 2006 and 2007 complex examination was supplemented with 24-hour monitoring of arterial pressure, stress EchoCG, noninvasive arteriography. Complex ambulatory examination of subjects of working age with FR of CVD development with the use of noninvasive methods of functional diagnostics allowed to diagnose in 56% of studied persons various early and/or oligosymptomatic CVD manifestations which often appeared in combination, including ischemic heart disease (in 15%), hypertensive disease- (in 42%), cerebral atherosclerosis - (in 23.5%).

[Cystatin C level is independently related to risk of unfavorable outcome after acute coronary syndrome in individuals with normal or moderately reduced renal function].

We studied relation between cystatin C level and risk of unfavorable outcome (unstable angina, fatal and nonfatal myocardial infarction [MI], fatal and nonfatal stroke, and death) in patients stabilized after exacerbation of ischemic heart disease. Patients (n=272) were included on day 10 after onset of acute coronary syndrome. No relationship between studied outcomes and cystatin was found in a group as a whole. In patients with normal of slightly reduced renal function (glomerular filtration rate more or equal 60 ml/min/1.73 m2) unfavorable outcomes were independently associated with history of myocardial infarction and stroke, elevated levels of brain natriuretic peptide and cystatin. In subjects with moderately or severely reduced renal function elevation of cystatin level lost its significance. Risk of development of unfavorable outcomes among these subjects was independently related to history of MI and GFR <60 ml/min/1.73 m2 (OR 2.130, 95% CI 1.010-4,489; =0,047). Our data confirm possibility of use of cystatin C level measured early after ACS in patients with normal or slightly lowered renal function as a parameter characterizing risk of cardiovascular complications and death.

[Clinical value of antracycline toxicity: modern approaches to diagnosis, prevention, and treatment].

In this literature review we present analysis of various aspects of the problem of cardiotoxicity of antracyclines used for the treatment of the breast cancer. We consider mechanisms of their cardiotoxic action, role of risk factors, clinical manifestations of acute and chronic cardiotoxicity, and dependence of their severity on treatment duration and drug dose. We give data on contemporary methods of diagnostics of early toxic cardiac effects of antracyclines from the side of cardiovascular system. We also conducted assessment of possibility of prevention of toxic action of antracyclines with the use of combination of different methods including dose sparing regimens and schemes of treatment, combinations of drugs, use of cardioprotectors as well as novel preparations from the antracycline group, possessing lesser cardiotoxicity. Clinical and experimental data on the treatment of manifestations of cardiotoxicity with consideration of pathogenetic mechanisms of their development are given.

[The use of screening methods in diagnosis of disturbances of respiration during sleep in patients with cardiac pathology].

Disturbances of respiration during sleep especially those of obstructive character are sufficiently widespread phenomena. In addition to worsening of the quality of sleep itself they facilitate formation and development of concomitant pathology of cardiovascular system, endocrine system, cognitive sphere. This results in lowering of quality of life and its duration. At present standard method of diagnosis of disturbances of respiration during sleep is polysomnographical examination. At the same time more accessible screening methods are also actively used with the aim of detection of subjects with high probability of respiratory disturbances during sleep. Among them cardiorespiratory monitoring, nocturnal pulsoximetry, registration of oro-nasal flow during sleep, are questionnaires most widely-spread.

[Drug prevention of pulmonary embolism in orthopedic practice: traditional and novel approaches].

We consider in this review traditional and novel approaches to drug prevention of pulmonary embolism (PE) which in predominant number of cases is related to deep vein thrombosis of lower extremities. Risk of PE development is especially high in patients after orthopedic hip or knee surgery. Modern recommendations contemplate use of unfractionated and low molecular weight heparins, vitamin K antagonists (warfarin in the first place), fondaparinux. Oral direct anticoagulants related to selective inhibitors of blood coagulation factors IIa (thrombin) and Xa have appeared recently and proved their preventive efficacy and safety in randomized controlled studies. Preventive efficacy and safety of dabigatran among direct selective factor IIa (thrombin) inhibitors and of rivaroxaban, apixaban, and edoxaban among direct selective factor IIa inhibitors have been studied best.

[Gene IL6 G(-174)C and gene IL10 G(-1082)A polymorphisms are associated with unfavourable outcomes in patients with acute coronary syndrome].

We investigated the association of gene IL6 G(-174)C polymorphism and gene IL10 G(-1082)A polymorphism with coronary artery disease (CAD) in the Russian population. A total of 1145 patients with CAD diagnose on the basis of clinical studies in cardiological hospitals of Moscow, St -Petersburg, Kazan, Chelyabinsk, Perm, Stavropol and Rostov-on-Don. Supervision term was 9.10 +/- 5.03 months (the maximum term 18 months). In case of gene IL10 G(-1082)A polymorphism we determined that patients with CAD diagnose and A alleles gene IL10 had unfavorable outcome more often than patients with homozygous G alleles. Survival time from end point from carrier genotype GA and AA is 11.68 +/- 0.67 months against 12.69 +/- 0.65 months from carrier phenotype GG gene IL10 (chi2 = 4.13, p = 0.042). The group studied do not differ significantly with respect to the distributions of gene IL6 G(-174)C alleles and genotypes. However in case combined group studies of gene IL10 G(-1082)A polymorphism and IL6 G(-174)C polymorphism we determined that patients with CAD diagnose and carrier genotype GG gene IL6 and genotype GA and AA gene IL10 had unfavorable outcome more often (survival time 11.01 +/- 1.24 months) than patients with genotype CC and CG gene IL6 and genotype GG gene IL10 (survival time 13.28 +/- 0.83 months) chi2 = 10.23, p = 0.017. The obtained data allows assuming the important role of the IL6 and IL10 genes which are responsible for functioning of inflammation system, in the accelerated formation of failures at the patients who had a coronary syndrome.

[In-hospital and long-term (to 3 years) results of using bare-metal stents in patients with coronary artery disease and chronic kidney disease].

Patients (n=727) who had been subjected to implantation of one or several standard stents in 2004 were included into this study. These patients were divided into 3 groups according to initial level of glomerular filtration rate (GFR, MDRD equation): group 1 - 466 patients with GFR >60 ml/min/1,73 m(2), group 2 - 233 patients with GFR 30 - 60 ml/min/1,73 m(2), group 3 - 38 patients with GFR <30 ml/min/1,73 m(2). In all group 2 and 3 patients prevention of contrast induced nephropathy (CIN) was implemented: hydration before and after angiography, limitation of intake of nephrotoxic drugs, N acetylcysteine 600 mg/day orally. In all group 2 and 3 patients only contrast preparation iodixanol was used. Total amount of contrast did not exceed 350 ml in patients with GFR 45-59 ml/min/1.73 m(2) and 250 ml - with GFR <45 ml/min/1.73 m(2). In all patients with GFR 60 ml/min/1.73 m(2) low osmolar contrast preparations were used (total amount - less then 600 ml per patient). Immediate success of PCI was similar in all groups (99.4%, 98.2% 97.4%, respectively). Rate of CIN rose significantly in groups 2 and 3 (0.4%, 4.9%, 13.2%, respectively, <0.001). Before 6 months after PCI restenosis developed more frequently with lowering of GFR (group 1 - 11%, group 2 - 22%, group 3 - 34%, <0.001). Myocardial infarction developed by 3 years in 6, 10, and 26% of patients in groups 1, 2, and 3, respectively. Lethality during 3 years was 5, 10, and 24% in groups 1, 2, and 3, respectively. Regression analysis showed that as a whole 3 years rate of myocardial infarction rose 1.57 times in group 2 compared with group 1, and 3.91 times in group 3 compared with group 1. Mortality by 3 years rose 1.93 times in group 2 compared with group 1, and 4.52 times in group 3 compared with group 1. Thus, presence of initially lowered GFR increases risk of CIN after elective implantations of standard stents, leads to rise of restenosis rate by 6 months and increase of mortality and rate of nonfatal myocardial infarction by 3 years.

[The role of reduction of glomerular filtration rate in outcomes of drug-eluting stents implantation in patients with ischemic heart disease and chronic kidney disease].

Patients (n=432) subjected to percutaneous coronary interventions (PCI) with implantation of one or more drug eluting stents (DES) in 2005 were included in this study. These patients were divided into 3 groups according to baseline glomerular filtration rate (GFR): group 1 - GFR 60 ml/min/1.73 m2, n=271, group 2 - GFR 30-60 ml/min/1.73 m2, n=132, group 3 - GFR <30 ml/min/1.73 m2, n=29. In all patients only contrast preparation iodixanol was used and prevention of contrast induced nephropathy (CIN) was implemented. Immediate success of PCI was higher and comparable between groups. Rate of development of CIN turned out significantly higher in groups 2 and 3 (6.8 and 17.2% compared with 0.7% in group 1, <0.001). During 12 months of follow up restenosis rate was higher in groups 2 and 3 (15.9 and 27.6% compared with 6.6% in group 1, <0.001). Lowered GFR became predictor of long term (up to 3 years) mortality in patients with CKD as for group 2 compared with group 1 relative risk (RR) of death was 1.77 (95%CI 1.19-3.74, =0.001), and for group 3 compared with group 1 - 3.69 (95%CI 1.58-6.87), =0.001. In addition lowered GFR was predictor of nonfatal myocardial infarction (MI) up to 3 years: for group 2 compared with group 1 RR 1.69 95%CI 1.12-3.07, =0.009, for group 3 compared with group 1 RR 3.44 95%CI 1.37-6.19, =0.001. The conducted study showed that initially lowered GFR after stenting increased risk of development of CIN, led to rise of restenosis rate and repeat revascularizations up to 12 months, and also appears to be predictor of death and nonfatal MI in remote period up to 3 years.

[The risk factors and predictors of the clinically significant progression of atherosclerosis in patients with chronic lower extremity ischemia].

AIM: To define the risk factors and predictors of atherosclerosis progression leading to clinical worsening in patients with chronic lower extremity ischemia (CLEI). SUBJECTS AND METHODS: Two hundred and forty patients with lower extremity arterial (LEA) atherosclerosis were examined. All the patients underwent color duplex ultrasound scanning of the great arteries supplying blood to the brain and LEA. Later on an annual observation was made for 11 months to 11 years (mean 45.6 months). To evaluate the influence of various factors on the progression of LEA atherosclerosis, the authors estimated overall survival without progression of CLEI. RESULTS: The one-year overall CLEI progression-free survival was 93.5% (SE = 0.016); 5- and 7-year survival was 66.9% (SE = 0.040) and 53.7% (SE = 0.054), respectively. Over 5 years, a clinically significant progression of CLEI was noted in 32% of the smokers and in 8% of the non-smokers, also in 26% of the patients with grade 1 or 2 hypertensive disease (HD) and in 43% of those with grade 3 HD. The overall CLEI progression-free survival did not depend on the severity of type 2 diabetes mellitus (patients with the severe course were excluded from the analysis). LEA atherosclerosis showed a significantly rapider progression in patients with increased common carotid intima-media thickness (IMT) (p = 0.004). During 5 years, CLEI progression occurred in 18% of the patients with an IMT of < or = 1.0 mm and in 38% of those with an IMT of more than 1.0 mm, in 15% of the patients without hemodynamically significant stenosis (HDSS) of brachiocephalic arteries (BCA) and in 52% of those with HDSS of BCA, as well as in 20% of the patients without ischemic heart disease (IHD) and in 36% of those with symptoms of IHD. CONCLUSION: Smoking that increases the risk of CLEI progression by 2.1 times and severe hypertension are the most important factor influencing the progression of atherosclerosis. The IMT index is a universal predictor of progressive atherosclerosis. It may be presumed that there is a higher process development rate in the detection of HDSS of one of the arterial beds (LEA, BCA, and symptoms of IHD) at the first examination.

[Immediate and remote results after percutaneous transluminal coronary angioplasty and coronary bypass surgery in patients with multivascular involvement of coronary arteries].

Relatively little time has passed since elaboration and introduction of coronary angioplasty however interventional cardiology in these years has made a swift leap in its development. Initially coronary interventions were carried out only on isolated proximal stenoses but later interventions became to be performed on more complex lesions of coronary arteries and then on multivessel disease intruding into area which previously had belonged exclusively to coronary bypass surgery. Although both methods of revascularization rapidly developed the researchers were interested in assessment and comparison of results of two strategies. Thus studies appeared in which patients were randomized for coronary bypass surgery or percutaneous coronary angioplasty. Below we present data of the largest and most interesting studies in which these strategies of revascularization in patients with multivessel involvement have been compared. We also separately consider results of revascularization in a subgroup of patients with diabetes mellitus.

[The use of tirofiban in invasive treatment of patients with non-ST-elevation acute coronary syndrome].

The study assessed 123 patients with non-ST-elevation acute coronary syndrome who were randomized into two groups: percutaneous coronary intervention (PCI) (62 patients) and PCI against background of tirofiban injection (61 patients). The results of the study were estimated during the early (up to 30 days) and the late (up to 180 days) follow-up. It was stated that the use of tirofiban has led to the increase of minor bleedings (11% versus 4.8%, p<0.05), but the total amount of bleedings between the groups did not differ: 19.7% in the tirofiban group versus 14.5% in group I. The use of tirofiban has led to the significant growth of the LV ejection fraction (5+/-4% versus 2+/-3%, p<0.05) and increment of the LV wall motion index (0.28+/-0.18 versus 0.12+/-0.21, p<0.001). There was no difference in the frequency of the early events: 9.6% versus 8.2% in the groups without and with the use of tirofiban accordingly (p<0.05). The use of tirofiban was associated with the decrease in the frequency of all events during the first 180 days after PCI: 30.7% in group I and 13.1% in the tirofiban group (p<0.005). Absence the main cardiovascular complications according to Kaplan-Meier method for all patients amounted to 77+/-6%, in the group of the patients who received tirofiban 88+/-6%, and 64+/-8% in the group of the patients who did not receive tirofiban (p=0.009). Thereby, the use of tirofiban in the treatment of the patients with non-ST-elevation acute coronary syndrome does not lead to the increase in the frequency and severity of bleedings. At the same time, the use of tirofiban in the treatment of the patients with acute coronary syndrome has a significant influence on the growth of the LV wall motion index and the LV ejection fraction by increasing them. Under these conditions when using tirofiban in the late period the frequency of all events during PCI is 2.3 times lower compared to the patients who did not receive tirofiban.

[Thienopyridines in the treatment and prevention of cardiovascular diseases. Part I. Ticlopidine].

In a series of articles the authors consider clinical pharmacology and experience of clinical application of blockers of platelet P2Y12 receptors, most well known representatives of which ticlopidine and clopidogrel according to chemical structure belong to thienopyridine derivatives. In the first communication pharmacodynamics and pharmacokinetics of the first thienopyridine ticlopidine are described in detail. Results of randomized studies in which cerebro and cardioprotective efficacy and safety of ticlopidine was studied in patients with cerebrovascular, peripheral artery diseases, and acute coronary syndromes are discussed. It has been established that ticlopidine is more effective and safe in patients having undergone coronary and femoral bypass surgery. Results of meta analyses have shown which evidence that ticlopidine is not less and may be more effective than clopidogrel in patients after coronary bypass surgery. Most frequent and most severe side effects of ticlopidine and measures of their prevention are also considered.

[Percutaneous coronary interventions on unprotected left main coronary artery: contemporary outlook of the problem].

UNLABELLED: Coronary bypass surgery in patients with lesions in unprotected left main coronary artery (LMCA) remains gold standard of treatment. However there is a tendency to more frequent use of percutaneous coronary interventions (PCI) in patients with such lesions. Is PCI of LMCA justified, what is complication rate of PCI of LMCA? In order to answer these questions we analyzed modern studies in which PCI with the use of standard metal and drug eluting stents were carried out in patients with lesions in unprotected LMCA. Studies in which PCI was compared with coronary bypass surgery was also reviewed. CONCLUSION: Registry data, in which PCI and coronary bypass surgery were compared showed promising results of PCI, but designs of these studies did not allow to make unequivocal conclusion. The authors of considered studies has agreed that for definite reply randomized multicenter trials are required.

[Stenting of unprotected left main coronary artery: complications during 3 years follow up].

Aim of investigation was to study complications during 3 years follow up of patients after implantation of standard metal stents (SMS) in unprotected left main coronary artery (LMCA). Patients with high risk of surgery (n=124) with stenting of unprotected LMCA performed between August 2002 and November 2004 were included in this investigation. Study end points were death, myocardial infarction, repeat vessel revascularization. Success of intervention was achieved in 96.7% of cases. Mean duration of follow up was 38.1 +/- 1.8 months. Death due to cardiac causes was registered in 6.5% of cases, 3 of these deaths were sudden. Noncardiac mortality was 3.2% (4 patients died). Peripheral complications were noted in 1 case: in one patient pseudoaneurism of femoral artery developed and was successfully resolved by compression under ultrasound control. Restenosis in stented segment during follow up was noted in 25 patients (20.2%). Repeat percutaneous coronary intervention (PCI) was carried out in 18 patients. In other cases patients were referred to coronary bypass surgery. Total survival of patients in the investigation was 95.2, 91.9, 90.3% in 1, 2, an 3 years, respectively. Despite high success of PCI of unprotected LMCA with the use of SMS and relatively low percent of restenosis it is necessary to use this method carefully in the treatment of patients with lesions in unprotected LMCA. We consider PCI in unprotected LMCA justified only in patients with high risk of surgical intervention who are not suitable candidates for coronary bypass surgery.

[Diagnosis of malignant pericardial mesothelioma].

Continuing growth of rate of detection of primary tumors of the heart has been noted recently. Prevalence of cardiac tumors in European population according to data of different authors varies from 25 to 5500 cases per 1 million of autopsies. Malignant mesothelioma belongs to most rarely met tumors. In most cases pericardial malignant mesothelioma possesses high secretory capacity what allows to suspect tumorous process in hemorrhagic pericarditis with recurrences after repetitive punctures. The paper contains description of a patient with malignant pericardial mesothelioma. Special feature of this case has been atypical clinical course of the disease complicated by development of acute myocardial infarction of posterior left ventricular wall.

[Myxoma of the cor triatriatum].

We present a rare case of myxoma in a patient with cor triatriatum. This pathology was symptomless and was revealed at transthoracic echocardiographic examination in a patient with ischemic heart disease. The patient was successfully subjected to surgery which consisted in removal of the tumor together with accessory membrane to which myxoma was attached and reconstruction of the atrial wall. In international medical literature we found no communication on the combination of myxoma with cor triatriatum.