[Visualization of sinus node arteries by multislice spiral computed tomography coronary angiography].

OBJECTIVE: To assess the capabilities of multislice spiral computed tomography coronary angiography (MSCT-CA) to visualize the anatomy of the sinus node artery (SNA). MATERIAL AND METHODS: The retrospective analysis of coronary artery examinations covered 46 patients with the referral diagnosis of coronary heart disease. MSCT-CA showed no evidence of coronary artery stenosis. This sample included 23 (50%) men and 23 (50%) women; the mean age of the patients was 52.4 +/- 9.1 years; the mean height was 170 +/- 6.67 cm; the mean weight was 80.7 +/- 12.1 kg. X-ray computed tomography was carried out using a SOMATOM Definition AS+ 128-slice computed tomography scanner with retrospective ECG synchronization, reconstructed slice thicknesses of 1 and 3-mm. The Spearman correlation test was used for statistical data analysis. RESULTS: The SNA was visualized in 83% of the patients. It originated from the right coronary artery (RCA) and the circumflex branch of the left coronary artery in 84 and 16% of cases, respectively. No significant association was found between the type of heart blood supply and that of sinus node one (r = 0.06). In 18% of cases, the SNA was visualized only at the level of the ostium, allowing the assessment of the origin of the artery, and at the level of its mid-third in 32%; the distal SNA bed was visualized up to its division; in 10% of them the artery could be visualized all the way, including the division (the dissipation site). Unclear visualization of the proximal SNA was observed among 17% of the patients in whom the SNA could not be visualized with a heart rate (HR) of more than 80 beats/min in 62.5% of the patients, less than 41 beats/min in 12.5%, and 60-61 beats/min in 25%. HR was not found to be associated with the quality of SNA visualization (r = 0.09). CONCLUSION: MSCT can assess the anatomy of SNA up to the distal bed and dissipation site. In the overwhelming majority of the patients, the SNA originated from the RCA (84%) regardless of the type of heart blood supply. The best SNA visualization was noted with a HR of 50 to 80 beats per minute. There was no statistical relationship of the quality of visualization to HR.

[Structural features of cardiomyocytes in the atrialized right ventricle in patients with Ebstein anomaly].

Intraoperative biopsy specimens were used to analyze the sizes and ultrastructure of cardiomyocytes (CMC) in the atrialized right ventricle (ARV) versus those in the right ventricle (RV) and right atrium (RA) in 32 patients aged 9 months to 57 years with Ebstein anomaly. The mean CMC diameter in ARV, RV, and RA did not differ significantly in patients less than 10 years; that was equal in ARV and RV, but higher in RA in patients over 10 years of age. No specific atrial granules were found in the CMC of ARV, RV, and RA; but T system channels and multiple intercalated disks were encountered significantly more frequently than in the RA cells. Individual CMCs showed abnormal myofibrils with specific accumulations of Z-band material (more commonly in RA), as well as nuclear displacement under the sarcolemma (more commonly in ARV and RV). Conclusion. ARV cardiomyocytes preserve ventricular specificity in patients with Ebstein anomaly.

[Modern approaches to diagnostics and surgical correction of brachiocephalic arteries disorders in patients with ischemic heart disease].

The main causes of morbidity in Russia are ischemic heart and cerebrovascular disease. The mortality rate of these conditions accounts for almost 50% of all the lethality causes of the Russian population. The frequency of associated coronary and brachiocephalic arteries disorders varies from 18 to 54%. The complex evaluation of the anatomical and functional features of the disorder, as well as of the perfusion and functional heart and brain reserves allows to choose the appropriate methods of surgical treatment of patients with associated coronary and carotid disorders and to decrease the risk of intra- and postoperative cerebral and cardiac complications. The modern approaches of myocardium and cerebral revascularization enable to safely and effectively eliminate the myocardial and cerebral ischemia, to significantly decrease the risk of myocardial infarction and stroke development and to ensure the long ability to work among this group of patients. Over 500 patients with ischemic heart disease and associated brachiocephalic arteries disorders have been operated at the A.N. Bakoulev Scientific Centre for Cardiovascular Surgery for the last 5 years. The results of these operations are comparable to the ones of the leading European clinics.

[Clinical and morphological parallels in mitral valve disorders in infants with atrioventricular defect].

Mitral valves tissue samplings from children with complete (13 patients) and partial (6 patients) atrioventricular defects at the age of from I month to 3 years old were examined. The biopsy material was received during the repeat surgical operation on mitral valve, performed due to residual mitral valve regurgitation grade 3-4 at the period of time from 2 days to 1 year after radical defect correction. On histological examination the areas of myxomatous tissue degeneration occupying more than 50% of mitral valves surface were found in 6 (32%) of the 19 patients. There were dispersed star-shaped cells, architectonics disturbances, deposition of acid mucopolysaccharides and increased content of matrix metalloproteinase 13 in such areas of myxomatous degeneration. The sizes of these areas correlated with mitral valve regurgitation grade. After the radical correction of atrioventricular defect the sutures on the folds and fibrous ring of the mitral valve "cut through" reliably more often in patients with wider areas of myxomatous degeneration, which indicates poor prognosis. According to the ultrastructural classification the majority of mitral valve cells regarded as fibroblasts; there also were found cells with the signs of myogenic differentiation--myofibroblasts and isolated hystiocytes. According to the immunohistochemistry assay the cells phenotype regarded as fibroblastic and endothelial differentiation; in some patients there were found cells of smooth muscle origin.

[First experience with monitoring somatosensory and motor evoked potential during operations on the thoracic and thoracoabdominal portions of the aorta].

Specialists in Russia have recently gained vast experience in operations on the thoracic and thoracoabdominal portion of the aorta; however, studying evoked potentials for preventing lesions of the spinal marrow have not been studied in any clinic. The authors report herein their first experience in Russia in studying the function of the marrow during operations on the aorta followed by detailed description of the technique of registering evoked potentials. From June 2010 to January 2011, specialists of the Arterial Pathology Department of the A. N. Bakulev Scientific Centre for Cardiovascular Surgery under the Russian Academy of Medical Sciences carried out a neurophysiological study in a total of 19 patients during operations for thoracic and thoracoabdominal aortic aneurysms. The somatosensory and motor evoked potentials were studied using an 8-channel neuroenhancer Keypoint (Dantec, Denmark). The hospital mortality rate in the examined group amounted to 5.2% (1/19). Spinal stroke developed in 2 patients, i.e. in 10.5% (2/19). The alterations in the somatosensory and motor evoked potentials were subdivided into groups according to the morphological classification of Crawford-Cunningham. A further two patients were found to have during operation type III changes in the evoked potentials, with both having developed postoperative spinal stroke. Thus, the method of intraoperative monitoring of evoked potentials has high sensitivity and specificity and can be included into the protocol of operations on the thoracic and abdominothoracic portion of the aorta. During monitoring of evoked potentials it is necessary to maintain a permanent level of anaesthesia and myorelaxation with obligatory participation of the neurophysiologist in the operation.

[Remote results of open interventions in treatment of abdominal aortic aneurysms].

Analysed herein are the results of treating a total of 471 patients operated on at the Department of Surgical Treatment for Arterial Pathology of the Research Centre of Cardiovascular Surgery named after A. N. Bakulev under the Russian Academy of Medical Sciences for an aneurysm of the infrarenal portion of the abdominal aorta. Complicated forms of AAA were observed in 71 (15.1%) patients. Of these, 13 patients were admitted presenting with a clinical picture of aortic rupture, 56 patients with aortic wall tear (according to ultrasound and/or MSCH findings), and two patients had break of the inferior vena cava. The most frequently encountered accompanying diseases were as follows: CAD noted in 367 (78.2%) patients. Valvular heart defects were revealed in 68 (14.4%) patients. Atherosclerotic alterations of the ascending aorta were diagnosed in 97 (20.6%) patients, and an ascending aortic aneurysm in 14 (2.8%) patients. Operations on the heart were performed in 45 (19.1%) patients. Mitral valve plasty was carried out in 7 patients, and 11 patients had a history of prior interventions on the aortic root and ascending aorta (Bentall-De Bono operation in 3 patients, Carbol operation in 3 patients). 32 patients underwent reconstructive operations on coronary arteries. Transmyocardial laser revascularization of the myocardium was carried out in 4 patients. Endovascular interventions were performed in 32 (6.8%) patients (stenting or transluminal balloon angioplasty of coronary arteries). All patients underwent AAA resection with prosthetic repair. The mentioned operations were combined with the following simultaneous interventions: aortocoronary bypass grafting performed in 31 cases, carotid endarterectomy in 27 cases, and plasty of renal arteries was carried out in 48 patients. Complications in the immediate postoperative period were observed in 79 (16.8%) patients. Hospital mortality amounted to 11 (2.3%) patients. The cumulative survival rate after 1, 5 and 10 years after surgery amounted to 93%, 81% and 44%, respectively, in a complicated course amounting to 91%, 79% and 16%, respectively. The obtained findings of the study demonstrated that the results of the AAA resection should be regarded as fairly good. The main factors influencing the quality of life and surgical outcomes in abdominal aortic aneurysms are as follows: CAD, arterial hypertension, and chronic cerebrovascular diseases. In patients without accompanying diseases, the criteria of quality of life after surgery approximate to those in a healthy population.

[Modern approach towards surgical treatment of coronary heart disease in diabetic patients].

In the recent years there has been registered an increase in diabetes mellitus (DM) morbidity, especially among able-bodied citizens. The steady increase in amount of DM patients inevitably leads to the increase in the amount of diabetic CHD patients--candidates for the surgical myocardial revascularization. This article contains analysis of choice of myocardial revascularization technique in patients with CHD and concomitant DM. It also contains data from the study of endovascular and surgical treatment of CHD results in diabetic patients. This study also included postoperative complications analysis with exposure of complication development predictors and was held in Bakulev Scientific Centre of cardiovascular surgery. Results obtained in the study testify to the fact that DB increases relative risk of cardio-vascular complications (cardiac death, myocardial infarction and restenosis of special-purposed stenosis) development in patients with CHD after percutaneous coronary intervention with stenting. DM is an independent risk factor that increases myocardial infarction development risk, recurrence of stenocardia and shunt failure during the three year follow up after the coronary artery bypass grafting done in CHD patients.

[Expert assessment of operations' complexity and its interrelationship with lethal outcomes and duration of treatment].

The aim of the work was to carry out expert assessment of complexity of operations and to study interrelationship of the average score of complexity of the interventions with lethal outcome and duration of treatment in the Intensive Care Unit (exemplified by comparison with the outcomes of operations on cardiac valves performed in 2009 in the setting of artificial circulation in adult patients). Complexity was assessed by a total of 13 cardiovascular surgeons specialized in operations aimed at correcting valve defects (4 of them were from the A. N. Bakulev Scientific Centre for Cardiovascular Surgery), with none of the participants being aware of the therapeutic outcomes of each type of the operation performed. An average expert-defined score was assigned for each of the 33 names of the operations. The Kendall coefficient of concordance for all operations amounted to 0.29 (p<0.001); consensus in the complexity-score (from 69 to 85%) was achieved for 48.5% of the operations thus considered. The values of the mean scores of complexity of operations, defined by the specialists form the SCCS (2.02±0.54) were significantly lower (Wilcoxon's test; p<0.001) as compared with the average score assigned by specialists from other facilities (2.28±0.43). The duration of the stay at the ICU of the patients subdivided into groups depending on the expert score was found to differ significantly (p=0.007). The area under the ROC curve using the EuroSCORE (0.59) is suggestive of its lower accuracy in assessing the lethal outcome as compared to the expert score (0.68). The obtained findings strongly suggest advisability of using expert score of operations' complexity for solving complicated non-formalized tasks on allied problems of cardiovascular surgery and organization of public health care (accrediting of medical facilities, formation of the government order, and planning of the budget of medical facilities).

[Implantable cardioverters-defibrillators: prevention of sudden death].

The paper is devoted to review of results of clinical application of implantable cardioverters-defibrillators (ICD) as a method of prevention of sudden cardiac death (SCD). In this work definition, epidemiology, mechanism, and nosological causes of SCD are presented, followed by historical review of development of defibrillation, cardioversion, creation and improvement of implantable antiarrhythmic devices. Analysis of main clinical trials of efficacy of ICD in primary and secondary prevention of SCD has been conducted. Main advantages of these devices in patients with high risk of development of SCD are demonstrated.

[Surgical treatment of Taussig-Bing anomaly in children in the first year of life].

The history of surgical treatment, clinical features, and main variants of correction of Taussig-Bing anomaly in children during the first year of life is briefly reviewed including original data obtained in the Department of Urgent Surgery of newborn and first-year infants, A. N. Bakulev Research Centre of Cardiovascular Surgery for the period of 2000-2006.

[Atrial fibrillation: new approaches to intervention treatment].

New technologies for electrophysiological diagnosis of atrial fibrillation make possible elucidation of the mechanisms of the development and maintenance of arrhythmia and detection of the so-called arrythmogenic pulmonary veins. Radiofrequency ablation procedure (especially at the posterior wall of the left atrium) includes, besides electrical isolation of pulmonary veins, partial (parasympatic) denervation of the heart that also influences the efficiency of interventional treatment of atrial fibrillation (AF). Modem methods of interventional treatment help to efficaciously manage paroxysmal AF in 85-90% of the patients by means of radiofrequency ablation (RIA) of pulmonary veins. Combination of linear RIA and variants of the "Labyrinth" procedure using the CARTO non-fluoroscopic mapping system makes it possible to treat chronic and persisting forms of AF in patients with the left atrial volume up to 180 ml. A new algorithm for management of AF refractory to preventive anti-arrhythmic therapy.

[Causes of second operations after surgical treatment of congenital tricuspid valve abnormalities].

Main causes necessitating replacement of tricuspid valve (TV) prosthesis were calcinosis and infectious endocarditis of the bioprosthesis. Second operations after primary reconstructive surgery for the replacement of TV prosthesis were needed when medical indications did not fully justify the use of valve salving surgery by the Danielson's method and in case of procedural errors during surgery by the method of Carpentier in the initial period of mastering these approaches.

[Planning advanced research in the framework of goal-oriented scientific programs and their role in the development of cardiovascular surgery in the Russian Federation].

The role of goal-oriented scientific programs in the development of cardiovascular surgery is illustrated including its early and mature periods. Conceptual planning of such programs and their importance for the elaboration of new promising methods of diagnosis and surgical treatment of cardiovascular pathology are analysed in the context of organization of modem high-technology cardiosurgical care.

[The history of Wolf-Parkinson-White syndrome and evolution of surgical methods for its management].

Wolf-Parkinson-White syndrome (WPW syndrome) affects roughly 1% of the population. It usually occurs in subjects with normal heart function but may combine with congenital cardiac failure and cardiomyopathy. Paroxysmal tachycardia is recorded in 40-80% of he WPW patients, largely in the form of reciprocal tachycardia related to circulation of excitation in the atrioventricular junction and Kent's bundle. Development and improvement of surgical methods for the management of supraventricular tachycardia became possible with the advent of transcatheter registration of electrical activity in different heart regions and programmed heart stimulation techniques. Catheter-assisted methods for the treatment of cardiovascular disorders including arrhythmia have been extensively used in recent decades. Transvenous fulguration is one of them replaced at present by radiofrequency ablation (RFA). The discovery of WPW syndrome made possible a new approach to the the problem of sudden death in young age. Treatment of this syndrome by RFA of additional atrioventricular junction in the last 20 years permitted not only to manage the syndrome itself but also to ensure practically complete recovery of the patients.

[Possible complications of catheter ablation of atrial fibrillation].

Atrial fibrillation (AF) is the commonest form of disturbed cardiac rhythm. Hundreds of thousands of AF ablations are annually performed worldwide using different energy sources. One of the most popular methods is radiofrequency catheter ablation (RFA). This treatment is fraught with various risks being a highly complicated technical procedure. This review paper presents data on the most frequent complication of RFA, their frequency, causes, diagnosis, treatment and prevention. Much attention is given to the recognition and prevention of possible complications.

[Hybrid surgical palliation for hypoplastic left heart syndrome in newborn infants].

Hybrid surgery for the treatment of hypoplastic left heart syndrome was undertaken in 19 newborn infants from December 2007 to January 2009. An original method was used with the approach from posterolateral thoracotomy bypassing pulmonary arteries from the transverse pericardial sinus. The survival rate was 84%.

[Results of bidirectional cavapulmonary shunt operation without cardiopulmonary bypass in children with complicated congenital heart defects during the first year of life].

The authors present results of bidirectional cavapulmonary shunt operation without cardiopulmonary bypass for the treatment of complicated congenital heart defects. Temporary blood shunting during surgical intervention enables cavapulmonary anastomosis to be created without making resort to artificial circulation (AC) and limitation on the time of superior vena cava occlusion. The proposed method is free from additional risks and excludes negative effects of AC. It allows for conversion to AC as appropriate at any time during surgery in the "bypass stand-by" regime.

[Modern approaches to surgical treatment of patients with complicated and combined forms of coronary heart diseases].

The incidence of atherosclerotic lesions in coronary arteries combined with other vascular problems has been increasing during the last years. Hence, a rise in the number of patients with coronary heart disease, candidates for surgical myocardial revascularization. This paper reviews the history of surgical treatment of combined lesions of coronary and peripheral arteries and presents original criteria developed in A N Bakulev Research Centre of Cardiovascular Surgery for the choice of surgical strategy to treat multifocal atherosclerosis and postinfarction left ventricular aneurysm.

[Comparative evaluation of efficacy of intracoronary shunts in minimally invasive myocardial revascularization].

Intracoronary shunts (IS) are devices for maintaining distal coronary blood flow when placing anastomoses with coronary arteries. The use of IS ensures functional and electrical stability of myocardium during its revascularization on the working heart. There are reports of endothelial damage by IS leading to dysfunction of coronary shunts. This study compares 208 patients with and without IS. Results of surgery were evaluated during hospitalization period. The groups were matched for initial clinical and instrumental characteristics and the number of shunt placements. It was shown that minimally invasive myocardial revascularization with the use of IS when placing distal anastomoses has a number of advantages over similar surgery without IS, viz. smaller degree of intraoperative myocardial lesion, blood loss, and frequency of postoperative complications along with enhanced stability of intraoperative hemodynamics.