An Increase in the Left Atrium Volume During Exercise is Associated With a Positive Result of a Diastolic Stress Test in Patients With Arterial Hypertension.

AIM: To study the relationship between changes in left atrial volume (LAV) during exercise and the result of a diastolic stress test (DST) in patients with arterial hypertension (AH). MATERIAL AND METHODS: The study included 219 patients with AH without ischemic heart disease and atrial fibrillation. During the DST performed before and after exercise, the ratio of transmitral flow velocity to mitral annular velocity (E/e'), the left atrial global longitudinal strain in the reservoir phase (reservoir strain), and LAV were determined. The criterion for a positive DST was an increase in E/e' ≥15. RESULTS: A positive result of DST was observed in 90 (41.1%) patients. Patients with positive DST were older (65.0 and 59.0 years); among them, there were fewer men (24.4 and 41.1%), but more patients with obesity (66.7 and 40.3%) and diabetes mellitus (36.7 and 8.5%). At rest, patients with positive DST had higher E/e' ratio (11.5 and 8.8), pulmonary artery systolic pressure (29.0 and 27.0 mm Hg), and LAV (60.0 and 52.0 ml), but a lower left atrial reservoir strain (20.0 and 24.0%). During exercise in patients with positive and negative DST, E/e' increased by 5.46 and 0.47 units, respectively. Changes in the LAV and reservoir strain during exercise in these groups were directed differently. In patients with positive DST, the left atrial reservoir strain decreased by 1.0 percentage points (pp) whereas in patients with negative DST, it increased by 8.0 pp. During exercise, the LAV increased by 10.0 ml in patients with a positive DST, whereas in the alternative group, the LAV decreased by 8.5 ml. The AUC for changes in LAV as an indicator of a positive DST was 0.987 while the AUC for the resting left atrial reservoir strain was 0.938. An increase in LAV >1 ml, as an indicator of a positive DST has a sensitivity of 96.9% and a specificity of 95.1%. CONCLUSION: In AH patients, changes in left ventricular filling pressure are associated with a unidirectional change in LAV. An increase in LAV during exercise by more than 1 ml can serve as a criterion for a positive DST result. This assessment was consistent with the assessment of the DST result by the E/e' criterion >15 in 94.5% of cases.

Features of Left Atrial Appendage Thrombosis in Patients With Persistent Nonvalvular Atrial Fibrillation After COVID-19.

Aim      To evaluate the incidence and characteristic features of left atrial appendage (LAA) thrombosis in patients with persistent nonvalvular atrial fibrillation (AF) after COVID-19.Material and methods  Transesophageal echocardiography (TEE) was performed for 469 patients (57.4 % males; mean age, 64.0 [58.0; 70.0] years) with persistent nonvalvular AF before scheduled sinus rhythm restoration. In 131 of these patients (27.9 %), the most recent episode of arrhythmia developed during the coronavirus infection. The time from the onset of COVID-19 to TEE was 145 [62; 303] days. All patients received an adequate anticoagulant therapy, in most cases, with direct oral anticoagulants for at least 3 weeks preceding the study.Results A LAA thrombus was detected in 20 (5.9 %) patients who have had no coronavirus infection and in 19 (14.5 %) patients after COVID-19 (р=0.0045). 18 of 19 (94.7 %) thrombi found in patients who have had COVID-19 were mural whereas only 5 (25.0 %) of such thrombi were found in patients who have had no COVID-19 (p<0.0001). In the absence of LAA thrombus, the LAA emptying velocity was 32.0 [25.0; 40.0] cm/sec whereas in the presence of a mural thrombus, it was 25.0 [20.0; 32.3] cm/sec, and in the presence of a typical thrombus, it was 17.0 [13.5; 20.0] cm/sec (р<0.0001). A Kaplan-Meier analysis showed that the median time of mural thrombus dissolution was 35.0 (95 % confidence interval (CI), 24.0-55.0) days and for a typical thrombus, this time was 69.0 (95 % CI, 41.0-180.0) days (р=0.0018).Conclusion      Patients with persistent AF who have had COVID-19 had LAA thrombosis 2,5 times more frequently and, in most cases, the thrombus was mural. Mural thrombi, in contrast to typical, are not associated with a pronounced decrease in LAA emptying velocity and dissolve twice as fast as typical thrombi with an adequate anticoagulant treatment.

Left Atrial Strain as a Predictor of Diastolic Stress Test Results in Patients With Arterial Hypertension.

Aim      To study a possibility of using the left atrial strain (LAS) for predicting results of the noninvasive diastolic stress test (DST) in patients with arterial hypertension (AH).Material and methods  The study included 98 patients previously diagnosed with AH. As a part of evaluation for complaints of dyspnea, palpitation or pain in the area of the heart, DST and transthoracic echocardiography were performed. Echocardiography included measurements of LAS in the reservoir phase, left atrial volume index (LAVI), pulmonary artery systolic pressure (PASP), and ratio of early filling transmitral flow velocity to mitral annular velocity (Е / е').Results The DST was negative in 52 patients (group 1) and positive in 46 patients (group 2). Group 2 had greater values of mean Е / е' (11.0 [9.4; 12.6] vs 9.0 [7.9; 11.1], р=0.0003); LAVI (33.8 [29.0; 40.0] ml /m2 vs 28.0 ml /m2 [25.0; 32.9], р=0.0001); and PASP (29.0 mm Hg [28.0; 30.0] vs 26.0 mm Hg [25.0; 28.0], р<0.0001 were greater, but LAS values were lower (19.0 % [18.0; 21.0] vs 24.0 % [22.0; 28.0], р<0.0001. The predictive capability of LAS with respect of heart failure was higher than of other echocardiographic parameters. The area under the ROC curve (AUC) for the reservoir strain was 0.922 (95 % confidence interval, CI, 0.851-0.967), which was significantly greater than for Е / е': 0.713 (0.613-0.800); the LAVI was 0.724 (0.624-0.809); and the PASP was 0.764 (0.668-0.844). A LAS value in the reservoir phase less than 22 % predicts a positive result of DST with a probability of 88.9 % (76.5-95.2 %). Higher values of the strain allow expecting a negative DST result with a probability of 88.7 % (77.4-94.7 %).Conclusion      If the DST cannot be performed for a noninvasive diagnosis of heart failure with preserved ejection fraction, a positive result of this test can be predicted by a decrease of LAS in the reservoir phase to 21 % or lower. The diagnostic accuracy of this criterion is 88.8 % (81.0-93.6 %).

The left atrial appendage thrombosis of in patients with persistent atrial fibrillation after the novel coronavirus infection.

Aim      To evaluate the incidence and features of left atrial appendage (LAA) thrombosis in patients with persistent atrial fibrillation (AF) after novel coronavirus infection (COVID-19).Material and methods  Percutaneous echocardiography (pcEchoCG) was performed for 128 patients with persistent AF prepared for cardioversion, 36 (28.1 %) of whom had had COVID-19. In 3 (8.3 %) patients, the lung lesion area was 50-75 %; in 31 (86.1 %) patients, 25-50 %; in 1 (2.8 %) patient, less than 25 %. One patient had no lung lesion. Median time from the onset of COVID-19 to the patient enrollment in the study was 76.5 days. At the time of enrollment, the polymerase chain reaction test for SARS-CoV-2 was negative in all patients.Results Patients after COVID-19 and those who had not had COVID-19 were comparable by age (62.5±9.2 and 62.4±9.1 years, respectively; р=0.956), gender (men 52.8 and 59.8 %, respectively; р=0.471), and risk of stroke (score 2.19±1.28 and score 1.95±1.35, respectively; р=0.350). Duration of the last arrhythmia episode was longer for patients after COVID-19 than for the comparison group (76.5 and 45.0 days, respectively; р=0.011). All patients received oral anticoagulants. 55.6 % of COVID-19 patients received rivaroxaban, whereas 62.0% of patients who had not had COVID-19 were treated with apixaban. Median duration of the anticoagulant treatment was longer for COVID-19 patients than for the comparison group (61.5 and 32.0 days; р=0.051). LAA thrombus was detected in 7 (19.4 %) patients after COVID-19 and in 6 (6.5 %) patients of the comparison group (р=0.030). In COVID-19 patients, the thrombus adhered to LAA wall over the entire thrombus length whereas in patients who had not have COVID-19, the thrombus had a free part that formed a sharp angle with LAA walls. In the presence of LAA thrombus, the LAA blood flow velocity was considerably higher for COVID-19 patients than for the comparison group (31.0±8.9 and 18.8±4.9 cm/sec, respectively; p=0.010). At the follow-up examination performed at 24.0 days on the average, the thrombus was found to be dissolved in 80 and 50% of patients after and without COVID-19, respectively (р=0.343).Conclusion      In patients with persistent AF after the novel coronavirus infection, LAA thrombosis was detected more frequently than in patients who had never had COVID-19; it was characterized by mural localization and was not associated with a decrease in LAA blood flow velocity.

[Diagnostic difficulties of isolated right ventricular myocardial infarction].

The article describes a case of isolated right ventricular myocardial infarction induced by proximal occlusion of the right coronary artery in a patient with the left type of heart blood supply. A specific feature of the case was detection of the McConnell's sign, which is considered characteristic of pulmonary artery thromboembolism.

Risk of Cardiovascular Complications in Patients with Persistent Atrial Fibrillation after Dissolution of a Thrombus in the Left Atrial Appendage.

Aim      To compare the incidence of cardiovascular complications (CVC) in patients with persistent atrial fibrillation (AF) following thrombus dissolution in the left atrial appendage (LAA) and in patients with persistent AF without preceding LAA thrombosis.Material and methods  The main group included 43 patients who had been diagnosed with LAA thrombosis on the first examination, transesophageal echocardiography, and who showed dissolution of the thrombus on a repeated study performed after 7.1+2.0 weeks of the anticoagulant treatment. The control group consisted of 123 patients with a risk score >0 for men without LAA thrombosis and score >1 for women without LAA thrombosis according to the CHA2DS2­VASc scale. The patients were followed up for 47.3±17.9 months. The following unfavorable outcomes were recorded: all-cause mortality, ischemic stroke or systemic thromboembolism, hemorrhagic stroke or severe bleeding, and myocardial infarction (MI).Results Unfavorable clinical outcomes were observed in 39.5 % of patients in the main group and in 3.3 % of patients in the control group (p<0.001). Furthermore, the incidence of ischemic stroke (relative risk (RR), 12.9; 95 % confidence interval (CI), 2.89-57.2), and MI (RR, 5.72; 95 % CI, 1.09-30.1) was higher in the main group. However, the number of MI cases in both groups and the number of stroke cases in the control group increased during the entire follow-up period, while the number of stroke cases rapidly increased only during the first year of follow-up.Conclusion      In patients with persistent AF, the risk of CVC after LAA thrombus dissolution remains significantly higher than in patients with AF without LAA thrombosis.

[Clinical and angiopulmonographic association in pulmonary embolism].

AIM: To detect the effect of the feature of the pulmonary vascular obstruction on the clinical manifestations of pulmonary embolism (PE). MATERIALS AND METHODS: The 127 patients with PE were included in this study. PE verified with multidetector computed tomography with pulmonary angiography. Among them were 57 patients with high-risk PE, and 39 patients with intermediate-risk PE and 31 patients with low-risk PE. The pulmonary artery obstruction index and the obstruction level were determined. RESULTS: The mean values of the pulmonary artery obstruction index in high and intermediate risk patients were 42.5%, and in low risk patients 12.5% (p0.001). The trunk or main branches obstruction was in 80.7% of high-risk PE patients, the main or lobar branches obstruction in 92.3% of intermediate-risk patients and lobar or segmental branches obstruction in 93.5% of low-risk patients. Pulmonary infarction was detected in 89.2% of patients with the segmental branches obstruction and with another level of obstruction in 28.0% of patients only (p0.001). CONCLUSION: The hemodynamic disorder in pulmonary embolism associate with the pulmonary artery obstruction index of more than 30%. The development of obstructive shock is associated with the pulmonary artery trunk obstruction, and the development of pulmonary infarction associated with the segmental branches obstruction.

Right Ventricular Longitudinal Strain in Acute Pulmonary Embolism and Right Ventricular Myocardial Infarction in Patients with McConnell's Sign.

Aim      To study the right ventricular (RV) myocardial longitudinal systolic strain in patient with RV myocardial infarction (MI), and pulmonary embolism (PE) with and without McConnell' phenomenon.Material and methods  This study included 53 patients with PE (mean age, 59.0±15.1 years; men, 58.5 %) and 30 patients with RVMI (mean age, 61.8±10.9 years; men, 90 %). Longitudinal strain of basal, medial and apical segments of the RV free wall (RVFW) and the interventricular septum (IVS) was determined in the mode of two-dimensional speckle tracking. Ratio of the IVS apical strain to the RVFW strain (apical ratio) was calculated. Systolic excursion of the RVFW apical segment (apical excursion) was measured in the anatomical M-mode from the apical four-chamber view.Results The McConnell's sign was observed in 23 (43.4 %) of 53 patients with PE and in 16 (53.3 %) of 30 patients with RVMI (p>0.05). Irrespective of the cause for the RV damage, patients with the McConnell's sign had higher values of the apical ratio (1.69±0.50 vs. 0.95±0.22; p<0.001; cutoff point, 1.18) and apical excursion (7.9±1.7 vs. 2.6±1.4 mm; p<0.001; cutoff point, 5.0 mm). Apical excursion closely correlated with the value of apical ratio (r=0.65; p<0.001) but not with the RVFW apical segment strain (r= -0.07; p>0.05).Conclusion      Incidence of the McConnell's sign was similar in patients with PE and RVMI. McConnell's sign is based on a passive systolic shift of the RVFW apical segment, which develops during contraction of the IVS apical segment. The greater the ratio of IVS apical segment to RBFW global strain the greater the amplitude of this shift. With the ratio value of 1.18 or more, the systolic shift of RVFW apical segment was >5 mm, which was visually perceived as the McConnell's sign.

[On the Causes of Angina Pectoris in Patients With Pulmonary Embolism].

Objective Compare the distance between the pulmonary artery (PA) and the left coronary artery (LCA) using pulmonary angiography and the rate of detection of the signs of left ventricular myocardial ischemiain the first electrocardiogram (ECG) in pulmonary embolism (PE) patients with or without angina to detect possible causes of angina pectoris.Material and Methods Measurement of the minimum distance between the PA and LCA in multislice spiral computed tomography and analysis of the first ECG were performed in 55 PE patients. 15 (27.3%) patients had angina pectoris at the onset of the disease.Results Angina pectoris was observed in 14 (93.3%) of 15 patients with the distance between the PA andLCA less than 4.3 mm, and in one (2.5%) of 40 patients with the distance between these vessels equalto or exceeding the specified value (p<0.001). In the first ECG, the ST elevation in the aVR lead wasdetected in 10 (66.7%) patients with angina pectoris, and only in 3 (7.5%) patients without anginapectoris (p<0.001).Conclusions The findings suggest that angina pectoris in acute pulmonary embolism may be caused by compression of the LCA by the dilated PA.

[Microbiocenosis and activity of the inflammatory process in the colon of the patients with chronic cardiac failure].

The aim of this work was to study colonic microbiocenosis, endotoxin level, intensity of systemic inflammation and the state of matrix metalloproteinase (MMP) system and MMP tissue inhibitors (TIMP) in 75 patients with post-infarction cardiosclerosis at different stages of chronic cardiac failure (CCF). The patients were examined by clinical, echocardiographic and laboratory methods including bacteriological analysis of feces and measurement of amino-terminal brain natriuruetic peptide, endotoxin, TNF-alpha, MMP-9, and TIMP-4. The progress of CCF was shown to be associated with increasing colonic dysbiosis, endotoxin and TNF-alpha levels, disbalance in the MMO and TIMP systems.

[Gustatory sensitivity threshold to table salt and efficacy of the treatment of newly diagnosed patients with antihypertensive therapy].

Gustatory sensitivity threshold to table salt (GST) and extracellular fluid volume (EFV) were determined in 128 patients with arterial hypertension (mean age 54.1+-0.5 yr; 79 men) before and 3 month after antihypertensive therapy. Those with the initially high GST (sensing salt in its 0.32% solution) had AP 161+-2/97+-1 mm Hg, myocardial mass 235.1+-13.2 g and left ventricular diastolic size 4.91+-0.07 compared with 151 +- 1/93+-1, 203.5+-7.8 and 4.71+-0.05 respectively in patients with low GST. The treatment resulted in a decrease of AP and EFV by 14-19 and 12% respectively in all the patients. In those with high GST it decreased after intake of indapamide by 49% vs 24 % in the absence of therapy. In patients with initially low GST it decreased (by 37%) only after intake of diuretics. It is concluded that changes of GST reflect activation of mechanisms leading to a stable drop of AP.

[The activity of components of system of matrix metalloproteinase and tissue inhibitors of metalloproteinase on different stages of chronic cardiac failure].

The article discusses the results of detection of activity of matrix metalloproteinase-9, tissue inhibitors of metalloproteinases-4, endotoxin, tumor necrosis factor-alpha, C-reactive protein, sE-selectine in blood of patients with chronic cardiac failure depending on severity of disease. It is demonstrated that progressing of chronic cardiac failure is associated with the increase of level of endotoxemia, activation of systemic inflammation and misbalance in the system of matrix metalloproteinase and tissue inhibitors of metalloproteinase.

[Features of intestine microbiocenosis and systemic inflammation factors in chronic heart failure patients].

AIM: Intestine microbiocenosis structure, endotoxinemia level, C-reactive protein (CRP) and TNFalpha concentration in chronic heart failure patients (CHF) were studied depending on disease severity. MATERIALS AND METHODS: Clinical, echocardiographic and laboratory examination of 104 patients was performed: 75 CHF patients and 29 healthy volunteers. Laboratory examination included bacteriologic analysis of feces for dysbiosis, determination of endotoxin (ET) levels, CRP and TNFalpha levels in blood serum. RESULTS: More expressed alterations in large intestine microbiocenosis and an increase of endotoxinemia and systemic inflammation factors (TNFalpha and CRP) levels were detected in patients with CHF in comparison to individuals without circulatory system pathology. CHF progression is associated with an increase of intestine dysbiosis, and ET, TNFalpha and CRP levels in blood. CONCLUSION: Endotoxinemia in CHF patients, that is caused by an increase in intestine wall permeability during development of venous congestion in systemic circulation, results in immune system activation manifesting in an increase of systemic inflammation factor level in blood that can aggravate the CHF course.

[Trends in systemic inflammatory factors and aminoterminal brain natriuretic propeptide in the treatment of chronic heart failure].

AIM: To study trends in systemic inflammatory factors and aminoterminal brain natriuretic propeptide (NT-proBNP) in the blood of patients with stage IIA and IIB chronic heart failure (CHF) during therapy aimed at reducing venous congestion. MATERIAL AND METHODS: The study enrolled 52 patients with postinfarction cardiosclerosis (PICS). Clinical, echocardiographic and laboratory studies were conducted. The levels of TNF-alpha, IL-6, IL-10 and C-reactive protein (CRP) were measured by enzyme immunoassay. The concentration of endotoxin (ET) was estimated by the end-point chromogenic LAL test, that of NT-proBNP--by immunochromotographic assay. RESULTS: In the patients with CHF, clinical signs of pulmonary venous congestion are associated with a statistically significant increase in the blood levels of TNF-alpha and CRP, those of systemic venous congestion are related to a further rise in TNF-alpha levels and elevation of blood concentrations of NT-proBNP, ET and IL-10. Treatment-related reduction in pulmonary venous congection is associated with a decrease in the levels of TNF-alpha, CRP and IL-6; that in systemic venous congestion--with lower concentrations of NT-proBNP, TNF-alpha and ET. CONCLUSION: Specific changes in the levels of systemic inflammatory factors and NT-proBNP were found in patients with CHF in the presence of pulmonary and systemic venous congestion. Treatment aimed at elimination of the latter leads to reduction in the levels of systemic inflammatory factors and NT-proBNP.

[Heart remodeling in case of isolated systolic arterial hypertension].

Examination of 32 patients with isolated systolic arterial hypertension (office blood pressure 171.9 = -3.3/79.7 +/- 0.2 mm Hg) and 54 ones with systolic/diastolic hypertension) 179.8 +/- 3.9/114.8 +/- 1.9 mm Hg) showed that the former are characterized by isolated hypertrophy of interventricular septum, the latter by symmetric hypertrophy of the septum and free left ventricular wall. Septal hypertrophy affects the initial phase of diastolic filling of the left ventricle as appears from longer time of isovolume relaxation and low peak rate of early transmitral blood flow; it does not influence diastolic function of the right ventricle. Hypertrophy of the free left ventricular wall disturbs the final stage of early diastolic filling of both right and left ventricles manifest as increased duration of their slowed early filling.

[Diffusion and diffusion-osmosis models of the charged macromolecule transfer in barriers of biosystems].

Mathematical models of the transfer of charged macromolecules have been constructed on the basis of the classical equations of electromigration diffusion of Helmholtz-Smolukhovskii, Goldman, and Goldman-Hodgkin-Katz. It was shown that ion transfer in placental (mimicking lipid-protein barriers) and muscle barriers occurs by different mechanisms. In placental barriers, the electromigration diffusion occurs along lipid-protein channels formed due to the conformational deformation of phospholipid and protein molecules with the coefficients of diffusion D = (2.6-3.6) x 10(-8) cm2/s. The transfer in muscle barriers is due to the migration across charged interfibrillar channels with the negative diffusion activation energy, which is explained by changes in the structure of muscle fibers and expenditures of thermal energy for the extrusion of Cl- from channel walls with the diffusion coefficient D = (6.0-10.0) x 10(-6) cm2/s.

[Right ventricle remodeling in patients with hypertensive disease].

Examination of 92 patients with grade I-II hypertensive disease showed that the emergence and enhancement of left ventricular concentric hypertrophy cause no changes in the volume of heart cavities and ventricular systolic function but result in the lengthening of the left ventricle and the diminishing of the right ventricle. These findings are interpreted in terms of Torrent-Guasp's theory of monolayer spiral ventricular structure.

[Simulation methods in biophysical pharmacokinetics].

The effect of low-amplitude physical fields of various natures (electric, magnetic, acoustic, electromagnetic, microwave, etc.) on drug transport in biological tissues is analyzed to assess the efficiency of combined physical and chemotherapy. The obtained data are used to develop devices for phoretic physical therapy based on combination of effects of various physical fields. Examination methods and equipment are described.

[Optimization of devices for antibiotic phoretic physiotherapy on the basis of a two-barrier model of diffusion and diffusion-osmotic migration of antibiotic anions].

One-, two-, three-, and four-component low-amplitude field phoretic effects on permeability of placental and muscular biological barriers to levomycetin, benzylpenicillin, and oxacillin anions were studied. Experimental data on exposure to constant electric fields, sinusoidal alternating magnetic field, thermal heating, and vibroacoustic and UHF effects were used to determine the mean coefficients of acceleration of antibiotic anion migration through placental and muscular barriers. The effect of physical fields was interpreted in terms of the sensitivity coefficient, total factor of systemic response of human body, and trade-off optimization index. The results of calculation of trade-off optimization index showed that the maximal relative therapeutic efficiency was observed for optimal numbers of combined fields (2-3) both for placental and muscular barriers. The obtained results showed that optimal stimulated migration of antibiotic anions in placental or muscular barrier was already observed in two-component physical fields, such as magnetoelectric, UHF-magnetic, UHF-electric, UHF-vibroacoustic, magnetovibroacoustic, electrovibroacoustic, etc. Clinical use of stimulated anion migration is illustrated by the example of its physiotherapeutic effect in male urology, ophthalmology, dentistry, and dental implantation.

[Long-term results of treatment in patients with pulmonary tuberculosis, by using main bronchial occlusion, impact of pulmonary hemodynamics].

The outcomes of treatment were analyzed in 108 patients with disseminated and complicated pulmonary tuberculosis. The patient's mean age was 38.3 +/- 4.2 years. Transsternal occlusion of the main bronchus was performed. Concurrently, the following draining interventions were made: thoracostomy, cavernotomy, cavernostomy, or stepwise thoracoplasty. Nine (8.3%) patients intraoperatively died; 20 (18.5%) patients developed recanalization of the main bronchus. Twenty-four (22.2%) patients had a progressive tuberculous process in the contralateral lung. The operation was effective and ensured recovery or stabilization of the tuberculous process in 55 (50.9%) patients. After surgery, dilatation of the pulmonary trunk was 2.8 cm; stroke volume in the pulmonary trunk was 42.4 ml and its distribution along the branches was 83% on the side of the least affection and 17% on that of the greatest affection. At diastole, there was a retrograde blood flow in the branch of the pulmonary artery of the collapsed lung in the volume of 61% of the systolic stroke volume. The calculated pulmonary pressure was 52 mm Hg. Transsternal occlusion of the main bronchus, involving stepwise draining interventions, should be considered the method of choice in treating these patients.