[Morphology of the myocardium of the interventricular septum in children with hypertrophic cardiomyopathy]. / Morfologiya miokarda mezhzheludochkovoi peregorodki u detei s gipertroficheskoi kardiomiopatiei.

OBJECTIVE: To carry out a comparative analysis of the morphology of the interventricular septum (IVS) myocardium in children with hypertrophic cardiomyopathy (HCM) and without cardiovascular pathology. MATERIAL AND METHODS: A study of myocardial biopsies of the IVS in children with HCM (n=18, 1.2-17 years) and children without cardiovascular pathology (n=11, 1-16 years) was carried out. The volume of interstitial tissue in the IVS myocardium was determined, a morphometric study of the size of cardiomyocytes (CMCs), the myofibrillogenesis level and the ploidy of CMCs was carried out, the ultrastructure of the CMCs was studied, and the localization of the gap junction protein, connexin43 (Cx43), was revealed by immunohistochemistry. RESULTS: The proportion of interstitial tissue in the myocardium of children with HCM was 9-10% and did not differ from its proportion in the myocardium of children in the control group. The diameter of the CMCs of the IVS in children with HCM reached the limit of ontogenetic growth and exceeded the parameters of the control group (average 18.9±5.7 µm vs 9.3±4.4 µm). CMCs ploidy in children with HCM was 2 times higher than CMCs ploidy in control patients (5.3c vs 2.7c). In the myocardium of children with HCM, the assembly of myofibrils most actively occurred in small CMCs. At the ultrastructural level, signs of immaturity of the contractile apparatus and intercalated discs of the CMC in HCM were demonstrated. In the myocardium of children with HCM, Cx43-containing gap junctions were more often located on the lateral surfaces of the CMC than in the myocardium of the control group. CONCLUSION: In children with HCM, a morphological picture of an increase in the size of the CMCs and their ploidy during accelerated ontogenetic development was demonstrated in combination with ultrastructural signs of immaturity of the contractile apparatus and intercalated discs and the lack of growth of interstitial tissue of the IVS myocardium compared with patients in the control group.

Effectiveness of Bokeria-Boldyrev ACH Solution in Surgerical Treatment of Adult Patients with Obstructive Hypertrophic Cardiomyopathy.

The study examined effectiveness of pharmaco-cold cardioplegia employing solutions of enhanced buffer capacity during surgery of obstructive hypertrophic cardiomyopathy in adult patients (N=51) operated during 2013-2018. In group 1 (N=28), the cardioplegia was performed with HTK (Custodiol) solution, whereas in group 2 (N=23), it was carried out with Bokeria-Boldyrev ACH solution. The mean, minimum, and maximum ages in group 1 were 46, 21, and 64 years, respectively; in group 2 - 42, 14, and 70 years, respectively. In both groups, the patients were subjected to myoectomy of exit pathway in the left ventricle according to Bokeria-Morrow operation and annuloplasty of tricuspid valve accompanied by reconstructive surgery (or replacement) of mitral valve. Atrial fibrillation (if any) was suppressed with cryoablation (-60°Ð¡) of the openings of the right and left pulmonary veins. The surgery was carried out in hypothermic mode at 28°C. The significant intergroup differences were observed in the asystole latent period after the onset of antegrade or retrograde injection of cardioplegic solution. In group 1, the asystole latent periods determined after antegrade or retrograde injection were 53±7 or 170±30 sec, respectively; in group 2 - 32±6 and 97±11 sec (p<0.0001), respectively. The mean times of aortic cross-clumping in groups 1 and 2 were 66±8 and 64±6 min, respectively; the electromechanical action of the heart restored after aortic unclamping in 35±7 and 30±6 sec, respectively. The biochemical and clinical data revealed no significant intergroup differences. Overall, novel Bokeria-Boldyrev ACH cardioplegic solution secured effective protection of the myocardium against intraoperative ischemia in adult patients with obstructive hypertrophic cardiomyopathy and significantly decreased the asystole latent period.

Implantable Cardioverter-Defibrillators are the Main Link in the Modern Concept of Sudden Cardiac Death Prevention. Problems and Prospects of the Development of the Method.

The article covers the development of the problem of sudden cardiac death prevention with the implantable cardioverter-defibrillators from the moment of creation of these devices to our days. The current concept of primary prevention of sudden cardiac death, based on the severity of manifestation of heart failure and left ventricular dysfunction, is not effective enough. Its practical application is difficult because it requires mass application of implantable defibrillators, with low predictive accuracy of these criteria in terms of development of life-threatening arrhythmias. The development of methods for visualizing the myocardium, allowing to assess the severity of myocardial fibrosis, as well as the possibilities of medical genetics, at the present stage, allows us to clarify indications for implantation of cardioverter-defibrillators and thereby significantly improve the concept of preventing sudden cardiac death with these instruments.

[Incidence of sinus node dysfunction in patients with long-standing, persistent atrial fibrillation who require simultaneous surgical correction of mitral and tricuspid valve defects and the "Maze IIIB" procedure].

BACKGROUND: Atrial fibrillation (AF) is the most common disorder of heart rhythm. A series of "Maze" surgery was developed, among which the "Maze III" modification is presently a gold standard for surgical treatment of AF. AIM: To study the sinoatrial node (SAN) function before and after the "Maze III" surgery. MATERIALS AND METHODS: The study included 100 patients (48 males) with persistent and long-standing persistent AF and valve abnormality. Mean age of patients was 59 years and mean AF duration - 4 years. Tachysystolic AF prevailed (62 %); normosystolic AF was observed in 31 % of patients; and bradysystolic - in 7 % of patients. Electric cardioversion was performed for all patients according to the standard method. After successful recovery of the sinus rhythm, the endocardial electrophysiological study (EPS) of the heart was performed. Correction of valve pathology and the "Maze IIIB" surgery were performed on days 1-2 following EPS. The SAN function was evaluated by the time of function recovery (SAN TFR). RESULTS: Using electric cardioversion, the sinus rhythm was restored in all patients. EPS showed abnormal prolongation of the corrected time for the SAN function recovery (CTSANFR) and sinoatrial conduction time (SACT) in 11 % of patients. In 2 % of patients, the abnormal prolongation of SACT was an isolated conduction disorder. In total, 13 % of patients had SAN dysfunction (SAND). These patients received implantable electric cardioverters after a surgical intervention (correction of valve abnormality and "Maze III"). The sinus rhythm recovered immediately after the surgery. On day 7, steady sinus rhythm was observed in 46 % of patients. During the postperfusion period and on the first day postsurgery, 62 % of patients had replacement atrioventricular nodal rhythm. By the time of discharge from the hospital, the nodal rhythm was observed in 25 % of patients. Starting from day 2, the replacement atrial rhythm developed in 13 % of patients, and by the time of discharge from the hospital, 24 % of patients had a stable atrial rhythm. CONCLUSION: Effectiveness of the surgical treatment for persistent and long-standing persistent AF (modified "Maze IIIB" surgery with simultaneous correction of the mitral valve (MV) and the tricuspid valve (TV)) in the early postsurgery period was 95 %. According to data of preoperative endocardial EPS, SAND was observed in 13 % of patients. Following the surgical correction of MV and TV defects and the criomodification of the "Maze IIIB" surgery, signs of SAND requiring implantation of an electric cardioverter were observed in a total of 24 % of patients.

[Sudden Cardiac Death in Patients With Ischemic Heart Disease: From Mechanisms to Clinical Practice].

Ischemic heart disease (IHD) and acute coronary syndrome are the main cause of sudden cardiac death (SCD). Incidence of SCD in patients after myocardial infarction (MI) is 4-6-fold higher than in general population. The review focuses on electrophysiological changes during acute myocardial ischemia and mechanisms of myocardial electromechanical remodeling in remote period after MI. Current data on arrhythmia substrates and triggers are presented. Nowadays, the main guide for implantable cardioverter-defibrillator (ICD) use for primary prevention of SCD is reduced left ventricular ejection fraction. The significance of this parameter has been repeatedly demonstrated in large randomized studies. However, the use of a single indicator cannot solve the problem. In this review we present analysis of modern additional predictors of fatal arrhythmias which are available in clinical practice, as well as the perspective for further research of this highly important scientific, clinical, and social problem.

[Results of endovascular treatment of abdominal aortic aneurysms].

OBJECTIVE: Studying the results of endovascular prosthetic repair in patients with abdominal aortic aneurysms. MATERIAL AND METHODS: A retrospective study of 34 elderly and aged patients (mean age 67.4±1.24 years) with severe concomitant pathology and the risk of Euroscore averagely amounting to 13.16±0.19, subjected to endoprosthetic repair for the presence of AAA. RESULTS: In all 34 cases we obtained good immediate results of endoprosthetic repair of the infrarenal portion of the abdominal aorta: positioning of stent grafts was adequate, expansion complete, with no sign of endoleak. Hospital lethality rate was 0%. The intra- and postoperative periods were not accompanied by the development of neither cardiological nor neurological complications. Analysing by the McNemar criterion showed that there was a statistically significant trend towards elevation of leukocytosis and ESR after surgery (p=0.074), and for other indices the shifts were statistically insignificant or absent. Since no signs of an inflammatory process were revealed, in all cases the postoperative wounds healed with fist intension, the alterations in the blood formula were associated with resorption of thrombotic masses in the paraprosthesis space. CONCLUSION: In all cases, implantation of the stent graft resulted in achieving the main objective, i. e. adequate isolation of the aneurysmatic sac in AAA. Dynamic follow up did not reveal any cases of stent graft dislocation, aneurysm rupture, thrombosis of endograft branches, or type 1a leaks.

[DISORDERS OF LUNG FUNCTION IN THE EARLY POSTOPERATIVE PERIOD IN PATIENTS OPERATED ON THE ASCENDING AORTA WITH THE EXPANSION OF INTERVENTION ON THE AORTIC ARCH].

Precapillary artery--arterial (bronchial artery--pulmonay artery) anastomoses, come into play in cases where the locking artery open and alveoli washed arterialized blood. Normally, these anastomoses are closed. Intrapulmonary shunts carry blood supply acinar hinder extraordinary circumstances (chronic pulmonary embolism, surgery, occurring in cardiopulmonary bypass, when the flaw of blood through the Iungs is suspended for the duration of cardiopulmonary bypass). Patients operated on the ascending aorta with the expansion of intervention on the nortic arch during the correction of pathology carry blood supply only the central nervous system. All other organs and systems at this time were protected by mild hypothermia. However, during circulatory arrest, required for correction of pathology acinar damage as a result of hypoxia, probably because there is no blood flow in the pulmonary artery and there is no blood flow in the bronchial arteries. Last, in the ordinary course of artificial circulation, capable due to arterio-arterial pulmonary anastomoses prevent hypoxic damage to acinar, not lead to persistent hypoxemia in the immediate postoperative period in these patients, as a result of violations of lung diffusion capacity.

[The assessment of mechanical heart valves stenosis in adults after aortic valve replacement: the advantage of full-flow design of mechanical valve].

The analysis of transprosthetic hemodynamics in adults after aortic valve replacement in the Bakoulev Center for Cardiovascular Surgery in 2007-2010 demonstrated the hemodynamic advantage of the concept of new full-flow mechanical aortic valve prosthesis "CorBeat". Having the same size of internal orifice and tissue annulus diameters, the values of transprosthetic parameters (peak and mean gradients, blood flow velocities) through "CorBeat" were close to physiological values of transvalvular native aortic parameters and had a tendency to be not dependent on the size of prosthesis (p = 0.63). In the article for the first time a morphometric database of geometric values of internal orifice area of normal native aortic valves in adults was used taking into account both the gender and the body surface area's of a patient. There was also used the standardized prosthesis size Z-score which represents the number of SDs by which the internal prosthesis area differs from the mean normal native aortic valve area for the patient's body surface area. The article emphasizes the need of the personal selection of the size and the type of prosthesis for any patient as well as the need for new design development of prosthetic heart valves.

[Hypertrophic cardiomyopathy. Clinical and morphological comparisons].

The paper comparatively analyzes myocardial morphology in children and adults with hypertrophic cardiomyopathy. All the cases analyzed had its obstructive form and significant asymmetric left ventricular hypertrophy--hypertrophy of the ventricular septum (VS). When stratifying the risk of sudden death from the obstructive form of the disease in adults, the most important characteristics are shown to be less than 45 years of age, stromal enlargement in the right VS closer to the endocardium of the right ventricle; and in some cases this fact must be considered when choosing a management tactic.

[The clinical variability of and approaches to treatment of life-threatening ventricular arrhythmias caused by SCN5A gene mutations].

The reasons for ventricular arrhythmias are variable enough. In many cases the presence and degree of ventricular arrhythmias cannot be explained satisfactorily by the presence of ischemic of inflammatory myocardial lesion. Now that the development of contemporary arrhythmology is associated with active development of molecular-and-genetic research methods, genetic aspects of the pathogenesis of arrhythmias are understood more clearly. Allelic series of diseases that are manifested by arrhythmias that differ clinically but result from mutations in one and the same gene have been described. This paper presents the results of molecular-and-genetic and clinical analysis of diseases caused by mutations in SCN5A gene, which codes the alpha-subunit of the sodium channel Na(v)1.5. Study of clinical manifestations of verified mutations makes it possible to more fully consider possible ways of the development of cardiac rhythm disorders and use the most optimal methods for their treatment.

[Treatment tactics for patients with combined atherosclerotic lesions of brachiocephalic and coronary arteries].

OBJECTIVE: To evaluate the tactics of surgical treatment of patients with coronary heart disease and atherosclerotic lesions of cerebral vessels in dependence of risk stratification of heart and brain complications. MATERIAL AND METHODS: One hundred and fifty-six patients were examined. Cerebral and coronary blood flow and functional state of the brain and heart were studied. According to treatment characteristics, 3 groups were singled out: patients of the 1(st) group underwent simultaneous surgery of coronary and brachiocephalic arteries, patients of the 2(nd) group were first operated for brachiocephalic arteries, in the 3(rd) group, bypass graft was performed in the first stage. RESULTS AND CONCLUSION: A role of coronary and brachiocephalic arteries, functional state of the myocardium and brain in the postoperative risk was established. The authors suggest the algorithm for choosing the order of priority of surgical interventions on coronary and brachiocephalic arteries.

One-stage correction of congenital heart disease and complex rhythm disorders.

In an 8-month-old baby, one-stage correction of an atrial septal defect, multiple right and left atrial aneurysms and non-paroxysmal ectopic right atrial tachycardia was performed. An ectopic focus of atrial tachycardia was localized by a pre- and intraoperative electrophysiological study. Postoperatively, the patient's clinical status improved significantly.

[Rehabilitation of patients with ischemic heart disease after aortocoronary bypass surgery]. / Reabilitatsiia bol'nykh ishemicheskoi bolezn'iu serdtsa posle operatsii aortokoronarnogo shuntirovaniia.

The paper outlines some experience in rehabilitating 1250 patients with coronary heart disease (CHD) undergone aortocoronary bypass surgery (ACBS). Rehabilitative measures promoted more rapid and maximally full recovery of physical fitness and cardiorespiratory parameters. The recommended groups of physical activity allow one to differentially approach to the choice of the optimum training regimen and hence to achieve the maximum training effect. The groundlessly high proportion of disabled patients with CHD after ACBS is due not to the quality of surgical treatment, but to the absence of a rehabilitative programme for this group of patients and to the presence of obsolete standard acts for definitions of disability groups by the medical-and-labor examination commission.

[Effect of different types of pharmacocryocardioplegia on the occurrence of cardiac rhythm and conduction disturbances in the early postoperative period in patients with ischemic heart disease]. / Vliianie razlichnykh vidov farmakokholodovoi kardioplegii na vozniknovenie narushenii ritma serdtsa i provodimosti v rannem posleoperatsionnom periode u bol'nykh ishemicheskoi bolezn'iu serdtsa.

109 patients who underwent operation for formation of an aortocoronary shunt (ACS) were divided into 3 groups according to the method of introducing a cardioplegic solution and reperfusion. Thirty-five patients (group 1) underwent antegrade cardioplegia and direct reperfusion. Thirty-seven (group 2) were subjected to mixed antegrade-retrograde cardioplegia. Group 3 consisted of 37 patients with myocardial protection accomplished by the same method as in group 2, but retrograde perfusion was with warmed oxygenated blood through the right atrium was conducted before removing the clamp from the aorta. The effect of various types of pharmacocryocardioplegia on the appearance of new disorders of rhythm and conductivity in the early postoperative period after ACS formation was analysed. The frequency of sinus tachycardia was less in group 3 (24%) than in groups 1 and 2 (51 and 51%, respectively, p less than 0.05). We obtained no statistically significant differences in the frequency of other types of arrhythmias in these 3 groups. However, the number of transient bundle-branch blocks and disorders of intraventricular conductivity (8.1 and 10.8%, respectively) in group 3 was also less than that in groups 1 and 2 (p less than 0.05) and their regression was faster. We believe that combined anterograde-retrograde cardioplegia applied together with retrograde reperfusion with warmed oxygenated blood is most effective not only in protection of the conduction system of the heart but also in protection of the right- and left-ventricular myocardium.