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Issue. Articles

2(26) // 2009

 

 

1.

 

The choice of surgical approach for ischemic muscular necrosis of the shank: amputation or stage;by;stage necrectomy

.S. Nikonenko, Ye.V. Yermolaev

Objective — to work out an optimal approach for the treatment of post-ischemic complications accompanied by acute shank ischemia.

Materials and methods. 14 patients developed muscular ischemic shank necrosis after surgical revascularization on behalf of lower limb acute ischemia within the period from1997 to 2008. Blood flow disturbances were estimated by angiography and ultrasound Doppler. The stage of acute ischemia was determined by V.S. Saveleev classification (1974).

Results and discussion. Acute cessation of arterial blood flow was caused by: thrombosis (3), embolism (3) and trauma (8). 10 (71.4 %) cases of severe blood flow disturbances in the shank and muscular ischemic necrosis resulted from acute occlusion of popliteal artery. Acute shank ischemia of II B – III A degree with signs of subfascial swelling onset was diagnosed in all patients. The following reconstructive surgery was carried out: auto-venous graft prosthesis of popliteal artery (8), popliteal artery embolectomy (2), direct abdominal aorta embolectomy (1), femoral-popliteal bypass grafting (1), thrombectomy from the branch of aortic-femoral prosthesis graft (1), crossed femoral – profound femoral bypass grafting (1). Extensive fasciotomy with decompression of all three fascial sheathes was carried out simultaneously with revascularization. Necrectomy was performed on the 2nd – 3rd day after surgery. Anterior tibial syndrome developed in 9 (64.3 %) cases. Necrotic extensors and lateral group of peroneal muscles were removed
in 3 (21.4 %) patients. Necrectomy of muscles posterior group was performed in 3 cases. Average hospital stay was 56.8 days. Positive outcome – salvage of limb and its supportive function was achieved in 13 (92.9 %) patients. The patients could walk during one year period. One amputation (7.1 %) was performed because of progressive necrosis of crural muscles.

Conclusions. Thus, the relevant approach to treatment of postischemic necrosis of crural muscles allows achieving good outcomes and saving limbs in the majority of cases.



Keywords: acute ischemia, revascularization, muscular necrosis, necrectomy.

2.

 

Combination antihypertensive therapy with angiotensin-converting enzyme inhibitors and calcium channel antagonists for correction of left ventricular diastolic dysfunction in hypertensive patients

Ye. P. Svyshchenko, . . Matova, S. V. Pavlenko

Objective — to evaluate the effect of angiotensin-converting enzyme (ACE) inhibitor spirapril and long-acting calcium channel antagonist nifedipine on the left ventricular (LV) diastolic function of II stage hypertensive patients with normal LV systolic function without symptoms of chronic heart failure.

Materials and methods. We examined 28 patients with II stage essential hypertension (EH) who were treated by spirapril (Quadropril, AWD pharma, Pliva, Croatia) in the dose of 6 mg daily. In 4 weeks nifedipine retard (Korinfar uno, AWD pharma, Pliva, Croatia) was added in the dose of 40 mg daily to increase the antihypertensive effect. The duration of the therapy was 12 weeks. At baseline and at the end of the treatment all the patients underwent general clinical examination, ambulatory arterial pressure (AP) monitoring, M-mode and Doppler echocardiography, impulse wave Doppler imaging of transmitral blood flow, venous pulmonary flow and tissue Doppler imaging of mitral annulus.

Results and discussion. The patients were divided into two groups: I group (20 patients) – had signs of LV diastolic dysfunction with abnormal relaxation diastolic filling; II group (8 patients) – had LV diastolic dysfunction with pseudonormal diastolic filling. The therapy led to a significant reduction of AP in both groups. The physiological circadian AP rhythm in non-dipper patients was restored. According to the results of Doppler echocardiography, the patients of I group manifested the decrease of isovolumic relaxation time (IVRT) from (102.9 ± 2.7) to (93.0 ± 2.5) ms, < 0.05) (transmitral blood flow), pulmonary vein atrial retrograde flow (Ar) from (0.29 ± 0.01) to (0.25 ± 0.01) m/s ( < 0.05), the increase of early diastolic mitral annular velocity m by 16.4 % ( = 0.0002) (tissue Doppler imaging). The patients of II group manifested the prolongation of IVRT from (96.0 ± 2.2) to (118.7 ± 1.4) ms, ( < 0.05) and deceleration time DT from (153.4 ± 6.9) to (210.6 ± 10.3) ms, < 0.05), the decrease of early filling velocity from (0.85 ± 0.01) to (0.64 ± 0.04) m/s, ( < 0.05) and Ar velocity by 33 % ( < 0.05).

Conclusions. The combined 12 weeks’ therapy with spirapril and long-acting nifedipine had positive influence on LV diastolic function of II stage hypertensive patients with hypertrophic and pseudonormal LV diastolic filling.



Keywords: arterial hypertension, combination therapy, angiotensinFconverting enzyme inhibitors, calcium channel antagonists, left ventricular diastolic function.

3.

 

Possibilities of intraoperative outflow measurement in prediction of thrombotic complications of infrainguinal reconstructions in patients with chronic critical lower limb ischaemia

V.N. Pshenychny

Objective — to determine the possibilities of intraoperative outflow measurement for peripheral arteries evaluation and prediction of thrombotic complications after infrainguinal reconstructions of arteries in patients with chronic critical lower limb ischaemia (CCLLI).

Materials and methods. The immediate and mid-term (within 2 years) results of surgical treatment of 76 patients after operations on account of CCLLI caused by atherosclerosis of infrainguinal arteries have been studied and analyzed. 35 patients underwent femoropopliteal bypass and 41 patients – femorotibial bypass. To assess the regional peripheral resistance of arteries, the intraoperative outflow mesurement was included into the examination program of patients, besides duplex and angiography researches. The aim of this method was to determine the quantity of physiological solution perfused through the recipient artery for one minute under the pressure of 120 cm H2O to the performance of distal anastomosis.

Results and discussion. The value of the outflow rate of less than 70 ml/min for tibial arteries was found in 10 patients, while the thrombosis of femorotibial (plantar) grafts developed in 8 (80 %), which was reliably more frequent than in patients with the outflow rate of more than 70 ml/min (in 3 patients (10.7 %) out of 28 (p = 0.001). In the group with femoropopliteal reconstructions, the outflow rate of the popliteal artery under 100 ml/min was found in 10 (28.6 %) and over 100 ml/min – in 25 (71.4 %) patients. The thrombosis of the femoropopliteal graft was registered in 7 (70 %) out of 10 patients after the operation with the outflow rate of the popliteal artery of less than 100 ml/min; and only 4 patients out of 25 (16 %, p = 0.005) with the outflow rate of more than 100 ml/min had thrombosis. The sensitivity and the specificity of the outflow measurement were 72.7 % and 93 % for the tibial segment and 63.6 %, 87.5 %, respectively, for the popliteal artery. The cumulative graft patency rate of infrainguinal grafts within 12 months was 83 % and 84 % for cases with high (more than 100 ml/min for femoropopliteal and more than 70 ml/min for femorotibial grafts) and marginal (equal to 100 ml/min and 70 ml/min) outflow rate vs. 33 % in the group with low (less than 100 ml/min and 70 ml/min) outflow rate (p < 0.05).

Conclusions. The decrease of the tibial outflow rate to less than 70 ml / min and of the popliteal outflow rate to less than 100 ml/min is a predictor of thrombotic complications after infraingvinal reconstructions of arteries in patients with CCLLI. The studies have shown the optimality of offered parameters with sensitivity and specificity of the intraoperative outflow measurement for predicting the results of femoro-popliteal reconstructions of 63.6 % and 87.5 %, and for the tibial reconstructions – 72.7 % and 93 %, respectively. The cumulative graft patency rate of infrainguinal grafts within 12 months was 84 % for patients with the outflow rate of more than 100 ml/min for femoropopliteal and more than 70 ml/min for femorotibial grafts vs. 33 % in the group with the outflow rate lower than the above mentioned indexes.



Keywords: thrombosis, prediction, infrainguinal reconstructions, surgical treatment.

4.

 

Clinical course and morphological and functional condition of myocardium in patients with chronic cor pulmonale resulting from chronic obstructive pulmonary disease depending on the presence of pulmonary hypertension

.. Amosova, L.F. Konopleva, I.D. Mazur

Objective — to define the specific features of clinical course and morphological and functional condition of myocardium in patients with chronic cor pulmonale (CCP) resulting from chronic obstructive pulmonary disease (COPD) depending on the presence of pulmonary hypertension (PH).

Materials and methods. 49 patients with CCP resulting from COPD (mean age 58.0 ± 4.4 years) were examined. Clinically significant diseases of the left heart, e.g. coronary heart disease (angina pectoris, postinfarction cardiosclerosis), essential hypertension, acquired and congenital valvular disease were excluded in the patients. 6-minute walking test (6-MWT) was used for evaluation of the functional condition of the patients. Conventional Doppler-echocardiography (Doppler-EchoCG) indices were used for evaluation of the right ventricle (RV) and the left ventricle (LV) systolic and diastolic functions and their remodeling. All the patients were divided into two groups depending on the presence of PH, according to the indexes of systolic pressure in the pulmonary artery (SPPA) obtained by Doppler research of transtricuspid blood flow. group (n = 18) consisted of CCP patients with SPPA 30
mmHG, (mean (24.8 ± 1.1) mmHG), I group (n = 31) – patients with SPPA over 30 mmHG (mean (40.3 ± 1.1) mmHG). Both groups were age, gender and COPD prescription matched. The control group consisted of 30 practically healthy persons who were age and gender matched. Reliability of differences in groups was evaluated by means of Student’s criterion.

Results and discussion. Lower extremities edema and enlarged liver were significantly more frequent (p < 0.01 for both parameters) in the group of patient with CP and PH than in the group of patients without PH. The mean distance of 6-minute walk was identical (457 ± 16.6) and (490 ± 19.1) m, respectively) and comparable with that in the control group ((505.0 ± 20.8) m; all > 0.05). In comparison with the healthy persons, the patients with CP comprising I group revealed: the increase of the RV diameter measured in parasternal position ((22.7 ± 0.3) and (18.9 ± 0.7) mm, respectively); < 0.001), thickening of RV free wall ((6.8 ± 0.8) and (4.8 ± 0.1) mm; < 0.01), reduction of the RV shortening fraction ((20.5 ± 1.3) and (23.9 ± 0.8) %; < 0.05). These indexes were changed by 24.8, 17.4, and 15.4 %, respectively, ( < 0.05) in CCP patients comprising II group in comparison with those comprising I group. The patients of both groups revealed diastolic dysfunction of the RV similar to relaxation type. II group, if compared with I group, demonstrated the reduction of / by 16.7 % and the increase of tDec by 12.0 % ( < 0.05).

Conclusions. Dilatation and hypertrophy of the RV, impaired systolic function and initial diastolic dysfunction are developed in patients with CCP resulting from COPD even before the development of PH. Such changes are evidently caused by the primary lesion of the myocardium against intoxication and hypoxia background which are typical of COPD. When PH was added, we revealed essential RV myocardium hypertrophy, its dilatation, systolic and diastolic dysfunctions progress which associate with frequent clinical symptoms of systemic venous congestion and dilated postcava but do not lead to essential deterioration of patients functional conditions according to 6-MWT.



Keywords: chronic cor pulmonale, systolic and diastolic dysfunctions of the right ventricle, pulmonary hypertension.

5.

 

Efficiency of spironolactone in treatment of patients with hypertrophic cardiomyopathy

V.Y. Tseluyko, S.V. Mordyashova, K.Yu. Kinoshenko

Objective — to evaluate the efficiency of treatment with aldosterone blocker – spironolactone – given in addition to the basic therapy with β-blockers and angiotensin II receptor blockers (ARBs) to patients with hypertrophic cardiomyopathy (HCM).

Materials and methods. Our study included 58 HCM patients aged from 11 to 71 years (mean age 45.12 ± 2.08 years), 38 of which were men (65.5 %) and 20 – women (34.5 %). The examination included: echocardiography with dopplercardiometry of transmitral blood flow on the «Sonoline G40» apparatus (Germany) against the background of synus rhythm with the cardiac contraction rate less than 90 per 1 min, Holter monitoring of ECG, 6-minutes walking test. All the patients received β-blockers and ARBs for at least 6 months. After the randomization, the patients of I group were additionally given spironolactone in the dose of 50 mg/day. The duration of the surveillance was 6–12 months. I group included 25 patients aged (44.1 ± 2.9) years, II group – 33 patients aged (45.9 ± 2.9) years.

Results and discussion. According to the results of clinical examination, Holter monitoring of ECG and 6-minutes walking test, the two groups differed neither at the beginning nor during further surveillance (p > 0.05). During the surveillance period the patients of II group manifested the increase of left ventricular mass from (218.85 ± 13.23) to (237.09 ± 11.20) g (p = 0.004), and left ventricular mass index from (95.20 ± 9.87) to (123.28 ± 7.58) g/m2, p = 0.003). No significant changes were fixed in the 1st group.

Conclusions. Spironolactone as addition to the complex therapy of HCM patients does not cause aggravation of LV outflow tract obstruction. The addition of spironolactone in the dose of 50 mg/day during 6 months to the complex therapy with β-blockers and ARBs slows down the progression of LV hypertrophy.



Keywords: hypertrophic cardiomyopathy, left ventricular hypertrophy, spironolactone.

6.

 

Dynamics of echocardiography indexes against the background of antihypertensive therapy in patients with essential arterial hypertension with bronchial asthma

V.G. Lyzogub, N.V. Altunina, O.M. Bondarchuk

Objective — to study the dynamics of echocardiography indexes in patients with essential arterial hypertension (AH) combined with bronchial asthma (BA) against the background of amlodipine, enalapril and candesartan administration.

Materials and methods. 73 patients were diagnosed (average age – 52.67 ± 0.70) with uncomplicated essential AH of II stage combined with bronchial asthma. The patients received one of the hypotension drugs: amlodipine 5–10 mg/day ( group, n = 27), enalapril 10–20 mg/day (I group, n = 23), candesartan 8–16 mg/day (II group, n = 23). Treatment duration and observation of patients lasted was 2 months. Doppler-echocardiography with the evaluation of indexes of cardiac structure and intracardiac hemodynamics was carried out at the beginning and at the end of the treatment. Credible differences while comparing the average indexes were found out using the Student t-criterion.

Results and discussion. The analysis of office arterial pressure (AP) dynamics in patients receiving anti-hypertensive therapy demonstrated its significant decrease during 2 months therapy. At the same time, there was no significant difference in the antihypertensive effect of amlodipine, enalapril and candersartan. The increase of the ejection fraction of the left ventricle (LV) from (54.12 ± 0.74) to (57.19 ± 0.76) % (p < 0.01) was revealed during the treatment by amlodipine due to the decrease of the end systolic index of the LV from (32.67 ± 1.34) to (29.12 ± 1.17) ml/m2 (p < 0.05). It was accompanied by the decrease of the mean pressure in the pulmonary artery (PA) from (33.42 ± 2.25) to (27.61 ± 1.82) mm Hg (p < 0.05). The improvement of indexes of diastolic function of the left and right parts of the heart was observed after the administration of all the medications (amlodipine, enalapril and candersartan): significant decrease of the velocity of late diastolic filling of ventricles, time of deceleration of early
diastolic filling, isovolumic relaxation of the LV, significant increase of the ratio of early and late velocity peaks of diastolic filling of ventricles were observed.

Conclusions. Administration of amlodipine, enalapril and candersartan during 2 months for patients with AH and BA equally improves the diastolic function of the left and right parts of the heart. Among the above-mentioned drugs, only amlodipine significantly influenced the pressure level in the pulmonary artery and improved the systolic function of the LV.



Keywords: bronchial asthma, essential arterial hypertension, amlodipine, enalapril, candersartan, dopplerFechocardiography, diastolic function.

7.

 

Dilatation of the right ventricle in patients with primary left ventricular chronic heart failure: precondition of the development

S.. Dubynska

Objective — determination of factors which are associated with the development of the dilatation of the right ventricle (RV) in patients with coronary chronic heart failure (CHF).

Materials and methods. We analyzed 329 medical cards of patients with chronic heart failure of II A degree and more, caused by the primary defeat of the left ventricle (LV) resulting from chronic ischemic heart disease. The age of the patients ranged from 55 to 80, the mean age was (66.7 ± 9.9) years (median 67 years, lower and upper quartiles 59–73 years). Among them there were 197 (59.9 %) men and 132 (40.1 %) women. The study included doppler-EchoCG with calculation of the standard indicators by Toshiba SSA 380A Powervision (Japan). The patients were divided into 2 groups for the analysis of clinical and cardiohemodynamical indexes. The 1st group included CHF patients without substantial dilatation of the right ventricle (end diastolic value (EDV) ≤ 2.6 cm; n = 250), the 2nd group included CHF patients with the dilatation of the right ventricle (EDV > 2.6 cm) (n = 79). The statistical analysis of the data was conducted by the criterion of Kolmogorov-Smirnov, criterion of Fisher with tables 2×2 and the chi-square
with Yates correction – with tables 2×3. The extreme points for parametrical indexes were determined by the  successive analysis of Valdes. The informativity (measure of informativity – MI) and diagnostic coefficients (relative risk – RR) and its confidence intervals – CI) were calculated by the method of Kulbaks. The determination of independent predictors of the RV dilatation development was conducted by the multivariate discrimination analysis.

Results and discussion. During the conducting of monovariate analysis the highest risk of the RV dilatation > 2.6 cm was in men with CHF (RR [95 % CI] = 5.2 [2.67–10.9]; < 0.0001), and in patients with myocardial infarction in the anamnesis (RR [95 % C] = 2.3 [1.48–3.66]; < 0.0001). Arterial hypertension had less important influence for our study (RR [95 % C] = 1.67 [1.07–2.51]; = 0.017). The development of the RV dilatation was also associated with the presence of permanent form of atrial fibrillation (RR [95 % C] = 2.76 [1.8–4.15]; < 0.0001), the increase of the left atrium (LA) > 4.3 cm (RR [95 % CI] = 3.68 [2.36–5.85], < 0.0001), LV EDV > 150 ml (RR [95 %CI] = 4.74 [2.91–7.96], < 0.0001), end systolic value (ESV) of the LV > 80 ml (RR [95 % CI] = 6.44 [3.94–1084]; < 0.0001), ejection fraction ≤ 45 % (RR [95 %CI] = 5.45 [3.52–8.59]; < 0.0001), III CHF NYHA functional class (FC) (RR [95 %CI] = 6.39 [CI 3.97–10.58]; < 0.0001), the development of complete right bundle bunch block (RR [95 %CI] = 3.14 [1.7–4.2]; < 0.0001). The multivariate analysis has revealed that the independent factors associated with the development of the RV dilatation are the diameter of the postcava (PC) > 2.0 cm (I 3.73; < 0.0001), NYHA FC III and more (I 3.08; < 0.001), LV ESV > 80 ml (I 3.06; < 0.017), total cholesterol (CS) blood level < 5.2 mmol/l (MI 2.54; < 0.008), chronic thrombophlebitis (I 0.46; < 0.036), systolic arterial blood pressure (SABP) > 140 mmHg (I 0.46; < 0.035), LA diameter > 4.3 cm (I 1.64; < 0.051), male gender (I 1.7; < 0.068). Vald analysis permitted dividing the patients with CHF into 2 groups of risk of RV dilatation according to the number of independent predictors. In case of 4 and more factors the sensitiveness will make up 88.5 %, and the specificity – 80.8 %.

Conclusions. The independent factors associated with the RV dilatation in patients with CHF, in the order of the decrease of their significance, are: PC diameter > 2.0 cm, FC of NYHA III and more, total CS blood level < 5.2 mmol/l, LV ESV > 80 ml, SABP > 140 mm Hg, chronic thrombophlebitis,, LA diameter > 4.3 cm, male gender. During the multivariate discrimination analysis, the presence of 4 or more factors is associated with the RV dilatation with sensitiveness of 73.4 % and specificity of 92.8 %.



Keywords: chronic heart failure, right ventricle, left ventricle, dilatation.

8.

 

Effect of the previous acetylsalicylic acid therapy on the clinical course of acute coronary syndrome without ST segment elevation according to the data of prospective observation `

N.V. Netyazhenko

Objective — to estimate the effect of the previous acetylsalicylic acid (ASA) therapy on the clinical course of acute coronary syndrome (ACS) without ST segment elevation according to the data of prospective observation.

Materials and methods. 465 patients with ACS without ST segment elevation were included into the research. All the patients were hospitalized within the first 24 hours from the onset of the disease, on the average, within (11.5 ± 3.1) h. Depending on the preceding ASA therapy for no less than 6 months before the hospitalization, all the patients were divided into 2 groups. The 1st group consisted of 140 (30.0 %) patients who systematically got ASA in doses from 80 to 100 mg/day (mean 88 ± 21 mg/day) during (1.6 ± 4) years. The 2nd group consisted of 325 patients (70.0 %), who did not take ASA or took it from time to time, 2–3 times per week.

Results and discussions. The patients of the 1st group significantly differed from the patients of the 2nd group by greater frequency of such factors of cardiac risk as smoking, obesity, arterial hypertension (AH) and lower frequency of diabetes mellitus of easy and medium-gravity flow (p < 0.05). Except for AH, this group of patients was characterized by higher frequency of previous stable angina and myocardial infarction (MI) (p < 0.05), as well as percutaneous coronary interventions (PCI) (p < 0.05). In the course of study, the group of patients who took ASA before the development of ACS revealed a heavier flow of ACS than the patients of the comparative group. The flow of ACS was evaluated by the combined eventual point which included death, non-fatal (re) -MI and relapse of unstable angina. This index substantially prevailed in the 1st group – 24 % against 5 % (p < 0.001), mainly, due to greater
frequency of non-fatal (re) MI and unstable angina (p < 0.05). At the same time, general lethality and frequency of Q-MI development in both groups were identical (r > 0.05). Large propensity to instability of ACS flow at the hospital stage among the patients of 1st group was also connected with greater frequency of paroxysm of atrial fibrillation – in 12 (8.6 %) patients against 7 (2.2 %) (p < 0.05). Mean amount of leucocytes in the peripheral blood at hospitalization did not differ substantially in both groups, however, the frequency of leukocytosis more than 8x109/l was substantially greater in the 1st group – 39 (27.9 %) and 58 (17.8 %), (p < 0.001), respectively. The mean fibrinogen level was also higher in the patients of the 1st group (p < 0.05).

Conclusions. Regular administration of ASA during at least 6 months before the development of ACS without ST segment elevation is associated with a graver flow of ACS with 18 % elevation of frequency of serious cardiac «events» within 30 days from the admission to hospital. The ACS patients without ST segment elevation who had taken ASA before ACS differ from the patients who had not taken this preparation by the elevation of heterospecific markers of inflammation – white blood cells and fibrinogen – in the blood.



Keywords: acetylsalicylic acid, acute coronary syndrome, leukocytes, fibrinogen.

9.

 

Opening of the infarct;related artery final aim or the beginning of the way?

Yu.V. Rudenko

Successful reperfusion after acute myocardial infarction (MI) has been considered to include restoration of epicardial patency and myocardial perfusion (MP). However, approximately 40 % of MI patients with ST segment elevation undergoing primary percutaneous coronary intervention with restoration of normal anterograde flow in the epicardial infarct-related artery do not have reperfusion of the myocardium at the tissue level. Microvascular dysfunction after epicardial reperfusion is a complex process with several probable interrelating stimuli and factors. Diagnostic tests for the assessment of myocardial tissue reperfusion include myocardial contrast echocardiography, cardiac magnetic resonance imaging, technetium-99m-sestamibi single-photon emission computed tomographic imaging, angiographic techniques and analysis of ST segment. Administration of glycoprotein IIb/IIIa inhibitors and possibly administration of adenosine have prevented the microvascular dysfunction and improved clinical outcomes of acute MI.



Keywords: myocardial infarction, primary coronary intervention, myocardial perfusion.

10.

 

Pathophysiological meaning of vasopressin in heart failure

A.N. Bilovol, I.I. Knyazkova

Vasopressin is a peptide hormone that modulates a number of processes involved in the pathogenesis of heart failure. Experimental and clinical data describing the effects of vasopressin on both normal physiology and heart failure were reviewed. Through activation of V1a and V2 receptors, vasopressin regulates various physiological processes including body fluid regulation, vascular tone regulation, and cardiovascular contractility. Vasopressin synthesis is significantly and chronically elevated in patients with heart failure despite the volume overload and reductions in plasma osmolality often observed in these patients. Vasopressin also appears to have an adverse effect on hemodynamics and cardiac remodeling, while potentiating the effects of norepinephrine and angiotensin II.



Keywords: vasopressin, V1- and V2-vasopressin receptors, heart failure.

11.

 

Right atrial re;entry tachycardias after open;heart surgery

V.K. Gryn, .V. Kravchenko, S.I. Estrin

Right atrial re-entry tachycardias (RATs) are common and potentially lifeFthreatening complications of congenital heart disease repair and palliation surgery. They are prevalent in patients who have undergone surgical procedures involving significant alteration of the atrium, such as the Mustard and Senning operations and the Fontan procedure. RATs manifestations are also caused by changes in atrial myocardium resulting from long-term hemodynamic overload of the latter. RATs occurrence among this category of patients reaches 56 %. RATs are less frequently caused by acquired heart disease repair, mix removal and coronary artery bypass grafting (10 %). RATs are often signs of hemodynamic impairment. Medical therapy is accompanied by potential side effects, including bradiarrhythmia, pro-arrhythmias, and is often ineffective. Antitachycardia pacing offers limited arrhythmia control, because it is used only in case of slow tachycardias. But even slow tachycardias can be transformed into fast and dangerous by means of stimulation. RATs may be successfully removed by catheter radiofrequency ablation (RFA) in the region of isthmus between the anatomical structure of the atrium and the surgically created barrier. Navigation systems must be used to identify these zones and eliminate tachycardias. Catheter RFA is effective in 70–94 %, the recurrence rate is 11–29 % cases at 1–2 years follow-up. This method should be preferred for treating RATs patients after cardiac surgery.



Keywords: right atrial reFentry tachycardias, atrial flutter, cardiopulmonary bypass, methods of treatment.

12.

 

Antiphospholipid syndrome as factor of thromboses risk

S.M. Genyk, S.I. Genyk

Antiphospholipid syndrome (APhS) is related to the hyperproduction of antibodies to phospholipides which react with different phospholipid antigens localized on cellular membranes. The leading clinical display of APhS is arterial and venous thromboses of vessels of all calibers with property to relapse. Various localizations of thromboses and also selectivity of vessel caliber are mainly related to the ability of antiphospholipid antibodies to co-operate with the cellular receptors of endothelial cells, thrombocytes and monocytes. Frequent complication of APhS is thrombotic pulmonary hypertension related both to relapse venous embolism and local thrombosis of pulmonary vessels. The characteristic hematological signs of APhS are thrombocytopenia and presence of antiphospholipid antibodies (APhLA) which are determined by immune enzyme assay. All patients with APhS must be under the protracted clinical supervision whose primary task is the estimation of thrombosis risk, its treatment and prophylaxis by therapy with antiagregants in case of high level of APhLA without clinical signs of APhS and, as the need arises, by protracted therapy and indirect anticoagulants for relapsed thromboses at patients with APhS.



Keywords: antiphospholipid syndrome, antiphospholipid antibodies, thromboses, thrombotic complications.

13.

 

Kawasaki disease as cause of myocardial infarction

Yu.V. Panichkin, D.A. Kuzmenko, Ye.V. Levchishina

The majority of pediatricians and cardiologists traditionally consider that myocardial infarction (MI) among children and youth occurs rarely. But, according to the literary fact, the disease among this category of patients occurs more and more often. Patient O., 22 years of age, with MI diagnosis in the anamnesis was hospitalized to M.M. Amosov National Institute of Cardio-vascular Surgery in August 2008. At the time of hospitalization the patient had no complaints, but two weeks before he had had onsets of stenocardia and the diagnosis of MI had been made. The anamnesis demonstrated that one year before the patient had had episodes of hyperthermia up to febrile norms, body eruption, which was diagnosed as allergy, arthralgia. Therefore, he was hospitalized to the Central Regional Hospital with the diagnosis of heavy case of severe acute respiratory syndrome (SARS) and hyperthermia syndrome. At the National Institute of Cardio-vascular Surgery, the patient underwent a complex of diagnostic procedures, including coronarography which helped to detect the aneurism of the anterior interventricular branch (AIVB) of the left coronary artery. Therefore, the diagnosis of Kawasaki disease complicated by the aneurism of AIVB was made. Then, AIVB stenting was performed using 1 stentgraft of the system of JOSTENT GraftMaster 3.5 g 16.0 mm in the proximal third part of the artery and 2 uncoated stents, Driver
4.5 g 24.0 mm, Driver 3.0 g 15.0 mm in the distal part. He was recommended to take 325 mg of aspirin per day and 75 mg of klopidogrel per day. The control coronarography in 1 month revealed the complete removal of the aneurism camera from the blood system. The circulation of blood was good in the left coronary artery and the lateral branches were saved. This case made us sure that MI does not have any age limitations and that atherosclerosis is not its only cause.



Keywords: myocardial infarction, aneurism, anterior interventricular branch, stenting, Kawasaki disease.

14.

 

Critical aortal stenosis, anomaly of coronary artery branching and successful aortic valve replacement

A.I. Osadchy, Ye.V. Levytska, V.V. Koziar

The article describes a successful case of aortic valve replacement in a patient with expressed systolic dysfunction of the left ventricle, critical aortal stenosis combined with an anomaly of coronary arteries.



Keywords: coronary angiography, aortal stenosis, anomaly of coronary arteries, single coronary artery, acute myocardial infarction.

Current Issue Highlights

4(60) // 2017

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K. M. Amosova 1, I. I. Gorda 1, A. B. Bezrodnyi 1, G. V. Mostbauer 1, Yu. V. Rudenko 1, A. V. Sablin 2, N. V. Melnychenko 2, Yu. O. Sychenko 1, I. V. Prudkiy 1&a

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