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Issue. Articles

4(28) // 2009

 

 

1.

 

The spread of kidney lesions in patients with type 2 diabetes mellitus as evidenced by the data of epidemiologic research

B.N. Mankovsky, D.D. Ivanov

The aim — to study the spread and degree of intensity of kidney lesions based on measuring glomerular filtration velocity (GFV) in patients with type 2 diabetes mellitus ( epidemiologic «cross-section» research).Materials and methods. The research included 1672 in-hospital patients with type 2 diabetes mellitus. 769 (46 %) of them were men and 903 (54 %) – women; the duration of the disease was from 1 to 3 years in 560 (33.5 %) patients, more than 3 but less than 5 years – in 303 (18.1 %), from 6 to 10 years – in 460 (27.5 %) and more than 10 years – in 349 (20.9 %) patients. GFV, with the help of creatinine clearance calculation by Cockcroft & Gault formula, was measured in 1610 patients and albuminuria level – in 784.

Results and discussions. Arterial hypertension was revealed in 1572 (94 %) patients. GFV exceeded 120 ml/min in 239 (14.8 %), was 90–120 ml/min – in 383 (23.8 %), 60–90 ml/min – in 605 (37.6 %), 30–60 ml/min – in 334 (20.8 %), less than 30 ml/min – in 49 (3 %). The markers of diabetic kidney disease (albuminuria) were revealed in 560 (71 %) out of 784 patients, including 341 (21.2 %) patients with decreased GFV < 90 ml/min.

Conclusions. Kidney lesion is a frequent complication of type 2 diabetes mellitus which results in expressed GFV decrease (less than 60 ml/min) in 23.8 % patients. It is favored by arterial hypertension which is revealed in 94 % of such patients. The results of research demonstrate the necessity of active kidney lesion reveal in type 2 diabetes mellitus patients, as well as of more intensive treatment of arterial hypertension with the aim of reducing the risk of renal failure development.



Keywords: diabetes mellitus, type 2 diabetes mellitus, diabetic nephropathy, arterial hypertension, renal failure, glomerular filtration velocity

2.

 

State of vertebral and carotid artery haemodynamics in patients with cervical osteochondrosis associated with atherosclerosis of brachiocephalic vessels

S.V. Dybkalyuk, A.M. Pyletsky, V.A. Chernyak, V.Yu. Zorgach

The aim – determination and evaluation of haemodynamic state of carotid and vertebral arteries in patients with x-ray verified cervical osteochondrosis associated with atherosclerosis of extracranial vessels during the selection of the surgical tactics (extravascular decompression and carotid endarterectomy).

Materials and methods. Haemodynamic state was defined in 164 patients and healthy volunteers who were under our observation from 2007 till 2009 and whose bloodflow in extracranial branches of brachiocephalic arteries was investigated by Doper sonography with spectral analysis. The main group consisted of 134 patients, the control group – of 30 patients. The main group was divided into subgroups: subgroup A (n = 57) – patients with cervical osteochondrosis and vertebral artery (VA) syndrome without brachiocephalic artery (BCA) disease; subgroup B (n = 77) – patients with concomitant lesion of one internal carotid artery (ICA) and/or several main branches of BCA.

Results and discussion. During the study of haemodynamic state of carotid arteries in subgroup A (patients with cervical osteochondrosis and lesion of both VA), the reduction of Vmax in common carotid artery (CCA) by 18 % (p < 0.01) in comparison with controls and by 14 % (p < 0.01) in comparison with patients suffering from isolated syndrome of VA was registered. The patients with BCA lesions had substantial IR increase in CCA by 10.5 % (p < 0.05), if compared with the controls, and by 6.5 % (p < 0.05), if compared with patients who had isolated syndrome of VA. These patients also had 12 % bigger Vmax in ICA than the patients of the control group. Subgroup B patients with 50–70 % ICA stenosis and VA syndrome had Vmax decrease in CCA at the side of ICA lesion by 23.2 % ( < 0.05), while patients with cervical osteochondrosis and lesion of several BCA – by 31.4 % ( < 0.05) in comparison with the controls; IR in CCA of these patients, if compared with the controls, was increased by 18.3 % ( < 0.05) at the side of lesion and – by 16.6 % ( < 0.05) at the unaffected side. The patients with 70–90 % of ICA stenosis and VA compression had Vmax equal to (23 ± 0.54) cm/sec, which was 33.6 % ( < 0.05) lower at the side of lesion than in the controls. In these patients, IR at the side of lesion was 23.4 % ( < 0.05) higher than in the controls and 11.5 % ( < 0.05) higher than in patients with isolated syndrome of VA. In comparison with the controls, substantial IR increase by 18.2 % (p < 0.05) at the unaffected side was registered only in patients with cervical osteochondrosis and pathology of several BCA.

Conclusions. According to the ultrasonic diagnosis, patients with cervical osteochondrosis combined with BCA lesions resulting from obliterating atherosclerosis (mainly of ICA) revealed dangerous from the prognostic point of view decrease of Vmax in CCA and increase of IR. Patients with this pathology must be included into the group with high risk of ischemic lesions of cerebral bloodflow. Cervical osteochondrosis with expressed VA compression should be considered an unfavorable factor which substantially deteriorates cerebral perfusion reserve and leads to the decrease of cerebral bloodflow in patients with concomitant lesion of carotid arteries. Endarterectomy of ICA and extra vessel decompression of VA, in two steps, are indicated for patients with 50–70 % of carotid artery stenoses associated with VA compression. In cases where ICA stenoses reach 70–90 %, one-stage operations are indicated on both arterial beds.



Keywords: carotid artery, osteochondrosis, vertebral artery, brachiocephalic arteries, haemodynamics

3.

 

Symptomatic myocardial bridges: clinic, diagnostics and treatment

.K. Gogayeva, G.V. Knyshov, L.S. Dzakhoeva, A.V. Rudenko, Yu.V. Panichkin

The aim – to investigate the clinical and diagnostic features of symptomatic myocardial «bridges» and develop treatment for patients with this anomaly.

Materials and methods. For the last 4 years we observed 113 patients (87 men, 26 women) with symptomatic myocardial «bridges», diagnosed during coronarography. In order to improve the verification of the anomaly, along with the standard methods of diagnosis we performed provocative tests during the coronarography and intravascular ultrasound (IVUS).

Results and discussion. The analysis of so much clinical data has been done in Ukraine for the first time. It allowed identifying the characteristic clinical features and new diagnostic criteria for the verification of symptomatic myocardial «bridges». Thus, the most common symptoms of this anomaly were: angina pectoris (92 %), psychosomatic disorders (85.8 %) and dyspnea (67.2 %). Despite the lack of published data on the ECG diagnosis of myocardial «bridges», we have identified a number of highly informative ECG signs. Introduction into practice of the test with intracoronary isosorbide dinitrate resulted in improved visualization of systolic compression of coronary artery (CA) in 76 % cases. Hypotheses about the causes of myocardial ischemia with this anomaly, available in literature, have been supplemented by us with modeling the anatomy tunneled CA. The method of treatment for patients was determined on a strictly individual basis, taking into account the length of the myocardial «bridge», the degree of systolic compression of CA, the presence of concomitant cardiac disease. We also used drug therapy, stenting of the tunneled segment of CA and surgical correction as coronary bypass surgery, myotomy or epicardiotomy with denervation of CA.

Conclusions. The specific features of symptomatic myocardial «bridges» include nitrates intolerance. IVUS allows confirming the diagnosis of the anomaly that reveals itself as the phenomenon of «half moon» in 87 % of cases. The big length of the CA tunneled segment is a contraindication to stent placement because of the high risk of restenosis (23.1 %). The individual approach to treating patients with this anomaly helps to avoid life-threatening events and improve the quality of life of patients with this anomaly.



Keywords: myocardial bridges, tunneled coronary arteries, diagnosis, treatment

4.

 

Variants of left ventricular non-compaction progress in adults

N.Yu. Osovska, O.O. Kavatsuk

The aim – to demonstrate different clinical variants of left ventricular non-compaction progress in adults as well as to highlight some nosotropic aspects of the pathology.

Materials and methods. A complex examination of 66 patients aged 16–36 years was conducted, including 28 patients with the multiple anomalous chords of the left ventricle (LV), 26 patients with dilated cardiomyopathies, 12 patients with the left ventricular non-compaction (LVNC). Their clinical and instrumental study results were compared. Some clinical examples of different variants of LVNC progress were given.

Results and discussion. The results of our research showed that 16 out of 28 patients with multiple anomalous chords of the left ventricle had ejection faction more than 55 %, 6 patients had this index within the limits of 50–54 %, and the other 6 patients’ index ranged within 45–49 %. Multiple anomalous chords of the LV were associated with a greater number of clinical, phenotypical, structural and hemodynamic changes than the controls and the single chords ( < 0.05). In the process of the research 12 young patients were found with multiple anomalous chords of the LV and the ejection faction (EF) of 22–41 %. Other criteria of LVNC were revealed during the detailed analysis of the echocardiographic data in their dynamics. We observed that asthenic persons with dysplastic signs were significantly more common among LVNC patients ( < 0.05) than among the controls. The data obtained suggest an idea about the cognation of nosotropic mechanisms of heart pathology development in patients with the syndrome of connective tissue dysplasia and in patients with LVN.

Conclusions. Left ventricular noncompaction occurs much more frequently than diagnosed. Another pathology may be diagnosed instead, especially dilated cardiomyopathy. The clinical course of the disease, depending on the intensity of LVN, can be asymptomatic or accompanied by cardiac complaints and signs of chronic heart failure. There are common anthropo-phenotypic and structural changes in patients with isolated anomalous chords of the LV at the background of connective tissue dysplasia syndrome and LVN, which suggests the probable cognation of these diseases. Thus, the detection of multiple anomalous chords of the LV during the echocardiographic study suggests the necessity of purposeful search of LVN signs and of timely LV dilation disclosure. The importance of the early LVN diagnosis is determined by the need in timely symptomatic treatment necessitated by the progressive nature and unfavorable prognosis.



Keywords: left ventricular noncompaction, anomalous chords of the left ventricle, dilated cardiomyopathy

5.

 

Diagnostic value of contrast multislice spiral computed tomography for coronary vessels evaluation in patients with coronary artery disease

M.N. Dolzhenko, .V. Rudenko, S.V. Potashev, S.A. Rudenko, O.A. Sharayevskiy, I.L. Sarbash

The aim — comparative estimation of the information value efficacy of contrast multislice spiral computed tomography (MSCT) for diagnosis and assessment of coronary vessels lesion severity in patients with coronary artery disease (CAD) as compared to the «golden standard» of conventional coronaroventriculography (CVG).

Materials and methods. 116 patients aged (43.8 ± 10.2) with clinical CAD and heart failure (HF) of I– FC by NYHA (left ventricle ejection fraction 37.1 ± 12.4 %) underwent prospective X-ray contrast CVG and contrast MSCT with calculation of cardiac calcium index (CI) by A.S. Agatston. Accuracy, specificity, sensitivity, positive and negative predictive value of contrast MSCT as compared to CVG were calculated for the diagnosis of coronaroatherosclerosis.

Results and discussion. Data of contrast MSCT in coronary lesion evaluation of CAD patients had rather high specificity (94.75 %, < 0.0001) and positive predictive value (91.7 %, < 0.0001) and significantly correlated with CVG data in main coronary artery lesion diagnosis: left coronary artery trunk (LCA; r = 0.75, < 0.0001), anterior interventricular branch of LCA (r = 0.33, = 0.0002), circumflex branch of LCA (r = 0.49, < 0.0001) and the right coronary artery (r = 0.61, < 0.0001). Data of calcium index by A.S. Agatston, as coronary atherosclerosis marker, significantly correlated with the extent and prevalence of coronary lesions both according to MSCT (r = 0.45, < 0.0001) and CVG data (r = 0.39, = 0.0004). At the same time, 16-sliced MSCT had low sensitivity (66.1 %, < 0.0001) and negative prognostic value (76.1 %, < 0.0001) as compared to CVG in patients with verified CAD.

Conclusions. 16-sliced MSCT is unable to diagnose the distal coronary lesions and cannot be considered an alternative to the conventional CVG for patients with verified CAD before a planned surgical revascularization. However, significant correlation of coronary vessel lesion and CI coronary atherosclerosis marker evaluations by MSCT and CVG allows considering contrast MSCT a reliable instrument for screening and stratification of patients with a high risk of CAD suspicion as well as for taking a decision about myocardial revascularization.



Keywords: contrast multislice spiral computed tomography, coronaroventriculography, calcium index, coronary artery disease

6.

 

The effect of long-term statin therapy in different doses on the variability of the cardiac rhythm in patients with acute coronary syndrome without ST segment elevation

K.M. Amosova, Ye.V. Andreyev, I.S. Kovaliova, P.O. Lazarev

The aim — to determine the changes in variability of the cardiac rhythm (VCR) of patients with acute coronary syndrome (ACS) without ST segment elevation under the impact of long-term therapy with different doses of simvastatin at rest and in anti-ortho-static test.

Materials and methods. 90 patients with ACS without ST segment elevation were examined and randomized into three groups in the order of hospitalization. The patients of group 1 (controls, n = 30) received only conventional therapy (unfractionated or low molecular weight heparin during the first 8 days, aspirin and/or clopidogrel, – adrenergic blockers, nitrates, angiotensin converting enzyme (ACE) inhibitors, in case of concomitant arterial hypertension) without statins. The patients of group 2 (n = 30), along with the conventional therapy, took 20 mg of simvastatin, and the patients of group 3 (n = 30) – 60 mg of simvastatin daily. The medication «Sigmal» of IVAX Company (Czech Republic) was administered starting with the 1–4th day of hospitalization. The period of observation was 3 months. All the patients were matched by age, gender, occurrence of arterial hypertension and myocardial infarction in the anamnesis, presence of biochemical markers of myocardial necrosis (all p > 0.05) and lipid metabolism. 30 healthy persons, age and gender matched with the patients of the groups under investigation, were examined as controls. The study of cardiac rhythm variability was conducted on the 21st day of hospitalization and in 3 months after ACS onset. It was conducted in accordance with the guidelines of the European Society of Cardiology and North American of Pacing and Electrophysiology using Schiller CS-100 hardware and software complex (Switzeland). The indexes were measured by 128 NN intervals at rest and when loaded by volume while raising the lower extremities at 45° (L.G. Voronkov antiorthostatic test).

Results and discussion. On the 21st day of hospitalization, the patients of all the groups, as evidenced by VCR data, revealed the signs of hyperactivity of the sympathetic branch of the involuntary nervous system according to linear distribution and frequency spectrum analysis results (p > 0.05 among groups). After 3 months of therapy, there was positive VCR dynamics in groups 2 and 3 (p < 0.05 as compared with the base values). VCR indexes substantially improved in these groups if compared with group 1 (p < 0.05). No differences were revealed between group 2 and group 3 data (p > 0.05). During the anti-orthostatic test conducted on the 21 day of treatment, the indexes of patients in the three groups had no differences (all p > 0.05) and were substantially lower than those of the healthy persons (p < 0.01). But in 3 months, groups 2 and 3 were marked with positive dynamics of indexes of cardiac function autonomic support during volume loading (p < 0.05 as compared with the base values; p2–3 > 0.05), which was not observed in group 1.

Conclusions. On evidence of VCR evaluation, long-term (3 months’) therapy with simvastatin in the dose of 20 mg/day for patients after ACS without ST segment elevation has a corrective effect on the activation of the sympathetic nervous system and the decreased activity of the parasympathetic nervous system at rest and when loaded by volume. The threefold increase of the daily simvastatin dose does not influence the intensity of this effect.



Keywords: acute coronary syndrome, statins, variability of the cardiac rhythm

7.

 

Classification of vasculites and critical evaluation of the problem

D.D. Zerbino, V.V. Chopiak

Vasculites are classified depending on the caliber of the damaged vessels, localization of lesion, type of vessels, character of the cellular infiltrate and localization of the lesion in the vascular wall. There are primary and secondary system vasculites. There have been many attempts to create a single classification and nomenclature of vasculites since 1940s. Of practical importance is the list of system vasculites in the International Statistical Classification of Diseases of the 10th review (ICD-10), but many vasculites are absent from this list, especially secondary ones. This requires serious updating while reviewing ICD-10. Generalized classification of system vasculites with consideration for genetic, etiological factors and pathogenetic mechanisms of development was produced by V.V. Chopiak in 2003–2008. Inflammatory and autoimmune vascular diseases are a separate problem and division of medicine. It's necessary to create specialized angiological departments for treating such patients who need consultation and observation of a clinical immunologist. There is urgent necessity in updating the classifications of system vasculites, conducting advanced immunological, molecular and genetic researches and creating a valid international register of these vascular diseases.



Keywords: vessels, lesion, system vasculites, classification

8.

 

Atrial fibrillation after coronary artery bypass grafting

B.. odurov, .J. Zharinov, .. Epanchintseva, .P. Nadorak

The article reviews mechanisms of onset, predictors and principles of treatment and prevention of atrial fibrillation (AF) after coronary artery bypass grafting (CABG). The risk of AF constitutes 25–43 % after CABG, 35–45 % after valve prosthesis surgery and 55–60 % after combined CABG and valve prosthesis surgery. Postoperative AF (POAF) influences the duration of in-hospital treatment, number of strokes and postoperative lethality. The main predictors of AF during postoperative period are age, gender, dimensions of left atrium, AF before operation. Beta-blockers and amiodarone are the most effective and tested means of prevention of AF related to CABG. Statins, due to their pleiotropic effects, have an obvious perspective; renin-angiotensin-aldosterone blockers are indicated in many cases. Management of POAF and terms of cardioversion depend on hemodynamic parameters.



Keywords: artery bypass grafting, coronary heart disease, atrial fibrillation

9.

 

Endovascular treatment of thoracic aorta aneurism after surgical correction of aorta angusta

S.N. Furkalo, V.I. Smorzhevsky, I.V. Khasianova

Enhancement of endovascular surgery made it possible to make a new step in treatment of isolated thoracic aorta aneurisms. The article describes the experience of successful treatment of a patient who had the aneurism of aortic arch and had been operated for aorta angusta. The first step of the operation was subclavian-somnolescent switching and the next step was prosthetics of aorta. Three months later, the control computer tomography of the thoracic region of aorta with contrast intensifying showed that the endoprosthesis was adequately positioned, endoleakage into aneurysmal sac was not fixed, and the stump of the clavicular artery was visualized. Thus, our experience proves that endovascular prosthesis of post-coarctation aneurism of aorta thoracic region is a good alternative of the open surgical correction. The hybrid method of the operation is less traumatic and gives a good short-term result.



Keywords: aorta angusta, aortic aneurism, endovascular prosthesis

10.

 

Case of association of uncommon aortic arch coarctation with left atrial myxoma

S.. Dykukha, R.M. Vitovsky, L.R. Naumova, V.V. Isaenko, T.A. Yalinska, O.P. Malinovsky, .V. Kryvenkiy, .V. Satmary, V.M. Beshlyaga, I.G. Yakovenko, D.O. Kuzmenko, .B. Yershova

The article is based on clinical observation of successful surgical treatment of vascular ring with the coarctation of aortic arch and left atrial myxoma combined with congenital heavy deformation of the thorax. The aim of the publication was demonstration of the tactics of treatment. A 40 year old female patient was operated on 14/04/2008 by left(side access (plasty of the posterior aortic arc within the limits of coarctation and division of vascular ring). On 21/04/2008, left atrial myxoma was removed through the middle sternotomy. Postoperative periods after both operations were uncomplicated, which confirmed the appropriateness of the selected surgical tactics.



Keywords: vascular ring, coarctation of aortic arch, left atrial myxoma

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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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