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Issue. Articles

1(1) // 2003





Cardiosurgery in Ukraine: past, present, and future

G.V. Knyshov

In the article the main stages of a cardiosurgery development in Ukraine are set up, the modern state of a problem of surgical treatment of congenital and acquired heart diseases is lighted, the perspective routes of outcomes improvement in surgical treatment of a cardiac pathology are intended. The organizational structure and basic features of scientific, medical and methodical activity in the head Ukrainian cardiosurgical center — Institute of cardiovascular surgery MSA (Medical Sciences Academy) of Ukraine are submitted.

Keywords: cardiosurgery, ischemic heart disease, congenital and acquired heart disease, organization of a cardiosurgical service.



The history of cardio pulmonary bypass doctrine

V.B. Maksymenko

The history of the first ideas and evolution of CPB method from the first simple heart lung machines till implantable artificial heart is described. Represented almost 45-year history of CPB development in Ukraine.

Keywords: cardiopulmonary bypass, artificial heart, cardiopulmonary bypass device, mechanical heart support, cardiosurgery.



Modern approaches to the treatment of non-ST-elevated acute coronary syndrome by European Society of Cardiology recommendation in 2002 and future trends

K.M. Amosova

According to new recommendations of the European Society of Cardiology there are the following new approaches to the treatment of non-ST-elevated acute coronary syndrome (non-STEACS): including platelet ADP-aggregation ingibitor clopidogrel in the standard treatment according to CURE trial results; emphasis on the role of low-molecular weight heparins (LMWH), as their clinical efficacy compared to placebo has appeared to be more convincing than those of unfractionated heparin (UFH) out of all available LMWH only enoxaparin has been proven to be more beneficial compared to UFH, according tj the data of ESSENCE and TIMI IIB clinical studies and their further meta-analysis; increase of the role of «entive» invasive strategy — coronary arteri ography (CA) and surgical revascularization in the early phase (first 48 hours) in a high-risk patient population is considered to be a method of choice, compared to «conservative» strategy (the data of FRISC II and TACTICS studies). This recommendations are also important for daily clinical practice in cardiology. The use of up-to-date markers of myocardial necrosis (more importantly, cardiac troponinesT and I) in order to differentiate non-Q-wave myocardial infarction from unstable angina and to establish indications for CA and the need for stenting, becomes obligatory in daily clinical practice. Evaluation of efficacy of the eluting stents, early aggressive treatment with statins and the entive use of ACE ingibitors in order to «passivate» the plaque are the promising trends that require further investigation and may improve the treatment of non-STEACS.

Keywords: non-ST-elevated acute coronary syndrome, treatment.



Cigarette smoking impact on the features and prognosis of acute myocardial infarction in fibrinolytic therapy use: imaginary "smokers paradox"

A.N. Parhomenko, A.A. Skarzhevskiy, O.I. Irkin, O.O. Solyarik, L.V. Shklyar

Impact of smoking in anamnesis on hospital period course of acute myocardial infarct (AMI) in 254 patients with acute myocardial infarct (AMI), treated with systemic fibrinolytic therapy (FT) in first 24 hours from onset by streptokynase was estimated. Efficacy of coronary hemodynamics restoration, forming of necrosis zone, circadion rhythm of AMI development, parameters of intracardiac hemodynamics and clinical features were studied. Cigarette smokers (59,4 of patients) were younger than nonGsmokers were rare had arterial hypertension, stable angina in anamnesis, anterior AMI, massive myocardial impairment. Unstable angina preceded AMI more frequently. At the same time, efficacy of FT was lower and hospital period of AMI was less favorable and mortality was not reduced in such patients (called by other authors "smokers paradox"). Investigators showed that efficacy of FT in smokers were maximal in the morning and decreased afternoon. It was supposed that unstable IHD followed by AMI played role as the mechanism that increased the rate of infarctionGrelated coronary artery recanalization.

Keywords: acute myocardial infarction, smoking, fibrinolytic therapy, streptokinasa.



Aldosterone antagonist spironolactone in treatment of patients with arterial hypertension and chronic heart failure

G.V. Dzyack, O.O. Khanyukov

The aim of our study was to determine the efficiency of aldosterone antagonist spironolactone in treatment of patients with arterial hypertension (AH) and chronic heart failure (CHF). We performed standard clinical investigation, definition of plasma renin activity (PRA) and blood levels of angiotesin II and aldosterone, electrocardiography, echocardiography, blood pressure (BP) monitoring and holter monitoring among 160 patients with III stage of essential AH and II — III functional class of CHF, included in the study. Patients were divided in two group: Ia — 40 persons with III stage of AH received ACE-inhibitor and diuretic; Ib — 40 patients with III stage of AH took the basis antihypertensive therapy and spironolactone; IIa — 40 persons with III stage of AH and II — III functional class of CHF received ACE-inhibitor, beta-blocker and diuretic; IIb — 40 patients with III stage of AH and II — III functional class of CHF took ACE-inhibitor, beta-blocker, diuretic and spironolactone.. At the end of observation period blood level of aldosterone increased at Ia and IIa groups, while at Ib and IIb groups this index diminished markedly. The control of BP level was more safe at the patients of Ib and IIb groups then that of the persons of Ia and IIa groups. After 3 months of therapy marked decreasing of left ventricle myocardial mass index was found out at the patients of Ib and IIb in comparison with Ia and IIa group. Improvement of CHF functional class registered at 19 persons of IIa group and 23 patients of IIb group. Thus, using of spironolactone (25 mg daily) provides the normalizing of aldosterone system status, leads to safe control of the BP level, promotes the decreasing of left ventricle myocardial mass index, improves the functional class of CHF at the patients with essential AH.

Keywords: arterial hypertension, chronic heart failure, aldosterone, spironolactone.



Functional status of skeletal muscles at a chronic heart failure: connection with clinical features

L.G. Voronkov, E.M. Besaga

The aim. To study functional parameters of skeletal muscles and their connection with parameters of a clinical haemodynamic status in patients with a chronic heart failure (CHF).

Material. 77 patients with CHF in the age of 52,58 ± 1,3 years, 13 females (16,9 %) and 64 males (83,1 %) are studied. Stage CHF II A is established in nine patients (11,7 %), II B — for 63 (81,8 %), III — for five (6,5 %). The functional class (FC) by NYHA criteria was 2,74 ± 0,07. All received standard therapy. For all patients an expressiveness of a precursor stagnant syndrome by dynamics of body weight measuring, an index of body weight (IBW) was determined. An echocardiography in M- and B — regimes, test with 6-minute walking (O6W) were conducted functional parameters of leg muscles were investigated. Maximum arbitrary force and fatigue life of both groups of leg muscles with a high veracity were smaller, than conforming parameters in a control group, and, the force of extensors and flexors in the healthy subjects appeared greater, on the average, accordingly 52 % and 76 %, and their fatigue life — accordingly 101 % and 68 %. The maximum arbitrary force of extensors and flexors of the leg with a high veracity indirectly correlated with age of the patients (accordingly, r = –0,3345, p = 0,004 and r = –0,3586, p = 0,003) and IBW (accordingly, r = 0,4156, p = 0,000... and r = 0,4487, p = 0,000...). It was not detected connection between force, fatigue life of muscles and duration of CHF symptoms, and also of expression of a precursor stagnant syndrome. The strong correlation between arbitrary force of muscles — extensors (r = 0,3593, p = 0,006), flexors (r = 0,4416, p = 0,001), fatigue life of flexors (r = 0,4043, p = 0,002) and a O6W distance is established. The outcomes of O6W indirectly correlated with FC (r = –0,2621, p = 0,041). Tendency to a possible indirect correlation between dynamics of body weight (r = –0,2306, p = 0,074) were detected and, to the contrary, was no evidences of correlation between last one and age, CHF duration, IBW, sizes and ejection fraction of a left ventricle.

Conclusions. The maximum arbitrary force of leg muscles in patients with a haemodynamic stabilized chronic heart failure without evidences of a cachexia directly correlates with an index of body weight, indirectly — with age of the patients and it was no connection with parameters of their intracardiac haemodynamics, and the tolerance to an stress tests under the data of the test with 6-minute walking directly correlates with force and fatigue life of leg muscles and indirect — with the functional class (NYHA). The prognostic value of a functional condition of skeletal muscles at CHF demands further analysis.

Keywords: chronic heart failure, skeletal muscles, stress tests.



Myocardial ischemia in patients with hypertrophic cardiomyopathy and its medicational correction

V.I. Celujko, O.S. Kovalevskaya, I.G. Krays, I.A. Litvinova, Alnahala Muhamed

The purpose of study was comparative assesment of ACE-inhibitors therapy and their combination with βGblockers impact on the development of myocardial ischemia in patients with nonGobstructive hypertrophic cardiomyopathy (HCMP) by ECG monitoring. 22 patients with HCMP were examined. ACEGinhibitors (enalapril) 2,5–10 mg/day were prescribed in 10 pts (the first group), enalapril with βGblockers — in 12 pts (the second one). The results of study allow to recommend ACEGingibitors as monotherapy or with βGblockers, if there (the last) are not clinically effective in nonGobstructive HCMP patients.

Keywords: hypertrophic cardimyopathy, myocardial ischemia, ECG monitoring, Ace-inhibitors.



Results of antiembolic vena cava filter "OSOT" transluminal implantation: follow!up examination with duplex ultrasonography

M.V. Kostylev

Objective. To assess the short- and long-term outcomes of new vena cava filter "OSOT" (CF) transluminal implantation with duplex ultrasonography (DS) results.

Patients and methods. 82 patients (52 males and 40 females), who underwent transluminal CF implantation from March, 1998 to January, 2003 were included in the study. Indications to the vena cava inferior (VCI) interruption were: lower limbs deep veins thrombosis with pulmonary embolism episodes (73,2 %) or massive ileofemoral thrombosis (26,8 %). Infrarenal CF placement was provided in 92,7 % of patient. In 6 cases CF were placed above the level of renal veins origin (due to infrarenal VCI thrombosis — 2 cases, pregnancy — 2 cases, renal vein thrombosis — 1 case, implanted before CF dysfunction — 1 case). Decision about CF implantation was made on background of prior investigation results, including ECG, fluoroscopy, heart and veins DS, pulmonary angiography and cavagraphy. All patients during 3 days after CF implantation underwent control DS examination, 46 (56,1 %) persons were examined dynamically during 1 — 38 months after implantation.

Results. With adequate patient preparation the rate of direct CF visualization was 96,3 %. In short terms after implantation 4 (4,9 %) cases of distal migration and 5 cases (6,1 %) of nonobstructive CF embolization were diagnosed. In long terms distal migration took place in 2,2 %, CF embolization — in 8,7 % (including 4,3 % of complete VCI occlusion in place of CF location), VCI walls asymptomatic perforation by CF struts — in 4,3 % of cases. There was no cases of proximal CF migration. In all cases of distal migration VCI diameter was more than 2,6 cm, and in 80 % — more than 3,1 cm. Pulmonary embolism episodes were noted in 2 (4,3 %) patients: due to CF migration with dysfunction in first case and on background of left jugular and subclavian veins thrombosis formation — in second. In 9,8 % of patients CF tilting <20° in relation to VCI axis was diagnosed during fluoroscopy. This tilting was not complicated by CF dysfunction.

Conclusions. 1.Prophylactic effectiveness and complication rate of CF "OSOT" implantation is non different significantly from corresponding parameters of best samples such type devices. 2. With adequate patients preparation, DS is reliable method of persons with implanted CF follow-up examination.

Keywords: cava filter, complications, implantation, venous trombosis and embolization.



Comparative effects of long!term therapy with diltiazem and atenolol on heart rate variability after non!Q!wave acute coronary syndrome

E.N. Amosova, E.V. Andreev, E.V. Chodakovskaya

The aim of our open randomized study was the comparative assessment of the effects of diltiazem and atenolol on the heart rate variability (HRV) and sympatovagal balance after non-Q-wave acute coronary (nQACS) in patients with ehjection fraction >45 %.

Method. Basal time (SDNN, pNN50) and frequency (HF, LF, LF/HF) parameters of HRV on days 1, 18—21 and in 6 months in patients treated with atenolol 75±25 mg p. d. (group 1) and 26 patients treated with diltiazem (Diacordin) 270±90 mg p. d. (group 2) were studied.

Results. Both SDNN and pNN50 in both groups on day 1 were equelly lowered in comparison to healthy controls (p<0,05). By 6 months SDNN in group 1 elevated from 17,35±0,99 to 24,89±1.28 ms (p<0,05), in group 2 — from 19,28±2,14 t 30,99±1,67 ms, (p<0,05, P1—2>0,05) and pNN50 accordingly from 2,29±0,94 t 4,25±0,83 min-1, p<0,05, and from 3,29±0,81 t 6,25±1,01 min-1, p<0,05, (1—2)<0,05. Positive influence of therapy in both groups was evident also from the analysis of HF, LF and LF/HF. As a result LF/HF by 6 months in the 1st group lowered by 23,1 % (p<0,05), remaining elevated compared to healthy controls (p<0,05), and in the 2nd — lowered by 34,8 % (p<0,01) and reached its normal value. Positive dynamics of HRV indexes in both groups was evident by the 3rd week and progressively increased by 6 months of treatment.

Concluson. No less pronounced positive influence of the therapy with diltiazem, compared to the atenolol on the time and frequency parameters of the HRV in patients with nQACS may contribute to explanation of positive results of diltiazem treatment that have been reported in previous large controlled clinical trials.



Staged surgical treatment of pulmonary artery atresia with ventricular septal defect

M.F. Zynkovsky, S.E. Dykuha

Possibilities of repair of pulmonary atresia with ventricular septal defect (PA+VSD) by preliminary forming the pulmonary vascular bed were studied.

Methods: In 128 patients 208 operations were performed: in 10 — primary repair, in 118 — palliative operations — systemicpulmonary shunts (64), unifocalization of pulmonary blood supply sources (37), surgical dilatation of hypoplastic pulmonary arteries (33).

Results: Unifocalization as a step to total repair was successful in 24 (64,9 %) patients out of 37 with arborization anomalies. After central palliation procedures pulmonary arteries have enlarged 4,1 times and have become near normal. After preliminary operations total repair was performed in 57 (44,5 %) patients.

Conclusion: surgical forming of the pulmonary vascular bed allows to perform total repair of PA+VSD in a half of patients due to mortality rate on previous stages and individual features of collateral arteries.

Keywords: pulmonary artery atresia, big aortopulmonary callaterals, pulmonary arteries hypoplasia, pulmonary arteries anoG malies, unifocalisation.



The surgical treatment of brachiocephalicareries disease

A.S. Nikonenko, A.V. Gubka, V.I. Pertzov, L.P. Karnauh, T.P. Kotova, V.O. Gubka

745 patients — 320 (43 %) men and 425 (57 %) women in the age of from 27 till 73 years with a brahiocephal arteries disease were inspected. An atherosclerotic stenosis and occlusion of this arteries were revealed in 284 (38,2 %) patients, pathological tortuosity of an atherosclerosis and idiopathic hypertension origin — in 162 (21,7 %), pathological tortuosity caused by atherosclerosis and fibromuscular dysplasia — in 197 (26,4 %), hypoplasia of this arteries — for 49 (6,6 %) and orto-arteriitis — in 53 (7,1 %) patients. The indications to surgical treatment of chronic cerebrovascular insufficiency in patients with brahiocephal arteries disease were — V degree of an ischemia if lesions of this arteries were verificated. 11 types of operations depending on nature of a brahicephal lesion completed by intraoperative brainprotective program were performed, 867 reconstructive operations were made. The early good and satisfactory outcomes are obtained in 629 (91,2 %) patients. In the late term this results were inspected in 450: good results were in 64,8 %, satisfactory — in 22,3 %, have no improvements — 30 (6,2 %), have died — 28 (6,2 %). The program of complex examination and surgical treatment shown in article has allowed considerable improvement in outcomes of chronic brain ischemic disease treatment.

Keywords: brachiocephalicareries disease, diagnostic, surgical treatment, indications for operation.



Surgical management of internal carotid artery disease

I.I. Kobza

Early results of 526 different operations on internal carotid artery (ICA) in 485 patients were analyzed. Asymptomatic lesions were revealed only in 73 (15 %) patients, symptomatic disease — in 412 (85 %). 495 (94,1 %) operations on ICA were performed under local anesthesia and only 31 (5,9 %) — using general anesthesia. Serious complications of local anesthetic management were not observed. Perioperative reversable neurologic deficit took place in 5 (1 %) cases. Early thrombosis of operated artery developed in 4 (0,8 %) patients. Among different operations in patients with atherosclerotic ICA disease less thrombotic complications were observed after retrograde carotid endarterectomy with redressation.

Keywords: internal cartid artery, disease, surgigal treatment, outcomes.



Peculiarities of surgical treatment of brachycephalic arteries' atherosclerotic lesions in patients with concomitant ischemic heart disease

V.G. Mishalov, N.Yu. Litvinova

The aim of our investigation was to establish ischemic heart disease (IHD) incidence in patients with the necessity of surgery of extracraneal brachycephalic vessels' atherosclerotic lesions, to optimize surgical tactics in accordance with the obtained data, to analyze the early and long-term results of surgical treatment.

Materials. Over the period from 1999 till 2003, 205 patients were undergone the surgical operations of brachycephalic arteries' atherosclerotic occlusion in Kiev Central Municipal Clinical Hospital. From them, the earlier or present IHD diagnosis was established in 135 patients (65,9 %). All patients with brachycephalic arteries' lesions were undergone preoperative exposure and treatment of concomitant IHD. New surgical techniques were worked out. Local anesthesia during surgery was used by indications.

Results. Good and satisfactory results were obtained in 92,7 % of patients in early postoperative period and in 62 % of cases in long-term period.

Conclusions. In 65,9 % of patients, who are to have surgical operations on brachycephalic arteries, the combined coronary artery lesions occurs, whish is to be estimated as separate condition, demanding definite surgical tactics. It is advisable to perform ECG, echocardiography, stress tests and sometimes, coronarographic study by indications, to all patients before operations on brachycephalic arteries with the aim of concomitant IHD exposure. We consider appropriate, in the case of presence of combined lesion of coronary and brachycephalic arteries, to perform brain artery surgery at the first stage. Besides, such patients need medication treatment of IHD before and after operation with the purpose of clinical IHD manifestations' correction. In the case of combined pathology, the necessity of additional methods of perioperative cerebroprotection occurs more often, than in patients without IHD, due to insufficiency of collateral cerebral blood flow. New methods of operations, developed by us (internal carotid artery and superior thyroid artery shunting or transposition of thyrocervical trunk in vertebral artery) allowed us to reduce the using of temporary intravascular shunts and, respectively, the rate of associated complications.

Keywords: atherosclerosis, brachycephalic arteries, ischemic heart disease, surgical treatment.



Diagnostics and complex surgical treatment of arterial complications of thoracic outlet!syndrome

N.F. Dryuk, A.V. Samsonov

The aim of investigation is to develop a diagnostics algorithm of thoracic outlet-syndrome complication (TOS) and complex surgical treatment of such patients.

Materials and methods. The results of diagnostics and surgical treatment of 73 patients with TOS arterial complications from 1980 till 2002 were analyzed. Diagnostic algorithm including X-ray examination of chest and neck vertebral column and upper chest aperture bones, ultrasound scanning of main arteries, duplex and photoplethysmography, X-ray aorto-arteriography, selective arteriography with function assays is developed. Compression causes of a vessels-nervous fascicle were next: accessory cervical ribs G in 32 (44,0 %) patients, anomaly of the first rib, first and second ribs G in 24 (34,0 %) patients, enlarged transversal process of seventh cervical vertebral G in 7 (10,0 %); additional fibromuscular structures of scalene muscles and fibrosis between abnormal osseous formations — in 7 (9,0 %), consequence of traumas G in 2 (3,0 %) patients. The combination of several compression causes was in 92,0 %. All patients with arterial complications underwent operations. Decompression of thoracic outlet and reconstructive operations on vessels of the upper extremity were performed, by the indications — a thoracic sympathectomy or indirect revascularization was performed. The late-term results are traced from 5 till 7 years.

The results. At compensation and subcompensation blood flow disturbance of the upper extremity good (reconstructed blood flow, eliminated ischemia of tissues) and satisfactory (residual neurologic disorders, limitation of exercise stresses) results of surgical treatment are obtained in 93,5 % patients; at a decompensation of blood flow disturbance — in 83,0 %.

Conclusions. Developed algorithm of diagnostics of TOS arterial complications allows installing the reasons of compression of a vessels-nervous fascicle in all patients. The surgical treatment of TOS arterial complications should be complex and consists from decompressive operations of a thoracic outlet and reconstructive operation on vessels, on indications in a combination with thoracic sympathectomy or indirect revascularization that allows receiving good and satisfactory results in 86,3 %.

Keywords: thoracic outlet syndrome, arterial complications, surgical treatment.



Role of angiotensin!converting enzyme inhibitors in current treatment and prevention of heart failure

O.J. Zharinov

From point of evidence-based medicine view, angiotensin-converting enzyme inhibitors (ACEI) are effective medications in treatment and prophylaxis of chronic heart failure (CHF). When used in optimal therapeutic dosages, these drugs ensure improvement of survival and quality of life of patients with CHF, slow down the development of the disease, prevent decompensation of circulation. Usage of ACEI is characterized by excellent cost-efficacy ratio. The most convincing evidence of efficacy in patients with severe, moderate CHF and asymptomatic left ventricular (LV) dysfunction has been obtained in classic controlled studies CONSENSUS, SOLVD and V-HeFT II with enalapril. Besides, ACEI are considered to be effective means of prevention of postinfarction heart remodeling. International and national guidelines on treatment of CHF unanimously recommend that all patients with LV systolic dysfunction, with or without symptoms of CHF and whenever contraindicated, should receive ACEI on long-term basis, usually life-long. The position of ACEI as drugs of first choice didn't change after introduction of β-adrenoblockers and angiotensin-II receptor antagonists into the treatment of CHF, as well as after performing studies comparing efficacy of these medications with ACEI. The investigation of the possibilities of usage of ACEI in patients with CHF and preserved LV systolic function has a special perspective.

Keywords: heart failure, asymptomatic left ventricular, angiotensin-converting enzyme inhibitors, enalapril.



The atherosclerosis as a from of the arteriosclerosis: discussion points of the problems

D.D. Zerbino, T.M. Solomenchuk, V.A. Skybchyk

The term «atherosclerosis» was used in vain for marking different kinds of the arteriosclerosis, which of them has their own characteristic traits and specific causes and pathogenesis mechanisms. Particularly, unlipid intimal lesion of the arteries with development of the myofibrotic plaque fibrotic hyalimizated plaque, circular or local myoelastic hyperplasia of the intima at the young age was mostly observed. Such type of the arteriosclerosis in people with occupational hazard under the influence of the xenobiotics was arised. The establishment of the real and concrete causes of each arteriosclerosis types would display new horizonts in prevention of diseases.

Keywords: arteriosclerosis, atherosclerosis, peculiarities of the arteries pathomorphology, etiology, pathogenesis, xenobiotics.



Contemporary tendency of epidemiology infectious endocarditis, aetiology and pathogenesis

A.V. Rudenko, A.A. Krikunov

Infectious endocarditis (IE) morbidity in different regions is 0,22—2,6 % cases per 100 000 per year. Contemporary tendencies of it's epidemiology include: increasing in mean patient's age and increasing rate of degenerative valve pathology; decreasing of rheumatic disease frequency in secondary IE; increasing enlargement of staphilococcus infection, gram-negative bacteria and fungi revealing and reducing of streptococcus as aetiological factor of disease; creating of new risk groups, which include patients with previously medically treated IE, those, who underwent cardiosurgery and drug-abusers. The role of heart and the main vessels endothelial changes. Local disturbances at hemodynamics, pathogenity of aetiological factors, violations of local and general resistancy, microembolism of valve's capillars are discussed.

Keywords: infectious endocarditis, aetiology, pathogenesis.

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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