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Issue. Articles

3(19) // 2007





Morphological changes of mucous membrane of the stomach, duodenum and vessels of submucosal layer in the deceased of acute myocardial infarction

V.G. Mishalov, E.N. Amosova, L.Yu. Marculan, I.M. Leshchishin, P.L. Byck, S.V. Pacryshen

The purpose — to estimate the occurrence and character of changes of the stomach and duodenum mucous membrane as well as the condition of arterial and venous vessels of the submucosal layer among the deceased of acute myocardial infarction (MI) who had not had clinical attributes of gastrointestinal bleedings (GIB) according to the data of macro- and microscopic research of the autopsy material.

Materials and methods. 172 patients who died in the Central City Clinical Hospital in Kyiv within the period from January 2005 till May 2007 were included in the research. The patients were divided into three groups: MI group (104) — those who died of myocardial infarction 18 hours after the onset of the disease, CIS group (68) — of cerebral ischemic stroke (CIS), C group (control) (9) — of accidents. The cause of death of patients in MI group was acute cardiac failure, in CIS group — cerebral oedema, in C group — polytraumas incompatible with life. The groups were age and gender matched. Patients who had undergone percutaneous coronary interventions, thrombolysis, artificial ventilation of lungs for more than 24 hours, those who died of cardiogenic shock, septic complications, or had had concomitant renal failure were not included in the research. The patients did not receive antacid medicines, proton pomp blockers, 2- blockers. The treatment of MI and CIS groups’ patients did not differ in frequency of aspirin, heparin and saluretics administration. Prevalence, depth and relative volume of MI zone as well as expressiveness of lung edema were estimated at macroscopical research of heart tissues. The presence of petechias, erosions, ulcers and bleedings was estimated at macroscopical research of the mucous membrane of the stomach (MMS) and duodenum. At histological research, the areas of lumen of arterial and venous vessels of submucosal layer of the stomach and duodenum were measured by means of the program I-1000.

Results and discussion. In MI group, acute damages of gastroduodenal mucous membrane (ADGMM) were fixed in 82 (78.8 %) of the deceased, which was substantially higher than in CIS and C groups, 24 (35.3 %) and 1 (11.1 %), accordingly, = 0.001. Also in MI group, the occurrence of different forms of ADGMM was higher than in CIS and control groups ( < 0.05). Attributes of GIB were found in 21 (20.2 %) patients of MI group and in 2 (2.9 %) — of CIS group ( = 0.001). GIB was not fixed in control group. The analysis of dependence of different ADGMM and GIB forms occurrence on the time period which passed from the onset of the disease to death revealed positive and authentic ( < 0.01) dependence between these parameters. In CIS group such dependence was not revealed. Only the occurrence of petechias along with MMS and duodenum erosions correlated with the volume of MI at a level of statistical importance (r = 0.291; = 0.003 and r = 0.194; = 0.048). Factors of correlation between MI volume and frequency of ulcers and bleedings are r = –0.123, r = 0.026, accordingly (all > 0.05). Patients of group with MI had authentically higher total frequency of all MMS and duodenum defeats in case of acute left ventricle failure (ALVF) of III class by Killip-Kimball than in case of ALVF of II class — 94.6 % against 59.3 %, accordingly ( = 0.017). Patients with CIS did not reveal any authentic differences between the total frequency of all ADGMM forms and the frequency of bleedings at different stages of chronic cardiac failure. In MI group, weak authentic connection between the expressiveness of lung edema at autopsy and the presence of MMS and duodenum petechias (r = 0.234, = 0.002) and erosions (r = 0.151, = 0.048) was revealed; in CIS group, only weak positive correlation between expressiveness of these morphological changes and frequency of petechias was fixed (r = 0.325, = 0.007). Arteries of submucous layer of MMS and duodenum in MI group did not differ essentially by the area of the lumen and cross-section cut from those in CIS and control groups ( > 0.05), whereas all morphological parameters of venous vessels in average values were authentically higher in MI group than in CIS and C groups ( < 0.05). The average lumen area of venous vessels had positive correlation with ALVF class (p = 0.432, = 0.001), bleeding occurrence (r = 0.346; p = 0.011), erosions (r = 0.364; p = 0.009) and the time period from the onset of the disease to the moment of death (r = 0.35; p = 0.01). It has also been established that the presence of erosions in the deceased of MI associates with authentic increase of the average area of veins. Such dependence was not found in patients with CIS.

Conclusions. Among the deceased of MI without GIB diagnosed during life, ADGMM at autopsy was fixed in 78.8 % cases, including those combined with ulcers (11.5 %), which was 2.17 times more often than in the deceased of CIS; diffuse bleedings were fixed in 20.2 % cases. The deceased of myocardial infarction, in comparison with those who died of ischemic insult and accidents, had the average area of the lumen of venous vessels of MMS and duodenum submucosal layer, which was, according to microscopy investigation, increased in size and in positive correlation with the frequency of ADGMM and GIB, with the time period from the onset of the disease till the moment of death, ALVF class.

Keywords: myocardial infarction, gastrointestinal bleeding, acute damages of gastroduodenal mucous membrane, venous vessels



Comparative evaluation of omapatrilat and enalapril influence on the pulse intraction between the left heart ventricle and the arterial system in patients with arterial hypertension: a model analysis of clinical data

G.V. Knyshov, B.L. Palets, O.M. Burkot

The fact that pulse AP () is informative as predictor of disorders caused by arterial hypertension (AH), and heart insufficiency (HI), triggered the development of hypotensive means reducing aorta stiffness. Among these, a vasopeptidase inhibitor omapatrilat seems to be the most promising.

The purpose of this work was to find out for groups of patients with AH a set of cardiovascular parameters that change under the effect of enalapril and omapatrilat, and to compare their relative contribution into the reducing of pulse load on the left ventricle (LV) as well as into normalization of its interaction with the arterial system.

Material and methods. Clinical material consisted of the data obtained by G.F. Mitchell et al. (2002) in the course of international studies of monotherapy by enalapril (40 mg daily) and omapatrilat (80 mg daily) in two groups of patients with AH. Systolic, mean and pulse arterial pressure (AP), heart rate, mean blood flow, total peripheral vascular resistance (TPVR, Ra), characteristic aorta impedance (Rc), aorta compliance per unit of length (C′), and the AP pulse wave velocity (vpw) were measured in the initial condition as well as after 12 weeks of treatment. Clinical data were analyzed by means of a cardiovascular system model describing the dynamics of pressures, volumes and blood flow in a closed circuit consisting of the right heart ventricle, pulmonary arteries and veins, left heart ventricle, systemic arteries and veins, and venae cavae. The aorta was represented as an elastic tube with parameters uniformly distributed over its length. The load on the LV (Ns) was determined as an integral of tension (ns) in the LV wall over the time of ejection, while the integral of an increment in ns — as a pulse load on the LV (Np), for which a term PTTI (pulse tension-time index) was introduced.

Results and discussion. The data obtained by modeling were close enough to clinical. In the initial state, TPVR in both groups was 1.6 times greater, while the aorta compliance (C′) and that of systemic arteries – about three times lower than the norm (p < 0.01). All the AP parameters were higher than the norm (p); ppincreased about twice (p < 0.05). The greatest increase of 2.7 times was shown by PTTI (p < 0.05). The pulse component’s contribution into the total load increased considerably as well. The ratio k = Np / Ns increased from 0.240 in the norm to 0.46 in patients with AH (p < 0.05). The reduction of PTTI by omapatrilat treatment was almost twice greater than that by enalapril treatment (15 % vs. 8 %; p < 0.05). Both drugs caused the increase of unstressed venous volume Δuv (60 and 75 cm3, respectively; p < 0.05). C′ increased by 31 % after treatment with omapatrilat, while after that with enalapril – by only 11 % (p < 0.05). vpw reduced by 10 % and 5 %, respectively, (p < 0.05). Rc reduced under the effect of omapatrilat by 11 % (p < 0.05) due to the increase of C′. With respect to their effect on changes of the pulse load (ΔNp), the cardiovascular system parameters in both groups formed the same sequence: C′, uv, Ra. The increase of the blood flow damping over the length of aorta was twice greater after the treatment with omapatrilat (20 cm3/s vs. 11 cm3/s; p < 0.05). The difference y1—y2 (y1 = pd/ps, y2 = pp/pd) reduced by 8 % (p < 0.05) under the effect of omapatrilat. As we showed earlier, when y1—y2 = 0, the cardiovascular system operates in the vicinity of the maximum LV efficiency.

Conclusions. Changes of the pulse load (ΔNp) on the LV under the effect of both omapatrilat and enalapril are determined by the resultant action of the increase in aorta compliance, preload (Δuv) and afterload decrease. The advantage of omapatrilat over enalapril is that it normalizes the damping function of aorta and brings the interaction of LV and arterial system close to its optimum.

Keywords: omapatrilat, enalapril, pulse load, arterial hypertension, mathematical modeling



Mathematical model of endotension following endovascular exclusion of aortic aneurysm

S.N. Volodos, V. N. Fenchenko

The purpose of the research was to define the value of different factors, as well as their interaction, for development of endotension following endovascular aneurysm repair (EVAR).

Materials and methods. Using a specially designed mathematical model «stent graft (SG) in aortic aneurysm», the roles of some parameters and physical properties of the SG and the aneurysm, along with the level of systemic arterial pressure (AP), for the development of endotension were considered. The following situations and functions were described mathematically: 1) the behavior of the SG wall implanted into the region of aortic aneurysm in cases when it was completely and not completely expanded at the moment of the aneurysm exclusion from the main blood circulation; 2) correlation between physical properties and dimensions of the SG and the aneurysm, and its role in the development of endotension.

Results and discussion. The mathematical description of the SG wall behavior under the influence of blood pressure in cases when it was completely and not completely expanded at the moment of the aneurysm exclusion from the main blood circulation gives substantial evidence of the fact that the SG which was not completely expanded can not suppress the transmission of the pulsatory blood flow pressure into the aneurysm. The membrane of the SG which was completely expanded must stop the pressure transmission into the aneurysm. High arterial pressure at the moment of SG implantation into the aorta suggests that in a number of cases the patient may preserve the mechanisms of pressure elevation in the aneurysm following the elevation of pressure in the main aortic blood flow. The above mentioned factors may be important for endotension formation, but the practical use of this discovery depends on the results of further experimentations and clinical observations. The results we obtained also suggest that low systemic arterial pressure at the moment of SG implantation into the aorta may help endotension prophylaxis. To provide a «perfect» procedure, the SG should be completely expanded and the systemic arterial pressure lowered at the moment of the aneurysm exclusion from the flow. Physical parameters and sizes of the SG and their correlation with aneurysm sac dimensions and elastic properties may influence the development of endotension, too. The probability of endotension following EVAR increases with small dimensions and low compliance of the aneurysm. In some clinical cases the development of endotension in the aneurysm might be natural and require subsequent expansion of the procedure (aneurysm sac fenestration). Further in vitro experimental and clinical studies are required to clarify the practical value of the above mentioned mechanisms of endotension development in the aneurysm sac after EVAR, so that their results can be used both for further modernization of SG design and for the modification of the EVAR procedure aimed at reducing the number of endotension development cases.

Conclusions. The factors contributing to endotension development after EVAR can be: SG which was incompletely expanded at the moment of the aneurysm exclusion from the main blood circulation; high systemic arterial pressure during the procedure; low aneurismal wall elasticity. The following methods can be used for the prophylaxis of complications: temporary decrease of systemic arterial pressure at the moment of SG implantation; the choice of SG whose design will provide its complete self-expansion, or a more thorough use of a balloon catheter for these purposes. If endotension is detected after EVAR, it is necessary to use aneurysm sac fenestration, especially in patients with small dimension and rigid wall aneurysms.

Keywords: aortic aneurysm, endovascular surgery, stent grafting, endotension



The estimation of the results of stress-echocardiography test with dipiridamol in patients with X coronary syndrome

V.I. Zakharova

The purpose of the research was to estimate the results of stress-echocardiography test (SET) with dipiridamol in patients with X coronary syndrome (X-CS) and to analyze the factors which influence them.

Material and methods. 40 patients with X-CS, including 18 (45%) men and 22 (55%) women, mean age (52.4 ± 1.3) years, were examined. The diagnosis was based on stenocardia, ischemic depression of ST segment during the treadmill test in the absence of coronary artery (CA) changes at coronography (CG). The comparison group consisted of 30 patients with initial CA atherosclerosis (AS) of — 1—2 vessel lesions of CA with stenoses of 20—50 %, including 26 (86.7 %) men, 4 (13.3 %) women, mean age (54.6 ± 1.5) years. Normative indices were received during the examination of 30 healthy persons. The examination included SET with dipiridamol, treadmill test, the evaluation of the indices of cardiac rate variability (CRV) at rest, endothelium dependent (EDVD) and endothelium independent (EIVD) vasodilatation of the brachial artery and the thickness of intima-media complex (IMC) of the common carotid artery.

Results and discussion. During SET with dipiridamol, the positive coronary heart disease probe was fixed in 23 (57.5 %) patients of X-CS group and in 16 (53.3 %) patients of CA AS group ( > 0.05). The X-CS patients with positive SET had ischemic changes on the ECG without impairments of left ventricle (LV) myocardial contractility in 21 out of 23 (91.3%) cases, while in the group with CA AS — only in 4 out of 16 (25 %; p < 0.05). The rest of the patients with CA AS with positive SET had impaired local LV myocardial contractility. X-CS patients with positive SET, if compared with those with negative SET, more often manifested the impairment of glucose tolerance (34.7 vs. 6.25 %, respectively; < 0.05), substantially lower threshold power of load (correspondingly (7.7 ± 0.2) and (8.4 ± 0.3) ; < 0.05) and the duration of the load ((6.9 ± 0.3) and (7.6 ± 0.3) min, correspondingly; < 0.05), CRV indices — RMSSD ((16.5 ± 1.2) and (21.6 ± 1.1) ms, correspondingly; p < 0.05), pNN50 (correspondingly (1.0 ± 0.2) and (2.06 ± 0.2) min–1; p < 0.05). LF/HF relation increased ((2.2 ± 0.2) (1.4 ± 0.2) conventional units, correspondingly; p < 0.05). The patients with positive and negative SET, if compared with healthy persons, had equally decreased EDVD ((4.73 ± 0.26) and (4.78 ± 0.31) %, correspondingly, vs. (10.88 ± 0.29) %; p < 0.05), whereas EIVD of the former didn’t differ from the norm ((24.56 ± 1.23) and (23.19 ± 0.72) %, respectively; > 0.05), and EIVD of the latter was decreased ((16.22 ± 0.48) %; both p < 0.05).

Conclusions. The sensitivity of SET with dipiridamol being equal in patients with X-CS and CA AS (58.9 55.1 %), its positive result in the first case is caused mainly by the appearance of ischemic changes on the ECG in the absence of impairments of local LV contractility, and in the second case — by the combination of these signs. The induction of ischemia in X-CS patients with positive probe is associated with bigger impairment of glucose tolerance, smaller tolerance to physical load, more pronounced sympathicotonia, according to the results of CRV evaluation at rest and bigger EIVD, than in patients with its negative result.

Keywords: X coronary syndrome, stress-echocardiography test with dipiridamol, endothelial dysfunction, treadmill test, cardiac rate variability



Varied tactics of deep femoral artery plastics in patients with femoral-popliteal segment occlusion

O.S. Nikonenko, O.V. Gubka, V.O. Gubka, O.V. Suzdalenko, I.N. Belkin, Yu.V. Sushko, S.O. Moskalenko

The purpose of the research was to develop varied tactics of deep femoral artery plastics in patients with occlusive-stenotic lesions of femoral-popliteal segment and to study the short-term results of the surgical treatment of the patients.

Materials and methods. Deep femoral artery (DFA) plastics was performed in 142 patients in clinic of hospital surgery of Zaporizhzhya medical university from 2003 to 2006. 131 (92.2 %) of them were men, 11 (7.8 %) — women, mean age was (61.1 ± 3.8) years. The examination included: duplex scanning, dopplerography of lower extremity arteries, digital subtraction angiography. Analyzing the results of the examination and intra-operative revision we differentiated between 3 variants of atherosclerotic DFA lesions. The choice of DFA reconstruction method depended on the variant of its lesion. Endarterectomy of DFA orifice was performed in 54 patients with I variant. Endarterectomy with the removal of the plaque from the orifice of the lateral artery bending round the femur and further DFA plastics was performed in 66 patients with II variant. Arteriotomy was performed along the whole stenotic DFA segment with liberation of orifices of all the branches in 22 patients with III variant of lesion. The short-term results of DFA plastics were evaluated by the change of pain syndrome, walking distance, healing of trophic ulcers.

Results and discussion. Good results were achieved in 83 (58.5 %) patients with different degree of ischemia: night pain and pain at rest stopped, the walking distance substantially (more than twice) increased. Different kinds of amputations were performed in 45 (31.7 %) patients with good results who had IV degree of chronic ischemia. As a result of finger amputation, the wounds healed, the trophic ulcers purified, became smaller and epithelization began. Amputation of the lower extremity at femur level was performed in 14 patients (9.8 %) because of ischemia progression. In case of occlusive-stenotic lesions of femoral-popliteal segment, the variant of vascular reconstruction should be chosen with taking into consideration the character of their lesion.

Conclusions. Deep femoral artery reconstruction is indicated to patients with widespread occlusive-stenotic lesions of femoralpopliteal segment arteries with defeat of popliteal artery and the arteries of shin. The choice of the method depends on the spread of the lesion. This approach provides good and satisfactory results in 90.2 % patients. Unsatisfactory results achieved in 9.8 % patients with occlusion of femoral-popliteal segment were caused by occlusive-stenotic lesions of the arteries of shin and inadequate collateral blood flow.

Keywords: femoral-popliteal occlusions, deep femoral artery plastics, type of defeat



Insulin resistance impact on the condition of the systolic function of the left heart ventricle and its determining factors in patients with essential arterial hypertension

E.N. Amosova, G.V. Miasnikov, L.L. Sidorova

The purpose of the research was, relying on the analysis of mathematical models of intra-cardiac hemodynamics, to determine the factors affecting the condition of the systolic function of the left heart ventricle (LV) in patients with essential arterial hypertension (AH) depending on the presence or absence of insulin resistance (IR).

Material and methods. Dopplerechocardiography indices of the systolic, diastolic function, hypertrophy of the left and right heart ventricles of 138 patients with AH II and preserved sensibility of the tissues to insulin (PSTI) and 178 patients with combination of AH and IR, according to HOMA index, with chronic heart failure not exceeding II functional class and LV ejection fraction (EF) not exceeding 45 % were examined by means of correlation, Analysis of Variances, ANOVA and regression analysis. The informative value of mathematical models was measured by Box-Vets coefficient, the adequacy – by Fisher criterion.

Results and discussion. The mean value of HOMA index in PSTI group was (2.42 ± 0.2) μUnits/ml × μmol/l, in IR group – (3.1 ± 0.2) μUnits/ml × μmol/l ( < 0.001). The models of intra-cardiac hemodynamics which possess informative value, adequacy and descriptive values are as follows:
– In AH patients with PSTI:
LV EF = 8.42 + 4.12 RV + 3.87 LV + 0.54 LV EDI – 0.73 LV ESI +7.29 LV ESP/ESV
(Box-Vets coefficient 14.98, Fisher criterion 23.1);
– In AH patients with IR syndrome:
LV EF = 3.43 + 3.36 LA + 0.66 LV EDI – 0.64 LV ESI + 0.95 ESP/ESV
(Box-Vets coefficient 28.51, Fisher criterion 22.93),
Where LV EF is left ventricle ejection fraction;
RV is anterior-posterior size of the right ventricle;
LV EDI is left ventricle end-diastolic index;
LV ESI is left ventricle end-systolic index;
LV ESP/ESV is end-systolic pressure/ end-systolic volume of the left ventricle.

Conclusions. The analysis of the models of intra-cardiac hemodynamics in AH patients, irrespective of tissue sensibility to insulin, shows the support of LV ejection fraction with the help of two mechanisms – its elevated contractility and Frank-Starling mechanism of LV and left atrium. The function of supporting the value of this index in AH patients with PSTI is also performed by Frank-Starling mechanism of the right heart ventricle that is lost with IR development, which leads to the increase of the role of Frank-Starling mechanism of LV in such patients.

Keywords: intra-cardiac hemodynamics, mathematical models, insulin resistance, arterial hypertension



Antihypertensive and antiapoptotic efficacy of combination treatment with angiotensin II receptor antagonists and calcium channel antagonists in patients with arterial hypertension

T.V. Ashcheulova, O.M. Kovalyova

The purpose of the study was to assess clinical, hemodynamic and antiapoptotic efficacy of combination therapy with angiotensin II receptor antagonist — candesartan and calcium channel antagonist — lacidipine in patients with arterial hypertension (AH).

Material and methods.We examined 39 patients with AH who received 4 mg of candesartan and 2 mg of lacidipine in one doze daily. I stage of AH was diagnosed in 1 patient (2.6 %), II stage — in 35 (89.7 %), III stage — in 3 patients (7.7 %). According to the degree of arterial pressure (AP) elevation, the following division was observed: the 1st degree of AH was present in 6 patients (15.4 %), 2nd degree — in 14 (35.9 %) and 3rd degree — in 19 (48.7 %). AP control, echocardiography and measuring plasma apoptosis markers — tumor necrosis factor-α (TNF-α), soluble TNF-α receptor of type 1 (sTNF-R1), soluble Fas ligand (sFasL) by immune-enzyme method were performed at baseline and 12 weeks after treatment.

Results and discussions. The therapy with candesartan + lacidipine combination caused significant systolic AP lowering by 51.7 mmHg (28.7 %, = 0.001), diastolic AP — by 27.0 mmHg (25.3 %, = 0.002). The target AP level (140/90 mmHg and less) was achieved in 35 patients (89.7 %). The left ventricle systolic function values did not change significantly ( > 0.05). The therapy with this combination contributed to the decrease of TNF-α/sTNF-R1 ratio in the plasma from 63.2 to 17.1 ( = 0.001; the norm is 11.03), plasma levels of proinflammatory cytokine (TNF-α) — from (132.6 ± 22.58) to (45.99 ± 5.63) pg/ml ( = 0.00002; the norm is 13.23 ± 3.40), the rate of apoptosis inductor detection in plasma (sFasL) — from 56.4 % to 38.5 % ( = 0.034) and the elevation of TNF-α endogenous antagonist plasma level (sTNF-R1) from 2.1 to 2.6 ng/ml ( = 0.04) (the norm is (1.2 ± 0.60) ng/ml).

Conclusions. The 12-week therapy of AH patients with candesartan and lacidipine combination caused the reduction of systolic AP by 28.7 % and diastolic AP — by 25.3 %. The target AP was achieved in 89.7 % patients. The therapy with this combination caused immuno-inflammatory activity reduction and prevention of TNF-dependent and Fas-dependent cardiomyocyte apoptosis pathway, which was confirmed by the decrease of plasma levels of proinflammatory cytokine — TNF-α by 66.1 %, TNF-α/sTNF-R1 ratio — by 72.9 %, the rate of sFasL apoptosis inductor detection in plasma — by 17.9 % and the elevation of TNF-α — sTNF-R1 endogenous antagonist level — by 25.2 %.

Keywords: arterial hypertension, combination therapy, angiotensin II receptor antagonists, calcium channel antagonists, apoptosis



The influence of the condition of myocardial reperfusion after primary coronary interventions in patients with acute myocardial infarction with the elevation of ST segment on the systolic function of the left ventricle in the early post-infarction period

Yu.V. Rudenko

The purpose of the research was to estimate the condition of the systolic function of the left ventricle (LV) in the dynamics of its change during the hospital period of acute myocardial infarction (AMI) depending on the effectiveness of myocardial reperfusion in patients who underwent primary coronary interventions (PCI) on the first day of the disease.

Material and methods. The patients (n = 41) were divided into groups depending on the level of myocardial perfusion (MP) which was estimated using angiography (index MBG). The 1st group — MBG ≥ 2 (n = 23), the 2nd — MBG ≤ 1 (n = 18). The velocity of epicardial bloodflow (EB; CTFC index), the presence of distal microembolia (DME) according to the results of angiography and the indices of the systolic function of the LV: end-systolic (ESI) and end-diastolic (EDI) indices, ejection fraction (EF) — on the 2nd — 3rd, 7th—10th and 19th—21st days of the disease were estimated in each group.

Results and discussion. The patients of both groups were matched by gender, age, frequency of concomitant essential arterial hypertension and diabetes mellitus of type 2, AMI location, the time from the onset of the disease to «balloon», the spread of the atherosclerotic lesion of the coronary bed, the division according to the localization of the infarction dependent artery, the presence of the collateral bloodflow (all p > 0.05). The patients of the 1st group were characterized by higher EB velocity: CTFC index was 34.1 ± 1.88 and 63.4 ± 7.6, respectively (p < 0.05). DME was less frequent: 5 (21.7 %) and 9 (50 %) cases, respectively (p < 0.05). The indices of the LV systolic function did not differ (EDI, ESI, EF) on the 2nd — 3rd day of the disease: (65.14 ± 2.29) and (67.66 ± 3.60) ml/m2; (33.66 ± 1.89) and (35.66 ± 3.29) ml/m2; 51.01 ± 0.02 and 48.04 ± 0.03, respectively (all p > 0.05). The patients of the 1st group manifested substantially smaller values of the LV cavity and big EF both on the 7th—10th (61.96 ± 2.15) and (65.5 ± 2.35) ml/m2; (27.11 ± 1.47) and (30.92 ± 1.69) ml/m2; 55.89 ± 0.02 and 51.02 ± 0.01, respectively (p < 0.05), and on the 19th—21st days of the disease — (56.01 ± 1.82) and (59.57 ± 2.25) ml/m2; (26.02 ± 1.71) and (30.13 ± 2.38) ml/m2; 59.28 ± 0.01 and 55.42 ± 0.03, respectively (p < 0.05).

Conclusions. Inadequate MP (MBG index = 0—1) after PCI in AMI patients with the elevation of ST segment is associated with EB deceleration in 61.1 % cases and with DME — in 50 %. Optimal MP after PCI in AMI patients with the elevation of ST segment contributes to the increase of the EF and the decrease of EDI and ESI, of the LV starting with the 7th—10th day of the disease onset.

Keywords: acute myocardial infarction, primary coronary interventions, myocardial perfusion, systolic function of the left ventricle



Changes of heart rate variability in the patients with myocardial infarction, which complicated early post-infarction angina

O.I. Rokyta

The purpose — to estimate changes of heart rate variability (HRV) in patients with myocardial infarction (MI), complicated by early post-infarction angina (EPIA), at rest and after antiorthostatic test in comparison with those in MI patients without such complication.

Materials and methods. 94 patients with acute MI were examined. They were divided in two groups. The basic group (n = 45) consisted of patients with EPIA, the control group (n = 49) — patients without such complication. The study of HRV with the estimation of nonspectral (SDNN, RMSSD, pNN50, pNN50%) and spectral (LF, HF, LF/HF) indexes was conducted in the basic group on 1—2 days after EPIA onset, and in the control group — in comparable terms. ECG results for the analysis of HRV indexes were registered in the morning before eating and taking medicines, in the gorizontal position and in the condition of antiorthostatic test with passive rise of legs to 45° during 5 min.

Results and discussion. Paradoxical reaction of HRV to the volume load which was displayed by the increase of LF/HF value was fixed in 24 (53.3 %) patients of the basic group, which was substantially more frequent than in the control group — 24.5 % ( < 0.05). The patients of the basic group with the normal reaction of HRV to the antiorthostatic test made up I group (n = 21), with paradoxical — II (n = 24); patients with normal reaction composed III (n = 37) group (control), patients with paradoxical reaction — IV group (n = 12). Patients of all groups did not have significant differences in age, gender, risk factors, depth and localization of MI. In comparison with III group, the patients of I group at rest had substantially lower SDNN (24.1 ± 1.2 vs. 34.5 ± 2.0), pNN50 % (2.9 ± 0.1 vs. 11.5 ± 0.8), LF (21.2 ± 2.5 vs. 64.5 ± 3.2), HF (12.8 ± 0.9 vs. 37.4 ± 2.1) indexes ( < 0.001). Substantially lower SDNN (22.1 ± 0.9 vs. 28.1 ± 1.5), pNN50 % (4.8 ± 0.1 vs. 5.3 ± 0.3), LF (13.3 ± 0.7 vs. 23.6 ± 1.3) indexes ( < 0.05) were revealed in patients of II group in comparison with IV group. Indexes pNN50 % and LF/HF ratio ( < 0.05) were different in I and II groups. The substantial increase of SDNN, PNN50, HF % indexes ( < 0.001) and RMSSD ( < 0.05) was registered during the antiorthostatic test in healthy persons. The decrease of LF/HF value was 36.9 % ( < 0.001). Changes of PNN50, HF%, RMSSD in the patient of I group during the antiortostatic test were absent. Only the increase of SDNN — (17.7 ± 1.1 %) ( < 0.05) was registered. The decrease of LF/HF value was 32.8 % ( < 0.05). The reaction to antiorthostatic test in II group (53.3 % of the patients with EPIA) was paradoxical. Significant decrease of PNN50 — (63.1 ± 2.0 %) ( < 0.001) and SDNN (20.0 ± 1.0) %, HF% — (26.3 ± 1.0) % ( < 0.05) was fixed. The increase of LF/HF value was 59.6 % ( < 0.001). In patients of II group, in comparison with I group, EPIA ended by recurrent MI much more often (29.2 % vs. 9.5 %, < 0.05, respectively), the stabilization (reverse development) of EPIA was more seldom (12.5 % vs. 33.3 %, < 0.05).

Conclusions. In the patients with MI, complicated by EPIA, the paradoxical reaction of HRV manifested as LF/HF value increase during antiorthostatic test was registered 2.5 times more often than in MI patients without EPIA and was associated with the increased frequency of recurrent MI and the decreased frequency of angina stabilization. Patients with MI complicated by EPIA had substantially lower HRV than MI patients without this complication.

Keywords: early post-infarction angina, heart rate variability



Papillary fibroelastoma rare tumor heart disease

R.M. Vitovsky, V.P. Zakharova, A.M. Dovhan, V.M. Beshliaha, I.H. Yakovenko, V.V. Isayenko, A.V. Kryvenky

One of benign tumors of the heart which rarely occurs is papillary fibroelastoma (PF). Histogenesis, clinical picture, diagnosis and surgical treatment of this neoplasm are insufficiently studied.

The purpose of the research was to determine the specific features of the clinical course, diagnosis and surgical treatment of heart PF.

Materials and methods. 512 patients with primary benign tumors of the heart were under investigation at M.M. Amosov Scientific and Research Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine from 01.01.1969 to 01.01.2007. 15 of them had benign nonmyxomatous neoplasms. PF was diagnosed in two cases which was 0.4% of all the primary tumors of the heart. The diagnosis was based on the data of transthoracic and transesophageal two-dimensional Doppler echocardiography with colored Doppler mapping, which made it possible to detect neoplasms, determine the extent of cardiac structure involvement and the degree of hemodynamics impairment.

Results and discussion.We analyzed two clinical cases of diagnosis and surgical treatment of PF in 42 and 56 years old patients without clinical signs of chronic heart failure. According to Doppler echocardiography results, in one case the tumor of 3.5 × 2.5 cm in size, was attached to the anterior cusp of the mitral valve causing the narrowing of the left atrioventricular orifice with 22 mmHg diastolic gradient of pressure. In the second case, PF of 1 × 1 m in size was attached to the left coronary cusp of the aortal valve, causing insignificant deformation of the cusp with minor impairment of the closing function. In both cases the sizes of the heart cavities and the ejection fraction of the left ventricle had minor changes. Both patients underwent operative treatment in conditions of artificial blood circulation by emergency indication. It included PF removal (in one case — approaching through the aorta, in the other — through the right atrium and the interatrial septum) and the estimation of the closing function of the valve, from which the tumor grew. In case of aortal valve PF removal, additional plastic correction was necessary to achieve the valve competence. The competence of the valves after the operation was preserved in both cases. The post-operative period proceeded without complications.

Conclusions. Clinical manifestations of papillary fibroelastoma are not numerous and they are non-specific. The main method of its diagnosis is two-dimensional multi-planar transthoracic and transesophageal Doppler echocardiography, which makes it possible to detect neoplasms and dysfunction of the valve apparatus connected with it. Emergency operative treatment aimed at removal of the tumor with possible preservation of the valve apparatus was indicated to the patients with papillary fibroelastoma.

Keywords: heart tumors, papillary fibroelastoma, diagnosis, surgical treatment, morphology



Atresia of pulmonary artery with ventricular septal defect

M.F. Zinkovsky, R.J. Lekan

Pulmonary atresia with ventricular septal defect (PA-VSD) represents a complex congenital heart disease (CHD) with absence of continuity between the right ventricle (RV) and the pulmonary artery (PA), anomaly of the structure of the pulmonary arterial bed and also extracardiac sources of collateral pulmonary blood supply in the form of major aortopulmonary collateral arteries (MAPCAs), open ductus arteriosus (ODA), bronchial vessels. At present, two approaches to the choice of method of surgery coexist in the tactics of PA-VSD surgical treatment: early single stage unifocalization with radical correction of the disease and staged correction of CHD with one or several palliative procedures and the further complete radical operation. The technique of single stage unifocalization with complete repair provides one-stage separation of the MAPCAs from the aorta uniting all lung segments into the system of neopulmonary blood circulation with VSD closing and the implantation of valve conduit between the RV and the PA in babies under conditions of artificial blood circulation (ABC). In case of the second approach, staged sequential thoracotomies are prformed which are based on MAPCAs unifocalization with the creation of neopulmonary artery, the latter being formed with the use of vascular artificial prostheses or pericardial tube with the implantation of the systemic pulmonary modified Blalock-Tausig shunt (MBTS) into it. The final procedures of the surgical treatment are VSD closure, uniting central PA by means of a pericardial tube and connecting the RV with the PA by means of a valve conduit under ABC conditions.

Keywords: congenital heart disease, pulmonary atresia, ventricular septal defect, major aortopulmonary collateral arteries, modified Blalock-Tausig shunt, unifocalization of major aortopulmonary collateral arteries



Integrated positron emission and X-ray computed tomography in cardiology

O.B. Dynnyk, M.M. Zhayvoronok, V.M. Zalessky

The article presents data on the new method of molecular noninvasive diagnosis – integrated positron emission and X-ray computed (PET-CT) imaging. The main characteristics of the method as well as the modes of its application for imaging coronary and myocardial pathology are presented. Perspectives of PET-CT research development in cardiology are displayed. Integrated PET-CT offers an opportunity to assess the presence and magnitude of subclinical atherosclerosis. While stress-associated PET imaging of obstructive coronary artery lesions is universally recognized, the problem of their extent and severity assessment is still under investigation together with the problem of the identification of endothelial dysfunction and so-called vulnerable plaques. Emission (PET) component of PET-CT integrated research can become the «golden» standard in assessment of myocardium vital capacity due to the possibility of integral evaluation of its functional activity, perfusion and metabolism.

Keywords: integrated positron emission and X-ray computed imaging, positron emission tomography, radiopharmpreparation, tomography imaging, molecular diagnosis, 18F-fluorodeoxyglucose, cardiology

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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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