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Issue. Articles

4(32) // 2010





Relationship of lack of antiplatelet effect of acetylsalicylic acid with a change in membrane fatty acid composition of platelets in elderly patients with chronic ischemic heart disease. Possibility of correction using the

V.Yu. Lyshnevskaya, M.P. Kalmykov, T.S. Bryuzgina

The aim – the assessment of the relationships between the degree of FA platelets aggregation, composition of their cell membranes during therapy with acetylsalicylic acid (ASA) in elderly patients with chronic ischemic heart disease (IHD) and opportunities to improve the antiplatelet effectiveness of ASA with ω3-polyunsaturated fatty acid (ω3-PUFA) therapy.

Materials and methods. 787 CHD patients, aged 60 to 89 years, who had regularly received ASA (100 mg) at least one year, were included into the study. In all these subjects, aggregative activity of platelets against aspirin therapy remained high. Of them, a group of 60 patients was randomly selected who had the platelet membrane fatty acid contents as well as the number and aggregative activity of platelets determined. For comparison, we enrolled two control groups: (1) analogous group of patients (n = 25) with a normalized level of platelets aggregation against aspirin therapy; and (2) the group of elderly patients (n = 20) who, according to their functional examination, had no essential internal organs pathology. The fatty acid composition of platelet membranes was determined by gas chromatography on the gas chromatograph «-500». The platelet aggregative activity was measured by the turbidimetric method on a two-channel laser analyzer 230LA («», Russia). Upon primary examination, the patients with an elevated platelet aggregation and low (8.6 ± 0.6 % against 16.5 ± 1.3 % in both control and comparable groups) level of the arachidonic acid were administered w3-PUFA («», Kiev vitamin factory product, 1 g daily). Following 10-day therapy with «», the patients were repetitively prescribed ASA (100 mg daily). After 2 days of ASA administration we measured the level of platelet aggregative activity again. Data were analyzed according to the Statistica 6.0 program using Excel Windows XP.

Results and discussion. In 65 % of the main group patients, the arachidonic acid level was lower than that in control group of IHD patients. Mean arachidonic acid values for both groups made up (8.6 ± 0.6) and (16.5 ± 1.3) %, respectively. 10 days after treatment with ω3-PUFA preparation, the initial high level of spontaneous aggregative activity of platelets decreased on the average by almost 35 % (p < 0.05), attaining the level of control group of IHD patients (2.1 % ± 0.1 %). In 72 % patients after resumed ASA intake against ω3-PUFA, the spontaneous aggregation decreased to the level in group of healthy individuals.

Conclusions. In 44 % elderly patients with chronic IHD, against prolonged (over 12 months) aspirin therapy (100 mg daily), the levels of spontaneous as well as adenosine phosphate) and adrenalin-induced platelet aggregation remained increased. In 65 % of the cases, this was associated with the decrease of membrane platelet arachidonic acid content (gas chromatography data) in the comparison with that in the patients showing fair spontaneous aggregation response to aspirin treatment. Testing for investigation of arachidonic acid-induced aggregation of platelets is not sufficient to educe residual activity of platelets in patients with decrease of arachidonic acid in platelets membrane. Decrease of platelet membrane arachidonic acid content is associated with an increased lynolic acid content and total PUFA at the expense of omega 3-PUFA. Resumption of aspirin intake (1 g during 10 days) by the chronic IHD patients with a reduced platelet membrane arachidonic acid content and an increased level of spontaneous and induced platelet aggregation was accompanied with the decrease of aggregation values in 72 % of patients to aggregation level which was observed in patients with normal response to aspirin intake. These observations may indirectly evidence for recovery of platelet response to ASA.

Keywords: acetylsalicylic acid, aspirin resistance, ischemic heart disease, ω3-polyunsaturated fatty acid.



Two-staged surgical treatment of ascending acute varicothrombophlebitis of lower limbs in elderly patients

V.A. Prasol

The aim to analyze the efficiency of two-staged surgical treatment for ascending acute varicothrombophlebitis of lower limbs in elderly patients.

Materials and methods. The initial experience with two-staged surgical treatment for ascending acute varicothrombophlebitis (AVTP) was analyzed. The first stage included urgent palliative surgery as a minimum intervention required to prevent pulmonary embolism (PE). The second stage consisted of postponed radical combining phlebectomy for ascending AVTP preceded by conservative therapy for comorbidity: arterial hypertension (AH), atherosclerosis, ischemic heart disease (IHD), chronic heart insufficiency (HI). 25 elderly patients were operated on including 5 men and 20 women (aged 6075 years, mean age 66 years with AVTP which existed up to 5 days and signs of chronic venous insufficiency (CVI) of clinical class C3 (CEAP) in 18 (72 %) and C4 in 7 (28 %) patients. During preoperative examination using ultrasound phlebography, types I, II and III of ascending AVTP were revealed in 15, 4 and 6 cases, respectively. During physical examination, the following comorbidities were diagnosed: AH of grade II in 76 %, AH of grade III in 24 % patients, IHD of II functional class (FC) in 68 %, III FC in 32 %, HI of grade IIA in 72 %, HI of grade IIB in 28 % patients. As the first stage, urgent crossectomy (7) or high ligation of the great saphenous vein (GSV) or small saphenous vein (SSV) (18) were performed. Additional thrombectomy of femoral or popliteal vein were carried out in 9 cases to prevent PE. During the next 57 days, the patients received conservative treatment for AH and IHD as well as AVTP. The following method was radical combining phlebectomy as the second stage of surgical treatment for ascending AVTP.

Results and discussion. All patients underwent palliative surgery without thromboembolic complications. According to echo-CG data after the conservative treatment, the augmentations of ejection fraction (EF) by 5 % and stroke volume of the left ventricle by 6 % were noted in all patients (p < 0.05). During clinical examination, the reduction in number of patients with III FC by 20 % and patients with IIB grade of HI by 8 % was revealed (p < 0.05), which evidenced the efficacy of treatment for comorbidities. To complete the surgical treatment a radical combining phlebectomy was performed in all patients. Thromboembolic complications, stroke, myocardial infarction, lethal outcomes after this operation were not registered. During clinical examination 6 months later, no limb pain, hyperhemia, signs of recurrent AVTP and varicose disease were revealed. All patients manifested mild odema, 7 (28 %) of them (those who had C4 of CVI prior to surgery) had a small territory of moderate hyperpigmentation on the leg. Thromboembolic complications, progression of chronic HI during 6 months after surgical treatment were not observed.

Conclusions. Tactics of two-staged surgical treatment proved to be effective in all elderly patients with ascending AVTP. Application of tactics proposed allows for prevention of PE and realization of radical treatment for ascending AVTP and varicose disease without any risk of intraoperative stoke and myocardial infarction.

Keywords: ascending acute varicothrombophlebitis, two-staged surgical treatment, elderly patients.



Comparative evaluation of the effect of coronary stenting and strategy of conservative medication on the tolerance to physical exertion, systolic function of the left ventricle and quality of life in patients with stable and unstable angina pectoris by t

D.I. Besh

The aim to determine and compare the effects of coronary artery stenting and conservative strategy on the tolerance to physical exertion, left ventricular (LV) systolic function and quality of life in patients with stable (IIV functional class) and unstable angina.

Materials and methods. The research recruited 152 post-coronography patients with stable IIV FC and unstable angina pectoris. The main group encompassed 78 patients who had undergone coronary stenting. Eluting stents were implanted in 46 (61.5 %) cases. The number of stents per patient averaged (1.7 0.8). All patients underwent complete revascularization. Group of comparison consisted of 74 patients who, after coronography, refused from revascularization although it was possible to perform. The groups under study were comparable by the main clinical characteristics and conservative medication. The following indicants were determined in all patients: the tolerance to physical exertion (TPE) on the treadmill, ejection fraction of the left ventricle (EF LV), index of contractility, final diastolic size of the LV cavity, quality of life with the use of Short Form 12v2 questionnaire, and functional status of patients kidneys. All the investigations were carried out at the beginning of the research and in 6 and 12 months of the surveillance.

Results and discussions. At the beginning of the investigation, the index of TPE was similar in both groups, but in 6 months in the main group it increased (from 4.89 MET 1.86 MET to 8.78 MET 2.67; p < 0.001) without any consequent dynamics, while in the group of comparison any significant changes of the TPF index were undetectable. Initial values of the EF LV index in both groups showed no difference, but in 6 months, the main group displayed a considerable rise of this index (from 46.4 8.0 % to 49.8 6.8 %; p < 0.001) which remained unaltered during the subsequent period of surveillance. At the same time, in the group of comparison, any significant changes failed to occur. Results of comparative evaluation of the indices of contractility and final diastolic size of the LV tended to be alike, i.e. they considerably improved in the main group and showed no changes in the group of comparison. As soon as in 6 months after coronary stenting, there was a significant growth of physical component of the quality of life in the main group (from the score of 30.5 5.1 to the score of 45.7 7.4; (p < 0.001) and this index remained stable up to the end of 12-month surveillance. In the group of comparison, significant changes were determined to occur only within the period from 6 to 12 months of surveillance (from the score of 33.4 4.5 to the score of 34.8 6.5; (p = 0.03). The index of mental component of the quality of life displayed similar dynamics. Rate of glomerular filtration and incidence of microalbuminuria showed no significant difference between the groups both at the beginning of the research and in 6 and 12 months of the surveillance.

Conclusions. By the data of the 1-year surveillance of the patients with stable and unstable angina pectoris receiving optimal medication, coronary stenting contributed to the increase of TPE, improvement of the global and regional systolic function of the LV and patients quality of life, which was not observed in conservative treatment of these patients. Moreover, any negative effect of this surgical intervention on the renal function was undetectable.

Keywords: coronary stenting, ischemic heart disease, angina pectoris, prognosis.



Evaluation of exercise tolerance, endothelial function and systemic inflammation in patients with hemodynamically insignificant atherosclerosis of heart coronary arteries in relation to its prevalence

O.T. Stremeniuk

The aim to evaluate and compare the exercise tolerance, indicators of endothelial function and systemic inflammation in patients with hemodynamically insignificant atherosclerosis of heart coronary arteries in relation to its prevalence.

Materials and methods. The study included 70 patients with hemodynamically insignificant coronary artery atherosclerosis (HICAA), according to coronary arteriography (CAG), who formed the main group, and 50 healthy individuals with intact CA, according to CAG and a negative test for coronary artery disease (CAD) based on stress testing (control group). The average age of patients with HICAA was (55.4 1.3) years, of which there were 44 men (62.9 %) and 26 women (37.1 %). Depending on the number of afflicted CA the patients with HICAA were divided into two subgroups: those with single-vessel (30 patients, or 42.9 %) and multivessel (40 patients, or 57.1 %) lesions. In addition to conventional clinical, instrumental and laboratory studies, all patients of the main group had levels of endothelin-1 and interleukin-6 (IL-6) and lipid profile in blood serum measured; the treadmill test with reactive hyperemia was performed.

Results and discussion. The subgroups did not differ significantly by age, gender, functional class of stable exertional angina, the number of patients with hypertension and smoking, body mass index. In the subgroup of patients with multivessel HICAA, the frequency of positive tests for CAD was by 60.7 % higher than that in the subgroup of patients with single-vessel HICAA (p < 0.01). Indicators of the average threshold power and the load time in subgroups of patients with single and multivessel HICAA were (9.4 0.6) and (8.3 0.8) MET and (8.4 0.5) and (6.2 0.7) min, respectively, (all p < 0.05). According to the reactive hyperemia test a significant (29.3 %) reduction of endothelium-dependent vasodilatation (EDVD) was found in patients with HICAA as compared with the healthy persons (p < 0.05). In the analysis of individual variables, EDVD was observed in 32 (45.7 %) patients with HICAA and only 3 (6.0 %) healthy persons (p < 0.001). Averages of endothelium-independent vasodilatation in HICAA group and in healthy individuals showed no significant differences (p > 0.05). A more expressed EDVD reduction was noted in HICAA subgroups (with both single-vessel (p < 0.05) and multivessel (p < 0.01) lesions) as compared with the subgroup of healthy individuals. According to EDVD, the endothelial function in the subgroup of patients with multivessel HICAA was reduced by 32.6 % as compared to patients with single-vessel HICAA (p < 0.01). No significant endothelium-independent vasodilatation differences were found in the group with HICAA depending on the number of affected arteries (p > 0.05). A significant increase was revealed in endothelin-1 in the blood serum of patients with HICAA as compared with healthy persons (p < 0.001). There was a significant increase in endothelin-1 in the subgroup of patients with multivessel lesions as compared to patients with single-vessel lesions (1.53 0.6) and (0.56 0.04) fmol/ml, respectively, (p < 0.001). A significant increase was revealed in IL-6 in serum of patients with HICAA compared to the control (p < 0.01), equally expressed in single and multivessel lesions of the CA.

Conclusions. In patients with hemodynamically insignificant coronary artery atherosclerosis endothelial dysfunction is observed (reduced EDVD in 46 % of patients and increased serum levels of endothelin-1 in all patients), which is accompanied by a significant increase in the content of pro-inflammatory interleukin-6 in serum and clinical presentation of stable angina III FC with ischemic response during the test with measured physical load in 31.4 %. Multivessel hemodynamically insignificant atherosclerotic lesion of coronary arteries compared with single-vessel lesion is associated with decreased exercise tolerance by 60 % and a more pronounced endothelial dysfunction at the background of the same activity of systemic inflammation.

Keywords: endothelial function, coronary artery atherosclerosis, exercise tolerance, interleukin-6, endothelin-1.



New approach to surgical treatment of congenital heart diseases with intact ventricular septum and hypoplastic right ventricle

.F. Zinkovsky, J. ll, R.R. Sydametov

The method was presented of predicting the possibility of closure of atrial septal defect before operation or in pre-bypass period during the one and one half ventricle repair of congenital heart diseases with hypoplastic right ventricle. The method is based on a comparison of the original volume of blood flow in the superior vena cava (SVC) with the volume of the right-left shunt at the atrial level. The defect can be closed if the flow in SVC and the shunt volume are approximately equal. According to the prognosis, in 16 of 37 ases the defect was closed. After operation there were no signes of congestive heart disease and cyanosis. This approach allows avoiding reoperations in at least half of patients. If shunt volume exceeds the flow in SVC, the defect must be left open with perspective of a ventricle growth and reinterventions for closure of defect or Fontan operation.

Keywords: hypoplastic of right ventricle, one and one half repair.



Ultrasound-guided foam-form sclerotherapy in treating varicose veins of lower extremities

V.V. Boyko, O.S. Riabinskaya, R.R. Osmanov, V.A. Prasol

The aim to study the possibilities and analyze short-term results of ultrasound-guided foam-form sclerotherapy (UGFS) in treating varicose veins of lower extremities (VVLE).

Materials and methods. The article presents the experience of treatment of 37 patients (43 limbs) with primary varicosity of lower extremities (VLE), clinical degree of CVI C2-C6, CEAP classification. All patients underwent ultrasound-guided foam-form sclerotherapy of vena saphena magna (VSM), vena saphena parva (VSP) stems and their tributaries. 13 % polidocanol (Sclerovein, Resinag AG, Switzerland) was used as a sclerosant; sclerosing foam was produced by L. Tessari method (2000). For diagnostic purposes in control during the manipulation, as well as for monitoring in post-manipulation period, the ultrasound scanner Philips iU 22 with a set of sensors was used. Clinical and ultrasound follow up was performed during the period 112 months (mean 7.8 months).

Results and discussion. Variceal obliteration of transformed stems of VSM, VSP, their tributaries, non-saphenous veins was achieved in 81.4 % of cases (35 limbs). In 18.6 % (8 limbs) cases a partial recanalization was observed of the lumen of varicose vein which was subjected to sclerotherapeutic intervention, with a substantial reduction of its diameter. The total number of complications was 8.1 %. No systemic complications were observed.

Conclusions. Ultrasound-guided foam-form sclerotherapy is an effective method of VVLE treatment. Ultrasonic guidance of manipulation allows us to harden on a case-by-case basis the varicose segments of trunks and tributaries of the saphenous veins, if necessary, to perform further sclerotherapeutic sessions in order to improve the effectiveness of treatment. The results of personal observations and literature data give grounds to consider ultrasound-guided foam-form sclerotherapy a relatively safe method.

Keywords: varicose veins of lower extremities, ultrasound-guided foam-form sclerotherapy; chronic venous insufficiency; Duplex ultrasonography.



Intraoperative assessment of inflow vessels in infra-inguinal reconstructions in patients with chronic critical lower limb ischemia

O.I. Miminoshvili, A.A. Shtutin, V.N. Pshenychny, A.A. Ivanenko, A.V. Gaevoi

The aim to estimate accuracy of infra-inguinal reconstructions in patients with chronic critical lower limb ischemia (CCLLI) by direct measurement of pressure gradients in vein grafts and inflow arteries.

Materials and methods. In this work, the results of examination and reconstructive operations of 135 patients with chronic atherosclerotic critical ischemia of the lower limbs were evaluated. The advisability of intra-operative measuring of the pressure gradients on inflow arteries and infra-inguinal vein graft was studied for estimation of adequacy of femoral-popliteal-tibial segment revascularization.

Results and discussion. The possibility was shown of detecting residual stenoses of the graft and derivative circulation after insitu vein bypass. The used technique has allowed decreasing the number of the arteries revisions and thrombotic complications in the early and midterm postoperative period by 2.2 times.

Conclusions. The direct measurement of pressure gradients in vein grafts and inguinal artery allows revealing and correcting in proper time the tactical and technical errors of primary vessel reconstructions in patients with CCLLI.

Keywords: infra-inguinal reconstructions, surgical treatment, thrombosis, prophylaxis.



Smoking and alcohol important factors of intracranial hemorrhage

O.M. Goncharuk

The aim to identify the frequency of smoking in patients with intracranial hemorrhage in relation to sex and the occurrence of these hemorrhages due to alcohol intake.

Materials and methods. The study included 312 patients with spontaneous hemorrhages in the postcranial fossa with different etiologies. The majority (92.9 %) of patients were under 60 years old, 80.8 % were people aged 30 to 50 years.

Results and discussion. The majority (56.4 2.8 %) of the examined persons were males. 90 % men and 26 % women regularly smoked 2 packs of cigarettes a day. In 71 % of men hemorrhage occurred on the first or second day after drinking.

Conclusions. Spontaneous hemorrhages in the postcranial fossa occurred against the background of long-term smoking in 90 % men and against the background of alcoholic intoxication in 71 %.

Keywords: smoking, alcohol, intracranial hemorrhage.



Aspirin resistance: diagnostic criteria, causes and clinical significance

N.V. Netiazhenko

Despite the demonstrated efficacy of aspirin in secondary prevention and a possible positive effect of primary prevention in some groups of people, there remains quite a big portion of patients that aspirin does not bring substantial benefit to. According to various sources from 1 to 68 % of patients with arterial thrombotic events that are on long-term treatment with aspirin, have such events again. In 1980, this phenomenon was first called «aspirin resistance» (AR). Currently, the concept of «clinical AR» has been rejected and was replaced by the term «biochemical AP». Biochemical AR is a laboratory-proven inability of aspirin to suppress COX-1-dependent production of thromboxane A2 and, correspondingly, thromboxane A2-dependent platelet function. To establish the biochemical AR it is necessary to confirm the absence of platelet sensitivity to aspirin by laboratory tests, among which the best studied are the aggregometry with inductor of arachidonic acid (AA), platelet function analyzers PFA-100 and VerifyNow Aspirin. To date, recommendations for overcoming AR have not been fully developed. A logical way to improve the clinical efficacy of antiplatelet therapy in patients with identified or potential AR is extra administration of other antiplatelet agents such as thienopyridine-ticlopidine derivatives. The action of these drugs is caused by noncompetitive and irreversible blockade of platelet ADP receptors whose interaction with ADP is a prerequisite for activation of glycoprotein receptors of IIb/a-final stage of platelet aggregation.

Keywords: aspirin resistance, acute coronary syndrome, arachidonic acid, platelets.



Pathophysiological basis of recurrence of angina after coronary artery bypass grafting

Yu.V. Panichkin, D.O. Kuzmenko, O.V. Levchyshyna

The basic causes of recurrence of angina after coronary bypass surgery are: thrombosis of the shunts, degenerative-dystrophic (including atherosclerotic) changes of arterial and venous bypass grafts and the progression of atherosclerosis in the coronary bed. Thrombosis represents the greatest threat to the functioning of the shunt during the first weeks or even months after surgery, and is often found in patients in the event of cardiac complications in early postoperative period. Preconditions for its occurrence can be a massive desquamation of the endothelium and strictures formed in the suture, as well as slowing of blood flow below the distal anastomosis. Degenerative-dystrophic changes (intimal hyperplasia and atherosclerosis) are typical of both arterial and venous grafts. However, it should be noted that, according to many scientists, the development of atherosclerotic changes is more characteristic of venous grafts. Atherosclerosis in saphenous veins develops rapidly and its histological picture fully corresponds coronary atherosclerosis. Hyperplastic changes in the vessel intima are characteristic of both arterial and venous grafts. Along with intimal hyperplasia, tunica media becomes depleted in the cellular elements and develops progressive fibrosis. The overall result of these processes is general thickening of the vessel wall. It should be noted that atherosclerotic and hyperplastic changes in the vessel wall in prospect contribute to graft thrombosis and provoke the development of recurrent angina.

Keywords: recurrence of angina, thrombosis, atherosclerosis, hyperplasia, intima, arterial shunt, venous shunt.

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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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