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Issue. Articles

№1(37) // 2012






Endovascular intervention in aortic arch

S.N. Furkalo, P.I. Nikulnikov, V.I. Smorzhevskіі, A.V. Ratushniuk, S.V. Sukhachov, I.V. Khasіanova

Introduction into clinical practice of endovascular surgery techniques has changed the algorithm of surgical treatment of pathology in thoracic region of aorta. Our experience of endovascular interventions at the aortic arc includes 5 patients: 2 cases of traumatic aneurisms, 2 cases of aneurysms after aortic coarctation correction and one case of type B dissection. All patients had stentgrafts implanted: in 2 cases – into aortic zone 3 (Ishimaru), in 2 cases – into zone 1, and in one case – into zone 2. Combined surgical and endovascular operations were performed in 2 cases, in other cases endovascular approach was applied. Long-term follow up was from 1 month to 3 years. All the patients are alive, in one case endolеаk type І has been fixed.

Keywords: aneurysm of the thoracic region of aorta, endoprosthesis, hybrid operations, dissection type B.



Effectiveness of methods of reperfusion therapy in various categories of patients with acute coronary syndrome with ST segment elevation

K.M. Amosova, Yu.O. Sychenko, Yu.V. Rudenko, L.S. Tkachuk, O.M. Herula, I.V. Prudkyi, A.B. Bezrodnyi

The aim – to compare the effects of two methods of reperfusion therapy (percutaneous coronary intervention (PCI) and thrombolytic therapy (TLT)) on the course and hospitalization consequences of acute coronary syndrome (ACS) with ST segment elevation, depending on the time of ischemia and the risk degree on TІMІ scale.

Materials and methods. Retrospective analysis has been performed of case histories of 286 patients with acute myocardial infarction (MI) with ST segment elevation, who were treated at Oleksandrivska Hospital in Kiev in 2009 and 2011 and who underwent PCI (171 patients) or TLT (115 patients). The patients were divided depending on the risk on TІMІ scale, time of ischemia. The influence of these factors on hospital mortality, complications of myocardial infarction and combined endpoints has been analyzed.

Results and discussion. No differences in sex, age, concomitant diseases, and localization of MI have been revealed in the two groups. The time of ischemia was significantly greater in the PCI group – (8.4 ± 1.3) h, whereas in the TLT group it was (5.4 ± 0.8) h (p < 0.05). Significant differences between the groups were found in the duration of the period of «03 – balloon / needle». In PCI group, it was (198 ± 10.7) h, which was significantly greater than in TLT group – (103 ± 14.1) h (p < 0.001). In patients of PCI group, the average risk on TІMІ scale (5.8 ± 0.18) was significantly higher than in TLT group – (3.8 ± 0.22) (p < 0.001). The number of patients with the risk of more than 5 points on TIMI scale was greater in PCI group – 102 (59.6 %) than in TLT group – 51 (44.3 %) (p < 0.05). The patients who underwent PCI had a higher risk, longer pre-hospitalization period and duration of ischemia, and underwent reperfusion later than the patients after thrombolytic therapy. As evidenced by the comparison of complications and mortality, the primary PCI was effective in patients with longer duration of ischemia and a higher risk. Hospital mortality was more dependent on the duration of ischemia than on the degree of risk. The highest hospital mortality – 12.9 % – was among patients who underwent thrombolytic therapy, had a high risk (> 5 points on TІMІ scale), and duration of ischemia of > 4 h, and the lowest mortality was in PCI and TLT groups with a low risk and early admission – 2.5 and 2.6 %, respectively.

Conclusions. Hospital mortality among patients with ACS with ST elevation without shock after primary PCI is more dependent on the duration of ischemia than on the degree of risk, and in patients after thrombolytic therapy it depends on both of these factors. In clinical practice, primary PCIs have shown a significant advantage over TLT with respect to hospital mortality and ischemic complications, mainly in patients admitted late and having a high risk on TІMІ scale.

Keywords: acute coronary syndrome, primary coronary interventions, thrombolytic therapy, the duration of ischemia, risk stratification.



Aneurysms of the arteries of extra-aortic location: surgical aspects of treatment

A.S. Nikonenko, Ye.V. Yermolaуev

The aim – to examine the immediate results of surgical treatment of aneurysms of the arteries of extra-aortic location.

Materials and methods. The tactics and results of the surgical treatment of 146 patients with aneurysms of the arteries (except for aortic aneurysms) have been analyzed. The average age was 47.7 years. 126 (86.3 %) cases of aneurysms were false, 49 (33.6 %) of them were posttraumatic, 77 (52.7 %) were aneurysms of vascular anastomoses. In 20 (13.7 %) patients true atherosclerotic aneurysms were diagnosed. To specify the anatomy of the aneurysm and the nature of vascular lesions ultrasound methods were preferred.

Results and discussion. 96 (65.8 %) patients were operated on with the performance of arterial reconstruction. In reconstructive-rehabilitative resection of aneurysm extrapouch prosthesis (or anastomosis) was preferred. Results of surgical treatment of patients with aneurysms of the arteries were positive. There was no need in amputation of limbs after reconstructive operations. Postoperative mortality was 0.8 %.

Conclusions. The choice of surgical tactics and extent of operation in case of arterial aneurysms should be based on anatomical and physiological features of the affected vascular bed.

Keywords: aneurysms of arteries, surgical treatment.



STIMUL pilot registry: gender-specific course of acute coronary syndromes with ST segment elevation. Assessment of hospital treatment

S.V. Valuyeva, V.I. Denysiuk

The aim – to provide clinical and anamnestic characteristics of patients with acute coronary syndrome (ACS) with ST segment elevation and to assess differences in the clinical course of disease and characteristics of the provision of medical care in a hospital, depending on gender of the patient.

Materials and methods. The results of a pilot registry of acute coronary syndromes with ST elevation STIMUL are presented. 1103 patients from Vinnytsia and Khmelnytsky regions (three centers) took part in it. This register is the first in Ukraine, which will include the results of a two-year observation of patients (from January 2008 to June 2011), who have consistently been admitted to hospital within 24 hours from the onset of the disease.

Results and discussion. The specific weight of women aged 75 years and older was 3.5 times greater (p < 0.001) than that of men – 37.7 and 10.9 %. Diabetes mellitus, the symptoms of chronic heart failure before the development of ACS are also more common in women (33.1 vs. 22.7 % and 27.8 vs. 21.0 %, p < 0.01). On admission, 44.72 % of women had an index GRACE > 150 points against 31.0 % in men, but the duration of the period from the onset of symptoms to hospitalization was less in men – respectively (4.8 ± 0.08) and (6.3 ± 0.15) % (p < 0.01). Prior to the development of ACS men took aspirin and statins more regularly (30.0 vs. 17.6 % and 11.2 vs. 7.4 %, p < 0.05). In women, the frequency of reperfusion therapy was 18.3 %, in men – 33.9 % (p < 0.001), including primary coronary intervention (12.7 and 24.5 % respectively, p < 0.001). The frequency of medication prescription in hospital was high regardless of gender. Women were more likely to develop congestive heart failure (80.63 and 58.24 %), recurrent heart attack (10.2 and 3.3 %), sudden cardiac arrest (22.9 and 10.0 %), the rapture of free wall infarction (8.1 and 1.5 %, all p < 0.001). Hospital mortality was 21.48 % in women and 7.8 % in men (p < 0.001).

Conclusions. ACS in women develops in old age, is associated with an increase in the number of comorbidities. Measures of primary prophylaxis in women are less common. Low frequency of reperfusion therapy, a high risk of hospital complications also worsen the prognosis and increases mortality.

Keywords: acute coronary syndrome with elevation of ST segment, registry, gender features, treatment, prognosis.



Пилотный регистр STIMUL: гендерные особенности течения острых коронарных синдромов с элевацией сегмента ST. Оценка госпитального этапа лечения

С.В. Валуева, В.И. Денисюк

Цель работы — дать клинико-анамнестическую характеристику больным с острым коронарным синдромом (ОКС) с элевацией сегмента ST и оценить отличия в клиническом течении заболевания и особенностях предоставления медицинской помощи в стационаре в зависимости от пола пациента.

Материалы и методы. Представлены результаты пилотного регистра STIMUL, в котором приняли участие 1103 больных с ОКС с элевацией ST из Винницкой и Хмельницкой областей (три центра). Данный регистр является первым в Украине, который будет включать результаты двухлетнего наблюдения за пациентами (от января 2008-го до июня 2011 г.), которые последовательно поступили в течение 24 ч от начала заболевания.

Результаты и обсуждение. Удельный вес женщин в возрасте 75 лет и старше был в 3,5 раза больше (р < 0,001), чем мужчин, — 37,7 и 10,9 %. Сахарный диабет, признаки хронической сердечной недостаточности до развития ОКС также чаще встречались у женщин (соответственно 33,1 по сравнению с 22,7 и 27,8 по сравнению с 21,0 %; р < 0,01). При поступлении у 44,72 % женщин был индекс GRACE > 150 баллов по сравнению с 31,01 % у мужчин, но длительность периода от возникновения симптомов до госпитализации была меньше у мужчин — соответственно (4,8 ± 0,08) и (6,3 ± 0,15) % (р < 0,01). До развития ОКС более регулярно принимали ацетилсалициловую кислоту и статины мужчины (30,04 по сравнению с 17,6 % и 11,2 по сравнению с 7,4 %; р < 0,05). У женщин частота реперфузионной терапии составила 18,31 %, у мужчин — 33,94 % (р < 0,001), в т. ч. первичных коронарных вмешательств (12,7 и 24,5 % соответственно; р < 0,001). Частота назначения лекарственных средств в стационаре была высокой независимо от пола. У женщин была выше вероятность развития острой сердечной недостаточности (80,6 и 58,2 %,), рецидива инфаркта (10,2 и 3,3 %), внезапной остановки кровообращения (22,9 и 10,0 %,), разрыва свободной стенки миокарда (8,1 и 1,5 %; все р < 0,001). Госпитальная летальность составила 21,48 % у женщин и 7,81 % у мужчин (р < 0,001).

Выводы. У женщин ОКС развиваются в старческом возрасте, ассоциируются с увеличением количества сопутствующей патологии. Мероприятия первичной профилактики у женщин проводят реже. Низкая частота реперфузионной терапии, высокая вероятность развития госпитальных осложнений также ухудшают прогноз, повышают летальность.

Keywords: острый коронарный синдром с элевацией сегмента ST, регистр, гендерные особенности, лечение, прогноз.



Endovascular interventions in leg arteries in patients with critical ischemia of lower extremities

А.І. Pityk

The aim – to assess the effectiveness of endovascular interventions for restoration of blood flow in leg arteries in patients with critical ischemia of lower extremities (CILE) and also the observation of limb preservation in remote period after revascularization.

Materials and methods. The results have been analyzed of endovascular interventions in leg arteries of 98 lower extremities in 95 patients with CILE performed in the Institute of General and Urgent Surgery of the Academy of Medical Sciences of Ukraine in the period from April 2008 to June 2011. All patients underwent percutaneous balloon angioplasty (PBA) of leg arteries and of associated lesions located above arterial segments, completed, if necessary, with stenting. The observation of the patients was performed outpatiently with monitoring the CILE recurrences, cases of new interventions on the treated limb, amputations and mortality.

Results and discussion. Endovascular interventions were performed in 211 arterial segments. 140 of them were performed in leg arteries, 69 – in arteries of femoral-popliteal segment (FPS) and 2 – in the iliac arteries. All patients had obstructive lesions of leg arteries, 70 % of them had associated lesions of FPS arteries and 2 % – of the iliac arteries. PBA was performed in 77 % of cases, PBA and stenting – in 23 %. Technical success was achieved in 85 % of cases. The ratio of complications requiring surgical treatment equaled 4.6 %. In 90 % of patients whose arterial blood flow to the foot was restored, clinical recovery manifested as disappearance of pain at rest and the healing of ulcerous-necrotic defects was observed. Duration of patients observation was on average (14.1 ± 10.8) months. Repeated endovascular interventions were performed in 9.5 % of patients due to recurrence of CILE. Among patients who underwent successful revascularization, the ratio of limb preservation during the period of observation was 92.6 %, survival ratio was 89.5 %.

Conclusions. Endovascular intervention in leg arteries are possible and effective in most patients with CILE and are accompanied with a small ratio of complications and mortality. Percentage of limb preservation in remote period after endovascular interventions is not inferior to the same indicator after surgical shunting operations. The PBA with possible stenting may be the method of revascularization choice in patients with CILE, caused by lesions of leg arteries.

Keywords: occlusive diseases of leg arteries, critical ischemia of lower extremities, endovascular interventions.



Connection of compliance in treatment of arterial hypertension with psychological factors of personality

K.M. Amosova, L.Ye. Trachuk, N.V. Bereza, Yu.V. Rudenko

The aim – to identify psychological factors that affect the compliance during antihypertensive therapy.

Materials and methods. The study was conducted on the basis of cardiological departments of Alexandrovskaya Hospital in Kiev in the period from 17.01.2011 to 25.03.2011. A total of 80 patients with arterial hypertension aged 30 to 69 years were examined. The following methods of investigation were used: clinical and diagnostic interview with filling in the card of clinical and experimental-psychological examination of a patient with arterial hypertension; a survey of patients with the use of Morisky scale of inclination to treatment (MMAS); testing of patients with the use of Spielberger-Hanin method for determining anxiety; testing patients with Minnesota multiphasic personality inquiry (MMPІ); survey with the use of «level of subjective control» method.

Results and discussion. According to the results of testing with the use of an 8-point scale of inclination to treatment (after Morisky), the patients were devided into three groups depending on the level of compliance: high (27.5 %), moderate (25 %) and low (47.5 %). The analysis of socio-biological and psychological characteristics of the patients revealed that the highest level of compliance was observed in patients with specialized secondary and higher education, with external type of control, as well as with high personal anxiety, and personality types characterized by conformality (p < 0.05).

Conclusions. In patients with arterial hypertension, low compliance level is associated with an internal type of subjective control (86.8 %), low personal anxiety (68.4 %), and nonconformal type of personality (81.6 %). In order to improve the compliance the doctor should pay much more attention to the systematic persuading of the patient in the importance of the compliance to therapy. The perspective areas are the involvement of medical psychologists in the work with such patients, as well as the development and implementation of special training programs which take into account individual and psychological features of the patient, namely, personality type, locus of control and level of anxiety.

Keywords: compliance, arterial hypertension, type of subjective control, anxiety level, personality type.



Связь комплаенса при лечении артериальной гипертензии с психологическими факторами личности

Е.Н. Амосова, Л.Е. Трачук, Н.В. Береза, Ю.В. Руденко

Цель работы — определить психологические факторы, которые влияют на комплаенс при антигипертензивной терапии.

Материалы и методы. Исследование проведено на базе кардиологических отделений Александровской клинической больницы г. Киева в период от 17.01.2011 до 25.03.2011 г. В целом обследовано 80 пациентов с артериальной гипертензией в возрасте от 30 до 69 лет. Использовали такие методы исследования: клинико-диагностическая беседа с заполнением карты клинического и экспериментально-психологического обследований пациента с артериальной гипертензией; опрос больных по шкале приверженности к лечению Morisky (MMAS); тестирование больных с использованием методики определения тревожности Спилбергера—Ханина; тестирование пациентов с помощью Миннесотского многоаспектного личностного опросника (ММРІ); опрос по методике «Уровень субъективного контроля».

Результаты и обсуждения. Согласно результатам тестирования, с помощью 8-пунктовой шкалы приверженности к лечению (по Morisky) пациентов распределили на три группы в соответствии с уровнем комплаенса: с высоким (27,5 %), средним (25 %) и низким (47,5 %). По данным анализа социально-биологических и психологических характеристик пациентов установлено, что высший уровень комплаенса наблюдается у пациентов со средним специальным и высшим образованием, с экстернальным типом контроля, а также с высокой личностной тревожностью и типами личности, которые характеризуются конформностью (р < 0,05).

Выводы. У больных с артериальной гипертензией низкий уровень комплаенса ассоциируется с интернальным типом субъективного контроля (в 86,8 %), низкой личностной тревожностью (в 68,4 %) и неконформными типами личности (в 81,6 %). С целью повышения комплаенса врачу целесообразно уделять значительно больше внимания систематическому убеждению больного в важности приверженности к терапии. Перспективными направлениями являются привлечение к работе с такими больными медицинских психологов, а также разработка и внедрение специальных тренинговых программ с учетом индивидуально-психологических свойств пациента, а именно типа личности, локуса контроля и уровня тревожности.

Keywords: комплаенс, артериальная гипертензия, тип субъективного контроля, уровень тревожности, тип личности.



Marfan syndrome: the status of patients after surgical treatment of aneurysm of the ascending aorta

R.K. Zhuraev, I.M. Kravchenko, V.I. Kravchenko, O.V. Olkhova

The aim – to investigate the status of patients after surgery of an aneurysm of the ascending aorta by replacing the ascending aorta and aortic valve (Bentall procedure) in patients with Marfan syndrome (MS), as well as to study changes in the skeleton, face, heart and eyes.

Materials and methods. The study involved 33 patients with MS – 23 men (69.7 %) and 10 women (30.3 %) aged 22 to 70 years (mean age – 43.8 ± 13.6). The patients were operated on in the period from 1996 to 2010 on account of ascending aorta aneurysm with replacement of the ascending aorta and aortic valve (Bentall procedure) at N.N. Amosov National Institute of Cardiovascular Surgery. The average age of patients at the time of surgery was (38.1 ± 12.6) years. The survey was conducted in (5.7 ± 3.8) years after the operation.

Results and discussion. The average diameter of the aorta at sinuses of Valsalva level during the surgery was (6.8 ± 0.7) cm, Z-Score measure before the surgery was 12.4 ± 4.4. The average time period from the diagnosing of MS to the surgery on account of an aneurysm of the aorta was (9.6 ± 5.9) years. The condition of all patients after the surgery was satisfactory, hemodynamic parameters were stable. Average systemic evaluation of symptoms and tests of the patient with MS was (7.9 ± 3.2) points. Prothrombin index was (74.7 ± 13.1) %. 27 (81.8 %) patients with MS revealed mitral valve prolapse, 31 (93.9 %) patients – mitral valve insufficiency with regurgitation and 26 patients (78.8 %) – tricuspid valve insufficiency. According to an ophthalmologist’s examination, refractive anomalies were detected in 22 (66.7 %) patients under survey, including myopia and myopic astigmatism in 18 (54.5 %) patients, ectopic lenses in 6 (18.2 %) patients, retinal detachment in 1 patient, glaucoma in 5 (15.1 %) patients, dry eyes in 28 (84.8 %) patients.

Conclusions. The analysis of case histories of patients with MS showed that all of them were operated on urgently on account of dissecting aneurysm of the ascending aorta and significant failure of aortic valve. Good long-term results of surgical treatment of patients with MS have been registered. Bentall procedure is a surgical intervention of choice for these patients. It provides stable hemodynamics, the work of the prosthesis and prolongs life.

Keywords: Marfan syndrome, aortic aneurysm, Bentall procedure, echocardiography, hemostasis, anthropometry.



Iron deficiency medication correction impact on physical activity tolerance and myocardium functional condition in patients with chronic cardiac insufficiency and associated anemia without frank iron deficiency causes: near-term results

Ye.N. Amosova, V.N. Tsaralunga

The aim – to estimate the iron deficiency oral medication correction impact on physical activity tolerance and myocardium functional condition in patients with chronic cardiac insufficiency (CCI) of coronary genesis with associated anemia without frank iron deficiency causes while 3 months observation.

Materials and methods. 51 patients aged over 50 years (mean age 68.4 ± 1.0 year; male – 56.9 %, female – 43.1 %) were under the examination. All of them were diagnosed CCI ІІА–ІІІ stages according to N.D. Strazhesko and V.H. Vasylenko classification. Patients presented without cardiac insufficiency decompensation due to CCI associated anemia without frank iron deficiency causes. Anemia criteria were Hb level reduction 130 g/l and lower in male and 120 g/l and lower in female patients, iron deficiency was diagnosed on the ground of color index reduction, erythrocytic index lowering and blood serum iron level decreasing. Left ventricular (LV) ejection fraction (EF) ≤ 45 % was in 11 (21.6 %) patients, ІІ functional class according to NYHA – in 17 (33.3 %), ІІІ – in 29 (56.9 %) and ІV – in 5 (9.8 %) patients. The examination included 6 minutes walking test, Doppler echocardiography with systolic and diastolic LV functions indexes estimations, indexes of iron exchange in the blood serum which were determined initially and after 3 months of therapy by means of Actiferrine. During 3 months patients received oral indication of Actiferrine 103.5 mg daily. Not less than 2 weeks before the examination and during the whole period of observation medication therapy and doses weren’t significantly changed.

Results and discussion. Initial level of Hb was 90 g/l in 66.7 % patients, < 90 g/l – in 33.3 %. Following 3 months therapy with iron medication Hb level increased from (97.1 ± 1.8) to (128.4 ± 0.8) g/l (р < 0.001),and it was accompanied with blood serum iron level increasing from (6.7 ± 0.2) to (12.9 ± 0.3) mkml/l (р < 0.001) and transferring iron saturation from (8.0 ± 0.3) to (17.4 ± 0.5) % (р < 0.001). Functional class according to NYHA improved for one class in 40 (78.4 %) patients, 6 minutes walk distance increased from (266.7 ± 8.6) to (455.3 ± 9.3) m (р < 0.001). At the same time absolute Hb level increasing didn’t correlate with 6 minutes distance increasing (r = 0.25; р > 0.05). After the treatment the frequency of cardiac contractions at rest decreased from (70.4 ± 1.8) to (64.3 ± 2.9) per 1 min (р > 0.05), LV end-diastolic volume elevated from (166.2 ± 9.3) to (131.5 ± 4.9) ml (р < 0.001), end-systolic – from (82.2 ± 7.2) to (58.3 ± 4.0) ml (р < 0.01), functional class of LV increased from (53.6 ± 1.7) to (58.8 ± 1.3) % (р < 0.05). But therapy with iron medications didn’t have significant impact on LV diastolic function in patients with ejection fraction > 45 % and sinus rhythm.

Conclusions. Iron exchange indexes correction by means of 3 months iron contained oral medications causes Hb level increasing for 24.4 % in patients with CCI of coronary genesis and associated iron anemia (Hb and 90 g/l in 66.7 % patients) without frank causes of iron deficiency. It also improves functional condition for one class NYHA in 78.4 %, increases 6 minutes walk distance for 40.4 % and improves LV systolic function (ejection fraction increasing for 8.8 %). 6 minutes walk distance increasing doesn’t correlate with Hb level index increasing.

Keywords: chronic cardiac insufficiency, anemia, iron deficiency.



Early post-infarction angina: modern view on the problem

O.I. Rokyta

Review of literature on early post-infarction angina (EPIA) was conducted with The aim of finding out risk factors of its development, clinical significance and principles of treatment with consideration of the research results. According to the data presented in the literature, the frequency of EPIA was from 15 to 52 %. The development of EPIA significantly worsens the prognosis of myocardial infarction (MI). The patients with EPIA more often reveal the development of MI recurrence (from 22 to 56 %), recurrent MI (12–26 %) and cardiac death (5–13.3 %). During one year of observation, the patients more often needed hospitalization on account of unstable angina. The literature provides results of further study of coronary vessels condition at EPIA. Of important prognostic significance is the presence of an unstable plaque in the non- culprit artery. Basing on the results of multicenter placebo controlled trials, European Society of Cardiology in 2011 suggested a tactics of EPIA treatment, using new antiplatelet drugs (ticagrelor, prazugrel), dual therapy with antiplatelet drugs, early revascularization and high doses of statins.

Keywords: acute coronary syndrome, myocardial infarction, early post-infarction angina, antiplatelet therapy.



Case of giant posterior-lateral aneurism of the left ventricle

V.M. Beshlіaga, G.V. Knyshov, V.I. Ursulenko, L.S. Dzakhoуeva, Ye.О. Lebedeva, S.V. Salo, А.А. Beregovoi, V.I. Poznіak, О.V. Poznіak, L.V. Yakob

At computer tomography of lungs and mediastinum of patient P., 64 years old, a big voluminous neoplasm was detected on the left contour of heart. Echocardiography revealed a connection between the cavity of this neoplasm and left ventricle (LV) as 2 defects in the posterior-lateral wall of LV. Considering the large size of the cavity of neoplasm and the narrowness of its connection to LV, the neoplasm was classed as a giant pseudoaneurysm of LV. During the operation no significant pericardial adhesion was found; the wall of the post-infarction aneurysm, measured 10 × 15 cm, was formed of scar tissue of the LV wall; the aneurysm was a rare variant of a true one.

Keywords: echocardiography, the left ventricle, pseudoaneurysm of the left ventricle, true aneurysm of the left ventricle.



A clinical case of ante-retrograde recanalisation of chronic total occlusion of right coronary artery in patient with anomalous coronary arteries

S.N. Furkalo

In this article we discussed a case of recanalisation of chronic total occlusion in a patient with coronary artery disease and anomalous origin of coronary arteries. We described indications, technical approaches and clinical scenarios of such an operation, as well as some principles of application of specialized equipment.

Keywords: coronary artery disease, anomalous coronary arteries, chronic occlusion of the artery, coronary artery stenting.



Влияние медикаментозной коррекции железодефицита на толерантность к физической нагрузке и функциональное состояние миокарда больных с хронической сердечной недостаточностью и сопутствующей анемией без явных причин потери железа: ближайшие результаты

Е.Н. Амосова, В.Н. Царалунга

Цель работы — оценить влияние медикаментозной коррекции железодефицита у больных с хронической сердечной недостаточностью (ХСН) коронарного генеза с сопутствующей анемией при отсутствии явных причин потери железа путем его приема внутрь на толерантность к физической нагрузке и функциональное состояние миокарда при трехмесячном наблюдении.

Материалы и методы. Под нашим наблюдением был 51 больной старше 50 лет (в среднем 68,4 года ± 1,0 год; в том числе мужчин — 56,9 %, женщин — 43,1 %) c ХСН ІІА—ІІІ стадий по классификации Н.Д. Стражеско и В.Х. Василенко без декомпенсации сердечной недостаточности, вследствие хронической ишемической болезни сердца, с сопутствующей железодефицитной анемией без явных причин потери железа. Критериями анемии являлись снижение уровня гемоглобина (Hb) 130 г/л и ниже у мужчин и 120 г/л и ниже — у женщин, а дефицит железа диагностировали на основании снижения цветного показателя, эритроцитарных индексов и уровня железа сыворотки крови. Фракция выброса (ФВ) левого желудочка (ЛЖ) ≤ 45 % была у 11 (21,6 %) больных, ІІ функциональный класс (ФК) по NYHA — у 17 (33,3 %), ІІІ — у 29 (56,9 %) и ІV — у 5 (9,8 %) пациентов. Обследование включало тест с 6-минутной ходьбой, допплерэхокардиографии с оценкой показателей систолической и диастолической функций ЛЖ, показатели обмена железа в сыворотке крови, которые определяли исходно и после 3 мес терапии «Актиферрином». В течение 3 мес больные получали перорально «Актиферрин» в дозе 103,5 мг/сут. Не менее 2 нед до включения в исследование и на всем протяжении периода наблюдения медикаментозная терапия ХСН и дозы препаратов существенно не изменялись.

Результаты и обсуждение. Исходно уровень Hb был ≥ 90 г/л у 66,7 % больных, < 90 г/л — у 33,3 %. После 3 мес терапии препаратом железа Hb увеличился с (97,1 ± 1,8) до (128,4 ± 0,8) г/л (р < 0,001), что сопровождалось повышением уровня сывороточного железа с (6,7 ± 0,2) до (12,9 ± 0,3) мкмоль/л (р < 0,001) и насыщением трансферрина железом с (8,0 ± 0,3) до (17,4 ± 0,5) % (р < 0,001). ФК по NYHA улучшился на один класс у 40 (78,4 %) больных, дистанция 6-минутной ходьбы увеличилась с (266,7 ± 8,6) до (455,3 ± 9,3) м (р < 0,001). При этом абсолютный прирост уровня Hb не коррелировал с приростом дистанции 6-минутной ходьбы (r = 0,25; р > 0,05). После лечения частота сердечных сокращений в состоянии покоя уменьшилась с (70,4 ± 1,8) до (64,3 ± 2,9) в 1 мин (р > 0,05), конечнодиастолический объем ЛЖ уменьшился с (166,2 ± 9,3) до (131,5 ± 4,9) мл (р < 0,001), конечносистолический — с (82,2 ± 7,2) до (58,3 ± 4,0) мл (р < 0,01), ФВ ЛЖ увеличилась с (53,6 ± 1,7) до (58,8 ± 1,3) % (р < 0,05). Однако терапия препаратами железа не оказала существенного влияния на состояние диастолической функции ЛЖ у больных с ФВ > 45 % и синусовым ритмом.

Выводы. У больных с ХСН коронарного генеза с сопутствующей умеренной железодефицитной анемией (Hb ≥ 90 г/л у 66,7 % больных) без явных причин потери железа коррекция показателей обмена железа с помощью трехмесячной терапии железосодержащими препаратами внутрь приводит к увеличению уровня гемоглобина на 24,4 %, что способствует улучшению функционального состояния на один классс по NYHA в 78,4 % случаев, увеличению дистанции 6-минутной ходьбы на 40,4 % и улучшению систолической функции ЛЖ (увеличению ФВ ЛЖ на 8,8 %). Выраженность увеличения дистанции 6-минутной ходьбы у таких больных не коррелирует с величиной прироста уровня Hb.

Keywords: хроническая сердечная недостаточность, анемия, дефицит железа.



Эндоваскулярные вмешательства на дуге аорты

С.Н. Фуркало, П.И. Никульников, В.И. Сморжевский, А.В. Ратушнюк, С.В. Сухачев, И.В. Хасянова

Внедрение в клиническую практику эндоваскулярных методик изменило алгоритм хирургического лечения патологии грудного отдела аорты. Наш опыт эндоваскулярных вмешательств на дуге аорты включает 5 больных: 2 случая травматических аневризм, 2 случая аневризм после коррекции коарктации аорты и один случай диссекции типа В. Всем больным имплантированы стент-графты — в 2 случаях в зону аорты 3, в двух случаях в зону 1 и в одном случае в зону 2, по S. Ishimaru. При этом комбинированные традиционные хирургические и эндоваскулярные операции выполнены в 2 случаях, в остальных применен эндоваскулярный подход. Срок наблюдения за больными составил от 1 мес до 3 лет. Все больные живы, в одном случае фиксировался эндолик I типа.

Keywords: аневризма грудного отдела аорты, эндопротезирование, гибридные операции, диссекция типа В.

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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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