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Issue. Articles

1(5) // 2004





Pulmonary artery thromboembolism: current status of problem

V.G. Mishalov, E.N. Amosova

Contemporary principles of classification are shown, pulmonary artery thromboembolism (PAT) risk factors are specified, the main phases of pathogenesis are considered in the article. Algorithm of diagnosis on suspicion of PAT is given, sensitivity and specificity of different methods of diagnosis are evaluated. Information about methods of PAT treatment with their indications and contraindications is presented. Doses of medications used for PAT treatment are given. Ways of prophylaxis improvement are designed.

Keywords: pulmonary artery thromboembolism, classification, pathogenesis, diagnosis, treatment, prophylaxis.



From coronary heart disease to all cardiovascular disease prevention: new look at the problem

E.A. Koval'

New approach is established in the last joint European guidelines on cardiovascular diseases (CVD) prevention, which were published in 2003. It is based on common 10-year risk of cardiovascular fatal events assessment instead of previous estimation of the only coronary unfavorable events probability. According to that the definition of high risk persons was changed: from 10-year probability ≥20 % of any coronary event to ≥5 % of all cardiovascular fatal events. The 2-nd type of diabetes mellitus and the 1-st type with microalbuminuria became of equal risk level with established coronary heart disease; new glycaemic and lipid metabolism severe control goals were set; the new functional methods of examination (ultrasound, MRT) and biochemical data (apoB, Lp(a), fibrinogen, homocystein, C-reactive protein) as additional risk estimating criteria were determined. The new treatment goals of total cholesterol (TChol), low density lipoproteins (LDLChol) and triglycerides were established. Aspirin and statins as the first line prevention therapy for all CVD patients were recommended, widespread use of ACE inhibitors and beta-blockers was recommended too.

Keywords: cardiovascular disease, prevention.



Markers of myocardial damage and anticoagulant system activity in patients with nonST elevation Acute Coronary Syndromes

V.Z. Netyazhenko, Ya.V. Korost, O.M. Plenova, Y.O. Moshkovska, A.M. Gontar, O.M. Barna

Measurement of cardiac troponin levels plays an important role in diagnosis of myocardial infarction and risk stratification in patients with acute coronary syndrome (ACS).

Objective. To evaluate the activity of blood anticoagulant system in correlation with troponin T (TnT) level in patients with non-ST elevation ACS.

Materials. 41 patients with non-ST elevation ACS (<24h from pain onset) were examined. All patients were divided in two groups according to initial TnT level: in 14 patients (1 group) n level was > 0,1 ng/ml, in 27 patients (2 group) TnT level ≤ 0,1 ng/ml. Plasma levels of fibrinogen (F), free heparin (FH), antithrombin III (AT III), protein C (PC), activated partial thrombine time (APTT), thpomboplastine time (TPT) and thrombine time (TT) were assessed at baseline.

Results. Both groups had decreased levels of AT III in comparison with healthy individuals, the group 2 had decreased levels of FH (p<0,01—0,001). TnT-positive patients demonstrated more expressed in comparison with TnT-negative ones oppression of AT III (33±15 % vs 53±20 %, =0,04) and PC activity (50,6±31,4 % vs 93,0±41,8 %, =0,014), but at the same time, level of FH in this group was normal (3,4±1,03 sec) and three times exceeded FH level in group 2 (1,0±0,8 sec, =0,0001) with the lower F (3,75±1,8 g/l vs 4,8±1,2 g/l, p=0,05).

Conclusion. TnT-positive patients with non-ST elevation acute coronary syndrome demonstrate more significant exhaustion of blood anticoagulant system activity in comparison with TnT-negative patients. It has to be taken into account in making the choice of anticoagulant therapy regime.

Keywords: acute coronary syndrome, myocardial necrosis, troponin, protein C, antithrombin III.



Oxidative stress role in nitric oxide metabolism violation in patients with essential hypertension

S.N. Polyvoda, A.A. Cherepok

Objective. To investigate the role of oxidative stress in nitric oxide (NO) metabolism violation in patients with essential hypertension.

Materials and methods. 86 hypertensive patients and 30 practically healthy persons were examined. The level of spontaneous (CLs) and peroxide-induced (CLp) chemiluminescence of blood serum and blood plasma 8-isoprostane content were determined for the assessment of free radicals generation activity. Total antioxidant activity of blood serum (TAAS) was determined for the assessment of endogenous antioxidant systems activity. Endothelial NO-synthase activity by the original technique during evaluation of NADPH-diaphorase platelets activity, the level of terminal NO metabolites (NOx) and 3-nitrotirosine in blood serum were determined for the assesment of NO metabolism.

Results. Significant (p<0,05—0,01) elevation of CLs and CLp (by 49,18 % (1,82±0,21 standard units in hypertensive patients and 1,22±0,12 standard units in healthy persons) and by 31,80 % (58,9±2,51 standard units in hypertensive patients and 44,7±3,47 standard units in healthy persons) respectively), increasing of blood plasma content of 8-isoprostane and decreasing of TAAS (by 190,81 % and 48,93 % respectively) were fixed in hypertensive patients. Substantial elevation of 3-nitrotirosine in blood serum (0,52±0,07 nmol/l in comparison with 0,15±0,04 nmol/l, p<0,001) and significant decreasing of NOx (16,1±3,1 micromol/l and 26,3±3,8 micromol/l respectively) (by 246,67 % and 38,85 % respectively) with normal NO-synthase activity were shown in hypertension. Strong positive correlation was found between serum CLs (r=0,86), CLp (r=0,88) and 8-isoprostane (r=0,92) and 3-nitrotirosine, moderate correlation between NOx and CLs (r=–0,65), CLp (r=–0,69), 8-isoprostane and TAAS (r=0,78).

Conclusions. Significant activation of free radicals production and the state of oxidative stress development is specific for hypertensive patients. The latter factor is one of the basic mechanisms of NO metabolism violation with activation of damage in unchanged level of it's synthesis in essential hypertension.

Keywords: essential hypertension, oxidative stress, nitric oxide, metabolism.



Experience of surgical treatment of the acute pulmonary artery thromboembolism and postembolic pulmonary hypertension

B.M. Todurov

Objective. To evaluate the efficacy of surgical treatment in patients with acute pulmonary artery thromboembolism (PAT) and postembolic pulmonary hypertension (PTEPH).

Materials and methods. The investigation is based on the results of 45 patients' treatment (18-75 y.o.). 21 patient had acute massive or submassive PAT for 30 days (group I); 24 patients had PTEPH or recurrent PAT against the background of pulmonary hypertension (PH) (group II). Diagnosis was based on angiopulmonography, doppler-echocardiography. Systolic pulmonary artery (PA) pressure by direct measurement in patients of group I was 62±18 mm Hg, group II — 72±24 mm Hg (<0,05); Miller's index was, respectively, 26,3±6,2 and 21,9±7,8 points (<0,05). All patients underwent surgical treatment in moderate or deep hypothermic artificial circulation. Access to trunk and the main brunches of PA was fulfilled by midline sternotomy.

Results. Surgical mortality was 28,8 % (13 patients). Mortality was 19,0 % (4 patients) in the first group. That was substantially higher than in the group II 37,5% (9 patients). Mortality reasons in both groups were acute heart failure due to high residual PH, PAT recurrence, pulmonary hemorrhage. PA systolic pressure decreased for less than 10% in 5 of 9 died patients of the group II, that was determined by extensive sclerosis of both thrombosed and intact pulmonary arterioles during histological investigation. PA systolic pressure was decreased by 61,3% (<0,05) in discharged survived patients of group I and by 50,0% ( <0,05) — group II; 2, respectively, was increased by 25,8% and 29,8% (<0,05); Miller's index was reduced to 3,2±4,3 and 7,2±5,9 points (<0,05). Patients with NYHA I class were prevalent in patients of group I (14 of 17), the II class — in group II (9 of 15).

Conclusions. Thrombembolectomy off the PA in artificial circulation is the effective method of acute PAT treatment, especially in unsatisfactory result of thrombolisis or it's impossibility with in-hospital mortality of 19,0%. It's implementation guarantees the reduction of PA pressure by 61,3%, significant improvement in arterial blood oxygenation and functional condition of patients by NYHA criteria. Surgical treatment of chronic PTEPH is associated with the higher level of operative mortality in comparison with acute PTEPH (37,5%) and the worse functional condition by discharge. It was partly caused by development of the extensive sclerosis of both thrombosed and intact pulmonary vessels. In cases, when PA pressure is 75% and more of the systemic one, and the duration of disease is more than 6 months, surgical treatment is inexpedient and may lead to lethal outcome.

Keywords: pulmonary artery thromboembolism, thromembolectomy, postembolic pulmonary hypertension, venous thromboembolism, pulmonary artery thromembolectomy.



The nearest results of surgical treatment in patients with chronic postembolic pulmonary hypertension

V.G. Mishalov, .I. Osadchy

Non-surgical (conservative) methods of chronic postembolic pulmonary hypertension (CPEPH) treatment have limited opportunities, because they do not eliminate the real reasons of it's development — pulmonary artery (PA) brunches mechanical obstruction. But the limited occlusion of the upper pulmonary circulation part is the base for surgical treatment and restoration of PA circulation.

Objective. To evaluate the nearest results of surgical treatment in patients with CPEPH.

Materials and methods. 47 patients with CPEPH were observed in 2001—2003: 32 (60,4%) of them were men, 21 (39,6%) — women at the age of 18-64 y.o. (mean 48±7,4). The diagnosis was based on the clinical features (palpitations, shortness of breath, cyanosis, inclination to hypotension, accent of the second heart sound, ECG data (signs of right heart overload), thoracic X-ray (impoverishment of pulmonary vessels pattern, reduction of retrosternal space, right heart enlargement, cupula of diaphragm elevation, presence of atelectasis or pleural disturbances), doppler-echocardiographic data (elevation of PA systolic pressure — PASP — and right ventricle (RV) dilation), angiopulmonographic (APG) data as well (irregularities of pulmonary bloodstream, presence of truncal and lobar arteries stenotic constrictions, absence of PA branches completing, irregularities of circuit and «amputation» of segmental and lobar PA branches) and catheterization of heart and RV — jump of total pulmonary resistance (TPR). Examination consisted of clinical and biochemical blood analysis, coagulography (1st, 2nd, 5th and 7th day). Duration of clinical signs was from 8 months to 3 years — mean 1,4±0,3 years. The second degree of pulmonary hypertension (PH) took place in 33 (70,2%) patients, the 3d — in 14 (29,8%) of them. The second functional class (FC) by NYHA classification was registered in 2 (4,3%), the third — in 19 (40,4%), the fourth — in 26 (55,3%) patients. Surgical treatment was conducted in all cases. Artificial circulation and transsternal access was used in 29 (61,7%) patients in case of bilateral lesions of the main branches and PA truncus. Thrombendarterectomy was fulfilled in 18 (38,3%) patients in unilateral lesion. Heparin for 5 days with subsequent indirect anticoagulant for 4-5 months were prescribed. Prothrombin index was maintained on the level of 45-55%. There were no lethal outcomes for the observation period. Obtained results were statistically evaluated by Student's method.

Results. As the result of PA and branches blood supply restoration during 10,0±1,3 months after surgery significant decrease of PASP (from 70±16 to 41±9mm Hg — by 42,5%, <0,05) was registered. The first degree of PH was established in majority of patients — 39, or 95,12%. Analysis of hemodynamic data changes showed significant (in the whole group) improvement in comparison with preoperative ones. Reduction of mean PA pressure was 56,3% (<0,05) and was associated with TPR decrease to 270±110 dyn/sm/s-5 (<0,05). This data confirm the efficacy of PA desobliteration. Improvement of pulmonary circulation was accompanied by cardiac index (I) elevation by 58,3% (<0,05). Improvement of hemodynamic data stimulated the increase of exercise tolerance with changes of NYHA FC. The first FC was established in 70%, the second — in 21% of patients.

Conclusion. Desobliteration of PA branches in patients with CPEPH leads to significant decrease of PASP (by 42,5%) in 95,12% of those, who underwent the operation — after 10±1,3 months. Reduction of PASP was associated with TPR decrease, that contributed to cardiac output elevation at rest and improvement of functional class during postoperative period.

Keywords: pulmonary artery thromboembolism, pulmonary hypertension, chronic postembolic pulmonary hypertension, angiopulmonography, total pulmonary resistance, thrombendarterectomy, artificial circulation.



Features of cardiovascular system's functional condition and ventricular remodeling in patients with chronic cor pulmonale as a result of primary and postembolic pulmonary hypertension

K.M.Amosova, L.F.Konoplyova, D.O.Reshot'ko, V.E.Kazakov, Yu.V.Rudenko

Objective. To compare functional changes of cardiovascular system by the results of 6-minute walking test (6-MWT), systolic and diastolic myocardial functions of the right (RV) and left (LV) ventricles, the way of remodeling in patients with primary pulmonary hypertension (PPH) and postembolic pulmonary hypertension (PEPH).

Materials and methods. 40 patients with PPH (mean age 25,4±4,8 y.o.) and 30 patients with PEPH (mean age 46,7±5,8 y.o.) were examined. Their mean age was 32,9±6,3. 6-MWT was used for the evaluation of patient's functional condition. Standart doppler-echocardiographic (doppler-EchoCG) indices were used for the evaluation of RV and LV systolic and diastolic functions. RV and LV diastolic function indices were assessed by the level of deviation from those in healthy persons separately in the first (from 15 to 35 y.o., mean 27,3±4,3, n=24) and the second age-specific group (from 36 to 55 y.o., mean 48,6±5,2, n=16). Reliability of differences in groups was evaluated by Kolmogorov—Smirnov criterion, correlation analysis was carried out by Pierson's linear correlative coefficient.

Results. Pulmonary artery systolic pressure (PASP) in patients with PPH was on average 100,2±4,3 mm Hg, in patients with PEPH — 57,4±4,9 mm Hg (p<0,001). Functional condition of patients with PPH was worse than those with PEPH, which was confirmed by overwhelming majority of patients, who passed less than 400 m during 6-MWT, in the first group in comparison with the second one (77,5% 43,0%, correspondingly, p<0,05). There was the correlation between distance of 6-MWT and PASP (for PPH patients r=-0,76, for PEPH patients r=-0,67, p<0,05) and heart failure functional grade by NYHA (r, correspondingly, - 0,68 and -0,54, p<0,05) in both groups. In spite of the differences in PASP, patients of both groups had the same increase of RV dimension (correspondingly 29,4±1,3 mm and 31,1±2,0 mm, p>0,05) and RV free wall thickness (correspondingly 8,0±0,4 mm and 8,2±0,9 mm, p>0,05). But only patients with PPH had significant decrease in RV shortening fraction and acceleration in pulmonary artery in comparison with healthy people (by 2,1 and 1,5 times, <0,05) and correlation of these indeces with PASP (correspondingly r=-0,85 and r=0,64, <0,05). RV and LV diastolic dysfunction was more strongly pronounced in patients with PEPH than in PPH ones. It was confirmed by significant (<0,05) decrease in V\V (by 47,1% and 27,3% for RV, correspondingly; by 51,1% and 19,0% for LV) in comparison with normal ranges and presence of peak E asymmetry because of deceleration time shortening in comparison with healthy persons only in patients with PEPH (by 24,9% for RV, by 26,8% for LV, <0,001).

Conclusions. Patients with PPH demonstrate more pronounced functional disturbances of cardiovascular system by 6-MWT in comparison with PEPH. Results of this test correlate with NYHA functional grade. In spite of the higher PASP (by 57,3%, p<0,001) in patients with PPH, than PEPH, RV remodeling in both groups is the same and is manifested by it's dilation, which predominates over hypertrophy. Parients with PEPH have more pronounced RV and LV impaired relaxation diastolic dysfunction type, than those with PPH, in spite of the same level of hypertrophy.

Keywords: primary pulmonary hypertension, postembolic pulmonary hypertension, systolic and diastolic right and left ventriG cle dysfunction, remodeling, functional condition of cardiovascular system.



Clinical and hemodynamic features of Eisenmenger syndrome in adulthood

S.P. Tashova

Congenital heart diseases (CHD) with increased pulmonary circulation — patent ductus arteriosus (PDA), ventricular septal defect (VSD) and atrial septal defect (ASD) — lead to high pulmonary hypertension (PH), morphological changes in pulmonary vessels with their fibrosis, elevation of pulmonary vascular resistance (PVR) and change to right-to-left shunt (Eisenmenger syndrome (ES), or reaction) in 10—50% cases. Approaches to the treatment and prognosis in patients with CHD are changed at this stage.

Objective. To study the peculiarities of clinical course and intracardiac hemodynamics by doppler-EchoCG in patients with ES.

Materials and methods. Diagnostics and hemodynamical evaluation in grown-ups with ES were carried out in 55 patients 14— 53 y.o. with CHD (28 with VSD, 16 with ASD and 11 with PDA). Mean age was 29,7±3,2 y.o. Heart failure of the I—II functional grades by NYHA was registered in 28 patients (50,9%) and III—IV — in 27 (49,1%). Patients examination included clinical methods, ECG in 12 leads, radiographic thorax examination, pulsoxymetry. Catheterization of cardiac cavities and angioventriculography were carried out in 32 patients. Intracardiac hemodinamics, right (RV) and left (LV) ventricles' function, diagnostics of shunts were assessed by two-dimensional doppler-EchoCG. Pulmonary artery systolic pressure (PASP) was measured by the level of tricuspid regurgitation; cavities dimensions, LV ejection fraction (EF, %), thickness of the ventricle walls, RV shortening fraction (SF, %), diameter of vena cava inferior (VCI) and it's collapse after deep breath (%) were estimated.

Results. Clinical features of CHD in ES stage were determined by high PH and PVR on the one hand and right-to-left shunton the other hand. The most frequent symptoms in patients of the first group were dyspnea without orthopnea (100%), accent of the second heart sound over pulmonary artery (PA) (100%), dizziness during the exercise (70%). Signs of right-to-left shunt were not always revealed at rest. «Central» cyanosis was in 76,4%, «watch crystals» and «clubbed» fingers were in 38,2%. So their absence didn't exclude ES. xygen saturation SaO2 was 80,6±4,8%, PASP — 98,7±4,1 mm Hg, RV diameter (apical) — 35,3±1,1 (normal ranges — 24,6±0,7 mm), RV free wall thickness 9,5±0,3 (normal ranges 4,8±0,1 mm), interventricular septum — 11,3±0,3 (normal ranges 8,9±0,2 mm) (all p<0,05). Longitudinal (apical) size of the right atrium (RA) was 47,9±2,0 in comparison with 36,5±1,7 mm in healthy persons, VCI diameter was 19,4±0,7 and 14,8±0,4 mm, respectively (all p<0,05). Elevated PH and PVR were associated with decreased end-diastolic volume by 16,4% in unchanged end-systolic volume and decreased stroke and cardiac indices (by 24,0 and 10,0%, p<0,05).

Conclusions. Clinical features of the right-to-left shunt in adults with CHD in ES stage may be absent. Frequency of «central» cyanosis was in 76,4%, «watch crystals» and «clubbed» fingers were in 38,2%. In spite of the RV overload because of the elevated PVR and it's dilation by 72,0%, myocardial compensatory potential was significant, that was confirmed by the minimal enlargement of RA and VCI diameter, absence of RV insufficiency clinical features at rest in overwhelming majority of patients and moderate exercise tolerance decrease, which corresponded to the — NYHA grades in 50,9% cases.

Keywords: congenital heart disease, Eisenmenger syndrome, clinical features, doppler-EchoCG, hemodynamics.



Morphological and morphometrical myocardial peculiarities in patients with Fallot's tetralogy

.F. Zin'kovskyi, V.P. Zakharova, N.Yu. Zagainov

Objective. To study the level of myocardial injury severity in patients of different age on the base of inlet and outlet right ventricle wall examination in Fallot's tetralogy by intraoperative and autopsy material.

Materials and methods. Autopsy heart materials of 29 patients 18—47 years old (mean age 27,2 ± 0,5) and 34 patients at the age of 3 to 17 years (mean 5,7 ± 1,2). Right ventricle outlet part myocardial condition was assessed by tissue samples, which were resected during radical correction of Fallot's tetralogy (RCFT). Morphological changes of myocardial inlet tract were evaluated by tissue samples, which were obtained during the operation and investigation of those patients' autopsy materials, who died in different terms after it. To study the level of cardiomyocytes' injury light and electronic microscopy were carried out.

Results. Substantial changes of cardiomyocytes' and their nucleus size, shape and staining were revealed during light microscopy of specimens, obtained from infundibular camera. Different degree of myofibrilla's degeneration was revealed as well. Morphometric investigations on the lightoptic level showed that mean diameter of right ventricle infundibular camera's muscle fibres was 22,4 ± 2,8 micrometers in patients at the age of 18—47. It substantially increases the normal cardiomyocyte size (no more than 15 micrometers for adults), and does not differ from the results in the younger group: (21,4 ± 2,1) micrometers (p<0,05). Volume density of this right ventricle area interstitial tissue in patients of both groups was significantly increased without substantial intergroup differences correspondingly (33,0 ± 3,8 and 35,9 ± 4,2; > 0,05). In contrast to this, significant hypertrophy and interstitial fibrosis of right ventricle lateral wall was increased with age: correspondingly (21,8 ± 2,3) and (15,7 ± 1,6) micrometers and (28,8 ± 3,1) and (21,7 ± 2,7)% (p<0,05). During electronic microscopy of endomyocardial material of right ventricle infundibular cameras ultrastructural changes that are the base of cardiomyocyte transformation in Fallot's tetralogy were revealed. Muscular fibers that had dilated -system's canaliculi, sparse similar to myelin figures in sarcoplasma, infrequent granules of intramitochondrion glycogen, sometimes — dilation of rough endoplasmic reticulum elements and intracellular edema were established.

Conclusions. Right ventricle infundibular camera in Fallot's tetralogy is characterized by significant cardiomyocyte hypertrophy, transferring to dystrophy and atrophy of muscular fibers and is accompanied by severe endocardial and interstitial sclerosis. These changes develop at an early age and do not have significant quantitative differences in groups of patients 3—7 and 18—47 years old. In adult patients with Fallot's tetralogy signs of muscular fibers hypertrophy and interstitial sclerosis become significantly more frequent. Therefore radical correction of Fallot's tetralogy has to be carried out expediently as early as possible.

Keywords: congenital heart diseases, Fallot's tetralogy, morphology and morphometry, cardiomyocites' injury types.



Hemorrhages in combined mitralaortic prosthesis and the ways of their prophylaxis

V.V. Popov

Objective. To elaborate the way of hemorrhages prophylaxis in combined mitral-aortic prosthesis based on analysis of their origin's causes.

Materials and methods. Single-stage double-valve prosthesis on account of combined mitral-aortic heart diseases was performed in 726 patients in the Institute of Heart and Vessels Surgery of Ukrainian Academy of Medical Sciences named after N.M.Amosov over the period of time 01.01.1981-01.09.2001. Ball-valve, hemiball, monodisk-shaped, double-leaf and biological prostheses were implanted. Fatal hemorrhage took place in 23 (3,2 %) patients. It was 11,1% in the structure of hospital mortality.

Results. The most frequent reasons of hemorrhage were: 1) perforation of the left ventricle posterior wall during excision of the calcinated mitral valve (MV) in impaired annulus fibrosus in patients with protractedly existed rheumatic process (n = 4); 2) perforation of the aortic posterior wall on the level of annulus fibrosus in marked precipitation of calcium mass and switching to the impaired annulus fibrosus (n = 3); 3) left atrium rupture on the level of sinus transversus during access to the MV (n = 4); 4) suture defect during suture ligation of the changed wall of the ascending aorta on the level of transverse incision (n = 4). The following methods for the hemorrhage prophylaxis were elaborated: exclusion of interatrial access, preservation of the subvalve apparatus of the MV posterior leaf, use of teflon pads behind and teflon bands in front of aorta in aortic valve prosthesis, use of aprotinin (gordox) 30 000 unites/kg. Their use allowed to reduce fatal hemorrhages since 01.01.1997 to 01.09.2001 up to 1,3 % (1 case per 76 operations) vs 3,4 % (22 cases per 650 prostheses) over the period of 01.01.1981- 01.01.1997.

Conclusions. The suggested and applied methods of prophylaxis of fatal hemorrhages by optimization of operation's technique and methodology allowed to decrease their number by three times and to exclude absolutely such reasons as posterior aortic wall and interatrial septum ruptures.

Keywords: combined mitral-aortic prosthesis, hemorrhage, prophylaxis.



Tolerability and efficiency of metoprolol in patients with chronic heart failure depending on appearance of atrial fibrillation

.J. Zharinov, .Ye. itura

Objective. To compare the tolerability and efficiency of selective β-adrenoblocker metoprolol in patients with chronic heart failure (CHF) with preserved sinus rhythm (SR) or atrial fibrillation (AF).

Materials and methods. The open uncontrolled study included 74 patients with CHF of —V functional classes NYHA, of ischemic and non-ischemic cause, with left ventricular ejection fraction ≤ 35 %, age — 38—74 years. Retrospectively we divided the patients into two groups: (n=43) — patients with preserved SR, (n=31) — with permanent AF. All patients received metoprolol by method of slow titration after stabilization. In 3, 6, 12 months the dosage of the drug and side effects were registered, exercise tolerance by the distance of 6-minute walking test (DSW), quality of life were evaluated, echocardiographic study was performed, blood levels of adrenaline and noradrenaline were estimated.

Results. It was established, that combination of CHF and AF is more common in senior patients, and is associated with higher heart rate (HR) at rest (p<0,05) and after exercise (p<0,05), significant decrease of DSW (p<0,05) and increase of the left atrium dimensions (p<0,05) in comparison with patients who had preserved SR. At the end of 3-months titration period the dosage of 100 mg has been achieved in 15 (34,9 %) patients of group and 16 (51,6 %) — group (p<0,05). Average daily dosage of metoprolol in patients of group was 69,9±15,4 mg, group — 74,8±16,6 mg (p>0,05). Treatment with metoprolol was satisfactorily tolerated by patients with CHF on background of SR and AF, and the prevalence of side effects and cases of treatment discontinuation were the same in both groups. Treatment with metoprolol was accompanied by significant decrease in HR at rest and after exercise, improvement of CHF functional class, associated with health status quality of life, decrease of catecholamines blood levels in both groups. The parameter of DSW increased in group from 225,6±16,0 t 346,4±12,0 m (p<0,001), in group — from 191,2±12,0 to 327,4±10,6 (p<0,001) after 12 months.

Conclusions. mbination of the systolic CHF with AF is associated with higher HR at rest and after exercise, than in patients with SR, as well as more significant dilatation of left atrium. The appearance of AF does not prevent from the running up to target dosages of metoprolol and is not associated with increase in number of side effects and discontinuation because of poor tolerability. Independently from AF, treatment with metoprolol resulted in the improvement of cardiac systolic function, exercise tolerability, quality of life, decrease of catecholamines blood level in patients with CHF.

Keywords: chronic heart failure, atrial fibrillation, heart rate, metoprolol.



Influence of 5HT2receptors blockade on the central hemodynamics and brain bioelectric activity in patients, who had ischemic stroke, in rehabilitation period

S.M. Kuznetsova, O.I. Lukach

Objective. To make the complex analysis of 5-HT-2-receptors blocker's naftidrofuril (Enelbin-retard) influence on the central hemodynamics, brain bioelectric activity in patients, who had ischemic stroke (IS), and to determine expediency of it's use in rehabilitation system of such patients.

Materials and methods. 20 patients, who had IS in carotid pool 2 months to 2 years before, at the age of 60-74 y.o. (mean — 68,0±0,7) were included into the investigation. Etiological factor of IS was combination of atherosclerosis and arterial hypertension. The presence of ischemic focus was verified by the data of computed tomography scan (CT-scan) and magnetic resonance imaging (MRI). Patients were divided in two groups. The first one consisted of patients with ischemic focus localization (IFL) in left hemisphere (LH) (n=10), the second — in the right hemisphere (RH) (n=10). Complex clinical and instrumental examination was made before and after treatment course. Psychoemotional and mnestic activities were assessed by gerontological scale of depressiveness, differentiated scale of health, activity and mood (HAM) self-concept and 10 words memorization test. Cerebral hemodynamics was assessed by ultrasound Doppler of extra- and intracranial vessels and by ultrasound duplex scanning. Brain bioelectric activity was investigated by the electroencephalogram (EEG). All patients took «Enelbin-retard» (naftid-rofuril) (Zentiva) (dose — 300 mg/day for 1 month).

Results. Naftidrofuril increased the level of linear systolic blood velocity (LSBV) in ipsilateral common carotid artery (CCA) by 16,6 % (p<0,05), in posterior cerebral artery (PCA) by 18,8 % (p<0,05) and volume flow rate in heterolateral medial cerebral artery (MCA) by 27,0 % (p<0,05) in patients with IFL in RH. Naftidrofuril increased the level of LSBV in heterolateral CCA by 14,2 % (p<0,05), in internal carotid artery by 11,2 % (p<0,05) and volume flow rate in MCA by 18,0 % (p<0,05) in patients with IFL in LH. Naftidrofuril in patients with IFL in LH led to considerable increase of alpha rhythm frequency in the central and occipital regions of affected hemisphere (by 7,5 % and 8,5 % correspondingly) and in occipital area of intact hemisphere (by 7,5 %, all p<0,05). Patients with IFL in RH had considerable increase of alpha rhythm frequency only in the central area of intact hemisphere (by 7,1 %, p<0,05). Medication led to significant changes of main EEG rhythms intensity correlation predominantly in affected hemisphere in patients, who had IS. These changes were more expressed in patients with IFL in LH (intensity of delta rhythm in temporal area decreased by 23,8 % and beta rhythm — by 14,1 %, intensity of alpha rhythm in temporal area increased by 26,3 %), than in those with IFL in RH (intensity of delta rhythm decreased by 16,2 %, intensity of alpha rhythm increased by 16,2 %, in temporal area). Naftidrofuril activated intrahemispheric intercommunications between cerebral structures, which generated the main EEG rhythms.

Conclusions. Naftidrofuril improved cerebral hemodynamics in the vessels of affected and intact hemispheres, harmonized intrahemispheric intercommunications in patients, who had ischemic stroke. Medication's impact on the cerebral hemodynamics and bioelectrical activity had hemispheric peculiarities, which were more expressed in patients with IFL in LH. It makes possible to recommend the insertion of medication into the complex system of patients rehabilitation.

Keywords: naftidrofuril, ischemic stroke, rehabilitation period.



Clinical manifestations and diagnostics of infectious endocarditis

A.V. Rudenko, A.A. Krikunov

Clinical manifestations of infectious endocarditis (IE) are various. They depend on clinical course of disease, etiology, way of pathogenic organism invasion, initial intracardiac pathology, valvular lesions due to the IE, patient's age, his initial immune status, time of prescription, duration and kind of antibiotic therapy in many aspects. Two types of clinical course are generally accepted — acute and subacute. The diagnosis of IE is based on clinical features and bacteriological blood data analysis. Classic manifestations are fever, valvulitis with murmur of valvular regurgitation or modification of previous auscultative picture, splenomegaly, embolic complications, anemia. At the same time latent clinical course is frequent. According to the septic genesis of disease and rapidity of valvular destruction, isolated therapeutical treatment of IE is possible only in early diagnosis. Consultation of cardiosurgeon is required.

Keywords: infectious endocarditis, clinical manifestations, complications, diagnostics.



Endotheliocyt: physiology and pathology

V.V. Chopyak, G.O. Potomkina, I.V. Valchuk

The data about morphological peculiarities of endotheliocytes are outlined in the article, their functional, metabolic and synthetic functions are described. The interrelation of blood cells and endotheliocytes is the primary and important factor of different physiological and pathophysiological reactions that are the basis of organism immune protection. Important role of endothelium in inflammation process and remodulation of vascular wall is described. The essential significance is given to the studying of the nitrogen oxide formation processes by endothelial cells and their role in endothelium functioning. The peculiarities of nitrogen oxide synthesis are shown due to the chronic hyperimmunocomplexemia conditions in experiments on the white rats.

Keywords: endotheliocyte, nitric oxide, hyperimmunocomplexemia.

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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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