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Issue. Articles

4(8) // 2004





Surgical strategy and tactics of myocardium revascularization on the beating heart in patients with ischemic heart disease

A.V. Rudenko, V.I. Ursulenko, A.N. Kupchynskyi

Objective. To elaborate and to improve surgical strategy and tactics of myocardium revascularization on the beating heart in patients in patients with schemic heart disease.

Materials and methods. 1257 off pump coronary artery bypass grafting operations (CABG) were performed in the M.Amosov Institute of Cardio-Vascular Surgery of the Academy of Medical Sciences of Ukraine during 2000—2003. In order to obtain an objective results of the elaborated method of CABG the analyzed material was divided in 2 periods: the 1st period of mastering of the method and of accumulating experience (78 operations performed during 2000), and the 2nd period of stable results (2001- 2003, 1179 operations on the reason of ischemic heart disease). CABG on the beating heart demands a detailed and a logic preoperative plan of the sequence of the anastomoses placement, which cardinally differs from the CABG with the use of extracorporeal circulation (ECC), where the sequence of anastomoses placement in the conditions of a total ischemia of myocardium arrested by cardiophlegia has no meaning. Strategy of CABG on the beating heart forsees a permanent decrease of ischemia in the process of distal anastomoses placement. In order to achieve this aim it is principally important to observe the following sequence: first, to dissect IMA and venous grafts, first to place proximal anastomoses (except cases, when hemodynamic situation demands a quick anastomosing of IMA to LAD), first to shunt an collaterized coronary arteries (CA), and after this — those CA, that give collaterals. In cases with equipotent lesions and with absent collaterals LAD ought to be anastomosed the first. If stabilization and occlusion of any of the diseased CA worsens the hemodynamics it is useful to go on ECC. These principles should be adapted to the concrete patients. Approach to the CA located on the posterior wall of the heart is provided by a vertical position of the heart, which is achieved by the use of a rotatory ligatures.

Results and discussion. During the period of mastering of the method and of accumulating the experience 78 operations were performed on the beating heart, 4 (5.1 %) patients had died. During the second period of stable results 1179 operations were fulfilled with mortality 0.9 %.

Conclusions. CABG on the beating heart permits to increase surgical help with a complete revascularization of the myocardium to patients with ischemic heart disease with mortality lower that 1 %, to decrease quantity of complications and duration of hospital stay, to obtain good immediate and early results.

Keywords: surgical strategy, coronary arteries bypass grafting, intervessels anastomoses, stabilization devices, vertical position of the heart.



Parameters of systemic immune inflammation in the patients with congenital heart diseases at Eisenmenger syndrome stage

K.M. Amosova, V.V. Chopyak, I.A. Susak, L.F. Konoplyova, Yu.V. Fedorv, S.P. Tashova, I.V. Valochuk, M. Azhdari Hosro Shahi

Objective. To estimate a pathogenetic role of systemic immune inflammation in the development of high pulmonary hypertension (PH) in patients with congenital heart diseases (CHD) at Eisenmenger syndrome (ES) stage on the basis of evaluation of some proinflammatory interleukins (IL) — (IL-1β, IL-2, IL-6), tumor necrosis factor-α (TNF-α) venous blood levels.

Materials and methods. The venous blood levels of IL-1β, IL-2, IL-4, IL-6, and TNF-α were determined by a hardphase method of the immuneferment analysis in 21 patients with CHD at a ES stage (mean age 26,4±5,8 years). The correlative analysis between the contents of cytokines was carried out.

Results and discussion. The significant increase of proinflammatory cytokines venous blood levels in patients with ES was revealed. The average content of IL-1β was 779,4 ± 109,9 pg/ml vs. 28,9 ± 8,26 pg/ml in healthy persons ( < 0,001), IL-2 — 1410,3 ± 695,2 pg/ml vs. 11,6 ± 2,24 pg/ml ( < 0,001); IL-6 — 14,3 ± 14,1 mg/ml vs. 2,1 ± 0,9 mg/ml ( < 0,001). The increased IL-1β and IL-2 levels were observed in 100% of patients, IL-6 — in 71,4%. The average TNF-α content did not differ from that in healthy persons (p >0,05), nevertheless, its increase was registered in 47,6% of patients (p < 0,01). At the same time 95,0% of patients with ES had the marked elevation in antiinflammatory IL-4, which average level was 484,9 ± 464,6 pg/ml in comparison with 56,5 ± 9,6 pg/ml in healthy persons (<0,001). Simultaneously the disturbances of cytokines inter-regulating influences were revealed at ES. In particular, there was no negative correlation between the contents of IL-2 and IL-4, which existed in healthy persons (r=-0,62, <0,05). There was the positive correlation between levels of proinflammatory cytokines — IL-6 and TNF-α (r=0,64, <0,01), which did not exist in healthy persons (r=0,40, > 0,05).

Conclusions. Patients with CHD in ES stage had the significantly increased levels of both inflammatory (IL-1β, -2, -4, TNF-α), and antiinflammatory (IL-4) interleukins. That, probably, testifies the role of systemic immune inflammation in pathogenesis of high PH in these patients. The disturbances in the regulation of cytokine production are characteristic of the patients with CHD in ES stage. It is testified by the direct correlative link between the levels of IL-6 and TNF-α, which is not inherent to healthy persons and absence of that between the levels of IL-2 and IL-4, existing in normal cases.

Keywords: congenital heart disease, Eisenmenger syndrome, cytokines, tumor necrosis factor-



Clinical masks of aortic aneurysm dissection

D.D. Zerbino, Yu.I. Kuzyk

Introduction. Aortic aneurysms dissections (AAD) occupy a fitting place among the aortic pathology. It is very difficult to make a correct diagnosis and to treat pathology with high mortality.

Objective — to investigate and describe the possible clinical symptoms — «masks» of AAD at aortic medianecrosis (AMN).

Methods and materials — 36 necropsy cases of AAD at AMN had been analyzed for the period of 1998-2001. Men predominated among the deceased — 28 (77%), 14 (39%) of them were younger than 50 years.

Results and discussion. The correct diagnosis of AAD was established in 40,6% cases in lifetime. By the analysis of clinical features and autopsy results the following clinical masks were singled out: coronary (in 16 — 44,4% cases), vascular peripheral (in 3 — 8,4%), pulmonary (in 4 — 11,1%), cerebral (in 5 — 13,9%), gastrointestinal (in 4 — 11,1%) and renal (in 4 — 11,1%). Three patients had true myocardial infarction. In these cases dissection was morphologically established at the level of coronary artery deviation and was accompanied by compression of their initial part. In all cases of coronary mask patients died because of acute haemotamponade. The correct AAD diagnosis was established during the echocardiographic examination in the majority of cases.

Conclusions. The AAD diagnosis was not established in 59% of patients in lifetime, because of variety of pathology symptoms according to the localization, dimension and rate of dissection, rupture zone, the secondary morphological internal organs and central nervous system changes, complications. Registration of all AAD clinical masks opens the new opportunities for the improvement of this pathology diagnosis.

Keywords: pathology of aorta, aortic aneurysm dissection, cystic medianecrosis, clinical masks of aortic dissection.



Pathomorphologic characteristics of aorta in abdominal aortic aneurysm

I.V. Homolyako, T.O. Dubovich, G.G. Vlaykov, N.E. Klotchkova

Objective. Clarification of structural base of abdominal aortic aneurysm (AAA) formation.

Materials and methods. Autopsy aorta of 56 patients (mean age 64,1±6,l years) with AAA, 12 patients (69,2±7,4 years) with uncomplicated atherosclerosis (AS) and control group (C) were examined. Light-optic microscopy and morphometry were carried out.

Results and discussion. The smaller area of a common atherosclerotic damage, the bigger aortic diameter of thoracic and suprarenal parts are typical for macroscopic picture of AAA in comparison with AS. The marked dystrophic changes in media with degradation of elastic membranes (elastolysis, fragmentation, multiplication, thinning, disorientation and replacement by collagen fibers, areas of hyperelastosis) with cysts and fissures formation, diminishing of the elastic membranes quantity (AAA — 29,30±7,49; AS — 49,32±7,09, C — 53,41±5,73, p<0,01 in both cases in comparison with AAA); necrobiosis and necrosis of smooth muscle cells were revealed during the light-optic microscopy. Moderate neoangiogenesis (AAA — 28,01±1,63; AS — 43,37±2,62, C — 18,54±1,26, p<0,01 in both cases in comparison with AAA); spreading of capillars in subintimal zones of media and microdissections formation.

Conclusions. The structural base of AAA is an expressed dystrophic changes of media with elastolysis, cysts and microdissections formation. Atherosclerosis creates additional conditions for development of disease.

Keywords: aorta, atherosclerosis, abdominal aortic aneurysm, pathomorphology, morphometry.



Ultrasound parameters of aorta in men at the age of 2180 years without cardiovascular pathology

T.V. Kondratova

Objective. To study the changes of the main aortic parameters (diameter, wall thickness) in men at different age without clinically significant cardiovascular pathology by the results of ultrasound scanning in B-regimen and regimen of color Doppler mapping.

Materials and methods. 125 men at the age of 21—80 years were examined by a method of ultrasound scanning of an ascending (APA) and abdominal parts of aorta (ABPA). Patients were divided into six age-groups. The first one — 21—30 years (n=7); the second — 31—40 years (n=8); the third — 41—50 years (n=39); the fourth — 51—60 years (n=44); the fifth — 61—70 years (n=20) and the sixth — 71—80 years (n=7). The following parameters were defined: a) APA diameter; b) APA wall thickness; c) diameter ABPA of an aorta at a proximal part (PP), median part (MP) and distal part (DP); d) ABPA wall thickness in PP, MP and DP.

Results and discussion. APA diameter in men ranged from 26,7 ±2,0 to 34,8 0,9 mm, wall thickness — from 2,4 0,9 to 3,3 0,8 mm. ABPA PP diameter changed from 20,0±1,0 to 22,5±2,1 mm, wall thickness — from 2,1±0,1 up to 3,5±0,4. Diameter AD ABG PA was from 15,4±1,1 up to 17,8±1,9 mm, wall thickness from 2,1±0,1 to 3,4±0,4 mm. ABPA DP diameter changed from 12,7±1,2 to 15,5±2,2 mm, wall thickness — from 2,1±0,1 to 3,4±0,4 mm. The greatest APA diameter increase was observed in the second age group in comparison with the first one (4,8 mm, 17,9 %, p<0,05). The APA wall thickening was expressed in men of the third in comparison with the second group (0,3 mm, 12 %) and the fifth age group in comparison with the fourth one (0,4 mm, 13,7 %). The significant increase of APA diameter was fixed in the second and sixth groups in comparison with the first one. Studying of PP APA structure had shown, that the most significant changes of diameter were observed in men of the fourth age group (1,4mm, 6,6 %) in comparison with the third one. During the investigation of the MP APA wall thickness changes the maximal increase was revealed in men of the second age group (0,5 mm, 23 %) in comparison with the first one. The greatest increase of DP APA diameter was observed in the fourth age group in comparison with the third (0,9mm, 6,2 %).

Keywords: an ascending part of aorta, abdominal part of aorta, diameter of aorta, wall thickness, age group.



Long-term dual chamber pacemaker function analysis in post-operative period

V.K. Green, A.S. Kuznetsov, V.V. Chernii, A.V. Filyuk, T.N. Isakova

Objective. An assessment of the main dysfunctions of dual-chamber cardiac pacing and parameters of pacemaker function, which are responsible for these malfunctions in post-operation period.

Methods and materials. The study lasted for 2 years and included 54 patients with implanted dual chamber pacemakers. Pacemaker parameters (amplitude, duration of impulse, AV delay, atrial refractory period, system sensitivity by every channel) were assessed with examination every 6 month for 2 years.

Results and discussion. Only 2 patients were changed to VVI because of permanent atrial fibrillation, the rest 52 patient completed two year period. The most common pacing disorder, which required reprogramming of pacemaker (39 cases, or 72.2%), was lack of detecting — atrial in 36 cases (66.6%), ventricular — in 3 cases (5.5%). The main causes of clinically manifested exit-block were reposition of electrodes in 2 cases (3.7%) and threshold increase in 12 (22.2%).

Conclusions. It was established that the most common dual chamber pacemaker dysfunctions and complicated for the diagnosis were desynchronization of atrial and ventricular rhythm. Implication of temporary VDD testing is crucial for analysis of spontaneous atrial rhythm.

Keywords: rhythm disturbances, dual chamber cardiac pacing, pacemaker follow-up and programming.



Features of the myocarditis clinical course in patients with out-of-hospital pneumococcus pneumonia against a background of the acute viral respiratory infection episode

A.S. Svintsytskyi, O.P. Slesarenko

Objective. The investigation of the frequency and clinical course of myocarditis during the two pneumococcus pneumonia against a background of the acute viral respiratory (AVRI) — respiratory syncytial (RS) and parainfluenza (PI) — infection episode.

Materials and methods. Among the military men of the service for a fixed period (men of 18—20 years) two episodes of out-of-hospital pneumococcus pneumonia were registered. 367 military men became ill against a background of RS infection during one of them, during another one — 212 against a background of PI infection, including moderate severity in 31.1 and 19.8 % cases correspondingly, severe cases — 6.5 and 3.8 % correspondingly. Etiological diagnosis was confirmed by the data of serological and bacteriological examinations in dynamics. At the first group by clinical and ECG data in dynamics myocarditis was established in 60 (16.4 %) cases. At the second one — in 25 (11.8 %). Examination consisted of echocardiography and X-ray.

Results and discussion. In all cases myocarditis was clinically silent and had light severity without signs of left ventricle systolic dysfunction with the complete recovery by the (37±1.7) day without any reliable distinction between the episodes. The main feature of RS-pneumococcus and PI-pneumococcus myocarditis was severe sinus node dysfunction — bradycardia (in 90.6 %), S blocks (SAB) (29.5 %), atrioventricular dissociation (VD) (37.7 %) and substitutive rhythms (17.7 %). Severity of sinus bradycardia was the same in both groups and averaged (48.2±1.3) and (49.9±1.7) beats/min (>0.05). Frequency of SAB and AVD was higher among the patients with RS-pneumococcus myocarditis (correspondingly 31.7 vs. 12 %, 43.3 vs. 24 %; <0.05). Repolarization disturbances was registered on average in 87.1 % cases with the prevalence at the group (90.2 vs. 76 %; <0.05).

Conclusions. Frequency of viral-pneumococcus myocarditis in young men (18—20 years) did not depend on the severity of pneumonia clinical course. The mild severity is typical for it without signs of myocardial systolic dysfunction with sinus node depression and sinus bradycardia, SAB and AVD.

Keywords: myocarditis, viral respiratory infection, pneumococcus pneumonia, clinical course.



About the informative value of simplified methods of quantitative estimation of the functional condition dynamics in pregnant women with heart pathology and anemia as the result of sanatorium treatment

A.A. Vladimirov, N.I. Tofan

Objective. To evaluate the informative value of 6-minute walk test for the estimation of functional condition dynamics in pregnant women with heart pathology as the result of sanatorium treatment.

Materials and methods. The complex sanatorium treatment with the active physical rehabilitation of 53 pregnant women with heart pathology (heart disease — 41, endocrinous cardiomyopathy — 12) and iron-deficiency anemia (of the I stage — in 14 cases, II — in 39) I—III NYHA classes was performed. The submaximal veloergometric test and 6-minute walk test were done to all patients at the beginning of treatment and at discharge after (26,8±5,2) days.

Results and discussion. The worked out system of sanatorium treatment leads to significant improvement of clinical status (decrease in complaints frequency by 62,3%; p<0,05), improvement of erythrocytic group and iron exchange (red blood cell amount had increased by 22,6%, serum iron — by 2,7 times, serum ferritin — by 1,6 times; all p<0,05). According to the results of submaximal loading test physical working ability increased by 39,2%, distance of 6-minute walk test — by 46,9% (p<0,05). The mean NYHA functional class, evaluated by the clinical criteria, had been changed from (2,0±0,4) to (1,5±0,2) units, and by the results of 6-minute walk test — from (1,9±0,2) to (1,6±0,3) units.

Conclusions. The comparative assessment of physical condition of pregnant women with heart pathology and anemia on the base of submaximal loading veloergometric and 6-minute walk test did not reveal any significant difference in positive dynamics of these indices against a background of sanatorium treatment. It is the evidence of 6-minute walk test informative value in such patients and gives the opportunity to use this very simple and safe method for the objective estimation of their functional condition.

Keywords: regnancy, heart pathology, anemia, sanatorium treatment, functional condition, effectiveness, simplified quantitive estimation.



Endothelial function in elderly patients with acute Q-wave myocardial infarction and its changes against a background of treatment with different doses of ACE inhibitor inclusion

.V. Ryabtsev

Objective. To evaluate the endothelial function in elderly patients with acute Q-wave myocardial infarction (Q-MI) and its changes against a background of treatment with different doses of ACE inhibitor spirapril inclusion.

Materials and methods. 50 patients with the primary Q-MI were under the observation. 34 of them were men (68 %), 16 — women (32 %). The entry criteria were the acute left ventricle failure of the T. Killip — J. Kimbal (1969) class I—II on admission, atrioventricular block of I—II grades, essential arterial hypertension (AH) of the I—II grades. Patients with systolic blood pressure below 90 mm Hg, diabetes mellitus (DM) which required drug therapy, chronic renal and hepatic failure were not included. ACE inhibitor spirapril (quadropril — AWD, Germany), prescribed from the first day of the Q-MI once a day, was used in the treatment of all patients in addition to conventional standardized therapy. all patients were randomized in two groups according to the admission time. The I group consisted of 20 patients, who were administered the «low» dose of spirapril — 3 mg/day, the II — of 30 patients on the complete therapeutic medication dose (6 mg/day). Patients of both groups were comparable by the age, sex, incidence of AH and DM, Q-MI localization, frequency of the acute left ventricle failure of the T. Killip — J. Kimbal class II on an entry time (all >0,05). Evaluation of the serum endothelin-1 (ET-1) content and brachial artery vasomotor function (flow-dependant vasodilation), that were performed during the first day of Q-MI and after 24—28 days of the treatment, were used for the endothelial function assessment. Reference levels were received during the examination of 20 healthy volunteers comparable by the age and sex with patients. The normal value was the postocclusive diameter extension by more than 10 % from initial and by 20 % against a background of nitroglycerin.

Results and discussion. The initial levels of ET-1 were significantly higher in comparison with normal values (all p<0.01) among the examined patients. Patients of both groups were comparable (>0,05). Against a background of the treatment the levels of ET-1 were significantly decreased in both groups in comparison with the initial ones: in the I — by 18,9 % (<0,05), in the II — by 33,8 % (<0,01). By the end of observation period the level of ET-1 in patients who were treated with the «high» spirapril dose was 44,6 % lower in comparison with those, who were treated with the «low» drug doses (<0,01). Presence of endothelial dysfunction in patients with Q-MI was confirmed by the decrease of endothelium-dependent vasodilation (EDVD) in both groups at the treatment beginning in comparison with healthy persons. Endothelium-independent vasodilation (EIVD) was decreased in comparison with healthy persons (<0,05), but there were no significant differences between both groups, that can be explained by the development of tolerance to nitroglycerin due to its reiterated intake. Against a background of the treatment patients of the II group had significant EDVD improvement, that had increased by 2.1 times in comparison with initial level (<0,05) and became comparable with healthy persons (>0,05). The significant dynamics of this index in the I group in comparison with initial level was absent (>0,05), though by the end of observation period there were no significant differences in comparison with healthy persons (>0,05). There was no significant dynamics of EIVD indices both in 3 min and 5 min in both groups. It is adjusted with the absence of в1 and в3 changes (>0,05).

onclusions. 1. The elderly patients with acute Q-wave myocardial infarction have severe endothelial dysfunction by the serum ET-1 content and EDVD level. 2. Treatment of elderly patients with acute Q-wave myocardial infarction with inclusion of ACE inhibitor spirapril in «high» dose in comparison with the «low» one has more significant normalizing influence on the endothelial function by the changes of ET-1, at the same time dose-dependent action on the vasomotor function is absent.

Keywords: acute Q-wave myocardial infarction, endothelial dysfunction, endothelinG1, endotheliumGdependent and endothelium-independent vasodilation.



Surgical treatment of false anastomotic aneurysms after aorto-femoral reconstructive operations

A.V. Gubka, A.B. Shestakova

Objective. Modernization of the reiterative reconstructive operations technique in false anastomotic aneurysms after aortofemoral reconstructions.

Materials and methods. Since 1990 to 2004, 68 patients were examined and re-operated due to anastomotic aneurysms. All of them were men, mean age — 57,7 years. The diagnosis of these complications was made by physical examination, ultrasonography or arteriography. The features of the operative technique in 68 reiterative reconstructions are described.

Results and discussion. The following methods of the distal anastomotic reconstructions were used: prosthesis-deepfemoral anastomosis was created in 44 patients, prosthesis-superficialfemoral anastomosis — in 8 cases, prosthesis-commonfemoral anastomosis — in 16 patients. Pulsation of the lower extremities arteries was restored in 20 patients (29.4 %), of the popliteal artery — in 5 (7.4 %), of the branch prosthesis — in 40 (58.8 %) after the operative treatment. The following complications were registered in post-operative period: lymphorrhea in 25 (36.8 %) patients, operative wound bleeding — in 1 patient, that required urgent operative treatment. The branch prosthesis thrombosis took place because of the distal artery inconsistency and decompensation of the lower extremity circulation, that have led to amputation on the level of a proximal one-third of femoral bone. One of these patients (1.5 %) have died because of acute cardiovascular failure. Thus amputation on the level of a proximal one-third of femoral bone was performed in 3 (4.4 %) patients. Good result of operative treatment was achieved in 58.8 % cases, satisfactory result — in 36.8 %, poor result — in 4.4 %.

Conclusions. The false anastomotic aneurysms in the remote period after aorto-femoral reconstructions have arisen in 4.5 % of patients. The most efficient method of false anastomotic aneurysms operative treatment is resection, building-up of adaptive anastomosis with anastomotic reconstruction. The active approach to the operative treatment of patients with false anastomotic aneurysms allowed to achieve the good results of treatment in 58.8 % cases.

Keywords: reconstructive operations, remote complications, anastomotic aneurysm, aorto-bifemoral bypass.



Endovascular treatment of the internal carotid artery stenoses

S.N. Furkalo, M.P. Kostuk

The indications for stent-angioplasty of internal carotid artery (ICA) are not finally established and depend on clinical stage, the degree, morphology and location of the lesion and the regional cerebral perfusion.

Objective — the analysis of initial experience of stent-angioplasty in patients with ICA stenoses.

Materials and methods. We have conducted 19 stentings of carotid artery: 18 of atherosclerotic origin and one case of vasculitis. 14 patients had concomitant disease (CAD, hypertension, diabetes mellitus). Selfexpanded stents were used in 15 cases and ballonexpanded ones in 4 of them. In the last cases neuroprotective devices were used. Before the intervention double antiplatelet therapy, including aspirin and clopidogrel, was administrated. The long-term follow-up was 17,5 months on average.

Results and discussion. We had the technical success in all cases. There were three cases of complications — one stroke and two transient ischemic attacks. No intraoperation deths were registered. Carotid stenting was performed in one patient; one coronary intervention and two coronary bypass operations were made during this period. One angioplasty due to in-stent restenosis was performed in vasculitis patient.

Conclusion. The carried out endovascular treatment of ICA stenoses lead to satisfactory technical effect in all 19 cases and was connected with low complication frequency (3 cases) in the absence on intraoperative mortality.

Keywords: stent-angioplasty, stenosis of internal carotid artery, selfexpanded and ballon-expanded stents.



Magnetocardiography: the new view on the old ideas

V.N. Sosnitsky, L.A. Stadnyuk, T.V. Sosnitskaya

Although significant number of experimental and clinical tests has been taken, a real value of magnetocardiography (MCG) for clinical practice has not been established yet. In our review advantages of MCG in comparison with other methods of diagnostics of changes in myocardial function were determined. Factors that caused a delay in implementation of MCG into clinical practice were analyzed and ways of further improvement in the use of MCG for diagnosis of the ischemic heart disease, arrhythmias and other heart diseases were considered.

Keywords: myocardium, ischemia, myocardial excitation, electrocardiography, cardiac magnetic field, magnetocardiography.



Beta-blockers in the treatment of cardiovascular pathology in patients with diabetes mellitus: more for, than against

V.. Skybchyk, .M. Solomenchuk

Results of multicentral clinical trials, devoted to the investigation of β-blockers in patients with diabetes mellitus (DM), arterial hypertension (AH), myocardial infarction (MI) and heart failure (HF), are summarized in the article. Results of own investigations are presented too.

Objective: to estimate clinical efficacy of β-blocker metoprolol and its impact on cardiohemodynamics data in patients with MI, complicated by the left ventricular systolic dysfunction (LVSD), with type 2 DM.

Materials and methods. 22 patients with Q-MI and concomitant type 2 DM (mean age 63,3±9,2 y.) were examined. Patients with LVSD (LV ejection fraction — EF<45 %) were included. Their blood glucose level was below 14 mmol/l (mean — 10,9±2,9 mmol/l) during the first day after admission. The first manifested type 2 DM was revealed in 5 patients. Another 17 had DM for 2 to 15 years. Metoprolol (egilok, «Egis», Hungary) was prescribed from 6,25 mg. The dose was elevated for 2—3 days to 25—50 mg/day twice a day against the background of conventional treatment. Simple insulin subcutaneously 3 times per day according to the level of glycemia was prescribed to all patients.

Results and discussion. Metoprolol tolerance in patients with MI and type 2 DM with moderate LVSD was good in total. 2 of them (9,1 %) had solitary asymptomatic ventricular premature beats during the first 3 days. 4 patients (18,2 %) had recurrent ischaemia. Bradycardia was registered in 3 (13,6 %) cases. Metoprolol dose was diminished in these patients. None of them had the increase of the acute LV failure class in the early period. 2 (9,1 %) patients had demonstrated the deterioration of the myocardial functional data (LV EF and end-diastolic pressure — EDP) and of HF clinical signs by the 21st day. Prescription of metoprolol in patients with MI and type 2 DM had led to positive dynamics in LVSD data: LV EDP decrease from 16,4 ± 0,3 to 14,9 ± 0,4 mm Hg (<0,05) and stroke index (SI) increase from 24,4±1,6 t 30,8 ± 2,1 ml/m2 (<0,05). Cardiac index was not changed substantially because of heart rate deceleration from 94,8 ± 3,8 to 77,1± 4,3 beats per min. (<0,05). Individual cardiohemodynamics data analysis had showed absence of changes in 6 of 22 patients, who used metoprolol (27,3 %). Initial dose of insulin was increased in 14 (63,6 %) patients for the control of optimal glycemia level, but not because of side effects of metoprolol. Substantial negative impact of the drug on the glucose exchange was not revealed.

Conclusions. It is expedient to prescribe cardioselective β-blockers in patients with AH and type 2 DM because they decrease the risk of MI, renal failure, stroke and HF substantially. The use of such β-blockers, as bisoprolol, carvedilol and metoprolol in patients with HF and concomitant DM, at least, improves prognosis as much as in absence of DM. In patients after acute MI with concomitant DM long-term use of β-blockers (metoprolol, timolol, propranolol, carvedilol) has the same cardioprotective effect as in those without DM. In patients with acute MI with LVSD metoprolol therapy leads to SI elevation and LV EDP decrease by 21st day in absence of LV EF substantial changes. Taking into account severe negative impact of concomitant DM on the clinical course and outcomes of AH, MI and HF from the one side, and high clinical efficacy of some β-blockers in such patients with combined pathology from the other side, this group of medications has to be used in wider circle of patients, even in presence of relative contraindications (COPD etc.).



Arteries remodeling at some cardiovascular diseases

N.V. Kalinkina, O.K. Kashanskaya, E.V. Keting, N.T. Vatutin

The review of the literature concerning a problem of arteries remodeling at some diseases of cardiovascular system (atherosclerosis, restenosis of the coronary artery, arterial and pulmonary hypertension, heart failure) is given in the article. The role of genetic factors, inflammation, endothelial dysfunction and kinds and structural base of remodeling in these diseases is discussed.

Keywords: remodeling, arteries, cardiovascular diseases.



The problem of peripheral vascular resistance in reconstructions of the shin arteries

I.M. Gudz

During reconstruction of the shin arteries we often have to deal with problem of high peripheral vascular resistance (PVR), which is provided by morphological and microcirculational changes in ischemic limb. In this work we made analysis of the literature information about possibilities of PVR reduction using technical improvements of shin arteries shunting, and parthogenetically based prostaglandin E1 use during operation and in early postoperative period.

Keywords: peripheral resistance, reconstruction, shin arteries.

Current Issue Highlights

4(60) // 2017

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K. M. Amosova 1, I. I. Gorda 1, A. B. Bezrodnyi 1, G. V. Mostbauer 1, Yu. V. Rudenko 1, A. V. Sablin 2, N. V. Melnychenko 2, Yu. O. Sychenko 1, I. V. Prudkiy 1&a

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