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Issue. Articles

1(9) // 2005





To the question about familial cardiac myxomas and myxoma syndrome

R.. Vitovskyi, L.L. Citar, .V. Kryvenkyi, S.I. Komissarov, V.V. Isaenko, .. Antoshchenko, .V. Vitovskaya

Cardiac myxomas in clinical practice are represented to a greater extent by soGcalled sporadic myxomas. But there are myxomas, combined with other organs and systems pathology. Such multiple organ pathology was called myxomas disease, or myxomas syndrome. Inadequate presentation of myxomas syndrome in domestic literature does not allow to make a diagnosis of this disease in time. In the article based on the particular clinical cases clinical features of pathology were analyzed. The most specific of them are spotty skin pigmentation, endocrine disturbances and extracardiac neoplasms. This signs are registered in 5—7 % patients with myxomas, and in childhood — in 23 % cases. Multiple neoplasms in different heart chambers and their recurrence after surgical treatment are specific for the myxomas in myxomas disease. Our observations confirm the possibility of cardiac myxomas familial nature, which is registered in considerable part of patients with clinical signs of myxomas syndrome.

Keywords: cardiac myxomas, Carney syndrome, familial myxomas.



Systemic inflammation as pathogenic basis of insulin resistance syndrome and efficiency of trimetazidine in preventing its development

T.V. Talaeva, T.A. Kryachok, O.V. Yanus, V.A. Shumakov, V.V. Bratus

Objective. To determine the pathogenic role of systemic inflammation and its connection with lipid metabolism disturbances in insulin resistance (IR) syndrome development, and in evaluation of its development possibility prevention by inhibition of free fatty acids (FFA) β-oxydation, using Trimetazidine MR on the experimental inflammation model in rabbits.

Materials and methods. The investigation was carried out on rabbits with the experimental model of IR syndrome, induced by intravenous injection of lipopolysaccharide. The main indexes of lipid and lipoprotein metabolism, blood contents of FFA, glucose and glycosylated hemoglobin, activity of postheparin lipoprotein lipase and insulin sensitivity were determined initially and after 2, 4, 6 and 8 weeks. There were also determined the circulating monocytes and neutrophils activity, severity of free radical blood reactions, blood C-reactive protein contents, antioxydant blood potential. Blood modified lipoprotein presence and concentration was determined with the use of mouse macrophages. Trimetazidine MR (Preductal MR, Servier, France) was used from the 1-st day (3 mg per 1 kg) through 8 weeks of experiment in 15 animals. Control group consisted of 15 animals.

Results. The 8 weeks course of systemic inflammation was shown to be accompanied with the pronounced elevation of glucose content — 2,4 times as much at the end of 4th week and 2 times as much — during the 6—8th weeks ( < 0,01), elevation of total cholesterol level by 30 % at the end of 4th week, by 78 % — 6th, by 96 % — 8th week ( < 0,01) and triglycerides level — by 50 % at the end of 4th week, by 150 % — during 6—8th weeks ( < 0,01). Insulin sensitivity decreased significantly in close connection both with inflammation intensity and free fatty acid blood concentration. Tri-metazidine MR use allowed to decrease the growth of C-reactive protein contents by 40 % ( < 0,01) by the end of 4—8th weeks, to prevent lipid, lipoprotein and glucose metabolism disturbances, and decreasing of insulin sensitivity.

Conclusion. The obtained data confirm the hypothesis about the significance of systemic inflammation and hyperlipidemia as the most important pathogenic factors of insulin resistance syndrome development. Inhibition of free fatty acids (FFA) β-oxydation after trimetazidine in experimental model facilitates inflammation severity and oxidant stress diminution, increase of plasma atherogenic potential and IR development prevention.

Keywords: insulin resistance, inflammation, oxidative stress, metabolism, lipids, lipoproteins.



Angiotensin converting enzyme activity and polymorphism in hypertrophic cardiomyopathy

V.Y. Tseluiko, .. Lytvynova

Objective. To evaluate and compare angiotensin converting enzyme (ACE) plasma activity level, its gene polymorphism in hypertrophic cardiomyopathy (HCMP), because one of the most pathognomonic features of this pathology is local or symmetric left ventricular hypertrophy.

Materials and methods. Sixty patients at the age of 7—71 (mean 45,2 ± 1,9 years) have been examined. Diagnosis was established on the basis of specific echocardiograhic (EchoCG) signs: presence of left ventricular (LV) hypertrophy (LVH), which was 1,3 times as much as maximal LV posterior wall thickness, or symmetric LVH greater than 15 mm without any reason for it. During EchoCG the following items were evaluated: presence or absence of the LV outflow tract (LVOT) obstruction, ventricular septum thickness (VST), end-diastolic and end-systolic LV size, ejection fraction (EF), cardiac output (CO). Diastolic function was evaluated on the basis of transmitral flow examination. ACE plasma activity was determined by kinetic method. Three genotypes (DD, ID, II) were identified in the HCMP patients with polymerase chain reaction (PCR).

Results. Patients with obstructive HCMP have significantly higher ACE plasma activity level — (76,3 ± 8,3) micromol·min–1·l–1 vs (54,7 ± 3,6) micromol·min–1·l–1 ( < 0,05) in patients without LVOT obstruction. The significant difference was established depending on the LV diastolic dysfunction. In patients with HCMP with restrictive (n=17) and pseudonormal (n=16) LV diastolic dysfunction types the level of ACE activity was (72,8 ± 6,7) and (62,6 ± 11,3) micromol·min–1·l–1 correspondingly. In the first case it was significantly higher in comparison with patients with hypertrophic type (n=27) — (54,9 ± 4,9) micromol·min–1·l–1 ( < 0,05). Frequency of I/D-polymorphism in patients with HCMP was the following: DD genotype — 27 patients (45,0%), ID-genotype — 22 (36,7%) and II genotype — 11 (18,3%). ACE plasma activity level in patients with DD genotype was significantly higher in comparison with patients with ID genotype — (73,7 ± 5,7) micromol·min–1·l–1 vs (49,6 ± 5,0) micromol·min–1·l–1 ( < 0,01) and II-genotype (54,6 ± 9,9 micromol·min–1·l–1, < 0,05). Correlation analysis verified close connection of ACE activity with the majority of studied indices — LV myocardium mass (r=0,67), VST (r=0,66), LV end-diastolic size (r=0,34), EF (r=0,56) — in the group of DD-genotype HCMP patients. Patients with ID genotype had direct connection of ACE activity only with LV end-diastolic size and O (r=0,300 in both cases; < 0,05). Patients with II genotype had no significant correlation.

Conclusions. DD genotype of ACE gene in patients with HCMP is associated with the higher ACE plasma activity level in comparison with ID and II genotypes. ACE plasma activity level has close connection with LV myocardium mass, VST, LV end-diastolic size and EF in patients with DD genotype.

Keywords: hypertrophic cardiomyopathy, angiotensin converting enzyme, ACE gene polymorphism.



Peculiarities of nitric oxide formation before and after operative correction of congenital heart diseases with pulmonary hypertension

M.F. Zinkovskiy, N.M. Gula, G.V. Kosyakova, A.M. Dovgan, M.Yu. Atamanyuk

Both endothelium and blood cells, which generate the biological substances with vasodilative and constrictive effects, participate in the tone regulation of pulmonary vessels. Imbalance in their synthesis may be the important part of pulmonary hypertension (PH) pathogenesis. It is well known, that the most powerful vasodilator is NO.

Objective — to determine the peculiarities of nitric oxide formation in the blood of patients with congenital heart diseases (CHD), complicated by pulmonary hypertension, and impact of extracorporeal circulation on it.

Materials and methods. 16 patients at the age of 3 to 48 months (mean — 8,2 ± 5,3 months) with CHD, complicated by pulmonary hypertension, were examined. Patients were divided into two groups. The I group consisted of 9 (56,3 %) patients with mild clinical and haemodynamic signs of obstructive pulmonary vascular disease (OPVD), the II — of 7 (45,7 %) patients with moderate signs. Control group included 4 patients with the same CHD, but with the normal pulmonary artery (PA) pressure. Activity of the main NO synthesis enzymes (constitutional (cNOS) and inducible (iNOS) NO synthases), and its stable metabolites (NO 2 — NO3 —) were assessed in erythrocytes suspension of arterial blood before and day after operation of CHD radical correction.

Results and discussion. Patients with PH had changes in activity of NOS isoforms correlation: iNOS activation in comparison with cNOS. cNOS activity in erythrocytes of arterial blood in patients of the I group was 1,09 ± 0,29, nd iNOS — 1,501 ± 0,410 pmol/min/mg of protein, in control group — 1,53 ± 0,37 pmol/min/mg vs 0,584 ± 0,109 pmol/min/mg (for iNOS p < 0,05 in comparison with patients). In postoperative period patients of the I group had demonstrated decrease of cNOS activity (0,386 ± 0,088 pmol/min/mg of protein, < 0,05), and absence of changes in iNOS activity (1,75 ± 0,39 pmol/min/mg of protein, > 0,05). Patients of II group had decreased both NOS isoforms activity in comparison with control and I groups (cNOS — 0,275 ± 0,072, iNOS — 0,807 ± 0,080 pmol/min/mg of protein, < 0,05) before operation. All indices had not significantly changed after operation — 0,316 ± 0,62 and 0,596 ± 0,13 pmol/min/mg of protein, correspondingly ( > 0,05). Before operation NO2 — NO3 — content in erythrocytes of the I group was elevated (correspondingly 20,57 ± 3,08 and 10,45 ± 0,79 vs 5,97 ± 0,53 and 2,67 ± 0,52 pmol/min/mg of protein in control, < 0,05) and did not change significantly after operation ( > 0,05). Considerable increase in NO2 — NO3 — content in erythrocytes before operation was registered in II group ( < 0,05) and did not change significantly after operation ( > 0,05).

1. Under presence of PH in patients with CHD there is an activation of L-arginine oxidative metabolism with changes in isoforms NOS activity of arterial blood erythrocytes with iNOS activity prevalence. Owing to them NO synthesis is increased.
2. Elimination of haemodynamic basis of PH during the surgical correction of CHD does not influence NO synthesis, obviously, due to absence of iNOS activity changes. It is accompanied by subsequent cNOS activity decrease in patients with mild clinical and haemodynamic signs of obstructive pulmonary vascular disease.

Keywords: congenital heart diseases, pulmonary hypertension, nitric oxide, extracorporeal circulation.



Echocardiographic data of the long-term results of the arterial switch operation of transposition of great heart arteries

E.M. Trembovetskaya, G.V. Knyshov, I.N. Yemets, N.N. Rudenko

Objective. Estimation of anatomic and functional state of heart ventricles by echocardiographic data in long-term postoperative period after arterial switch operation of transposition of great arteries regarding operation fulfillment terms and types of concomitant defects.

Materials and methods. Doppler echocardiographic examinations of 46 patients, mean age of which was 30 ± 12 days (9 days up to 1 year) for time of operation fulfillment, before and after arterial switch operationwere carried out. Patients were subdivided into groups according to their age (groups I,II) and types of concomitant defects (groups A,B,C). Mean term of long-term followup was 3,2 ± 0,6 year (0,4 up to 11 years). The examinations were carried out according to the standard procedure using the equipment Toshiba-SSH-60A, Toshiba-SSA-380A, Aloka-5500 with sensors of 3,5- or 5,0 MHz frequency. The calculations were performed in one- or two-dimensional mode applying continuous wave Doppler procedure and color Doppler mapping.

Results. Patients of groups IA and IB had had significantly diminished size of the left ventricle during preoperative period. After the operation the size reliably increased (p < 0,01) and conformed to normal. Myocardium mass index of the left ventricle of all patients before operation was low. After the operation it reliably increased (p < 0,001) and did not significantly differ from the normal. The patients operated at the age of more than 21 days had initially decreased (p < 0,001) relative indices of the left ventricle myocardium thickness. Although in the long-term period the indices became normal. Patients operated in the earlier period retained normal indices (p > 0,05). Left ventricle contractility either before or after operation remained normal (p > 0,05). The size of the right ventricle was initially significantly increased (p < 0,001), regardless of the age and the types of concomitant defects. In the long-term postoperative period it significantly decreased (p < 0,001). Systolic pressure gradient at the pulmonary artery valve of all patients conformed to normal before operation (6,2 ± 0,3 mm Hg), after operation 16 patients (34 %) had it increased from 10 up to 57 mm Hg (on average — 33,5 ± 12,8 mm Hg). Systolic pressure gradient at the aortic valve before and after arterial switch operation remained within the normal range (6,2 ± 0,2 mm Hg). None of the patients had aortic regurgitation before operation, after operation 14 patients (30 %) had it, however, it never exceeded the first degree. Patients, who suffered from concomitant coarctation of aorta, after the operation got systolic pressure gradient reliably decreased from 53,3 ± 3,4 mm Hg to 13,6 ± 1,1 mm Hg.

Conclusions: Left ventricle size and mass echocardiographic indices of the patients, who had transposition of great heart arteries in long-term period after arterial switch operation in general do correspond to the normal values, regardless of the period of operation fulfillment and the types of concomitant defects. Meanwhile the expressibility of right ventricle dilatation significantly decreases, which proves the results of the given operation to be good. The main complications of the arterial switch operation are moderate supravalvular stenosis of the pulmonary artery (34 %) and aortic regurgitation (30 %) not exceeding the first degree.

Keywords: transposition of the great arteries, echocardiography, arterial switch operation, long term postoperative period.



Diagnosis and surgical treatment of chronic brain critical ischemia in patients with multifocal atherosclerosis

V.G. Mishalov, V.A. Chernyak, N.Yu. Litvinova

Objective — to study the clinical presentation and methods of diagnosis of advanced brain ischemic impairments and to determine indications and methods of surgical treatment of this pathology and to assess the early results of surgical treatment.

Material and methods. There were 104 patients with III—IV functional class of chronic brain ischemia by our classification with multifocal atherosclerosis of other arterial areas under our supervision from 1997 to 2005. Diagnostics was made by 3-staged algorithm, developed in our clinic. MRI and CT were the obligatory steps of diagnosis plan. Different diagnostics methods were assessed. All patients underwent surgical reconstruction of extracranial vessels and other arterial areas.

Results. Early results analysis of the arch of aorta and other arterial areas reconstructive operations in patients with chronic critical brain ischemia had indicated that good and satisfactory results were achieved in 96 (95,0 %) patients on brachiocephalic arteries, and in 49 (83,1 %) patients on other arterial areas. Unsatisfactory results were achieved in 4 (4,0 %) 7 (11,9 %), correspondingly.

1. The main features of clinical presentation of advanced ischemical brain impairment are the prevalence of multifocal lesions of brachiocephalic arteries, low and critical cerebrovascular reserve.
2. For the diagnosis of advanced cerebral pathology 3-staged algorithm and MRI or CT should be used. It allows to make a proper diagnosis in 89 % cases. Duplex scanning has the highest accuracy of all used methods.
3. Indications for surgical treatment are arterial stenosis of more than 75 %, embologenic plaque, middle and light neurological deficiency or — stage of dyscirculatory progressive encephalopathy.
4. Good and satisfactory results were achieved in 96 % patients in case of adequate anesthesia and proper choice of surgical reconstructive technique (taking into account CVR).
5. In case of simultaneous atherosclerotic impairment of brachial arteries and other arterial areas operative treatment should be staged.

Keywords: chronic brain critical ischemia, surgical treatment, multifocal atherosclerosis, brachiocephalic arteries, cerebrovascular reserve.



Clinical efficacy of early simvastatin administration in patients with acute coronary syndromes without segment ST elevation and its influence on the markers of inflammation

V.Z. Netyazhenko, B.M. Yurochko, G.V. Ponomaryova, M.M. Stepanchuk

Objective. To evaluate the clinical efficacy of early simvastatin administration in patients with acute coronary syndromes (ACS) without segment ST elevation and its influence on the level of blood lipids and markers of inflammation during 3 months period of observation.

Materials and methods. 63 patients with unstable angina (UA) and non-Q-wave acute myocardial infarction (AMI) were included in open-label trial. 34 patients (including 18 (53,0 %) with UA and 16 (47,0 %) — with non-Q-wave AMI) were randomized to the main patients' group, who received simvastatin in a dose 20 mg once a day in addition to standard therapy. 29 patients were in control (2nd) group (including 17 (58,6 %) with UA and 12 (41,4 %) — with non-Q-wave AMI). They received standard therapy. We measured serum lipids level by enzyme colorimetric method, C-reactive protein (C-RP) level — by immunoturbidimetric method, fibrinogen level and hematological (white blood cells and ESR) parameters. Blood samples were taken on admission, at discharge (on days 15—20) and after 90 days.

Results. The level of total cholesterol (TC) was (5,98 ± 0,13) mmol/l, low density lipoproteins (LDL) level — (4,5 ± 0,12) mmol/l in patients on admission. During the in-hospital period there was a significant difference in combined end point accomplishment (non-fatal MI/re-MI/ refractory angina) between groups (20,5 % in the main group vs 44,8 % in control; p < 0,05). Simvastatin therapy was well tolerated. The level of TC decreased by 19,6 % and LDL cholesterol — by 25,3 % after 15—20 days, and by 28,4 32,4 % — by day 90th correspondingly in the main group (all p values < 0,001). Against a background of lipid-lowering therapy C-RP level decreased only in patients with UA after 15—20 days of treatment by 26,5 % (from 11,8 ± 1,1 t 8,67 ± 0,92 mg/l; p < 0,05) and 90th day — by 47,4 % (t 6,21 ± 1,14 mg/l; p < 0,01). Such dynamics was not registered in patients with non-Q-wave AMI. Levels of C-RP in these patients was below the levels of control group by the 90th day (p < 0,05) — (9,9 ± 1,05) mg/l. The level of white blood cells was reduced earlier (after 15—20 days) ( < 0,01).

Conclusions. Early (from the first day after admission) simvastatin administration in the dose of 20 mg/day in patients with ACS without ST segment elevation reduces the incidence of unfavorable ischemic events during the in-hospital period and is safe. Significant lipid-lowering simvastatin activity (20 mg/day) is accompanied with systemic inflammation markers levels (C-RP and white blood cells).

Keywords: unstable angina, non-Q-wave myocardial infarction, simvastatin, markers of inflammation, C-reactive protein.



Substantiation of hyperosmolar infusion sorbitol solution application in patients with decompensated chronic cor pulmonale

V.K. Gavrisyuk, N.I. Gumenyuk

Objective: to conduct a comparative study of diuretic effect and the influence on fluidic blood properties of hyperosmolar infusion solution of sorbitol and furosemide; to evaluate the safety of infusion solution of sorbitol in patients with decompensated chronic cor pulmonale (CCP).

Materials and methods. We examined 22 patients with CCP (as a result of chronic obstructive pulmonary disease (COPD) — 18 with heart failure (HF) stages I—II). Haematocrit (Ht) dynamics was assessed 2 hours after intravenous administration of furosemide (20 mg). Comparative analysis of diurnal diuresis and Ht changes was carried out in 15 patients with COPD and FH stages I—II after infusion of 200 ml of hyperosmolar solution of sorbitol with sodium lactate (sorbilact, «Yuriya-Pharm», Ukraine) and intravenous administration of furosemide (20 mg) after infusion of glucose-insulin-potassium (GIP) compound (200 ml) (5 % glucose solution, 4 insulin units of activity and 30 ml of 3 % potassium chloride solution). Safety of sorbitol (400 ml) was assessed by clinical and EchoCG data before and 30 min after infusion in 12 patients with COPD, complicated by CCP with HF stages I—II.

Results. Two hours after the injection of furosemide 20 mg 16 (73 %) of 22 patients had an increase of Ht (on average by 1,8 ± 0,4 %, (p < 0,001). After infusion of 200 ml GIP with subsequent injection of 20 mg of furosemide we registered a rise of Ht (by 2,4 ± 0,6 %; p < 0,001). After sorbitol infusion it decreased by 1,2 ± 0,5 ( < 0,05). Baseline value of diurnal diuresis was 804,6 ± 85,0 ml. At the day of GIP + furosemide trial the urine volume increased to 1575,0 ± 150,0 ml (p < 0,001). After infusion of sorbitol — less 1105,0 ± 101,9 ml (p < 0,05) in comparison with baseline after furosemide infusion. None of clinical side effect after sorbitol infusion was observed. There were no significant changes of end-systolic and end-diastolic volumes and ejection fraction of both ventricles, stroke and cardiac indices by EchoCG data.

Conclusions. Infusion of hyperosmolar sorbitol solution (200 ml) in patients with decompensated CCP has low-grade diuretic effect in comparison with intravenous bolus of furosemide (20 mg). At the same time, while furosemide increases a grade of haemoconcentration, sorbitol causes both diuretic effect and haemodilution. Hyperosmolar sorbitol solution (400 ml) during the intravenous dropwise introduction in patients with decompensated CCP is well tolerated and does not cause any negative changes of left and right ventricles functional condition by EchoCG data.

Keywords: cor pulmonale, diuretic therapy, furosemide, hyperosmolar solution of sorbitol.



Comparative analysis of heart failure clinical manifestation and morphological and functional changes of the heart in chronic cor pulmonale of vascular and bronchopulmonary genesis

D.O. Reshot'ko

Objective. To study and compare clinical manifestation of right ventricular heart failure (HF) and systolic and diastolic myocardial functions of the right (RV) and left (LV) ventricles, features of their remodeling in patients with two main forms of chronic cor pulmonale (CCP) — bronchopulmonary (as result of chronic obstructive pulmonary disease (COPD)) and vascular (as result of primary pulmonary hypertension (PPH)).

Materials and methods. 40 patients with CCP as a result of COPD (mean age 48,4 ± 5,1 years) and 40 patients with PPH (mean age 25,4 ± 4,8 years) were examined. The significant diseases of left heart, first of all coronary heart disease (angina pectoris, postinfarction conditions), essential hypertension, acquired and congenital heart diseases were excluded in patients with COPD. 6-minute walking test (6-MWT) was used for the evaluation of patients functional condition. Conventional doppler-echocardiographic (doppler-EchoCG) indices were used for the evaluation of RV and LV systolic and diastolic functions and their remodeling. Reliability of differences in groups was evaluated by Kolmogorov—Smirnov criterion.

Results. Neck veins swelling (80,0 % vs 60,0 % in PPH, p < 0,05) and increasing of liver (82,5 % vs 65,0 % in PPH, p < 0,05)were more frequent in patients with CCP as a result of COPD in contrast to PPH. Functional condition of patients with CCP as a result of COPD in contrast to PPH was better, which was confirmed by the longer distance of 6-MWT in comparison with the second one (494,7 ± 52,6 and 318,6 ± 45,4 m, correspondingly, p < 0,05) and lower heart failure functional grade by NYHA. Patients with CCP as a result of COPD had elevated pulmonary artery systolic pressure (PASP) (1,83 times higher in comparison with healthy persons, p < 0,001), and patients with PPH — 5,1 times ( < 0,001). Such difference in pressure overload brought to increasing of RV diameter, which was 1,25 in patients with PPH in comparison with COPD, and in apical position — 1,21 times more (both < 0,001). Patients with PPH had dilated vena cava inferior (VCI) in comparison with COPD by 5,8 % (< 0,001), and its collapse after deep breath was 2,44 times less in comparison with COPD ( < 0,001). Decrease of the LV contractility was more significant in patients with COPD in comparison with PPH, that was confirmed by max decrease, which was 1,39 times less ( < 0,001). RV and LV diastolic dysfunction was more strongly pronounced in patients with COPD than in PPH. It was confirmed by significant (p < 0,05) decrease in transtricuspid Ve and / (by 9,1 % and 21,3 %, < 0,05, correspondingly). Described changes pointed out the systolic and diastolic (relaxation type) dysfunctions of the RV in both groups of patients.

Conclusions. Patients with PPH demonstrate more significant functional disturbances of cardiovascular system by 6-MWT in contrast to COPD, in spite of the severe clinical features of systemic circulation venous stagnation in the last group. Patients with PPH have more strongly pronounced systolic dysfunction of RV, its dilatation and hypertrophy and systemic circulation venous stagnation. At the same time patients with CCP as a result of COPD have more strongly pronounced LV systolic dysfunction (by max in LV outflow tract). RV and LV diastolic dysfunction was more significant in patients with COPD than in PPH, which appeared by more evident deviation of Ve and / in COPD group in comparison with PPH.

Keywords: heart failure, systolic and diastolic dysfunctions of ventricles, chronic cor pulmonale.



Changes of erythrocytic morphology, indices of lipid peroxidation and blood plasma antioxidant defense in the presence of chronic critical lower extremities ischemia and their dynamics after surgical treatment

O.V. Pyptiuk

Introduction: Erythrocyte deformability is integral criterion of the oxygen provision dysfunction severity, that is intimately connected with pro-oxidant and anti- oxidant condition.

Objective. To study changes of erythrocytic morphology, condition of lipid peroxidation (LPO) and antioxidant defense (AOD) in patients with chronic critical lower extremities ischemia (CCLEI) and to assess their dynamics after surgical treatment.

Materials and methods: 115 patients with atherosclerosis obliterans of the lower extremities, complicated by CCLEI (in 46, or 40 % patients) and B degrees (in 69, or 60 %) were under our observation. Mean age was 59,3 ± 2,3 years. All of them underwent surgical procedures: in case of popliteal and distal arteries permeability reconstructive operations were conducted (54 patients), in case of peripheral vascular lesions osteotrepanation of the shin bone, resection of the cannon-bone veins and bone marrow autotransplantation into the shin bone of the damaged extremity (DE) were made (60 patients). Quantitative information about morphological condition of erythrocytes was received by erythrocytometry as erythrocytometric curve (Price-Jones curve). LPO activity was assessed in 115 patients by the blood level of diene conjugate (DC) by Placer in Gavrilov's modification, malonic dialdehyde (MDA) by the reaction with thiobarbituric acid and quantitative evaluation of coloured product by R.A.Timirbulatov. Activity of enzyme antioxidant systems was assessed by the level of ceruloplasmin (CP) by G.O.Babenko, catalase by A.N.Bach and S.T.Zubkova, superoxide dismutase (SOD) by F.T.Fridovich.

Results. Mean diameter of erythrocytes on admission in the blood from the cubital vein (CV) was 7,32 ± 0,02 micrometers, DE vein 6,57 ± 0,05 micrometers, DE bone marrow 6,18 ± 0,05 micrometers. These indices were significantly lower ( < 0,05) in comparison with the corresponding indices of the reference level. The level of MDA exceeded the reference level (3,69 ± 0,27) micromole/l 1,2 and 1,5 times as much in the blood from the CV in patients with CCLEI and B degrees, correspondingly ( < 0,05), on admission. The level of DC was 3,3 and 6,9 times higher, correspondingly, in comparison with healthy persons (0,38 ± 0,04 standard units, < 0,001). The level of CP was 1,5 and 2 times less in the groups and was (18,31 ± 1,15; 14,5 ± 1,21) standard units, correspondingly, the reference level was 29,1 ± 1,00 ( < 0,001). Catalase was 1,5 and 1,8 times lower in comparison with the healthy persons — 7,43 ± 1,12 and 6,32 ± 0,26 mg 22/microl (the reference level — 11,87 ± 0,13 mg22/microl). Positive clinical effect was received in 98,1 % patients after reconstructive operations, and in 85,0 % — after indirect revascularization. By the 5-7th day after reconstructive operations the CV blood level of DC became 1,2 times lower, CP — 1,2 times higher (< 0,05) in the absence of their significant dynamics in patients after indirect revascularization. By the 10-14th day these indices in both groups had became normal. By the 5-7th day after reconstructive operations the amount of normocytes in bone marrow of DE had increased significantly due to decrease in microcytes (all < 0,05).

1. The erythrocytes diameter ratio in the blood from the damaged extremity is changed with Price-Jones curve shift to the microcytes increase in patients with chronic critical lower extremities ischemia. These changes are the severest in DE bone marrow.
2. Patients with chronic critical lower extremities ischemia have the elevation of plasma levels of lipid peroxidation indices (MDA and DC) with simultaneous decrease of antioxidant defense indices. At the same time changes are the most expressed in the DE blood, in comparison with cubital vein.
3. Positive dynamics of the majority of DE blood PLO and AOD indices is registered after reconstructive operations by the 5- 7-th day. And after osteotrepanation and bone marrow autotransplantation — by the 10-14th day.
4. The increase of normocytes, decrease of microcytes is registered in the DE bone marrow by the 5-7th day after osteotrepanation and bone marrow autotransplantation. It is the possible evidence of microcirculation and bone marrow hemopoietic function improvement.

Keywords: chronic critical lower extremities ischemia, changes of erythrocytic morphology, lipid peroxidation, antioxidant defense.



Comparative assessment of diltiazem and atenolol impact on the residual myocardial ischemia and exercise tolerance in patients after non-Q-wave acute coronary syndrome

E.N. Amosova, E.V Khodakovskaya., E.V Andreev., P.A. Lazarev, A.V. Sablin

Objective. To carry out comparative analysis of diltiazem and atenolol impact on the residual myocardial ischemia by Holter 24-h ECG monitoring (HM) and exercise tolerance (ET) in patients with non-Q-wave acute coronary syndrome (ACS) during 6 months follow-up.

Materials and methods. 51 patient with non-Q-wave ACS and left ventricle ejection fraction greater than 45 % were examined. They were administered diltiazem (Diacordin, «Lechiva», Czechia) 270 ± 90 mg/day (I group, n = 26) and atenolol 75 ± 25 mg/day (II group, n = 25) for 6 months in addition to conventional therapy. Holter 24-h ECG monitoring was carried out in all patients on admission, at the 18—21th day and after 6 months with estimation of myocardial ischemia episodes at day and night time, their total duration, and mean, total and maximal ST depression. Bicycle exercise (BE) was carried out in all cases at the 21th day by submaximal protocol and after 6 months — by threshold one.

Results. Significant differences in baseline myocardial ischemia indices by HM in patients of both groups were absent (>0,05). The initial total duration of painful ischemia at the I and II groups was correspondingly (55,0 ± 4,43) min and (54,4 ± 0,47) min (p>0,05), and it was decreased in both groups by 6 months (<0,05 in comparison with baseline data) — correspondingly, t (1,60 ± 0,25) min and (5,12 ± 1,12) min ( < 0,05). Treatment with diltiazem was more effective ( < 0,05) in comparison with atenolol, in the case of total night silent ischemia duration (I group: initial (68,0 ± 2,39) min, by 6th month — (9,0 ± 0,34) min, p < 0,01; II group: initial (66,8 ± 2,67) min, by 6th month — (12,7 ± 0,74) min, p < 0,01). This regularity was registered in day-time silent ischemia ( < 0,05) (I group: initial (12,0 ± 0,47) min, by 6th month — (2,5 ± 0,07) min, = 0,05; II group: initial — (11,6 ± 0,16) min, by 6th month — (3,6 ± 0,91) min, <0,05). Patients of both groups had identical ET data by 21th day. But patients of the I group had more strongly pronounced, in comparison with II group ( < 0,05), increase in exercise capacity of the last stage in 6 months in comparison with 21th day: at I group — from (66,0 ± 1,56) watts to (95,0 ± 0,43) watts (p < 0,05), at II group — from (60,5 ± 0,85) watts t (90,6 ± 0,79) watts (p = 0,05). More strongly pronounced positive dynamics was registered in patients of I group by the analysis of heart work effectiveness index (p < 0,05), which decreased from (5,84 ± 0,18) unites t (3,44 ± 0,02) units (p < 0,05), II group — from (6,19 ± 0,22) units to (5,2 ± 0,18) units (p < 0,01).

Conclusions. Diltiazem is more effective in patients with non-Q-wave ACS and preserved left ventricle systolic function, in comparison with atenolol, in the case of day and night time painful and silent ischemia decrease, which became evident by 3th week and rises by 6 months. Treatment with diltiazem had more significant in comparison with atenolol, positive impact on restoration of residual exercise performance and heart activity efficiency by BE by 6 months.

Keywords: non-Q-wave acute coronary syndrome, Holter 24-h ECG monitoring, exercise tolerance, diltiazem, atenolol.



Nonpharmacological treatment of atrial fibrillation

.S. Stychinskyi

This article reviews the current status of various nonpharmacological options for the treatment of atrial fibrillation, including surgery, catheter ablation and different systems implantation. The benefits and disadvantages associated with these techniques, indications for their use in different cases of atrial fibrillation are discussed.

Keywords: atrial fibrillation, catheter ablation, fragmenting surgical procedures.



The advantages and disadvantages of different methods of insulin resistance detection

O.N. Kovalyova, A.A. Yankevich, S.V. Potabenko, E.V. Goptziy

Insulin resistance and compensatory hyperinsulinemia are established key features of metabolic syndrome, which plays an impotent role in development and progress of type 2 diabetes mellitus, ischemic heart disease, atherosclerosis and arterial hypertension. Moreover, hyperinsulinemia is independent predictor of cardiovascular morbidity and mortality in general population. But in present, the disagreement exists concerning informative value of different approaches to insulin sensitivity assessment. In this review methods of some popular tests are given, starting from very complex and ending by rather simple, and their practical value is analyzed. The mean attention was focused on evidences of informative value of different insulin sensitivity indices validation by reference method — hyperinsulinemic euglycemic clamp test. As a result, the working recommendations was made regarding to differential implementation of insulin resistance determination methods in scientific investigations and clinical practice.

Keywords: insulin resistance, hyperinsulinemia, insulin sensitivity indices.

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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