Anesthesiologic management of elective endovascular stenting of coronary artery

Introduction. Ischemic heart disease is the most common cause of death in the Russian Federation and in the world. One of the main methods of surgical treatment is endovascular stenting of the coronary arteries. Despite the minimally invasive method, there is a need to ensure sedation of the patient during the intervention. The main type of anesthetic aid for this procedure is monitored sedation.The aim of the study was to conduct a comparative analysis of the two most frequently used regimens of monitored sedation for elective endovascular interventions in world practice.Materials and methods. From January to July 2021, a prospective cohort study was conducted that included 70 patients. A comparison was made between the sedation group using phenazepam (n = 38) with the analgosedation group (n = 32) — a combination of sibazone and fentanyl. The comparison was made by the level of sedation (RASS scale), the severity of anginal pain at the stage of stenting of the coronary arteries according to the VAS; vital indicators of patients (sBP, dBP, avgBP, HR, SpO2).Results. The use of a monitored sedation regimen (sibazone + fentanyl) leads to deeper sedation according to the RASS and a more significant decrease in heart rate in patients at the stage of coronary artery stenting compared with the use of benzodiazepine (phenazepam) alone. Despite this, the incidence of anginal pain during the intervention did not differ statistically significantly between the comparison groups.Discussion. In this work, we compared two approaches to anesthetic protection when performing planned endovascular stenting of coronary arteries, which are most often used in foreign and domestic interventional practice.Conclusions. The use of analgosedation (sibazone + fentanyl) for elective endovascular stenting of coronary arteries has no significant advantages over sedation with benzodiazepines (phenozepam) for these types of interventions. It becomes obvious that it is necessary to continue the search for more effective and safer schemes of anesthetic management during planned endovascular stenting of coronary arteries.

Dual antiplatelet therapy of patients with acute myocardial infarction after coronary artery stenting

Objective: to study the effectiveness of dual antiplatelet therapy (DAPT) in patients with myocardial infarction (MI) after emergency percutaneous coronary intervention (PCI).Material and methods. The study involved 20 patients who underwent PCI at the Department of Interventional Cardiology in Khust district hospital, Zakarpattia region. After PCI and coronary artery stenting during 12 months in addition to the complex therapy (Metoprolol, Rosuvastatin, Ramipril, Pantoprazole) the patients received dual antiplatelet therapy (DAPT) with acetylsalicylic acid and Ticagrelor (Brilinta). A clinical course of the disease was analyzed. Prothrombin time, prothrombin index, international normalized ratio (INR), activity of the liver transaminases, and total bilirubin concentration in the blood serum were determined. Results. During the period of 12 months after PCI for acute transmural MI and coronary artery stenting, re-admissions for exacerbation of the underlying disease were not registered. One patient developed a side effect after DAPT in the form of mild gastrointestinal bleeding. 12 months after DAPT, a reliable increase of prothrombin time from 12,77±0,18 sec. to 13,45±0,34 sec. (р<0,05) and international normalized ratio (INR) from 0,95±0,008 Un to 1,0±0,026 Un were registered. (р<0,05). Inconsiderable but reliable increase of alanine aminotransferase (ALT) activity from 14,4±1,11 Un/L to 16,67±1,25 Un/L was found (р<0,05).Conclusions1. Patients after percutaneous coronary intervention (PCI) and coronary artery stenting for acute transmural myocardial infarction (MI) are well tolerant to dual antiplatelet therapy (DAPT) with acetylsalicylic acid and Ticagrelor. For 12 months re-admissions for exacerbation of the underlying disease were not registered.2. Increase of prothrombin time values and international normalized ratio in patients with MI after PCI and DAPT is indicative of a decrease in blood coagulation activity.

Aortocoronary Bypass Surgery in Patients with Recurrent Post-Coronary Stenting Angina

Background. A wide adoption of percutaneous coronary operations has led to an average one-third reduction in the aortocoronary bypass surgery (ACB) rate and altering of the ACB patient profile to mainly represent advanced occlusive coronary atherosclerosis.Materials and methods. The study analyses treatment outcomes in coronary heart disease patients with recurrent angina after a previous endovascular intervention. Over years 2009–2015, 1,023 ACB operations were performed at the Almetyevsk — OAO Tatneft Medical Unit cardiac surgery rooms. Pre-surgery coronary artery stenting (CAS) was rendered at various terms in 96 patients (23 % women, 76 % men; cohort 1). The main cohort (n = 96) was divided into 2 subgroups: IA (n = 64), single CAS; IB (n = 32), multiple CAS patients. For statistical significance, cohort 2 (control) comprised 185 patients (21 % women, 79 % men) to include every 5th history of the remaining 927 patients operated within same period.Results and discussion. The mean aortic occlusion time was shorter in multiple CAS patients vs. other cohorts (61.3 ± 31.2 vs. 72.5 ± 27.8 and 70.7 ± 41.2 min). Cohort 1 had an overall higher emergency resternotomy rate due to ongoing bleeding (7.4 and 8.3 vs. 2.0 %). Furthermore, pre-surgery multiple CAS patients more likely faced the complications of perioperative MI (8.5 vs. 3.1 and 1.4 %) and acute postoperative heart failure (7.2 vs. 2.3 and 1.4 %, p < 0.01). This cohort often required inotropic support (9.3 vs. 3.8 and 2.1 %).Conclusion. Statistical analysis revealed a significantly higher complication and mortality rate in patients with previous coronary stenting compared to ACB patients. Adverse ACB outcomes were observed with multiple-coronary stenting cases, in contrast to the cohort with no pre-surgery interventions.

Delayed endovascular surgery in patients with acute ST-segment elevation myocardial infarction due to massive culprit arterial thrombosis in the prevention of slow/no-reflow phenomenon

Aim. To assess whether delayed coronary artery stenting (CAS) can reduce the slow/no-reflow incidence in patients with ST-segment elevation myocardial infarction (STEMI) and massive thrombosis (TTG ≥3) of the infarct-related coronary artery (IRCA) compared with immediate CAS within primary PCI.Material and methods. Out of 3651 primary PCIs performed for acute STEMI in the period from January 2016 to May 2020 at the Mytishchi City Clinical Hospital, the retrospective analysis included 105 patients with massive IRCA thrombosis (TTG ≥3). The patients were divided into two groups: first group (n=55) — delayed CAS, second group (n=50) — immediate CAS. In the immediate CAS group, the PCI procedure ended with routine stent implantation, and in the delayed CAS group, stent implantation was delayed for at least 5 days.Results. In the delayed CAS group in comparison with immediate one, the slow/no-reflow phenomenon developed much less frequently in the form of a significant increase in the prevalence of TIMI 3 flow, better myocardial perfusion of myocardial blush grade (MBG) 2-3 (81,8 vs 64%; odds ratio (OR) 2,53; p=0,039) and ST segment resolution ≥70% (87,3% vs 58%; OR 4,97; p=0,001).Conclusion. Delayed CAS in patients with STEMI with massive thrombosis (TTG ≥3) of IRCA reduces the risk of slow/no-reflow phenomenon and can be considered as a possible alternative treatment vs immediate CAS, provided that stable coronary flow is restored before TIMI 3.

Cytokine status in middle-aged men with acute coronary syndrome after coronary artery stenting

Background. Inflammatory cytokines and growth factors are involved in various mechanisms of coronary artery disease. Clinical studies have shown the correlation between the increase in the level of proinflammatory cytokines and the severity of coronary artery disease, while the data on the role of proinflammatory interleukin IL-8 and anti-inflammatory interleukin IL-4 are contradictory. The aim of the study is to assess the levels of proinflammatory cytokines (IL-8, TNF-) and anti-inflammatory interleukin (IL-4) in patients with various forms of coronary artery disease who underwent coronary artery stenting. Materials and methods. By the method of enzyme-linked immunosorbent assay, the levels of cytokines were determined in 30 patients with acute coronary syndrome who underwent primary stenting of the coronary arteries and in 24 patients with chronic coronary syndrome who had previously had myocardial infarction with stenting of an infarction-associated artery, who were admitted to the clinic for staged stenting of the coronary arteries. Results. In patients with chronic coronary syndrome the levels of IL-4 a do not exceed the reference values, in patients with acute coronary syndrome the levels of IL-4 there was an increase 3,70 0,24 and 240,85 49,25 pg/ml, р 0,001. In patients with chronic coronary syndrome the levels of IL-8 a do not exceed the reference values, in patients with acute coronary syndrome the levels of IL-8 there was an increase 7,34 1,29 and 110,33 27,67 pg/ml, р 0,001. Conclusion. Most likely the increase in the level of IL-4 has a compensatory character and, along with a slight increase in TNF-, can be considered as a positive factor stabilizing the course of the disease. There may be some relationship between of the increase in the level of interleukins in patients with acute coronary syndrome on the degree of stenosis of the coronary arteries (9095%) and impaired myocardial contractility was established.

Modern aspects of the application of antiplatelet and hypolipidemic therapy in ischemic heart disease after coronary artery stenting

In this article it will be discussed actual issues and modern problems of the ischemic disease of the heart, antiplatelet therapy, its effects, hypolipidemic therapy, indications, counter indications, potential side effects as well as, successful management strategies after percutaneous coronary intervention following with drug eluted stents.

COMPREHENSIVE ASSESSMENT OF COMBORIDITY IN CLINICAL PRACTICE: METHODICAL APPROACHES AND PRACTICAL USE

Aim: to evaluate current approaches to the assessment of comorbidity in clinical practice and determine the prevalence of comorbidities in patients with coronary artery disease (CAD) who underwent coronary artery stenting. Material and methods. We performed a retrospective analysis of data from electronic medical records of 150 CAD patients below 75 yrs having undergone myocardial revascularization via percutaneous coronary intervention (coronary artery stenting). All of them were under the monitoring of the cardiologists of the State Institution of Science «Research and Practical Center of Preventive and Clinical Medicine” State Administrative Department. Comorbidity assessment was performed via diseases count; we have dealt only with diseases that are included in the Charlson Comorbidity Index (ССІ) and Combined Age Charlson Comorbidity Index (СА-ССІ) calculation proceeding. We used statistical software programs (Statistica v. 6.0) and Microsoft Excel 2007 applications for data analysis. Results. According to data of the medical records the most common comorbidities (among those used to calculate CCI and CA-CCI) in patients with CAD below 75 yrs who underwent coronary artery stenting were cerebrovascular disease (83.3 ± 3.0%), peripheral vascular diseases (42,7±4,0%), type 2 diabetes mellitus, and mild liver diseases (24,0±3,6%). It was found that the number of comorbid diseases in patients having been examined ranged from 2 to 7, with an average of 3,9±0,1. The mean number of diseases in patients of different ages did not differ significantly. The average CA-CCI value increased from 4,4±0,2 points in patients who had two diseases to 12,7±1,1 points in those with seven ones (р<0,05). Conclusions. Our study revealed a high prevalence of comorbidities in patients with CAD below 75 yrs who underwent coronary artery stenting. The use of CA-CCI allowed making a comprehensive assessment of patient’s conditions

Long-term electrocardiographic monitoring in a cardiac surgery hospital: modern views and experience of application of telemonitoring system after coronary stenting

Background. Diseases of the cardiovascular system in recent decades have taken the lead. In Ukraine alone, mortality rates reach half a million annually. Today, continuous ECG monitoring is a routine study in patients hospitalized with cardiovascular disease. The purpose was to analyze the experience of long-term electrocardiographic monitoring in patients in the early postoperative period of coronary artery stenting. Materials and methods. The study included 24 patients with coronary heart disease who underwent routine coronary artery stenting. All patients underwent long-term ECG monitoring after the operation. Results. Among the patients in our study, single supraventricular extrasystoles were recorded in 17 % of patients in the early postoperative period, and episodes of single ventricular extrasystoles were recorded in all patients. There was no significant ST segment dislocation observed in any patient. Based on the observation of patients with cardiovascular events in the postoperative period, it was shown that the usage of round-the-clock automatic recording of ECG by using mobile devices improves the ability to timely diagnose (including urgent) recurrences. Conclusions. Recommendations on the feasibility of its usage in different regimens for patients with different disease were formulated.