Modelling of hemodynamics in bifurcation lesions of coronary arteries before and after myocardial revascularization

Modelling of patient-specific hemodynamics for a clinical case of severe coronary artery disease with the bifurcation stenosis was carried out with allowance for standard angiographic data obtained before and after successfully performed myocardial revascularization by stenting of two arteries. Based on a non-Newtonian fluid model and an original algorithm for fluid dynamics computation operated with a limited amount of initial data, key characteristics of blood flow were determined to analyse the features of coronary disease and the consequences of its treatment. The results of hemodynamic modelling near bifurcation sites are presented with an emphasis on physical, physiological and clinical phenomena to demonstrate the feasibility of the proposed approach. The main limitations and ways to minimize them are the subjects of discussion as well. This article is part of the theme issue ‘Transport phenomena in complex systems (part 2)’.

Pathophysiological aspects of development myocardial infarction type 2 in subclinical hypothyroidism

The main purpose of the following article is to highlight one of the most pressing and poorly studied issues both for cardiology and endocrinology – treatment and prognosis for patients with severe coronary pathology and subclinical hypothyroidism (SH). Pathophysiological mechanisms of type 2 myocardial infarction (MI) development with SH as a background and hormone replacement therapy issues are considered. SH is a modifiable risk factor (RF) for cardiovascular diseases (CVD) and mortality that does not depend on traditional cardiovascular RF. SH is associated with high risk of developing coronary artery disease, MI, heart failure, and CVD mortality. SH incidence of morbidity increases with age, usually the course is oligo- or asymptomatic. SH leads to a number of pathological conditions that cause an imbalance between the myocardial oxygen demand and delivery with a possible development of type 2 MI. Clinical case of type 2 MI development in a patient with severe coronary atherosclerosis and SH is presented. The key point of type 2 MI development mechanism is insufficient oxygen (O2) supply to cardiomyocytes due to multivessel coronary artery atherosclerotic stenosis and sharp increase in O2 demand as a result of cardiomyocyte hypertrophy. Older patients with severe cardiac pathology and SH should refrain from treatment with levothyroxine or start treatment after myocardial revascularization, selecting the dose of the drug individually.

NT-proBNP as an Additional Marker of Significant Coronary Atherosclerotic Lesions

Coronary artery disease (CAD) is the leading cause for morbidity and mortality both in Ukraine and in the world, so the relevance of this problem for the society is undeniable. The priority is still to study the factors that affect both more severe CAD in patients with chronic coronary syndrome and after myocardial revascularization. The aim. To investigate the patterns of correlation between blood level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and CAD severity, especially in patients with multivessel lesion, to confirm its status of a useful additional marker for assessing the condition of cardiovascular system and one of the instruments to affect the tactics of treatment. Materials and methods. The study is based on data obtained from a prospective analysis of 40 patients at the age of 51 to 82 years old from January to December 2019, whose complaints could indicate the CAD. All the patients underwent a comprehensive clinical and laboratory examination (complete blood count, biochemical blood test). The main instrumental examination method was coronary angiography; the patients were divided into 2 groups on the basis of the examination results. The quantitative degree of lesion was assessed using the SYNTAX Score for each patient. Results. The groups were comparable in terms of age, sex, and comorbidities. The groups differed significantly in terms of body mass index. Moreover, the groups differed in the level of the following biochemical markers: NT-proBNP (p=0.0001), cholesterol (p=0.02), low-density lipoproteins (p=0.009), creatinine (p=0.02), glomerular filtration rate (p=0.08). A significant correlation was found between the NT-proBNP level and the degree of CAD ρ=0.718 (p=0.0001). Conclusion. NT-proBNP significantly correlates with the SYNTAX Score and is the highest in the group of patients with multivessel coronary disease. This indicator requires further study as an additional marker for assessing the state of the cardiovascular system and can influence the choice of treatment.

Comorbidities in Patients before Surgical Myocardial Revascularization: Current State of the Problem. Part I

Every year we see an increase in the number of patients with indications for surgical treatment of coronary artery disease. In addition to the difficulties of the cardiac surgery process, no less important is the therapeutic support of patients, which in addition to cardiac subtleties requires guidance in concomitant nosologies. As the age of patients increases, there is a higher comorbidity which is associated with difficult management of patients, extensive prescription of drugs and higher cost of medical care. The aim. To analyze the current literature data on comorbidity in patients hospitalized for coronary artery bypass grafting. Results. According to the literature data, there is a high Charlson comorbidity index, in average 5.7 ± 1.7, in the baseline status of patients with coronary artery disease. High comorbidity index is known for its negative effect on the functioning of grafts in the long-term period after surgical myocardial revascularization. Among patients who underwent surgical revascularization of the myocardium, 22.8–46.9% had diabetes mellitus, 37.5% had obesity, 1.1% had rheumatoid arthritis and 10–12% suffered from chronic kidney disease. There is no statistical data on preoperative status of gastrointestinal tract, but the main complications and predictors of death were identified. Due to the increase in the occurrence of autoimmune diseases on the background of the COVID-19 pandemic, an increase in the number patients with connective tissue diseases in cardiac surgery is predicted, and perioperative management of such patients has its own characteristics and requires further in-depth study. Conclusions. Searching for comorbidity in cardiac surgery patients with coronary artery disease is an important component of their preoperative preparation and risk stratification. The influence of type 2 diabetes mellitus, obesity, autoimmune diseases, chronic kidney disease on the occurrence of postoperative complications and the result of surgical myocardial revascularization has been proven. SARS-CoV-2 infection in the surgical treatment of coronary artery disease is another challenge of today that requires further observation and research to help address prognosis, complications, and mortality.

Dynamics of the number of myocardial revascularization operations in some countries in comparison with the Russian Federation in 2000–2018

Aim. To study the dynamics of the number of coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) in some countries and Russia in the 2000–2018..Methods. The data of the official statistics of the Organization for Economic Cooperation and Development on the number of CABG and PCI were used. The countries that have provided data for most of the analyzed years and have more than 30 CABG per 100,000 population (22 countries) were selected. Data on the number of interventions in Russia were obtained from the CNIIOiIZ and Bakulev NMICSSH. The US data are obtained from the literature.Results. In most countries, the number of CABG decreased by 2018.The United States, Denmark, Finland, Israel, and Luxembourg were the most variable in the average indicator. The most expressed decrease occurred in Finland (2.9 times). The number of PCI has increased significantly (in 9 countries by more than 2 times). The exception was the United States, where the number of PCI decreased by 2 times from 2003 to 2016. In Russia, there was an increase in CABG and PCI (by 10.2 and 50.5 times, respectively). The number of CABG and PCI per 100,000 population was 23 and 34 times less, respectively, in Russia than the international average in 2000, and 1.4 and 1.55 times less in 2018. The decrease in CABG is due to the improvement of PCI technologies, as well as the improvement of pharmaceutical treatment of coronary vessels. The number of proceedings, including court ones, on the validity of stent implantation is growing. The crosscountry variability of the use of cardiac surgical methods is influenced by the organizational and financial characteristics of the healthcare system, demographic and clinical characteristics of patients, the knowledge of doctors, etc. The experience of Russia fully confirms this.Conclusion. There is no optimal method for accurately assessing the population's need for certain treatment methods. Each country chooses its own tactics, taking into account its resource capabilities, approaches to decision-making, its values and preferences, but the general trend is a decrease in the number of CABG operations while increasing the PCI. In Russia, there is a multiple increase in the number of CABG and PCI, but it is less than the indicators of most countries.

The role of intravascular methods of examination of coronary arteries in the selection of patients with diffuse and multivessel lesions for myocardial revascularization

Objective Assessment of the role of intravascular imaging methods in choosing the surgical strategy of myocardial revascularization.Material and Methods The study included 62 patients with diffuse and multivessel coronary artery disease, who underwent percutaneous coronary infervention (PCI) using intravascular imaging methods. Measurement of fractional flow reserve (FFR) in diffusely altered arteries was performed under conditions of maximum hyperemia, sequentially between stenoses, using the sensor, starting from the distal segment. Initially, the most distal hemodynamically significant stenosis was stented. Then, a repeated measurement of FFR was performed, and the issue of the need for stenting of other stenoses was solved. The results of stenting, as well as determination of the area of stent implantation were carried out by the method of optical coherence tomography (OCT).Results After FFR measurement the number of arteries with hemodynamically significant stenoses decreased by 24.7% (from 93 to 70). It was also noted that in patients with two-vessel lesions, the average number of such stenoses decreased from 2.95 ± 0.65 to 1.82 ± 0.88, and in patients with three-vessel lesions – from 2.96 ± 0.6 to 2.24 ± 0.76 respectively (p = 0.0024). Complete (functionally adequate according to FFR measurements) myocardial revascularization was achieved in 88.7% of patients. The second-generation drug eluting stents were implanted in 82 (47.1%) patients, and the third generation stents – in 92 (52.9%) patients. At the same time, the success rate of recanalization of occlusions was 100%. Overall, optimal stent implantation was achieved in all patients. Major cardiovascular complications were observed in 1 (1.6%) patient, which required additional interventions.Conclusion Complex use of intravascular imaging methods (OCT and FFR measurements) allows a differentiated approach to the assessment of each stenosis of the affected artery in patients with diffuse and multivessel coronary lesions, to achieve a high frequency of complete myocardial revascularization, as well as to reduce the number of unnecessary interventions and intraoperative complications.

774 Young adults with acute coronary syndrome: still a long road ahead

Aims Acute coronary syndrome (ACS) are a leading cause for mortality and morbility worldwide. Despite ACS usually affects the older population, it also occurs in younger individuals. Young ACS patients (YACS) have a significantly worse prognosis compared to their age-mates in the general population. Despite YACS are characterized by a different risk profiles compared to their older mates, many aspects still remain elusive. Aim of this study was to describe the clinical profile of young adults with Acute Coronary Syndrome. Methods and results Young patients (≤50 years) with the first diagnose of Acute Coronary Syndrome admitted to the Magna Graecia University Hospital were enrolled in the ongoing GENEPAMY registry. Over 7 years, a total of 675 eligible patients with Acute Coronary Syndrome aged 44 ± 8 years were included. Men accounted for 84.9% of all patients. Overall, 11.9% of patients had diabetes, 69.1% hypertension, 17.6% obesity, 93.6% dyslipidemia, while 75.5% were smokers. In the overall cohort, 44.1% were first diagnosed with STEMI, 45.9% with NSTEMI, while the remaining had been admitted for Unstable Angina. Cardiogenic shock was present at admission in 2.7% of cases. Multivessel disease was present in 39% of cases and was significantly less frequent in women (P < 0.001). Thrombolysis was administered as the initial treatment in 15.1% of cases but was ineffective in 66.7% of patients. Percutaneous coronary angioplasty was performed in 79.1% of patients, while 1.9% of patients underwent surgical myocardial revascularization. Spontaneous coronary dissection was present in 0.7% of men and 17.2% of women (P < 0.001). At admission, 98.9% of patients had been treated with ASA, 17.9% with clopidogrel, 49.1% with ticagrelor and 28.4% with prasugrel. A complete revascularization was achieved in 81.6% during the index hospitalization but was significantly more frequent in women compared to men (86.3% vs. 80.8; P < 0.001). Conclusions Our data highlight that YACS present a peculiar clinical profile. In particular, the high cardiovascular risk profile demands attention. Finally, despite most patients were men, young women with ACS present several relevant differences compared to men, needing a more careful clinical management.

793 A single-centre experience with telemedicine-integrated chronic coronary syndrome care

Aims Over the last decades, both the improvement in cardiovascular prevention programmes and the advancement in medical and invasive therapies facing ischaemic heart disease have granted an outstanding reduction in mortality rates. However, coronary heart disease remains, by far, the most common disease in developed countries, and the progressive ageing of population leads to a constantly increasing prevalence of chronic coronary syndrome (CCS). The consequence is an unsustainable demand for access to collapsing hospital clinic and doctor’s office. The dramatic Covid-19 era has become the testing ground for alternative ways to deliver healthcare avoiding in-hospital contacts, thus affirming the validity of telemedicine as a key tool to improve the patient journey. In our centre, video consults have been integrated to CCS patients’ clinical care pathway, not only preventing the risk of contagion but also laying the groundwork for a paradigm shift in clinical care course. Methods and results Since pandemic outbreak, Lazio Region offered to its inhabitants free of charge teleconsulting for both primary care and specialist referral. At the cardiovascular department of Fondazione Policlinico Gemelli IRCCS, this opportunity has been recently applied to optimize the chronic coronary syndrome patient journey. Specifically, videoconsulting has been used in different steps of CCS clinical course, replacing both in-person first visit and follow-up consultation after percutaneous myocardial revascularization. Being CCS a context in which the therapy optimization or the transition to higher level tests are mainly indicated by symptoms, these remote consultations could work as well as in-hospital visits to assess risk stratification and to consequently arrange the best therapeutic–diagnostic pathway. Besides, as COVID-19 pandemic caused significant delays, further remote visits have addressed the need to keep in contact with patients waiting for coronary angiography and to reassess their urgency criteria. In our department, over last 9 months, 141 patients have been examined and followed-up through teleconsulting, amounting to 34.1% of all supplied visits. Despite a high median age (67 ± 19.7 years), the drop-out rate of the contacted patients due to inability or denial was quite low (7.5%) and this high adherence to videoconsulting suggests time is ripe for a full telemedicine employment in clinical care course. In the cohort of patients waiting for coronary angiography, a telemedical reassessment led to a significant rate of priority class switch (42.7%), probably preventing adverse cardiac events in those individuals with worsening symptoms (systematically evaluated using Seattle Angina Questionnaire). Of note, the implementation of this parallel virtual pathway for these patients allowed us to decrease the waiting times for in-person visits at our CCS clinic, with an estimated time reduction of almost 3 months. This result supports our idea that the adoption of a remote pathway for chronic illness management, like CCS, may provide more opportunities for treatment of severe cases at in-person clinics that are often overcrowded. Conclusions In conclusion, all the potential of telehealth to empower primary and specialty health care is gradually emerging, and CCS seems the perfect setting for an integrated physical and virtual health system.