Aortic Root Enlargement during Aortic Valve Replacement in Adults

Aortic valve replacement is a gold standard in the treatment of patients with severe aortic stenosis or combined aortic pathology. However, aortic valve pathology is often associated with a narrow aortic orifice, particularly in patients with severe aortic stenosis. In 1978, Rahimtoola first described the term of prosthesis-patient mismatch. He noted that effective orifice area of the prosthesis is smaller than that of the native valve. To minimize this complication, there are several surgical strategies: aortic root enlargement (ARE), implantation of a frameless biological prosthesis in the native position, neocuspidalization procedure, Ross procedure, aortic root replacement with xenograft or homograft. ARE is an excellent option, however, some authors outline additional perioperative risks. The aim. To analyze immediate results of ARE during isolated aortic valve replacement and in cases when it is combined with other heart pathologies. Materials and methods. Our study included 63 patients who underwent ARE. Isolated aortic valve replacement was performed in the majority of cases, but often aortic root replacement procedure was combined with coronary artery bypass grafting. Results and discussion. One of 63 patients died (hospital mortality 1.6%) at an early hospital stage (30 postoperative days). Measurement of the aortic valve ring was performed by two methods, through preoperative echocardiography and perioperative measurement using a valve sizer. However, perioperative dimension was chosen as the basis for the calculations. In 62 patients, the perioperative diameter of the aortic valve ring ranged from 19 to 23 mm, only one patient had a diameter of 24 mm. According to our findings, ARE enabled to achieve an average aortic ring size increase of 2.68 cm2 (from 1.5 to 3.4 cm2) and to prevent prosthesis-patient mismatch in 42 (66.7%) cases. Conclusions. Prosthesis-patient mismatch is considered a serious complication in the postoperative period. Narrow aortic root is a common pathology that should be considered during surgery. ARE is a safe procedure and is not associated with an increased risk of mortality and complications.

Atrial Cardiomyopathy: a Role in the Pathogenesis of Atrial Fibrillation and Influence on the Results of Its Treatment

The work is dedicated to the issue of atrial cardiomyopathies (ACs). They have a significant effect on the heart function, provoke rhythm disturbances and increase the risk of thromboembolic complications. The aim. To analyze the latest publications on the topic. The material for the analysis were the papers published by the leading arrhythmological clinics. Discussion. This paper describes the origin of the term “atrial cardiomyopathy”, highlights the conditional classification of changes in the atrial myocardium according to the EHRAS classification. The causes of this nosological form may be some types of gene mutations, as well as hypertension, congestive circulatory failure, diabetes mellitus, myocarditis, etc. ACs play an important role in the occurrence of atrial fibrillation (AF) and also affect its natural course and treatment outcomes. Electroanatomical mapping and magnetic resonance data show significant fibrotic changes in the atria in individuals with this form of arrhythmia. The DECAAF study (Delayed enhancement MRI and atrial fibrillation catheter ablation) showed that fibrotic changes in the atrial myocardium are directly related to the frequency of recurrent arrhythmias after catheter ablation. The DECAAFII study confirmed the effectiveness of the influence on the fibrous substrate in the catheter treatment of AF at stages 1 and 2 of fibrosis. The results of catheter treatment depend on the severity of fibrosis, which shows the importance of taking this factor into account when determining the indications for ablation. Conclusions. Thus, AC is an important component of the pathogenesis of AF. Improvement of techniques for influencing the fibrous substrate will improve the results of catheter treatment of AF.

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.

Postoperative Early Outcomes of Conventional versus Minimally Invasive Multivessel Coronary Artery Bypass Surgery: Retrospective Study

Minimally invasive coronary artery bypass grafting (CABG) is a new technique developed in recent years apart from the conventional method. Our first objective is to compare the postoperative early outcomes of conventional and minimally invasive multivessel (MIM) CABG methods, and second objective is to compare perioperative differences between two surgical techniques. This retrospective, comparative study was conducted at a university hospital with 100 patients, who underwent CABG surgery from November, 1 2019 to June, 1 2020. The data of 50 patients, who underwent MIM CABG (Group M), was certain. Among the patients operated with the conventional method (Group C), 50 patients were randomly selected from the same time period. Examination of early postoperative outcomes revealed that Group C had significantly higher intensive care unit (ICU) stay (p=0.013), significantly higher mechanical ventilation time in ICU (p<0.001), and significantly higher isolated systolic blood pressure (p=0.013). Examination of perioperative variables revealed that Group C had significantly shorter duration of surgery (p<0.001), significantly shorter aortic cross-clamp time (p<0.001), significantly shorter cardiopulmonary bypass (CPB) time (p<0.001), significantly lesser graft numbers (p<0.001), significantly lesser left internal mammary artery use (p<0.05), and significantly lesser inotropic support after CPB was discontinued (p<0.05). In the light of these results, MIM CABG was associated with enhanced postoperative early outcomes with prolonged surgery time compared to conventional method.

Features of Surgical Treatment of Malignant Tumors of the Heart and Ways to Improve Immediate Results

To date, the issues of surgical treatment of malignant cardiac tumors (MCT) remain relevant and are of particular interest to cardiac surgeons. Hospital mortality of this group of patients is extremely high (20–30%). Finding ways to reduce early postoperative mortality remains an extremely important task of oncocardiac surgery. The aim. To analyze the causes of early postoperative mortality based on the data of many years of experience in the surgical treatment of MCT and to propose methods for the prevention of early postoperative complications with the improvement of the immediate results of operations. Materials and methods. From 1970 to 01.01.2021, National Amosov Institute of Cardiovascular Surgery has provided surgical treatment of 67 patients with malignant tumors of the heart which amounted to 7.1% of the total number of observed patients with cardiac tumors (949). Of the 67 patients with MCT, 57 (84.9%) were operated using artificial circulation, three operations (4.6%) were emergency. Hospital mortality was 19.4% (13 patients). Results. Microscopic examination of the removed tumors revealed the presence of necrosis zones, their mechanical damage leads to significant intoxication of the patient. To prevent tumor intoxication (cause of postoperative mortality) in the operative and postoperative periods, new methods of combating such a factor of hospital mortality were used, which helped to improve the results of treatment of MCT. Hospital mortality reduced from 33.3% (1970–2001) to 5.5% (last 10 years), as a result of use these measures. Conclusions. Destruction of the tumor during surgery with artificial circulation leads to the entry of a significant number of tumor cells and toxins into the bloodstream, causing tumor intoxication. Improvement of the immediate results of surgical treatment of MCT depends on their timely diagnosis, which allows for adequate surgery with radical removal of the tumor and the use of detoxification measures, significantly reducing surgical mortality.

Ten-Year Experience in the Treatment of Coarctation of the Aorta through Endovascular Stenting in Patients of Different Age Groups

The aim. To analyze the 10-year experience in aortic coarctation endovascular stenting in patients of different age groups. Materials and methods. Examination and endovascular treatment of 194 patients aged 3 days to 60 years with coarctation of the aorta (CoA) with different anatomical and morphological variants was performed. According to the age criterion, the examined patients were divided into 4 study groups. The first group consisted of 84 patients (43.3%) over 25 years of age, group 2 included 33 patients (17.0%) aged 19 to 25 years, group 3 included 71 patients (36.6%) aged 5 to 18 years, and group 4 included 6 patients (3.1%) under 1 year of age. Results and discussion. We presented the clinical features of different anatomical and morphological variants of CoA. Endovascular treatment of CoA with stenting is considered the best method for adolescents and adults, due to the lower risk of aneurysm formation compared to balloon angioplasty. We were able to successfully reduce the invasive pressure gradient in patients of different ages and to establish the dependence of complication rate on the stent type used. The most common complications were aneurysm formation (2.1%) and stent migration (2.1%). Complications occurred more often in cases of uncovered stents compared to stent grafts (5.3% and 2.1%, respectively, p <0.05). No cases of hospital mortality were recorded in patients older than 5 years. Seven endovascular procedures were performed in 5 patients aged 3 days to 11 months (mean age 3.5 ± 1.6 months) with combined heart defects. Complications were documented in 1 child (20.0%). Endovascular intervention in pregnant women is indicated in refractory hypertension. We performed endovascular CoA stenting in 4 pregnant women at 15–23 weeks of gestation (average, 19.8 ± 3.1 weeks), and in 6 women with well-controlled hypertension stenting was performed within 48 hours to 5 years after delivery. In all the presented cases, successful revascularization was achieved. During follow-up (from 2 months to 10 years), all 10 women are alive, did not develop recoarctation or complications. Conclusions. The results of the analysis of CoA endovascular treatment showed that the chosen method and technique of intervention is appropriate and safe for patients of all ages, including pregnant women. Based on the results obtained, we have developed an algorithm for the management of patients who, according to clinical examination and echocardiography, were diagnosed with CoA during pregnancy.

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.

Bioethical Aspects in Modern Cardiosurgery of Coronary Artery Disease

The paper focuses on ethical issues, provides data on personality qualities and socio-ethical factors necessary for the professional activity of a cardiovascular surgeon. The aim. To identify the most relevant bioethical aspects, personality traits necessary for a cardiovascular surgeon to carry out his/her professional activities. Materials and methods. Analytical review of scientific publications was performed using the abstract database of scientific libraries, text database of medical and biological publications as well as analysis of observations of our own research works. Results. The main stages of development of surgical treatment of coronary artery disease in Ukraine are highlighted. Analysis of the basic bioethical aspects which take place in a profession of cardiovascular surgeon is carried out. Important personality traits which are necessary for professional activity in cardiac surgery are established. Ethical principles and problems that take place in modern cardiovascular surgery are analyzed. Autologous transplantation which takes place during reconstructive shunt surgery is emphasized. Conclusions. High-tech diagnostic and treatment technologies in cardiac surgery, their specificity, irreversibility of biomedical experience and certain event (intervention) to prolong life and improve health of the patient place new demands on the cardiac surgeon and require special responsibility. Today’s cardiac surgery requires not only high-tech skills in using modern methods of operations, responsibility, but also comprehensive support of aspects of biomedical ethics in the treatment of patients.

Correlation of the Myocardial Viability Score with Left Ventricular Ejection Fraction in Patients after Revascularization

Background. Coronary artery disease (CAD) is one of the main causes of cardiovascular death. The severity of CAD is determined by the left ventricular (LV) dysfunction which is caused by coronary atherosclerosis. The possibility of restoring functional capacity of the heart (ejection fraction (EF)) depends on hibernating volume of the myocardium which is a pitfall in revascularization. The aim. To assess the correlation between the score of the viable myocardium (VM) and EF with systolic dysfunction and preserved LVEF in patients after coronary artery bypass grafting (CABG). Material and methods. To implement the set clinical tasks, 62 patients with CAD with preserved systolic function and systolic dysfunction were examined, 35 (56%) patients had heart failure with an EF of 49% (group 2) and less. Twenty-seven (44%) patients had preserved ventricular function of 50% or more (group 1). The mean age of the subjects was 59.6 ± 8.2 years. Five (8.0%) patients denied myocardial infarction. Myocardial scintigraphy was performed on Infinia Hawkeye all purpose imaging system (GE, USA) with integrated CT. The studies were performed in SPECT and SPECT/CT with ECG synchronization (gated SPECT) modes. 99mTc-MIBI with an activity of 555–740 MBq was used. Myocardial scintigraphy was performed in the course of treatment (before CABG and after CABG) according to the One Day Rest protocol. A total of 124 scintigraphic studies were performed. Results and discussion. Samples of the studied patients “before” and “after” treatment were compared using Wilcoxon matched-pairs test. In group 1 in patients with EF ≥ 50% the score of VM increased after CABG with values from 81.7 CI 95% [78.5; 84.9] to 86.9 CI 95% [84.4; 89.3]. However, the EF itself before and after treatment remained the same or slightly decreased amounting to 54.9 CI 95% [50.8; 59.1] and 52.5 CI 95% [48.6; 56.3]. In group 2 in patients with EF ≤ 49% the amount of VM increased after CABG with values from 59.9 CI 95% [54.9; 64.8] to 65.9 CI 95% [60.2; 71.6] (p = 0.00005). However, the EF itself before and after treatment remained the same, amounting to 28.9 CI 95% [24.8; 32.9] and 31.1 CI 95% [26.8; 35.5] (p = 0.19). Conclusions. Myocardial viability in both study groups significantly improved, given the high statistical reliability of the results, although LVEF either remained unchanged or changed slightly. Improvement of static parameters (wall perfusion) also confirms positive effect of revascularization with constant dynamic parameters (EF, end-diastolic volume) or statistically insignificant changes thereof. There is no direct correlation between VM and EF.

Epidemiology of Post-Infarction Ventricular Septal Rupture in Patients Undergoing Surgical Repair at Different Times from the Development of Acute Myocardial Infarction

Introduction. The article is dedicated to the epidemiological aspects of the mechanical complication of acute myocardial infarction (AMI), particularly post-infarction ventricular septal rupture (VSR), problematic issues of its etiology and localization. Mortality of such patients is determined by rapid development of hemodynamic disorders and their severity, unpredictable clinical course, and the difficulty of early diagnosis. In addition, the high mortality rate of patients, especially when correcting the ventricular septal defect at the early stages after AMI, leaves open the question of the tactics of surgical treatment. The influence of certain risk factors of ischemic heart disease (IHD) on the development of post-infarction VSR is also considered. The aim. To study the epidemic features of post-infarction VSR in patients with different terms of surgical intervention after the development of AMI. Materials and methods. This study presents a retrospective analysis of 90 patients with coronary artery disease complicated by post-infarction VSR, who underwent surgical intervention for the period 2002-2019. The ages of hospitalized patients with post-infarction VSR ranged from 29 to 81 years. All the patients were divided into 3 groups depending on the time interval from AMI to surgical intervention. Results and discussion. It was found that post-infarction VSR is more common in men in the age range of 45-74 years after the manifestation of the first transmural AMI. More than a half of post-infarction VSR cases (56.7%) are associated with anterior localization of the ruptures in consequence of anterior AMI. Since the leading role in the treatment of AMI belongs to percutaneous coronary interventions (PCI), we analyzed the use of various reperfusion techniques to restore coronary blood flow in patients with post-infarction VSR. The analysis suggests that there are no statistically significant differences between the studied groups of patients with post-infarction VSR who underwent myocardial reperfusion (p = 0.103). Conclusions. The presence of chronic renal failure (CRF) in patients in the early post-infarction period can complicate the course of post-infarction VSR and affect perihospital mortality. The absence or untimeliness of myocardial reperfusion increases the risk of developing this complication of AMI. The ambiguous prognosis of treatment of post-infarction VSR makes a serious problem for clinicians.