Aim. To create a scale for assessing the myocardial ischemia severity and to study the effect of concomitant ischemia on the prognosis of myocardial infarction (MI) complicated by no-reflow phenomenon during percutaneous coronary intervention (PCI).Material and methods. A single-center cohort study was conducted. There were following inclusion criteria: MI, PCI, total ischemic time <48 h and no-reflow (TIMI flow grade <3 or Myocardial blush grade <2 or ST segment resolution <70%). The proposed scale included infarction-related lesion in the left main coronary artery or proximal left anterior descending artery — 2 points; total ischemic time >12 h — 1 point; TIMI flow grade 0-1 before PCI — 1 point; Rentrop collateral circulation grade 0-1 — 1 point. Severe ischemia — more than 3 points. Propensity score matching was used to correct differences between the groups. Median follow-up was 979 [743; 1318] days.Results. A total of 18079 patients with acute coronary syndrome were analyzed, while 219 were included. After comparison, 105 patients remained as follows: group 1 — 75 patients without assessed severe ischemia; group 2 — 30 patients with assessed severe ischemia. During the hospital stage, 6 (8,0%) and 9 (30,0%) patients died, respectively, p<0,001. The left ventricular ejection fraction was 47 [42; 50]% and 41 [39; 45]%, respectively, p<0,001. Severe ischemia was associated with a 4,15-fold increase in the long-term death risk (95% confidence interval 1,87-9,20; p<0,001).Conclusion. Concomitant severe ischemic damage in MI complicated by no-reflow during PCI is associated with worse left ventricular function and a higher death risk at the hospital stage and in the long-term follow-up period.

Objective: The study intends to evaluate the prognostic value of a comprehensive approach to prevention and treating the coronary microvascular obstruction (CMVO) upon percutaneous coronary interventions (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). Methods: A single-center cohort study was conducted in patients characterizing by type 1 STEMI, emergency PCI, a total ischemic time of less than 12 hours, and the development of CMVO (TIMI flow grade < 3 or Myocardial blush grade < 2). Patients with cardiogenic shock prior to PCI were excluded. A proposed comprehensive approach included the following five rules: thromboaspiration in case of severe thrombosis, platelet glycoprotein IIb/IIIa receptor blockers, "minimally invasive PCI," intracoronary administration of isosorbide dinitrate and verapamil hydrochloride upon the development of CMVO. The approach was considered to be applied if three or more rules were retained. The median follow-up period was 805 [14; 1,127] days. A multivariate analysis of the risk of long-term mortality was performed using the Cox proportional hazards model. Results: A total of 202 patients were included in the study and 53 (26.3%) of them had a fatal outcome; in particular, 16 (7.9%) patients died at the hospital stage and 27 (13.4%) after discharge. Multivariate analysis of predictors of mortality showed that the using of a comprehensive approach to prevention and treating CMVO reduces the probability of death during follow-up period by 4 times with risk ratio 0.22, 95% confidence interval 0.06–0.87 and p = 0.03. Conclusion: The introducing of the proposed comprehensive approach to prevention and treating CMVO upon PCI in patients with STEMI is associated with a lower probability of death within 805 days after the intervention. Received 30 July 2024. Revised 25 September 2024. Accepted 1 October 2024. FundingThe study did not have sponsorship. Conflict of interest The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.A. Frolov, E.G. Sharabrin, I.G. Pochinka Data collection and analysis: A.A. Frolov, I.A. Frolov, K.V. Kuzmichev Statistical analysis: A.A. Frolov, I.A. Frolov, K.V. Kuzmichev Drafting the article: A.A. Frolov, I.G. Pochinka, I.A. Frolov Critical revision of the article: I.G. Pochinka, A.S. Mukhin, E.G. Sharabrin Final approval of the version to be published: A.A. Frolov, I.G. Pochinka, I.A. Frolov, K.V. Kuzmichev, A.S. Mukhin, E.G. Sharabrin

Цель. Оценить влияние комплексного подхода к профилактике и лечению синдрома коронарной микрососудистой обструкции на прогноз при чрескожных коронарных вмешательствах у пациентов с инфарктом миокарда с подъемом сегмента ST. Методы. Провели одноцентровое когортное исследование пациентов с инфарктом миокарда с подъемом сегмента ST 1-го типа, экстренным чрескожным коронарным вмешательством, временем «боль – реперфузия» менее 12 ч и синдромом коронарной микрососудистой обструкции (TIMI flow grade < 3 ст. или Myocardial blush grade < 2 ст.). Не включили пациентов с кардиогенным шоком до чрескожного коронарного вмешательства. Предложили комплексный подход, включающий 5 правил: тромбаспирация при тяжелом тромбозе, применение блокаторов IIb/IIIa гликопротеиновых рецепторов тромбоцитов, минимально инвазивное чрес­кожное коронарное вмешательство, интракоронарное введение изосорбида динитрата и верапамила гидрохлорида при коронарной микрососудистой обструкции. Считали подход примененным при соблюдении трех и более правил. Медиана наблюдения составила 805 [14; 1 127] дней. Провели многофакторный анализ риска смерти в отдаленном периоде с помощью модели пропорциональных рисков Кокса. Результаты. На госпитальном этапе из 202 включенных пациентов умерло 16 (7,9 %), после выписки — 27 (13,4 %), всего — 53 (26,3 %). Согласно многофакторному анализу предикторов летальных исходов, комплексный подход к профилактике и лечению коронарной микрососудистой обструкции снижает риск смерти в течение периода наблюдения примерно в 4 раза: отношение рисков 0,22, 95% доверительный интервал 0,06–0,87, p = 0,03. Заключение. Использование комплексного подхода к профилактике и лечению коронарной микрососудистой обструкции при чрес­кожных коронарных вмешательствах у пациентов с инфарктом миокарда с подъемом сегмента ST ассоциировано с более низкой вероятностью смерти в течение 805 дней после вмешательства. Поступила в редакцию 30 июля 2024 г. Исправлена 25 сентября 2024 г. Принята к печати 1 октября 2024 г. Финансирование Исследование не имело спонсорской поддержки. Конфликт интересов Авторы заявляют об отсутствии конфликта интересов. Вклад авторов Концепция и дизайн работы: А.А. Фролов, Е.Г. Шарабрин, И.Г. Починка Сбор и анализ данных: А.А. Фролов, И.А. Фролов, К.В. Кузьмичев Статистическая обработка данных: А.А. Фролов, И.А. Фролов, К.В. Кузьмичев Написание статьи: А.А. Фролов, И.Г. Починка, И.А. Фролов Исправление статьи: И.Г. Починка, А.С. Мухин, Е.Г. Шарабрин Утверждение окончательного варианта статьи: все авторы

Актуальность. Нет шкалы, объединяющей традиционные критерии коронарной микрососудистой обструкции (no-reflow) для эффективной оценки тяжести и прогноза данного осложнения. Цель. Разработать и изучить прогностическую ценность шкалы оценки тяжести коронарной микрососудистой обструкции в ходе чрескожных коронарных вмешательств при инфаркте миокарда. Методы. В когортное исследование включено 203 пациента с инфарк­том миокарда 1-го типа и коронарной микрососудистой обструкцией при чрескожном коронарном вмешательстве по критерию кровоток < 3 баллов по Thrombolysis in Myocardial Infarction (TIMI) flow grade. По предложенной шкале оценки тяжести коронарной микрососудистой обструкции (ШОТ-КМСО) выделены 3 группы. Коронарная микрососудистая обструкция 1-й степени (умеренная): TIMI flow grade 2 балла, Myocardial blush grade 2–3 балла, резолюция сегмента ST после чрескожного коронарного вмешательства > 70 %. Коронарная микрососудистая обструкция 2-й степени (средней тяжести): TIMI flow grade 2 балла, Myocardial blush grade 0–1 балл или резолюция сегмента ST < 70 %. Коронарная микрососудистая обструкция 3-й степени (тяжелая): TIMI flow grade 0–1 балл. Результаты. Распределение групп с коронарной микрососудистой обструкцией 1-й, 2-й и 3-й степеней: 65 (32 %) / 88 (43 %) / 50 (25 %) пациентов соответственно. Госпитальные исходы по группам: острая сердечная недостаточность III–IV класса — 2 (3 %) / 11 (13 %) / 14 (28 %), p < 0,001; фракция выброса — 48 [44; 53] % / 46 [40; 50] % / 42 [39; 49] %, p = 0,004; госпитальная смерть — 1 (1,5 %) / 12 (13,6 %) / 16 (32,0 %), p < 0,001; смерть в течение двух лет — 8 (12,3 %) / 19 (21,6 %) / 22 (44,0 %), p < 0,001. Многофакторный анализ: отношение шансов смерти в течение двух лет для ШОТ-КМСО — 2,40 [95% доверительный интервал 1,23–5,17], p = 0,009. Вероятность выжить за двухлетний период при КМСО 1-й степени по ШОТ-КМСО — 87,7 %, 2-й — 78,4 %, 3-й — 56,0 % (p < 0,001). Заключение. Степень тяжести коронарной микрососудистой обструкции, оцененная с помощью предложенной шкалы, ассоциирована с развитием неблагоприятных госпитальных исходов и является независимым предиктором смерти в течение двух лет. Поступила в редакцию 15 мая 2023 г. Исправлена 27 сентября 2023 г. Принята к печати 24 октября 2023 г. Финансирование Исследование выполнено в рамках программы стратегического академического лидерства «Приоритет-2030». Конфликт интересов Авторы заявляют об отсутствии конфликта интересов. Вклад авторов Концепция и дизайн работы: А.А. Фролов, Е.Г. Шарабрин, И.Г. Починка Сбор и анализ данных: А.А. Фролов, И.А. Фролов, К.В. Кузьмичев Статистическая обработка данных: А.А. Фролов, И.А. Фролов, К.В. Кузьмичев Написание статьи: А.А. Фролов, И.Г. Починка, И.А. Фролов Исправление статьи: И.Г. Починка, А.С. Мухин, Е.Г. Шарабрин, В.Н. Синютин Утверждение окончательного варианта статьи: все авторы

Objective: using the clustering method, to determine and describe the clinical and pathogenetic phenotypes of the coronary microvascular obstruction phenomenon (CMVO) that occurs during percutaneous coronary interventions (PCI) in patients with myocardial infarction (MI).Materials and methods: the study group included 190 patients with CMVO that occurred during PCI for type 1 MI. Participants admitted in 2013-2020. CMVO criteria: blood flow < 3 points in the infarct-related artery (IRA) according to TIMI flow grade (TFG); perfusion < 2 points for Myocardial blush grade; ST segment resolution < 70%. Median age – 64 [56; 70] years, 137 (72%) men, 53 (28%) women. MI with ST elevation (STEMI) in 170 patients (89%). Primary PCI in 127 (67%) cases. Nine patients (4.7%) have died. Phenotyping was performed using the EM (expectation-maximization) clustering algorithm.Results: three phenotypes have been identified in a ratio of 56% (n = 106) / 27% (n = 52) / 17% (n = 32). The values of the parameters are respectively: age 62 [54; 67] / 73 [67; 79] / 59 [50; 65] years; women 8 (8%) / 39 (77%) / 6 (19%); STEMI 102 (96%) / 43 (83%) / 25 (78%); thrombolysis 46 (43%) / 6 (12%) / 11 (34%); acute heart failure 1 [1; 2] / 2 [1; 4] / 2 [2; 2] class; platelet to lymphocyte ratio 110 [78; 153] / 106 [85; 132] / 132 [100; 182]; glucose at admission 8,0 [6,9; 9,6] / 11,1 [8,8; 15,2] / 7,5 [6,1; 8,1] mmol/l; total cholesterol 4,7 [4,2; 5,4] / 5,3 [3,7; 6,2] / 5,1 [4,5; 6,2] mmol/l; glomerular filtration rate according to CKD-EPI 77 [64; 88] / 58 [46; 74] / 81 [64; 88] ml/min/1.73m2; Syntax Score 15 [10; 21] / 20 [14; 26] / 8 [5; 10] points; Syntax Score in IRA 9 [8; 15] / 12 [7; 16] / 6 [3; 7] points; collaterals according to Rentrop 0 [0; 1] / 0 [0; 1] / 0 [0; 0] degree; TIMI thrombus grade 5 [5; 5]/ 5 [3; 5] / 1 [0; 2] degree; TFG 0 [0; 0] / 0 [0; 1] / 2 [2; 3] degree; aspiration thrombectomy 30 (28%) / 7 (13%) /4 (13%); IRA diameter 3,5 [3,0; 3,5] / 3,0 [2,8; 3,5] / 3,5 [3,0; 3,5] mm; balloon angioplasty 99 (93%) / 45 (87%) /16 (50%); PCI of 2 or more arteries 0 (0%) / 4 (8%) / 3 (9). Deaths – 2 (1.9%), 7 (13.5%) and 0 (0%) patients, respectively (p = 0.002, χ2-Pearson).Conclusion. Тhree phenotypes have been identified. First phenotype: severe IRA thrombosis, mostly men, moderate atherosclerotic lesions. Second phenotype: mostly elderly women, high hyperglycemia, severe atherosclerotic lesions, severe AHF, impaired renal function, IRA thrombosis. Third phenotype: mostly men, minor changes in the coronary arteries, absence of significant thrombosis and preserved blood flow in the IRA before PCI, elevated levels of inflammatory markers and total cholesterol.

Acute arterial thrombosis against the background of the novel coronavirus infection COVID-19 is an unfavorable complication. The survival prognosis in this category of patients is much worse than in the rest of the patient population. The aim of the work is to compare the immediate results of various methods of treating acute arterial insufficiency in patients with the novel coronavirus infection COVID-19, complicated by the development of acute arterial thrombosis of various localizations. 42 clinical cases of treatment of acute arterial pathology in patients with confirmed COVID-19 infection were analyzed. The severity of the underlying disease was not considered as a criterion for exclusion from the study. Surgical treatment by open intra-arterial thrombectomy under local anesthesia was used in 9 patients. Endovascular balloon angioplasty of arteries followed by selective catheter-guided thrombolysis with alteplase was performed in 17 patients. Sixteen patients received systemic transvenous thrombolysis with the recombinant human tissue plasminogen activator alteplase at a dose of 100 mg. The development of arterial thrombosis against the background of the coronavirus infection is accompanied by a high risk of death in the absence of timely and active specialized care. In the study group, 18 patients (43 %) with acute arterial thrombosis associated with COVID-19 deceased; of these, eight patients underwent open thrombectomy, eight patients had systemic transvenous thrombolysis with alteplase, and two patients underwent endovascular balloon angioplasty with selective catheter-guided thrombolysis with alteplase. A favorable outcome of the disease was noted in 24 patients (57 %); of these, fifteen patients underwent endovascular balloon angioplasty with selective catheter-guided thrombolysis with alteplase, and 8 patients had systemic thrombolysis with alteplase. Optimal treatment results were achieved in the group of patients using minimally invasive endovascular treatment methods in combination with tissue plasminogen activator. In the group of non-transportable patients with grade 3 respiratory failure and high perioperative risks, positive results were achieved exclusively through the use of systemic transvenous thrombolysis. These data allow us to consider justified the use of options for systemic thrombolysis and selective catheter thrombolysis in combination with endovascular reconstruction as an alternative to «open» surgical methods for thevtreatment of acute arterial insufficiency against the background of COVID-19.

The aim of the study was to develop, evaluate, and validate an artificial neural network to predict coronary microvascular obstruction (CMVO) during percutaneous coronary interventions (PCI) in patients with myocardial infarctions (MI) based on the parameters, which are routinely available in an operating room when choosing a surgical approach.Materials and Methods.5621 patients with MI and emergency PCI were retrospectively selected from the database of the City Clinical Hospital No.13 (Nizhny Novgorod, Russia); among them, there were 3935 men (70%) and 1686 women (30%), their mean age was 61.5±10.8years.CMVO was recorded in 201 (4%) patients (the blood flow in the infarction-related artery after PCI was less than 3 points according to TIMI flow grade).The following input parameters were assessed: age, gender, past history of coronary artery disease, previous revascularization, presence of ST-segment elevation, a class of acute heart failure, a fact of systemic thrombolytic therapy administration and its effectiveness, symptom-to-balloon time, severity of coronary thrombosis and atherosclerosis, the number of stents and the number of operated coronary arteries.The sampling was divided into a training group (n=4060), a testing group (n=717), and an independent validation group (n=844).Results.We developed an artificial neural network by a fully connected multilayer perception with forward signal propagation and two hidden layers (the area under the ROC curve -0.69) to predict CMVO based on the subsampling for training and testing.The network model was tested on an independent subsampling (the area under the ROC curve -0.64, negative predictive value -97.4%, positive predictive value -14.6%). Conclusion.The developed artificial neural network enables to use the parameters routinely available in an operating room when choosing a surgical approach and predict CMVO development during PCI in MI patients with accuracy sufficient for practical use.

Aim. To evaluate the effect of culprit coronary artery revascularization after 48 hours from the symptoms’ onset on the prognosis of patients with ST-elevation myocardial infarction (STEMI).Material and methods. Of the 1172 patients admitted to City Clinical Hospital № 13 in 2018 due to STEMI, 43 patients (4%) were included in the retrospective study. There were following inclusion criteria: hospitalization after 48 hours from the symptoms’ onset, no clinical signs of myocardial ischemia, and complete coronary artery occlusion according to angiography. The mean age of the subjects was 61,3±10,6 years, 34 (79%) men and 9 (21%) women. The subjects were divided into two groups: group 1 (n=22) — management with percutaneous coronary intervention (PCI), group 2 (n=21) — management with medications. The groups differ only in the severity of coronary atherosclerosis according to SYNTAX score: group 1 — 14,0 [11.0; 19.5], group 2 — 26,0 [16,5; 31,0] (p=0,009). At the end of inpatient treatment, patients underwent echocardiography. Death and myocardial infarction were monitored during hospitalization and for 12 months after discharge.Results. During hospitalization, 2 patients died (4,7%; one in each group, p=1,00). No recurrent MI were reported. The left ventricular ejection fraction in the PCI group was 50 [46; 54] %, in the group with drug therapy — 43 [38; 50] % (p=0,01). Out of 43 included patients, long-term outcomes were followed up in 32 (74%). Among them, 1 (5,8%) patient died in group 1, 6 (33,3%) patients — in group 2 (p=0,04). In total, death or recurrent MI in the first group was observed in 2 (12%) patients, in the second group — in 5 (33%) patients (p=0,14).Conclusion. Revascularization of a fully occluded culprit coronary artery in stable patients with STEMI after 48 hours of symptoms’ onset is associated with a higher inhospital left ventricular ejection fraction and a decrease in 12-month mortality.

In cases of drug and endovascular myocardial reperfusion the risk of complications decreases due to the reduction of load on infarct related artery. This review is devoted to the problem of complications in prehospital thrombolysis in patients with acute coronary syndrome. There are many contraindications to thrombolysis, and efforts should be made to select those patients who do not have contraindications. The review explains the pathophysiological mechanisms that increase the risk of bleeding after thrombolysis. Fibrinolytics are an effective reperfusion therapy for many patients with myocardial infarction ST (STEMI), but they need to be administered on a tight schedule. For each 30-minute reperfusion delay, approximately 10% of the relative increase in the risk of death. No serious complications such as cerebral circulation and myocardial embologenic were detected among patients with acute myocardial infarction with ST segment elevation in the group with formed thrombus aspiration. As for a group with prehospital thrombolysis, there were no deaths in it, indicating the effectiveness of thrombolysis as a preventive measure.

Purpose of the study - to test the effect and safetythrombus aspiration procedure combining with urgent endovascular angioplastics on embolic artery of patients with acute coronary syndrome and elevated segment ST. In cases of drug and endovascular myocardial reperfusion the risk of complications decreases due to the reduction of load on infarct related artery. No serious complications such as cerebral circulation and myocardial embologenic were detected among patients with acute myocardial infarction with ST segment elevation in the group with formed thrombus aspiration. As for a group with prehospital thrombolysis, there were no deaths in it, indicating the effectiveness of thrombolysis as a preventive measure. Material and methods. We give direct results of 35 patients with acute coronary syndrome after urgent thrombus aspiration and 90 patients after urgent angioplastics without thrombus aspiration. Results. It is proved that complete or the of evacuated thrombotic mass or mostly occlusive substance from embolic artery has positive influence on angiophic results and is capable of dereas cases of distal embolization. Conclusion. After endovascular carring out embolic artery in thrombus aspiration groups we have complete rehabilitation of epicardial blood circulation and myocardial blush grade in comparison with groups without thrombus aspiration.

The paper deals with the review of literature devoted to one of the most important issues of contemporary oncology: treatment of malignant liver tumors. Much attention is paid to the analysis of modern endovascular treatment methods research, namely – transcatheter chemoembolization of the hepatic artery. The morphological and functional bases of chemoembolization are described in detail. The comparison between chemoembolization drugs are noted in the article, too. The results of research are shown. The conclusions about the efficiency that allows achieving positive dynamics and stabilization of the process are drawn.

Цель исследования изучить эффект от процедуры тробаспирации при ее сочетании со стентированием и ангиопластикой у пациентов с острым инфарктом миокарда с подъемом сегмента ST. При проведении последующих эндоваскулярного лечения на инфаркт ответственной артерии, в группах с тробэкстракцией чаще наблюдалось полное восстановление эпикардиального кровотока и миокардиального пропитывания, по сравнению с группой со стандартными эндоваскулярным лечением. Установлено, что правильно выполненная процедура тромбаспирации снижает частоту дистальной эмболизации и снижает частоту дислокации тромботических масс.

The search for new methods of adequate antegrade blood flow restoration in the coronary arteries of patients with acute coronary syndrome with ST-segment elevation (ACSesST) without hemodynamically significant atherosclerotic lesions of the coronary arteries is a poorly studied item. The author gives the clinical example of a patient with ACSesST without hemodynamically significant atherosclerotic lesions of the coronary arteries and deceleration of antegrade blood flow in the area of the anterior descending artery (ADA). Percutaneous temporary occlusion of the coronary sinus was done to the patient during 10 minutes in the balloon catheter «inflation-deflation». The procedure resulted in a positive impact on coronary hemodynamics such as distal coronary spasm cupping, myocardial perfusion improvement and restoration of adequate antegrade blood flow in the pool ADA.