Aim. To compare the effectiveness and safety of endovascular occlusion and thoracoscopic amputation of the left atrial appendage (LAA) in patients with atrial fibrillation (AF). Methods. We present a retrospective single-center study with a prospective component including 25 patients with AF who underwent thoracoscopic amputation of the LAA and 31 patients on prospective part who underwent endovascular occlusion of the LAA. All patients signed voluntary informed consent for medical intervention and participation in the study. The criteria for selecting patients for thoracoscopic amputation of the LAA were the impossibility of performing an endovascular technique, features of its anatomy and increased trabecularity. Results. In the group of patients with thoracoscopic amputation of the LAA, 2 cases of embologenic stump of the LAA with a depth of 1.6 cm (8%) were identified; these patients were recommended to continue taking anticoagulant therapy. Among patients who underwent thoracoscopic amputation, no complications were identified in the first 30 days after surgery, including mortality, bleeding, phrenic nerve paresis, acute cerebrovascular accident, pleurisy, pneumothorax, hemothorax. In 3 patients who underwent endovascular occlusion of the LAA, hematomas were detected at the site of puncture of the great vessels (9.7%), in 2 patients thrombus were detected on the occlusion device according to the results of transesophageal echocardiography (6.5%), which required the prescription of warfarin in these patients. Also, in 2 patients (6.5%) during implantation of the occluder into the LAA, as a result of the incorrect diameter of the disk of the occluding device, a residual cavity with a depth of 0.7 cm was formed between the ridge and the occluder. No significant differences in the frequency of non-severe complications were found in the groups, p =0.139. During the year of postoperative observation, thromboembolic complications were absent in the operated patients of both groups. Conclusion. When comparing two methods of LAA isolation, no severe complications were identified, either in the perioperative or in the early or late postoperative period. There were no significant differences in the incidence of non-severe complications in the early postoperative period. Thus, the effectiveness and safety of thoracoscopic amputation and endovascular occlusion of the left atrial appendage are comparable.

Aim To evaluate 5-year results of the HREVS (Hybrid REvascularization Versus Standarts) study.Material and methods The study included 155 consecutive patients with multivessel coronary artery disease who were randomized into 3 groups: coronary artery bypass grafting (CABG) (n=50), hybrid coronary revascularization (HCR) (n=52) and percutaneous coronary intervention (PCI) (n=53) according to the consensus of the cardiology team on the technical and clinical feasibility of each of the three coronary revascularization strategies. The primary endpoint of the study was residual ischemia 12 months after revascularization according to data of single-photon emission computed tomography (SPECT). Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) over 5 years of follow-up, which included all-cause death, myocardial infarction, stroke, and clinically determined repeat myocardial revascularization.Results Baseline characteristics of patients did not differ between study groups. Median residual ischemia determined by SPECT data after 12 months was not statistically significantly different in the CABG, HCR and PCI groups: 6.7 [4.6; 8.8]%, 6.4 [4.3; 8.5]% and 7.9 [5.9; 9.8]%, respectively (p=0.45). Mean follow-up period was 76.5 months (at least 60 months). There were no statistically significant differences in all-cause mortality between the CABG, HCR and PCI groups, 10.6, 12.8 and 8.2 %, respectively (p=0.23). Statistically significant differences between the groups of CABG, HCR and PCI in the incidence of myocardial infarction (12.8; 8.5 and 16.3 %; p=0.12), stroke (4.2; 6.4 and 10.2 % ; p=0.13), repeat revascularization for clinical indications (23.4; 23.4 and 34.7 %; p=0.11) were not observed either. However, the cumulative 5-year MACCE value was similar in the HCR group and the CABG group but significantly lower than in the PCI group (51.1, 51.1 and 69.4 %, respectively; p = 0.03).Conclusion HCR that combines advantages of PCI and CABG is a promising strategy for coronary revascularization in multivessel coronary artery disease. HCR demonstrates satisfactory long-term results comparable to those of CABG but superior to PCI. To confirm the safety and efficacy of HCR, a large multicenter study is required that would have a sufficient power to evaluate clinical endpoints.

A clinical case of successful radiofrequency thoracoscopic ablation of persistent atrial fibrillation after implantation of an occluder in the left atrium appendage is presented.

AIM:To determine the dependence of adiponectin gene expression by subcutaneous, epicardial and perivascular adipocytes on the degree of coronary lesion in coronary heart disease.MATERIALS AND METHODS:84 patients with coronary artery disease were examined. Of these, 39 people showed a moderate degree of atherosclerotic lesion of the coronary bed (less than or equal to 22 points) on the SYNTAX Score scale, 20 severe (2231 points), and 25 extremely severe (more than 32 points). Upon admission to the hospital, all patients underwent an echocardiographic study (Echocardiography, Acuson, Germany) with the calculation of the ejection fraction (EF) of the left ventricle (LV) to assess its systolic function. During a planned surgical intervention (coronary bypass surgery, CABG), adipocytes of subcutaneous, epicardial (EAT) and perivascular adipose tissue (PVAT) were taken. Adiponectin gene expression was evaluated by polymerase chain reaction (real-time PCR) using TaqMan probes. Statistical analysis was performed using Statistica 9.0.RESULTS:The maximum level of adiponectin expression was detected in adipocytes of PVAT, and the minimum EAT. With an increase in the degree of atherosclerotic lesion of the coronary bed, the expression of the adiponectin gene in adipocytes of local depots significantly decreases r=-0.82; p=0.023. Moreover, the low level of gene expression in EAT correlated with a decrease in LV EF by r=0.73; p=0.03. In adipocytes of subcutaneous and especially PVAT, gene expression was the highest in patients with a moderate degree of coronary lesion.CONCLUSIONS:Low adiponectin gene expression in EAT is associated with an increase in the degree of atherosclerotic lesion of the coronary bed and a decrease in LV EF.

This clinical case demonstrates the benefit of coronary artery bypass grafting as a method of revascularization in patients with high-risk non-ST-segment elevation acute coronary syndrome (NSTE ACS). Organizational measures set at the Research Institute for Complex Issues of Cardiovascular Diseases (the appointment of double antiplatelet therapy in patients with NSTE ACS after coronary angiography, Abstract   the selection of treatment strategy and timing, the accessibility of coronary artery bypass grafting in 24/7 mode) allowed performing revascularization in the set timing recommended by current guidelines for myocardial revascularization. This case has shown that coronary artery bypass grafting is as effective as percutaneous coronary intervention in patients with high-risk NSTE ACS and multivessel coronary artery disease.

Aim. Evaluation of short- and mid-term (up to one year) results of aт atrial fibrillation thoracoscopic radiofrequency ablation (TRFA) combined with left atrial appendage resection.Methods. 10 patients with persistent AF were included in the study. In 5 cases surgical ablation was performed as the primary intervention and in 5 cases surgery were preceded by two unsuccessful catheter procedures. Age of the patients was 54.4 (41; 63) years, duration of arrhythmic anamnesis – 5.6 (4.8; 6.8) years, anteroposterior size of the left atrium – 4.7 (45; 51 mm), LV ejection fraction – 63 (58; 68) %. TRFA included an isolation of right and left pulmonary veins, ablation lines along the roof and base of posterior wall of the left atrium, left atrial appendage resection.Results. In all cases of TRFA exit-block from the pulmonary veins was achieved. Among 10 procedures, a stable sinus rhythm was documented in 6 patients. In the remaining 4 patients AF was observed only in one case, and the other three demonstrated atypical atrial flutter, that given us a reason to repeat catheter procedures. In three cases of left atrial flutter, catheter ablation led to sinus rhythm restoration, and in case of AF and total sclerosis of left atrium a decision to refuse RF ablation was made. Complications were presented by a single case of bilateral phrenic nerve palsy, which required plication of the diaphragm, and two spontaneously resolved pulmonary atelectasis.Conclusion. The efficacy of atrial fibrillation thoracoscopic radiofrequency ablation during the follow-up period of one year was 90% regarding selective hybrid approach (thoracoscopic + catheter procedure). Procedure safety of TRFA was much lower than that of catheter ablation: the total number of small and big complications was 30%.

Introduction . Radionuclide imaging is included in diagnostic methods after PCI and CABG in patients with symptoms, but the recommendations caution against routine testing in all asymptomatic patients after revascularization. The paper shows the results of single-photon emission computed tomography after hybrid coronary myocardial revascularization; an analysis of the sensitivity and specificity of three methods of surgical myocardial revascularization was carried out in 12 months. Aim of the study was to determine the sensitivity and specificity of SPECT in determining coronary artery stenosis ≥ 50 % after performing three methods of surgical myocardial revascularization: CABG, PCI, and hybrid myocardial revascularization in patients with coronary artery disease and multi-vascular coronary lesion. Material and methods . A retrospective analysis of 82 patients with stable forms of coronary artery disease who underwent myocardial revascularization for the presence of the multivascular coronary lesion was carried out. The patients were divided into three groups: the first group consisted of 40 patients who underwent CABG, the second – 29 patients after PCI, and the third – 23 patients who underwent hybrid myocardial revascularization. Results. All patients after myocardial revascularization, on average, after 21.8±8.6 months, were hospitalized, where singlephoton emission computed tomography of the myocardium with 99mTc-technetril (SPECT) and control coronarography/ shuntography were performed. The frequency of the presence of significant stenosis during coronary angiography with a perfusion defect of ≥5 % on SPECT during exercise was 50, 50 and 33 % in the CABG, PCI, and hybrid revascularization, respectively (p=0.894). The least sensitivity of SPECT was after hybrid myocardial revascularization (20 %), while in the CABG group, the sensitivity was 71.4 % (p = 0.190). The SPECT specificity indices were much higher: in the GABG, PCI, and hybrid revascularization groups, respectively, 75.8, 79 and 88.9 % (p=0.530). Conclusion . There is no significant relationship between the size of the defect on SPECT and coronary angiography data, regardless of the type of surgical myocardial revascularization in patients after myocardial revascularization. Detection of a perfusion defect with a load of more than 10% in SPECT after surgical myocardial revascularization is the basis for coronary angiography in order to exclude stent restenosis or shunt dysfunction, as well as progression of coronary atherosclerosis.

The purpose of the study was to investigate the features of expression and adiponectin content in the adipocyte culture of subcutaneous, epicardial, and perivascular adipose tissue and the effect of various doses of rosuvastatin on these processes. 29 patients with coronary artery disease were examined. Adipocytes were isolated from the samples of SAT, EAT and PVAT which were taken during coronary artery bypass surgery, followed by cultivation in the presence of rosuvastatin and evaluation of gene expression and adiponectin concentration. Adipocytes SAT, EAT and PVAT differed in the level of adiponectin secretion and expression of its gene. On day 1 of cultivation the expression of the adiponectin gene in the EAT was 2.3 times lower than in the PVAT. On day 2 of cultivation the expression of the adiponectin gene was reduced both in the EAT and the PVAT as compared to the SAT. When rosuvastatin was added at a concentration of 1 mmol/L, adiponectin gene expression in PVAT was higher than when rosuvastatin was added at a concentration of 5 mmol/L, in the adipocyte culture of SAT effect was opposite. Thus, the adipocytes of EZhT and, to a greater extent, PAS, can be a therapeutic target for statins in the case of the pathological activation of adipose tissue.

Aim.  To evaluate the in-hospital results of minimally invasive direct coronary artery bypass grafting (MIDCAB) of the left anterior descending artery (LAD) on the beating heart. Methods.  146 patients with stable coronary artery disease and hemodynamically significant LAD lesions were included in a single-center prospective study. The study endpoints included death, myocardial infarction (MI), stroke, bleedings associated with the CABG, repeated non-elective myocardial revascularization during the in-hospital period. The completeness of the performed revascularization was assessed by estimating the residual SYNTAX score. Additionally, the volume of perioperative blood loss and patients’ ICU and in-hospital length of stay were recorded. Wound complications, heart rhythm and conduction disturbances, respiratory complications were assessed. Results.  The mean patient age was 60±8.9 (36–82) years. The mean EuroScore II was 1.61±1.66%. The SYNTAX score was 11.7±9.5 (5–25.5) scores. After MIDCAB, the residual SYNTAX was 1.8±2.1 (0–12.5). The majority of patients had single-vessel disease (n = 108; 73.9%). More than half of the patients had postinfarction cardiosclerosis (PICS). 17.8% of patients had diabetes mellitus. 19% of patients were present with class 1–2 obesity. The mean left ventricular ejection fraction (LVEF) in the total sample was 61.3±7.5% (37–74%). Eight patients (5.5%) required the conversion of lateral minitracotomy to sternotomy followed by the LAD grafting on the beating heart. The mean volume of intraoperative blood loss was 293.4±117.9 mL. Reasonable incomplete myocardial revascularization was achieved in 24.7% of cases. There were no cases of in-hospital deaths in the study cohort. The incidence of MI, stroke and repeated non-elective myocardial revascularization was within the acceptable range of 0.7%, 0% and 2.7%, respectively. 6.1% of patients (n = 9) had wound complications (deep incisional surgical site infection). The mean length of stay in the intensive care unit was 1±0.2 days. The absolute majority of patients (n = 108) were discharged from the Department of Cardiac Surgery in the period of 10±1.2 days. Conclusion.  Off-pump MIDCAB demonstrated good results, low rate of cardiovascular complications and low volume of perioperative blood loss, lack of deep wound infection and shorter hospital length of stay.

INTRODUCTION Percutaneous coronary intervention (PTI) and coronary artery bypass grafting (CABG) are currently the most commonly used techniques of myocardial revascularization. However, each of the methods has its own advantages and disadvantages. The creation of hybrid coronary revascularization (HCR) was based on an attempt to combine the benefits of CABG and PTI. AIM The study was aimed at assessing the immediate results of three methods of surgical myocardial revascularization in patients with multivessel lesions of the coronary bed in stable ischaemic heart disease. PATIENTS AND METHODS The study enrolled a total of 155 patients randomized into three groups of myocardial revascularization: HCR, CABG and PTI. In the HCR group, the first stage consisted in minimally invasive myocardial revascularization with the anterior descending artery (ADA) followed by PTI (within 1-3 days) with implantation of drug-eluting second-generation stents Xience to other coronary vessels. In the CABG and PTI groups we performed CABG and PTI, respectively, using the Xience stents. In all three groups we assessed the procedural success, frequency of major adverse cardiovascular events and bleeding. RESULTS Full myocardial revascularization was achieved in all three groups in more than 90% of cases. No statistically significant differences in either the procedural success rate or frequency of major adverse cardiovascular events between the CABG, PTI and HCR were revealed. The PTI group was characterized by the lowest frequency of bleeding, need for rehabilitation, and length of hospital stay. CONCLUSION Hybrid revascularization with the use of minimally invasive direct myocardial revascularization with the ADA followed by PTI with second-generation drug-eluting stents to other coronary arteries is a method of choice in treatment of patients with multivessel lesions of coronary arteries.

Введение. В настоящее время большое значение имеет определение места гибридной коронарной реваскуляризации (ГКР) среди стандартных методов реваскуляризации миокарда. Цель исследования: обосновать целесообразность ГКР у выборочной группы пациентов и провести комплексный анализ факторов, ассоциированных с неблагоприятным исходом. Материал и методы. Выполнено проспективное одноцентровое обсервационное исследование, в которое включили 50 больных с хронической ишемической болезнью сердца и многососудистым коронарным поражением с вовлечением передней межжелудочковой артерии. Возраст пациентов составил 62 года, преобладали пациенты мужского пола (76). Пациентам проведена ГКР, которая включала маммарокоронарное шунтирование передней нисходящей артерии из боковой мини-торакотомии с последующим чрескожным коронарным вмешательством других коронарных артерий. Через год после индексного вмешательства всем выжившим больным выполнена коронарошунтография. К конечным точкам исследования относились успех вмешательства и комбинированная конечная точка, включающая кардиальную смерть, инфаркт миокарда, инсульт и незапланированную повторную реваскуляризацию. Результаты. Большинству больных (88) удалось выполнить успешную ГКР. На годовом этапе наблюдения комбинированная конечная точка (частота крупных неблагоприятных событий) составила 20. К факторам, ассоциированным с неблагоприятным исходом, относились: курение, мужской пол, постинфарктный кардиосклероз, инсульт, сахарный диабет, хроническая обструктивная болезнь легких, снижение фракции выброса левого желудочка и скорости клубочковой фильтрации. Заключение. ГКР является рациональной методикой лечения и может быть успешно выполнена у отобранных пациентов с хронической ишемической болезнью сердца и многососудистым коронарным поражением. Комплексный анализ предоперационных показателей позволил выявить наиболее значимые факторы неблагоприятного исхода и разработать прогностическую модель.

Aim. To evaluate the in-hospital results of minimally invasive direct coronary artery bypass grafting (MIDCAB) of the left anterior descending artery (LAD) on the beating heart.Methods. 146 patients with stable coronary artery disease and hemodynamically significant LAD lesions were included in a single-center prospective study. The study endpoints included death, myocardial infarction (MI), stroke, bleedings associated with the CABG, repeated non-elective myocardial revascularization during the in-hospital period. The completeness of the performed revascularization was assessed by estimating the residual SYNTAX score. Additionally, the volume of perioperative blood loss and patients’ ICU and in-hospital length of stay were recorded. Wound complications, heart rhythm and conduction disturbances, respiratory complications were assessed.Results. The mean patient age was 60±8.9 (36–82) years. The mean EuroScore II was 1.61±1.66%. The SYNTAX score was 11.7±9.5 (5–25.5) scores. After MIDCAB, the residual SYNTAX was 1.8±2.1 (0–12.5). The majority of patients had single-vessel disease (n = 108; 73.9%). More than half of the patients had postinfarction cardiosclerosis (PICS). 17.8% of patients had diabetes mellitus. 19% of patients were present with class 1–2 obesity. The mean left ventricular ejection fraction (LVEF) in the total sample was 61.3±7.5% (37–74%). Eight patients (5.5%) required the conversion of lateral minitracotomy to sternotomy followed by the LAD grafting on the beating heart. The mean volume of intraoperative blood loss was 293.4±117.9 mL. Reasonable incomplete myocardial revascularization was achieved in 24.7% of cases. There were no cases of in-hospital deaths in the study cohort. The incidence of MI, stroke and repeated non-elective myocardial revascularization was within the acceptable range of 0.7%, 0% and 2.7%, respectively. 6.1% of patients (n = 9) had wound complications (deep incisional surgical site infection). The mean length of stay in the intensive care unit was 1±0.2 days. The absolute majority of patients (n = 108) were discharged from the Department of Cardiac Surgery in the period of 10±1.2 days.Conclusion. Off-pump MIDCAB demonstrated good results, low rate of cardiovascular complications and low volume of perioperative blood loss, lack of deep wound infection and shorter hospital length of stay.

Introduction. Radionuclide imaging is included in diagnostic methods after PCI and CABG in patients with symptoms, but the recommendations caution against routine testing in all asymptomatic patients after revascularization. The paper shows the results of single-photon emission computed tomography after hybrid coronary myocardial revascularization; an analysis of the sensitivity and specificity of three methods of surgical myocardial revascularization was carried out in 12 months.Aim of the study was to determine the sensitivity and specificity of SPECT in determining coronary artery stenosis ≥ 50 % after performing three methods of surgical myocardial revascularization: CABG, PCI, and hybrid myocardial revascularization in patients with coronary artery disease and multi-vascular coronary lesion.Material and methods. A retrospective analysis of 82 patients with stable forms of coronary artery disease who underwent myocardial revascularization for the presence of the multivascular coronary lesion was carried out. The patients were divided into three groups: the first group consisted of 40 patients who underwent CABG, the second – 29 patients after PCI, and the third – 23 patients who underwent hybrid myocardial revascularization.Results. All patients after myocardial revascularization, on average, after 21.8±8.6 months, were hospitalized, where singlephoton emission computed tomography of the myocardium with 99mTc-technetril (SPECT) and control coronarography/ shuntography were performed. The frequency of the presence of significant stenosis during coronary angiography with a perfusion defect of ≥5 % on SPECT during exercise was 50, 50 and 33 % in the CABG, PCI, and hybrid revascularization, respectively (p=0.894). The least sensitivity of SPECT was after hybrid myocardial revascularization (20 %), while in the CABG group, the sensitivity was 71.4 % (p = 0.190). The SPECT specificity indices were much higher: in the GABG, PCI, and hybrid revascularization groups, respectively, 75.8, 79 and 88.9 % (p=0.530).Conclusion. There is no significant relationship between the size of the defect on SPECT and coronary angiography data, regardless of the type of surgical myocardial revascularization in patients after myocardial revascularization. Detection of a perfusion defect with a load of more than 10% in SPECT after surgical myocardial revascularization is the basis for coronary angiography in order to exclude stent restenosis or shunt dysfunction, as well as progression of coronary atherosclerosis.

Aim. To estimate long-terms results of incomplete revascularization with the internal thoracic artery to the left anterior descending anastomosis performed during mammary-coronary bypass grafting (MCBG) in 228 patients with stable coronary artery disease using the single-center registry database.Methods.All patients were enrolled into 2 groups. Group 1 consisted of patients with residual SYNTAX score ≤8 (group SYNTAX ≤8, n = 75), Group 2 with residual SYNTAX score >8 (group SYNTAX ≥9, n = 153).Results.The reasons for the incomplete revascularization were: (1) small diameter of the distal segment of the coronary arteries in 52 (23%) patients, (2) calcification and transmural scar of the myocardium in 18 (8%) patients, (3) severe concomitant pathology in 33 (14%) patients, (4) danger and / or inability to place proximal anastomosis on the ascending aorta in 35 (16%) cases, (5) coronary artery hypoplasia in 11 (5%) patients, (6) unfit grafts for shunting in 6 (2%) patients, (7) technical difficulties in visualization of coronary arteries on the posterior and lateral walls due to Dressler's syndrome in 9 (4%) patients. (8) Incomplete revascularization was considered reasonable in 64 (28%) cases due to the number of causes. The three-year all-cause mortality was 4% in the group of SYNTAX ≤8 versus 3.9% in the SYNTAX group ≥9, P = 0.7, similarly to the cardiac death – 2.7% in the group of SYNTAX ≤8 versus 3.3% in the group SYNTAX ≥9, P = 0.9. The need for repeat coronary revascularization was the same in both groups (P = 0.4). The groups did not differ in the number of the combined endpoint (8% in the group of SYNTAX ≤8 versus 6.5% in the group SYNTAX ≥9, (P = 0.9).Conclusion.The study demonstrated that the results of incomplete revascularization with LIMA to LAD do not depend on the residual SYNTAX score.

Adipose tissue, an easily available and bioactive tissue, is currently considered as an attractive source of autologous cells for tissue engineering and regenerative medicine. Here we estimated endothelial cell yield of epicardial adipose tissue (EAT) and subcutaneous adipose tissue (SAT), the two major fat depots, in patients with coronary artery disease. Following enzymatic dissociation of adipose tissue, stromal vascular fraction was cultured in endothelial cell growth medium according to the established protocol. Endothelial phenotype was authenticated by a double immunostaining to VE-cadherin/CD144 and von Willebrand factor. We found that both EAT and SAT contain a comparable and significant amount of endothelial progenitor cells.

THE AIM:Evaluates long-term clinical outcomes of percutaneous coronary intervention (PCI) with bioresorbable vascular scaffold (BVS) versus minimally invasive direct coronary artery bypass (MIDCAB) surgery for the treatment of left anterior descending (LAD) lesions.METHODS AND RESULTS:In this single-center study were included 130 patients with stable angina and significant (≥ 70 %) LAD disease. Patients were randomly assigned in a 1:1 ratio to PCI with everolimus-eluting BVS (n=65) or MIDCAB (n=65). The primary end-point was major adverse cerebro-cardiovascular events (MACCE) and secondary was scaffold (graft) thrombosis at 1 year. The groups of patients were comparable for all baseline demographic, clinical and angiographic parameters. MACCE at 12 month occurred in 9.2 % of patients in the BVS group and in 4.6 % of patients in the MIDCAB group (p=0.3). There was no significant difference between the groups in rates of all cause death (1.5 % vs 1.5 %, p=1.0), myocardial infarction (3.1 % vs. 6.1 %, p=0.4), any revascularization (1.5 % vs. 6.1 %, p=0.1) and scaffold (graft) thrombosis (1.5 % vs. 1.5 %, p=1.00).CONCLUSION:At 12-month follow up, there was no significant difference in the rate of MACCE between PCI by BVS and MIDCAB in patients with isolated LAD lesions.