КЛИНИЧЕСКИЕ НАБЛЮДЕНИЯ ■ РезюмеЖенщина, 41 год, сердечная недостаточность III функционального класса по NYHA, обратилась в клинику с жалобами на одышку и боли в грудной клетке при обычных физических нагрузках, несмотря на проводимую медикаментозную терапию.Данные эхокардиографии (ЭхоКГ): объем левого предсердия (ЛП) 56 мл.Максимальная толщина левого желудочка (ЛЖ) 19 мм, фракция выброса (ФВ) ЛЖ 67%, конечно-диастолический объем (КДО) ЛЖ 46 мл, ударный объем (УО) ЛЖ 28 мл.Градиент давления в выходном отделе левого желудочка (ВОЛЖ) в покое 8 мм рт.ст.В течение последних 6 мес состоит в листе ожидания на пересадку сердца.Учитывая тяжелосимптомный статус пациента, прогрессирующую сердечную недостаточность, формирование аневризмы верхушки ЛЖ с трансмуральным фиброзом, неэффективность медикаментозной терапии, значимое снижение КДО и УО ЛЖ, с учетом низкого хирургического риска выполнена трансапикальная миоэктомия.Послеоперационный период протекал без осложнений.ЭхоКГ: объем ЛП 51 мл.Максимальная толщина ЛЖ 15 мм, ФВ ЛЖ 72%, КДО ЛЖ 88 мл, УО ЛЖ 63 мл.Градиент давления в ВОЛЖ в покое 7 мм рт.ст.Сердечный выброс увеличен с 2,1 до 4,6 л/мин, тест 6-минутной ходьбы увеличился с менее 50 до 200 м.Тяжелосимптомные пациенты с апикальной гипертрофической кардиомиопатией (ГКМП), выраженной диастолической дисфункцией и малыми размерами полости ЛЖ, могут быть рассмотрены в качестве кандидатов на трансапикальную миоэктомию, в том числе как альтернативу трансплантации сердца.Финансирование.Исследование не имело спонсорской поддержки.Конфликт интересов.Авторы заявляют об отсутствии конфликта интересов.

We present three cases of successful transatrial transcatheter valve-in-valve implantation in patients with bioprosthetic mitral valve dysfunction. Patients with a high surgical risk, with severe heart failure due to bioprosthetic mitral valve dysfunction, were implanted with transcatheter prostheses using the transatrial approach.Transesophageal echocardiography and fluoroscopy-guided transcatheter mitral prosthetic valve positioning was performed. With a cardiac pacing at 180 bpm, a transcatheter valve was implanted. The transcatheter valves functioned properly after surgery. The patients were discharged in satisfactory condition.

Surgical treatment of atrial fibrillation (AF) in patients with valvular heart disease remains one of the most pressing problems in cardiac surgery. The purpose of the study was to determine the dynamics of proANP and myocardial damage markers depending on a modification of the radiofrequency (RF) Maze procedure used. The study involved 86 patients operated over a period from November 2007 to December 2010. A concomitant RF Maze procedure during mitral valve (MV) surgery was performed in two groups of the cohort; in group 1 it was the standard Maze IV scheme, in group 2 it was the modified one. In both groups we assessed the levels of proANP and myocardial damage markers. In group 1 a more significant decrease in proANP (by 4 times) was seen as compared to group 2 (by half). In group 1, the pleural effusion rate was 46.2%, and thoracocentesis rate reached 25.6%. In group 2, the corresponding rates were lower,14.9% and 27.7%. During the first postoperative day there was an increase in creatine phosphokinase MB fraction and Troponin T in both groups, and the rise was significantly higher in group 1. It should be noted that modified Maze IV RF ablation results in 80% freedom from AF, which is consistent with that of the standard Maze IV scheme. In patients with left atrial ablation the proANP secretion is less prominent early after surgery, and myocardial damage is lower in comparison with biatrial ablation.

Aim. To analyze the results of valve-securing surgery on mitral valve in connective tissue dysplasia.Material and methods. From 2011 to 2014 y., totally 171 patient included, with isolated mitral regurgitation. Patients were randomized to 2 groups. Mean age in the Group D — ring, and Group C — flex, was 57 [42;65] and 54 [41;63] year old, respectively (p=0,092). Part of males was 69 and 67% in the groups, respectively.Results. There were no cases of 30-day mortality. During 24 months of follow-up, in D ring and C flex groups, survival was 96,0±2,3% (95% CI 88,6-98,7%) and 94,3±2,8% (95% CI 85,5- 97,9%), resp. (р=0,899); no re-operation — 97,0±2,1% (95% CI 88,4-99,3%) and 100%, resp. (р=0,044); no return of significant mitral regurgitation 80,8±6,5% (95% CI 64,0-90,3%) and 92,8±3,1% (95% CI 83,4-97,0%), resp. (р=0,002).Conclusion. Application of flexible C flex rings in valve-securing operations makes it to achieve better results in middle-long-term post-operation period comparing to the usage of semi-hard support rings in patients with connective tissue dysplasia and severe mitral regurgitation.

Pulmonary hypertension is an increase of pulmonary artery mean pressure for more than 25 mmHg at rest, measured by direct tensometry, and it includes a broad spectrum of diseases. Mechanisms of pulmonary hypertension are a connection of diverse vicious circles determining chronic progression of the disease, progradient worsening of patient’s condition and serious decline in life quality, and premature death. Severe pulmonary hypertension significantly raises risk of perioperation mortality and closely correlates with long-term survival. We propose an original technics of pulmonary artery denervation during one-stage cardiosurgical interventions, that confirmed its safety. Radiofrequency ablation of pulmonary artery in patients with dysplasia of connective tissue and high combined (precapillary and postcapillary) pulmonary hypertension, undergoing surgery for severe sympthomatic mitral insufficiency, is an effective procedure. An assessment is needed for short- and long-term results. Further studies will make it to know, whether the achieved hemodynamical benefits do turn to better clinical outcomes.

Objective. The purpose of this study was to compare clinical and hemodynamic efficacy of different surgical approaches to correct outflow tract obstruction and mitral insufficiency in patients with hypertrophic cardiomyopathy. Methods. Over a period from November 2010 to August 2013, 146 patients with hypertrophic obstructive cardiomyopathy (HOCM) underwent surgical treatment. 88 patients met the inclusion criteria and were randomized in two groups: Group I – extended myomectomy and MV replacement; Group II – extended myomectomy and MV repair. Mean age in Group I and Group II was 51.4±14.4 and 47.9±14.1 years respectively (p = 0.262). Mean peak gradient in Group I and Group II was 89.9±27.2 mm Hg. and 96.6±28.1 mm Hg. (p = 0.168). Pronounced MR was observed in 24 (58.5%) and 23 (56.1%) cases, moderate one in 17 (41.5%) and 18 (43.9%) cases in Group I and Group II respectively (p = 0.823). All patients demonstrated SAM syndrome. Results. There was one (2.4%) early death in Group I (p = 0.314). In both groups such complications as AV block, ventricular septal defect and rupture of the left ventricle (p = 1.0) didn’t differ significantly. Average follow-up was 23.2 months for Group 1 and 25.8 months for Group 2. The survival rate in group I and group II was 78.9% and 96.6% respectively (Log-rank test = 0.034). Freedom from thromboembolic events was 83.2% and 100% respectively (Log-rank test = 0.026). Conclusion. MV replacement and MV repair during extended septal myomectomy in patients with HOCM can be an effective method to eliminate MR and outflow tract obstruction. MV repair in patients with HOCM reduces thromboembolic events and provides better mid-term survival.

Objective. The purpose of this study was to compare clinical and hemodynamic efficacy of different surgical approaches to correct outflow tract obstruction and mitral insufficiency in patients with hypertrophic cardiomyopathy.Methods. Over a period from November 2010 to August 2013, 146 patients with hypertrophic obstructive cardiomyopathy (HOCM) underwent surgical treatment. 88 patients met the inclusion criteria and were randomized in two groups: Group I – extended myomectomy and MV replacement; Group II – extended myomectomy and MV repair. Mean age in Group I and Group II was 51.4±14.4 and 47.9±14.1 years respectively (p = 0.262). Mean peak gradient in Group I and Group II was 89.9±27.2 mm Hg. and 96.6±28.1 mm Hg. (p = 0.168). Pronounced MR was observed in 24 (58.5%) and 23 (56.1%) cases, moderate one in 17 (41.5%) and 18 (43.9%) cases in Group I and Group II respectively (p = 0.823). All patients demonstrated SAM syndrome. Results. There was one (2.4%) early death in Group I (p = 0.314). In both groups such complications as AV block, ventricular septal defect and rupture of the left ventricle (p = 1.0) didn’t differ significantly. Average follow-up was 23.2 months for Group 1 and 25.8 months for Group 2. The survival rate in group I and group II was 78.9% and 96.6% respectively (Log-rank test = 0.034). Freedom from thromboembolic events was 83.2% and 100% respectively (Log-rank test = 0.026).Conclusion. MV replacement and MV repair during extended septal myomectomy in patients with HOCM can be an effective method to eliminate MR and outflow tract obstruction. MV repair in patients with HOCM reduces thromboembolic events and provides better mid-term survival.

Objective. The purpose of the research was to compare early and mid-term results following mitral valve repair by using semirigid and flexible annuloplasty rings.Methods. Over a period from September 2011 to September 2014 171 patients with isolated mitral valve insufficiency were recruited and divided in two groups. Mean age in Group I (D-ring) was 57 years (42 to 65), while in group II (C flex) it was 54 years (41 to 63) (р = 0.092). Males constituted more than a half of patients in both groups (69% and 67% respectively).Results. No early deaths (90 days) were registered. There were 4 transient ischemic attacks in group I (p = 0.042). At midterm follow up (24 months) the survival rate in D-ring and C flex groups accounted for 96.0±2.3% (95% CI 88.6-98.7%) and 94.3±2.8% (95% CI 85.5-97.9%) respectively (log-rank test = 0.899); freedom from reoperation ran to 97.0±2.1% (95% CI 88.4-99.3%) and 100% respectively (log-rank test = 0.044); freedom from significant recurrent mitral regurgitation came to 80.8±6.5% (95% CI 64.0-90.3%) and 92.8±3.1% (95% CI 83.4-97.0%) respectively (log-rank test = 0.002). Conclusion. Using flexible C rings reduces the incidence of postoperative complications and provides better clinical and functional mid-term results as compared to semi-rigid annuloplasty rings in patients with severe mitral regurgitation due to degenerative mitral valve disease.

Objective . The purpose of the research was to compare early and mid-term results following mitral valve repair by using semirigid and flexible annuloplasty rings. Methods . Over a period from September 2011 to September 2014 171 patients with isolated mitral valve insufficiency were recruited and divided in two groups. Mean age in Group I (D-ring) was 57 years (42 to 65), while in group II (C flex) it was 54 years (41 to 63) (р = 0.092). Males constituted more than a half of patients in both groups (69% and 67% respectively). Results . No early deaths (90 days) were registered. There were 4 transient ischemic attacks in group I (p = 0.042). At midterm follow up (24 months) the survival rate in D-ring and C flex groups accounted for 96.0±2.3% (95% CI 88.6-98.7%) and 94.3±2.8% (95% CI 85.5-97.9%) respectively (log-rank test = 0.899); freedom from reoperation ran to 97.0±2.1% (95% CI 88.4-99.3%) and 100% respectively (log-rank test = 0.044); freedom from significant recurrent mitral regurgitation came to 80.8±6.5% (95% CI 64.0-90.3%) and 92.8±3.1% (95% CI 83.4-97.0%) respectively (log-rank test = 0.002). Conclusion . Using flexible C rings reduces the incidence of postoperative complications and provides better clinical and functional mid-term results as compared to semi-rigid annuloplasty rings in patients with severe mitral regurgitation due to degenerative mitral valve disease.

В настоящее время в мире доступны десятки различных моделей механических клапанов сердца. Выбор механического протеза остается актуальной проблемой в клапанной хирургии. Внедрение в клиническую практику любого искусственного клапана сердца требует доказательной базы, основанной на современных научных данных об эффективности и безопасности протеза в отдаленные сроки наблюдения. В настоящей статье представлены обзор исследований по сравнению наиболее часто используемых в мире зарубежных механических клапанов сердца в отдаленные сроки наблюдения, а также сравнительные результаты использования механических клапанов сердца отечественного производства в аортальной и митральной позиции.

A mitral valve prolapse nowadays is the most common cause of mitral insufficiency in the western countries and is associated with high morbidity and mortality. In the last decades repairing the mitral valve has become the operation of choice for treatment of the mitral valve prolapse, thus enabling to improve the geometry and function of the left ventricle and long-term survival. Literature related to mitral valve repair in patients with Barlow disease is reviewed.

Degenerative mitral valve disease nowadays is the most common cause of mitral insufficiency in developed countries and is associated with high morbidity and mortality. In the last decades repairing the mitral valve has become the operation of choice for treatment of the mitral valve prolapse, enabling to improve the geometry and function of the left ventricle and long-term survival. Nevertheless, the problem of choice of method of management of severe mitral regurgitation in asymptomatic patients with degenerative mitral valve disease remains unsolved. In this article we present immediate results of a prospective comparative study of mitral valve surgery in asymptomatic and symptomatic patients in dependence on NYHA class of heart failure.

More than 50 years have passed since the first successful heart valve replacement. Since then, many types of mechanical prostheses have been introduced. The prosthesis choice for the replacement of an affected valve is a major concern in valvular surgery. The introduction of a new heart valve prosthesis requires accurate data collection and data processing for a long follow-up period. In present article we sought to compare modern commercial available bileaflet foreign mechanical valve prosthesis for their long follow-up with Russian mechanical valve for aortic and mitral valve replacement.

To evaluate the impact of surgical strategy in concomitant mitral valve surgery or isolated aortic valve replacement (AVR) in patients with moderate secondary mitral regurgitation (MR), 1 574 patients underwent AVR over a period from January 2003 to December 2011. 241 patients had secondary MR 2+ and constituted the study population. Patients were stratified into two groups, those without concomitant mitral valve surgery (Group A, n = 113) and with it (Group B, n = 128). It was found out that AVR plastic correction of MI reduces its recurrence during short-term follow-up but increases the intervention time leading to an insignificant rise in lethality. In patients with aortic stenosis the age exceeding 70 years and the presence of atrial fibrillation are found to be the most significant predictors of preservation of residual mitral regurgitation in the early postoperative period, while more indicative for patients with aortic insufficiency is the presence of tricuspid regurgitation grade 2 or higher.

Проведен сравнительный анализ процедуры cut and sew Maze III с ее радиочастотной (РЧ) модификацией Maze IV. С 2004 по 2011 г. 182 пациентам выполнена полная биатриальная схема процедуры Maze при коррекции клапанных пороков сердца. Пациенты были разделены на две группы: в I группе выполнена процедура Maze III, во II группе выполнялась РЧ аблация по идентичной схеме с использованием биполярного электрода. Большая часть пациентов имела длительно персистирующую форму фибрилляции предсердий (ФП). Время выполнения процедуры cut and sew значительно превышало временные показатели РЧ аблации. Перманентная дисфункция синусового узла с необходимостью последующей имплантации постоянного пейсмейкера была достоверно чаще при выполнении процедуры Maze III. Как показали результаты трехлетнего наблюдения, технология Maze III cut and sew имеет более высокий уровень свободы от ФП, чем процедура РЧ фрагментации предсердий Maze IV у пациентов с клапанными пороками сердца, при отсутствии достоверной разницы мозговых эмболических осложнений.

The paper presents results from December 1999 to December 2011 years of surgical defect correction in patients with acquired combine mitral-aortal heart defects with low contraction function of left ventricular. Patients with ischemic heart disease were excluded from the study. Experimental group contained 49 cases.We revealed that correction could be made with low hospital mortality. Systolic dysfunction of the left ventricular is not a contraindication for surgical treatment of discussed heart defect. Patients with mitral-aortal insufficiency are more severe, had more complications and higher mortality

Influence associated diseases on risk of surgical treatment of the valvular heart diseases in elderly people. Jften valvular heart diseases associated with an arterial hypertensia, coronary diseases, an atherosclerosis. Also frequency of presence associated diseases is estimated at different etiology heart valvular diseases.

Microcirculation in the subepicardium was studied in 30 patients with aortic acquired valvular disease (AVD) and 20 with mitral AVD with the use of an ALF-21 laser Doppler blood flowmeter (Transonic Systems). In total, 845 measurements were made. Subepimyocardial flow (EMF) was measured on the anterior surface of the right and left atria and on the anterior, posterior, and diaphragmatic surfaces of the left and right ventricles of the heart before and after surgery. A decrease in the hyperfunctioning of the chambers of the heart led to a redistribution of myocardial flow. Differences (ΔEMF) between EMF values observed before and after treatment were analyzed, and the coefficients for the linear equation ΔEMF = a + kEMFbs were computed by the least-squares method. It was found that blood flow decreased when it was enhanced before treatment and increased when it was weak initially. Thus, blood flow was balanced, approaching a value that did not change after treatment, and heterogeneity of coronary flow in the microcirculatory link decreased. Control mechanisms were assumed to change blood flow so that it acquires stability, which is needed to preserve and maintain normal energy parameters of the functioning myocardium.