Aim. To study the inhospital outcomes of implantation of a centrifugal left ventricular assist device (LVAD) in patients with end-stage heart failure (HF). Material and methods. There were following inclusion criteria: estimated body surface area >1,2 m 2 , end-stage HF, LV ejection fraction <30%, cardiac index <2,2 l/min, long-term optimal therapy for HF. Patients were considered for implantation of a centrifugal (LVAD) as part of the final therapy, but subsequent heart transplantation was not ruled out if appropriate. Results. LVAD was implanted in 23 patients. All patients were men (mean age, 59,1±10 years; mean body mass index, 26±4,6 kg/m 2 ). Ten patients had dilated cardiomyopathy, while 13 — ischemic one. Diabetes was revealed on in 3 (13%) patients, while chronic kidney disease and cancer — in 3 (13%) and 4 (17%) patients, respectively. The mean value of the six-minute walk test (6MWT) upon admission to the hospital was 257±71 meters. In one patient with gastric cancer, the device was implanted as a part of bridging therapy strategy. Thirty-day mortality was 9% (n=2). One of the deceased patients had a long history of end-stage heart failure, body weight deficiency, and frailty with severe muscle weakness. The second death was the result of early postoperative right ventricular failure. At discharge, patients had optimal LVAD performance based on anthropometric characteristics and physical activity. According to echocardiography, the criteria for unloading the left heart chambers have been achieved. The distance of 6MWT at discharge was 298±78 meters. Conclusion. Inhospital outcomes of implantation of a centrifugal LVAD in patients with end-stage HF demonstrate high efficiency in supporting systemic hemodynamics with an acceptable safety profile in patients with extremely high perioperative risk.

The co-occurrence of chronic heart failure (CHF) and cancer is becoming more and more common as people live longer. The lack of a structured approach to the treatment of cancer patients with severe cardiovascular conditions is an essential issue. Up to 25% of cancer patients cannot be operated on for their main disease profile due to the presence of cardiovascular disease. This article describes a clinical case of successful treatment of a patient with two competing (prognosis-determining) diseases: end-stage heart failure and stomach cancer within the framework of a bridge-to-cancer strategy.

Aim. To analyze the factors associated with a poor outcome of pulmonary thromboendarterectomy (PTE) and complications of the hospital postoperative period; on the basis of this analysis to optimize preoperative preparation and therapeutic support of the operation. Materials and methods. The study included 47 patients with operable CTEPH, who underwent PTE in the Department of cardiovascular surgery of the national medical research center of cardiology from 2010 to 2018. Patients were observed during the intrahospital period, all were evaluated for clinical, instrumental, hemodynamic, and laboratory parameters. Diagnosis and treatment of complications, assessment of the relationship of factors associated with the development of these pathological conditions were carried out. Results. A comprehensive assessment of the parameters revealed that age over 50 years, the presence of proven antiphospholipid syndrome (AFS) were independently associated with a higher frequency of adverse surgical outcomes and in-hospital complications. Older age and a history of smoking were independently associated with a greater likelihood of developing reperfusion pulmonary edema. The probability of developing transient neurological complications is independently associated with a long duration of deep hypothermic circulatory arrest (DHCA), an increased level of D-dimer. A greater age and longer duration of ventilation are independently associated with the likelihood of developing acute kidney injury (AKI). A higher level of antithrombin III and the presence of AFS were independently associated with the likelihood of developing prolonged ventilation. Conclusion. When selecting candidates for surgery, in addition to the generally accepted clinical and instrumental parameters, it is necessary to take into account a history of Smoking, an increase in d-dimer, and the presence of AFS. Patients with this pathology need a more thorough risk assessment, correction of target levels of activated partial thromboplastin time (aPTT), activated clotting time (ACT) due to their falsely inflated indicators, and further development of standards for perioperative support. The main principle of cardiological support of the operation is the earliest possible diagnosis of all known perioperative complications and the rapid start of their treatment, which ensures the stabilization of the patient’s condition in 85% of cases in the hospital period. In the postoperative period, an early transition from ventilator to independent breathing is indicated for the prevention of associated complications, including AKI.

Aim. To analyze the factors associated with a poor outcome of pulmonary thromboendarterectomy (PTE) and complications of the hospital postoperative period; on the basis of this analysis to optimize preoperative preparation and therapeutic support of the operation. Materials and methods. The study included 47 patients with operable CTEPH, who underwent PTE in the Department of cardiovascular surgery of the national medical research center of cardiology from 2010 to 2018. Patients were observed during the intrahospital period, all were evaluated for clinical, instrumental, hemodynamic, and laboratory parameters. Diagnosis and treatment of complications, assessment of the relationship of factors associated with the development of these pathological conditions were carried out. Results. A comprehensive assessment of the parameters revealed that age over 50 years, the presence of proven antiphospholipid syndrome (AFS) were independently associated with a higher frequency of adverse surgical outcomes and in-hospital complications. Older age and a history of smoking were independently associated with a greater likelihood of developing reperfusion pulmonary edema. The probability of developing transient neurological complications is independently associated with a long duration of deep hypothermic circulatory arrest (DHCA), an increased level of D-dimer. A greater age and longer duration of ventilation are independently associated with the likelihood of developing acute kidney injury (AKI). A higher level of antithrombin III and the presence of AFS were independently associated with the likelihood of developing prolonged ventilation. Conclusion. When selecting candidates for surgery, in addition to the generally accepted clinical and instrumental parameters, it is necessary to take into account a history of Smoking, an increase in d-dimer, and the presence of AFS. Patients with this pathology need a more thorough risk assessment, correction of target levels of activated partial thromboplastin time (aPTT), activated clotting time (ACT) due to their falsely inflated indicators, and further development of standards for perioperative support. The main principle of cardiological support of the operation is the earliest possible diagnosis of all known perioperative complications and the rapid start of their treatment, which ensures the stabilization of the patient’s condition in 85% of cases in the hospital period. In the postoperative period, an early transition from ventilator to independent breathing is indicated for the prevention of associated complications, including AKI.

Disclaimer The EAC Guidelines represent the views of the EAC, and were produced after careful consideration of the scientific and medical knowledge, and the evidence available at the time of their publication. The EAC is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the EAC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the EAC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies; however, the EAC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the EAC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening delayed complication of acute pulmonary embolism. It is characterized by chronic obstruction of the branches of the pulmonary artery, arteriopathy and vasoconstriction of small vessels, that ultimately leading to right ventricular failure. Subtraction CT pulmonary angiography (CTPA) allows to perform a comprehensive the assessment of the state of the vascular bed and pulmonary perfusion, it is especially important for pathological changes in the distal branches of the pulmonary artery. Analysis of perfusion defects in combination with the standard protocol of CTPA can increase the diagnostic value of the method in examining patients with CTEPH that will select the optimal treatment strategy with the possibility of an objective assessment of its effectiveness. The aim of this work was to determine the possibilities of the method of subtraction CTPA in the evaluation of the effectiveness of the treatment of patients with CTEPH. Primary and repeated subtraction CTPA was performed 36 patients with the diagnosis of CTEPH (10 patients after surgical treatment, 13 patients after endovascular treatment and 13 patients after initiation of PAH-specific therapy) (figure).All patients were examined on 320-detector row CT scanner using the standard protocol Lung subtraction. Using subtraction CTPA was calculated of CT-scores of obstruction and perfusion defect. The data of primary and repeated CT studies were compared with the clinical and hemodynamic status of patients. CT color-coded iodine images were produced by subtraction of non-contrast from contrast images. According to repeated CTPA a decrease of the degree of obstruction was observed in 18 out of 36 (50%) patients: in 10 (100%) patients from the surgical treatment group and 8 (61.5%) patients from the endovascular treatment group. Subtraction CTPA was a good quality for interpreting perfusion maps in 28 of 36 (77.8%) patients.Evaluation of the dynamics of perfusion disorders was not performed in 8 patients: in 3 patients from the surgical treatment group and 5 patients from the endovascular treatment group. Improvement of lung perfusion according to perfusion maps was determined in 18 out of 28 (64.3%) patients: 7 (100%) patients from the surgical treatment group, 5 (62.5%) patients from the endovascular treatment group, and 6 (46.2%) patients from the group of drug treatment. Improvement of clinical and hemodynamic parameters was observed in all patients in the surgical and endovascular treatment groups. There was no statistically significant improvement in clinical and hemodynamic parameters in the drug treatment group. The results of the study demonstrated the possibility of using subtraction CTPA for an objective assessment of the effectiveness of the treatment of patients with CTEPH.

Aim: to assess the state of vascular bed, parenchyma, and perfusion of lungs in patients with chronic thromboembolic pulmonary hypertension (CTEPH) using the method of subtraction computed tomography (CT). Methods. CT pulmonary angiography (CTPA) was performed in 45 patients with verified CTEPH (18 men, 27 women, age 26-79 years) by CT scanner using the "Lung subtraction" standard protocol. Parameters analyzed were characteristics of the state of main pulmonary artery (MPA) and the right ventricle (RV), and calculated CT angiographic (CTA) obstruction and perfusion defect scores. Results. Significant correlation was found between CTA obstruction score and perfusion defect score (r=0.34, p=0.02). Mean pulmonary arterial pressure (mPAP) correlated with MPA diameter (r=0.4, p=0.02), RV wall thickness (r=0.6, p=0.0003) and the ratio of MPA diameter to ascending aortic diameter (r=0.5, p=0.002). Significant correlation was also found between RV wall thickness and pulmonary vascular resistance (PVR) (r=0.4, p=0.04). Neither CTA obstruction score nor perfusion defect score correlated with PVR and mPAP. The data of CT did not correlate with results of 6-minute walk test. Conclusion. In patients with CTEPH subtraction CTPA allows carrying out complex diagnostics of the state of vascular bed, parenchyma and perfusion of the lungs.

Objective: to study the pulmonary hemodynamics and kidney function in patients with chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary thromboendarterectomy (PTE). To analyze the main results of PTE.Material and methods: among 51 patients with CTEPH undergoing PTE, the group with chronic kidney disease (CKD) was identified. The main parameters of hemodynamics, such as cardiac output (CO), cardiac index (d), pulmonary arterial pressure (PAP), pulmonary vascular resistance (PVR), were determined. The cases of acute kidney injury (AKI) after PTE were identified. The correlation between hemodynamics and renal function was analyzed.Results: there was decrease of mean PAP, PVR and increase of CO and CI after PTE. In cases of AKI 1-2, the complete recovery of renal function were observed. Glomerular filtration rate (GFR) increased before discharge in patients with CKD and in other patients.Conclusion: the positive dynamics of renal function in patients with CTEPH after PTE is more probably associated with an increase in the С and renal perfusion.

Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the potentially curable forms of pulmonary hypertension, in which pulmonary thromboendarterectomy is the gold standard treatment. However, over the last decade, great attention has been given to a combined therapeutic approach including both drug therapy and surgical treatment and the application of endovascular technologies. This clinical case demonstrates the diagnostic difficulties of CTEPH and the opportunities of a comprehensive approach to therapy for the disease with mandatory assessment of preoperative surgical and medical treatment in order to improve the patient status and to prepare for surgery.

Pulmonary endarterectomy (PEA) is the method of choice in treatment of chronic thromboembolic pulmonary hypertension (CTEPH). There are a lot of factors still restricting the widespread use of these operations. Among them are the difficulties of diagnosing and patient selection, the peculiarities of operation and postoperative treatment, the unawareness of cardiological community about surgical outcomes. We discuss the preparation of the patient to PEA, standards of the surgery and postoperative treatment. The results of preoperative diagnostics and PEA-operations at our center are presented. The possible causes of postopreative mortality and adverse outcomes are also discussed.

Pulmonary endarterectomy (PEA) is the method of choice in treatment of chronic thromboembolic pulmonary hypertension (CTEPH). There are a lot of factors still restricting the widespread use of these operations. Among them are the difficulties of diagnosing and patient selection, the peculiarities of operation and postoperative treatment, the unawareness of cardiological community about surgical outcomes. We discuss the preparation of the patient to PEA, standards of the surgery and postoperative treatment. The results of preoperative diagnostics and PEA-operations at our center are presented. The possible causes of postopreative mortality and adverse outcomes are also discussed.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease which occurs in 1-3% of patients [2, 11] after pulmonary embolism. The incidence of CTEPH is 5-10 cases per 1 million population per year. Similar to other diseases associated with pulmonary hypertension (PH), CTEPH is malignant and has a poor prognosis. [4, 6, 8] There are a number of objective difficulties in the diagnosis of the disease: complaints and symptoms are very non-specific, there are often no X-ray aor ECG changes, echocardiographic signs of overload of right heart chambers are observed in the final stages of the disease. [9, 3] A strong inclination of doctors to primarily seek problems in the left heart chambers also plays a part in this. As a result, a patient may be visiting various specialists for years and receive treatment from different ailments including heart failure, asthma, pulmonary fibrosis, obstructive bronchitis. We had a case where a female patient with CTEPH received prednisolone for asthma for a long time while she had normal spirometry!

The currentguidelines on chronic thromboembolic pulmonary hypertension (CTEPH) treatment consider pulmonary thrombendarterectomy as the first therapy choice. In case of inoperability due to severe patient's condition, distal lesions of pulmonary vessels, extremely high pulmonary vascular resistance, medical treatment for CTEPH includes life-long anticoagulation therapy and reduction of heart failure symptoms. This clinical case of the 59-y-old patient M. with inoperable CTEPH demonstrates the efficacy of phosphodiеsterase-5 inhibitor Sildenafil usedin high doses. The diagnosis was confirmed by the results of the complete diagnostic process including right heart catheterization and pulmonary angiography. The initial functional class was assessed as III in accordance with WHO classification. Sildenafil 60 mg daily was added tothe standard therapy (anticoagulant, calcium channel blocker) for initial four weeks. To the 4wk visit Sildenafil dose was increased to 240 mgdailytaking into account good tolerance of the treatment.The significant improvement of functional class, positive dynamic ofhemodynamic and echo parameters were found to 4 month of follow-up.

Poster: ESCR 2014 / 461 / Comparison of pulmonary MRA and CTA in chronic thromboembolic pulmonary hypertension by: E. A. Mershina 1, M. A. Glazkova2, K. Mershin1, V. Sinitsyn1; 1Moscow/RU, 2Krasnogorsk/RU