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.

Objective.Atrial fibrillation (AF) is an independent risk factor affecting overall mortality.Concomitant surgical ablation of AF effectively restores the sinus rhythm and improves the quality of life.To date, there is no consensus on the optimal atrial fragmentation scheme for the treatment of AF in patients undergoing cardiac surgery.The purpose of this study is to compare the influence of left atrial and biatrial ablation on the frequency of pacemaker implantation in patients with persistent and long-standing persistent AF undergoing open heart surgery.Material and methods.Between January 2007 and December 2016, concomitant ablation was performed in 898 patients with valvular heart disease and AF, as planned, during the correction of valvular pathology.After exclusion of patients with paroxysmal AF 588 consecutive patients with either persistent (20.9%) or longstanding persistent (79.1%)AF were enrolled in the study.To reduce between-group differences, propensity score-matched groups (156 patients per group) were obtained, with similar preoperative and perioperative characteristics.The average duration of long-term monitoring was 37.3 ± 34.1 months in left atrial lesion set group and 37.1 ± 34.2 months in biatrial lesion set group.Evaluation of the rhythm was carried out using 24-hour Holter monitoring.Indications for implantation of the pacemaker included symptomatic syndrome of weakness of the sinus node (heart rate less than 60 beats per minute without adequate adaptation to physical activity) and some disorders of atrial-ventricular conduction.Results.After propensity score matching, biatrial lesions set in comparison with left atrial lesions set was associated with higher pacemaker implantation rate (17.3% vs. 3.8%; p < 0.001).The main reason for the higher demand for pacemaker implantation in the performance of biatrial lesions set was the higher frequency of sinus node dysfunction.There was no significant between-group difference regarding the incidence of atrioventricular conduction disturbances (7.0% vs. 3.2%, respectively; p = 0.211).Conclusion.Biatrial ablation was associated with higher incidence of sinus node dysfunction and higher rate of pacemaker implantation.

Commentary to the update 2017 AHA/ACC and ESC/EACTS Guidelines for the management of patients with valvular heart disease

Aim. Experimental evaluation of the viscous friction disk pump efficiency, studying the relationship between inter-disk clearance and sizes of input and output ports and pump performance parameters. Materials and methods . To assess the characteristics and to optimize the disk friction pump design the pump model and experimental stand were created. Pump dimensions were set on the basis of medical and biological requirements for mechanical heart support systems and with due consideration of the experimental studies of our colleagues from Pennsylvania. Flow volume of the working fluid was measured by float rotameter Krohne VA-40 with measurement error of not more than 1%. The pressure values in the hydrodynamic circuit were measured using a monitor manufactured by Biosoft-M. Expansion device allowed changing the flow resistance of the system simulating the total peripheral resistance of the circulatory system. Results . Linear direct correlation between the pump performance and the pressure drop of liquid being created at the inlet and outlet of the pump was obtained. The required flow rate (5–7 l/min) and pressure (90–100 mmHg) were reached when the rotor speed was in the range of 2500–3000 rev/min. It has been shown that the increase of the inlet diameter to 15 mm has not resulted in a significant increase in the pump performance, and that the highest efficiency values can be obtained for the magnitude of inter-disk gap of 0.4–0.5 mm. Conclusion. Designed and manufactured experimental disc pump model for pumping fluid has showed the fundamental possibility to use this model as a system for mechanical support of the heart.

Aim. This one-center cohort study focused on the identification of predictors of in-patient (up to 30 days) and late lethality in patients after Ross procedure over a period from 2002 to 2015. Methods. 760 patients aged 16-73 were evaluated. The analysis included methods of descriptive statistics and Kaplan-Meyer survival test. To identify the factors related to lethality outcomes, use was made of a log rank test, a chi-square test and Cox regression analysis. Results. In-patient lethality was from 0 to 5 deaths a year (95% confidence interval, 0 to 3), on average 5.6±1.6% (95% confidence interval; 4 to 7) over a period from 2002 to 2015. The cohort mean values of post-operative survival over 5 and 10 years were 98% and 98% respectively (late survival was 2%). The following statistically significant predictors of in-patient lethality (р<0.05) were revealed: type of surgical complications, type of suture used for transplant anastomosis, emergency coronary grafting, cardioplegia type, on-pump duration, New York Heart Association (NYHA) class, patient’s age. No statistically significant predictors of late lethality (р<0.05) were identified. Conclusion. The existing protocols for coronary arteries deformation, leakage from each of six anastomoses, right ventricle autograft bed, obligatory use of artificial circulation should be updated and added to the relevant Ross procedure guidelines.Received 22 December 2016. Accepted 14 March 2017.Financing: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Acknowledgments: The authors are grateful to Dr. Ponomarev D.N., Cand. Sci., for advice on biostatistics when preparing the article for submission.

Aim. The article compares long-term outcomes after Ross procedure in patients with combined coronary arteries lesion depending on a myocardial revascularization technique: coronary angioplasty or coronary artery bypass graft surgery (CABG). Methods. This prospective randomized one-center trial included 105 patients with aortic valve stenosis and combined arteriosclerotic involvement of coronary arteries. All patients received Ross procedure and myocardial revascularization. Aortic valve stenosis combined with hemodynamically significant lesion of the coronary bed served as the criteria of entry in the trial. A comparative analysis of the results in the immediate postoperative period and during 1-year follow-up was carried out. Results. The study revealed statistically significant differences in the survival rate (p = 0.024). In the CABG + Ross procedure group, the 1-year survival rate was 77 % [66; 89], which was considerably lower than that in the group with transluminal coronary angioplasty and Ross procedure – 92 % [85; 99]. Mortality in the groups under study predominantly occurred during the 1st postoperative month. In the CABG + Ross procedure group mortality was mostly recorded during the intervention and at 13th postoperative day. In the group with transluminal coronary angioplasty and Ross procedure fatal cases tended to happen at the 6th to 18th day after the intervention. Conclusion. The study was the first to show the advantage of 1-year lethality results in the percutaneous transluminal coronary angioplasty + Ross procedure group as compared to the CABG + Ross procedure group. Nevertheless, it should be noted that one-stage aortic stenosis repair and CABG is a conventional option. In this case, a multimodality approach could be recommended for taking an optimal decision. Received 1 March 2017. Accepted 31 March 2017.Financing: The study did not have sponsorship.Conflict of interest: Kretov E.I. served as executive editor of “Endovascular surgery” section. All other authors declare no conflict of interest.Author contributionsData collection and analysis: Zubarev D.D., Demin I.I., Naydenov R.A., Prohorihin A.A., Baystrukov V.I.Critical revision: Kretov E.I., Pokushalov E.A., Karaskov A.M.

Введение. Биологический ксеноперикардиальный протез «ЮниЛайн» применяется в клинической практике с 2008 г. При производстве этого протеза третьего поколения внедрен целый ряд принципиально новых технологий: лазерный раскрой с учетом толщины биоткани, антикальциевая обработка аминодифосфонатами, пространственное моделирование и композитный каркас, а также отсутствие синтетических материалов при производстве манжеты протеза. Целью настоящей работы стала оценка ближайших и среднеотдаленных результатов применения биологического клапана «ЮниЛайн» в митральной позиции. Материал и методы. За период с января 2009 по апрель 2015 г. по поводу митрального порока 215 пациентам был имплантирован биологический протез «ЮниЛайн». Средние сроки и объем наблюдения составили 2,3 ± 2,1 (от 0,1 до 5,9) года и 463,4 пациенто-лет соответственно. Возраст реципиентов протеза «ЮниЛайн» был в среднем 66,5 ± 9,7 года. В 68,1% случаев причиной митрального порока была хроническая ревматическая болезнь сердца. Средний функциональный класс по классификации Нью-Йоркской ассоциации сердца (NYHA) был 2,86 ± 0,2, 2Б стадию недостаточности кровообращения до операции имели 25% пациентов. Фибрилляция предсердий наблюдалась у 65,1% пациентов. Вмешательство было повторным для 28,4% прооперированных пациентов. Изолированное протезирование митрального клапана выполнено 88 (41%) пациентам. Результаты. Госпитальная летальность составила 5,1%. В структуре госпитальной летальности превалировал синдром полиорганной недостаточности (54,5%). Линеаризованный показатель отдаленной летальности составил 2,6% на пациента в год, актуарный показатель выживаемости через 6 лет наблюдения был 91%. В структуре отдаленной летальности преобладали некардиальные причины (41,7%). Линеаризованный показатель реопераций составил 0,86% на пациента в год, актуарный показатель отсутствия реопераций через 6 лет наблюдения был 96,5%. Линеаризованный показатель протезного эндокардита и первичной тканевой недостаточности с кальцификацией составил 0,65 и 0,22% на пациента в год соответственно. Семьдесят четыре (36,3%) пациента в отдаленном периоде получали антикоагулянтную терапию. Линеаризованный показа- тель кровотечений и эмболий в исследуемой группе был 0,43 и 0,22% на пациента в год соответственно. Актуарный показатель отсутствия кровотечений через 6 лет наблюдения составил 99%, тромбоэмболий – 98,5%. Заключение. Имплантация биологического ксеноперикардиального протеза «ЮниЛайн» при митральном пороке обеспечивает высокую выживаемость у пациентов всех возрастов за счет адекватной коррекции гемодинамики, что приводит к полноценному ремоделированию левого предсердия и достоверному снижению уровня легочной гипертензии. Отсутствие синтетических составляющих в конструкции протеза повышает устойчивость биологического клапана «ЮниЛайн» к развитию протезного эндокардита. Имплантация биопротеза «ЮниЛайн» показана пациентам с низкой приверженностью к лекарственной терапии и пациентам, не имеющим возможности адекватного контроля антикоагулянтной терапии.

Цель. Оценить возможность и безопасность транскатетерного закрытия постинфарктных дефектов межжелудочковой перегородки в различные сроки после острого инфаркта миокарда. Материал и методы. С 2010 по 2015 г. в Новосибирском научно-исследовательском институте патологии кровообращения имени академика Е.Н. Мешалкина транскатетерное закрытие постинфарктного дефекта межжелудочковой перегородки проводилось у 15 пациентов (11 женщин и 4 мужчин). Время от возникновения инфаркта миокарда до вмешательства составило от 1 дня до 6 мес. (в среднем 10,9 нед.). Три пациента подвергались вмешательству в острой фазе инфаркта миокарда (2 нед. и менее). Размеры дефекта по данным эхокардиографии составили 7–24 мм (в среднем 13,5 мм), размеры устройства от 12 до 34 мм (в среднем 22,8 мм). Время процедуры и флюороскопии составило 65–170 (в среднем 115,3) и 14–78 (32,5) мин. Результаты. Успешная имплантация окклюдера наблюдалась в 14 случаях из 15. У одного пациента произошла дислокация окклюдера. В дальнейшем пациент подвергся успешной хирургической коррекции дефекта. Имплантация окклюдера не улучшила клинический статус пациентов в критическом состоянии. В обоих случаях прогрессировала полиорганная недостаточность, в итоге первый пациент умер на 2-е сутки после операции, а второй на 9-е. Выводы. Эндоваскулярное закрытие может служить альтернативой и позволяет избежать открытой операции у пациентов с выраженной сопутствующей патологией и подходящей анатомией. Однако внутрибольничная летальность остается высокой, даже после успешной имплантации окклюдера.

Aim. The study was aimed at comparing the immediate and long-term results of aortic valve replacement in combination with various techniques of intervention for myocardial revascularization, namely: coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA).Methods. This randomized prospective controlled study involved 120 cardiac patients over 18 years old with combined aortic valve stenosis and arterial sclerotic disease of coronary arteries. The inclusion criteria were a combination of aortic valve stenosis and a hemodynamically significant lesion of the coronary bed. A comparative analysis of the results obtained in the nearest postoperative period and during 1-year follow-up is presented. Results. Hybrid intervention (aortic valve replacement + percutaneous transluminal coronary angioplasty) produces the results which are comparable with those of the control (aortic valve replacement + CABG), with a significantly greater decrease in the peak gradient on the aortic valve. During long-term follow-up, the group of patients who underwent hybrid intervention demonstrated a much higher myocardial infarction rate (12.5 versus 2.5 %, however, the severity of infarctions was significantly lower.Conclusion. PTCA, as compared to CABG, with concomitant coronary artery disease significantly improves the indicators of aortic valve insufficiency and the survival after repeated myocardial infarction, with the matching frequency of acute cerebral circulation abnormalities and the lethality rate in the long-term period.Received 29 August 2016. Accepted 5 October 2016.Funding: The study had no sponsorship. Conflict of interest: The authors declare no conflict of interest.

97 neonates were included in this prospective observational study. While using the exclusion criteria, two groups without demographic differences were formed: the first group included 35 patients with blood loss greater than 10 ml/kg in the first 4 hours postoperatively, the second one consisted of 46 patients who did not have such blood loss. Hemostatic standard tests and thromboelastography were performed before surgery, immediately after surgery and 24 hours after it. As a result, a detailed description of the changes of hemostasis in the perioperative period in newborns with CHD was developed. It was found out that significant postoperative bleeding increases the incidence of coagulopathy, resuscitation after surgery, duration of mechanical ventilation, length of stay at ICU and 30-day mortality. It is confirmed that the main pathogenetic mechanisms of increased bleeding in the first hours after the operation are due to cardiopulmonary bypass coagulopathy, the dynamics and implications of which are documented in our study. Also established are prognostic clinical and laboratory predictors of coagulopathy associated with severe multiple organ failure.

Objective: The aim of the study was to evaluate the ability of cytokine peripheral blood mononuclear cells and its correlation with the release of endothelial progenitor cells after mobilization of G-CSF in patients with chronic heart failure.Methods: Mononuclear cells were obtained from peripheral blood of 35 patients with chronic heart failure before and after mobilization procedures G-CSF (granulocyte colony stimulating factor). Spectrum of cytokine production and growth factors mononuclear cells was evaluated by ELISA in spontaneous conditions and upon stimulation of cells with concanavalin A, lipopolysaccharide, G-CSF, erythropoietin. Results: A statistically significant increase in the spontaneous production of IL-18, VEGF, Epo and reducing TNF-α production and G-CSF mononuclear cells after mobilization procedures G-CSF. A statistically significant increase in mononuclear cell production of IL-18, VEGF, and G-CSF in response to mitogenic stimulation (Con A) and decrease in production of IL-8 after mobilization procedures G-CSF. In response to an antigenic stimulus (LPS) mononuclear cells were enriched with endothelial progenitor cells from patients with chronic heart failure responded statistically significant increase in the production of IL-18 and G-CSF, and decreased production - TNF-α, as compared to similar products of cytokines and growth factors prior to the procedure to mobilize G-CSF. Proangiogenic cytokines G-CSF or Epo result in a statistically significant increase in the production TNF-α, IL-10, VEGF, and G-CSF mononuclear cells enriched endothelial progenitor cells in patients with chronic heart failure.Conclusion: Peripheral blood mononuclear cells, endothelial progenitor cells enriched after mobilization of G-CSF, in patients with chronic heart failure produce cytokines and growth factors with proangiogenic effect. Thus, endothelial progenitor cells contribute to the production of cytokines and growth factors such as TNF-α, IL-18, IL-10, Epo, VEGF. Mononuclear cells were obtained after mobilization of G-CSF, can be used to treat chronic heart failure.

Objective. Pulmonary hypertension impairs the mitral valve and often leads to more severe symptoms of heart failure, low exercise tolerance and thus higher rates of morbidity and mortality. The purpose of this study is to evaluate the safety and efficacy of simultaneous radiofrequency ablation of ganglionated plexi of the pulmonary artery in patients with high pulmonary hypertension during mitral valve surgery.Methods. The inclusion criteria were based on patients’ echocardiography/right heart catheterization data. The main criteria were mean pulmonary artery pressure ≥40 mm Hg at rest and a positive reactive test with nitric oxide inhalation. From January 2014 to May 2015, 14 patients underwent radiofrequency denervation of the pulmonary artery in addition to planned mitral valve surgery. Mean patient age was 53.4±7.8 years, with 57.1% of patients being females.Results. Mean cardiopulmonary bypass time was 116±12 minutes, mean cross-clamp time was 95±13 minutes, and mean ablation time amounted to 9.5±3.1 minutes. Pulmonary artery pressure decreased significantly from a mean of 56.5±9.8 mmHg to 32.0±7.3 mmHg immediately after the operation (p<0.001), and to 28.4±5.2 mmHg and 29.7±4.4 mmHg on the first and third days at ICU respectively. Mean ICU stay was 3.1±1.2 days. There were neither early deaths nor specific complications.Conclusions. Simultaneous radiofrequency ablation of pulmonary artery ganglionated plexi when performing mitral valve surgery in patients with pulmonary hypertension is a safe and effective procedure. Further research and long-term follow-up would help to determine whether a decrease in the mean pressure of the pulmonary artery can be interpreted as a clinical advantage.

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.

The study was carried out to diferentiate reference values for kaolin-activated thromboelastography in newborns with congenital heart disease. The study included two groups ofpatients. The first one consisted of 62 newborns with congenital heart disease and the second one consisted of 35 healthy newborns. The results of kaolin-activated thromboelastography implemented in groups are evaluated as condition of normal coagulation. The valuable diferences of homeostasis system in healthy newborns and newborns with congenital heart disease (without severe concomitant pathology) are not established. They have similar indicators of kaolin-activated thromboelastography. The derived results can be applied as standards in full-term newborns with congenital heart disease.

Караськов Александр Михайлович, доктор мед

Aim . To evaluate the results of prosthetic replacement of ascending aorta and the arc, according to the methods of brain protection. Material and methods . Totally, 63 patients included, 52 (42-60) year old with DeBakey type I chronic dissection. Group 1 (n=32) — with the method of antegrade brain perfusion (AP) within artificial circulation (AC) and hypothermia (23-24o C); group 2 (n=31) with retrograde perfusion (RP) within AC and profound hypothermia (18o C). With the cerebral oxymetry the frontal lobe oxygen supply was measured (rSO2, %) during the operation. Questionnaire SF-36 was in use for life quality assessment before and late after operation. Results. In the group 1 the rSO2 during AC reduced less than 10% from baseline, and in the group 2 values of rSO2 reduced by more than 30%, (p<0,05). Neurological complications in group 1 were registered in 12,5% cases, in the group 2 — in 35,4% (p<0,05). Logistic regression showed that decrease of rSO2 during AC for more than 33% from baseline does raise the odds for neurological disorders development 5 times. Mental health parameter (MH) in long-term follow-up of operation was negatively correlated with the duration of AC (r=-0,46; p=0,003). Conclusion. Antegrade perfusion of the brain under conditions of moderate hypothermia during reconstruction surgery of proxymal aorta demonstrated better cerebroprotection, which was showed by lower rate of neurological complications in early post-operation period comparing to patients after systemic hypothermic AC.

ЦельСравнение результатов процедуры Росса и операции Бенталла-Де Боно лечения пациентов с аортальнымипороками и сопутствующим расширением восходящего отдела аорты.Материал и методыВ исследование включили пациентов с пороками аортального клапана и расширением восходящей аорты≥45 мм, которым выполнили операции Росса (76 пациентов) и Бенталла-Де Боно (47). C помощью методики propensity score matching сформировали две группы по 42 пациента: I группа – процедура Росса, II – операция Бенталла-Де Боно. Проведен сравнительный анализ результатов оперативного лечения с оценкойкачества жизни. Медиана срока наблюдения для I группы – 24 (12; 35) мес., для II – 21 (14; 25) мес. (p = 0,27).РезультатыНе получено статистически значимых различий по показателям ранней и отдаленной летальности, а такжепо характеру осложнений в раннем послеоперационном периоде. Свобода от протез-зависимых осложне-ний для I группы составила 95,1±3,4%, для II – 76,2±8,2% (p = 0,08). Свобода от дисфункции протезов для I и II групп – 91,0±5,0 и 97,4±2,6% (p = 0,3). Качество жизни пациентов в первой группе было выше, статистически значимые различия получены для показателя физического функционирования (I группа – 85 (72,5; 90), II – 80 (65; 85), p = 0,02) и психического здоровья (I группа – 80 (70; 84), II – 68 (64; 76), p = 0,02) опросникаSF-36.ВыводыПроцедура Росса – безопасная методика лечения пациентов с аортальными пороками и сопутствующимрасширением восходящей аорты. Качество жизни после процедуры Росса выше, чем после операции Бен-талла-Де Боно.