Цель исследования – изучить влияние перенесенного COVID-19 на развитие раннего тромбоза коронарных шунтов после хирургической реваскуляризации миокарда у пациентов с ишемической болезнью сердца.

The introduction of drug-eluting stents (DES) into clinical practice has led to a significant reduction in the incidence of in-stent restenosis (ISR) compared to implantation of bare metal stents. However, in 2-4% of cases, the development of angiographic restenosis is observed. Vascular Endothelial Growth Factor-A (VEGF-A) promotes early endothelialization of the stented segment, but in some cases can promote progressive neointimal growth due to proinflammatory effects. Aim. To evaluate the influence of plasma VEGF-A level on ISR after DES implantation. Material and methods. We prospectively examined 49 patients who were implanted with DES due to stable coronary artery disease with ischemia-related arterial stenosis >70% according to a stress test, as well as with a fractional flow reserve <0,8. Plasma VEGF-A level was assessed immediately before the procedure and 24 hours after it. The follow-up period was 11±4 months from the moment of intervention. Subsequently, all study participants underwent repeated coronary angiography to determine whether they had angiographic ISR and to identify patients at risk of recurrent angina pectoris. In 9 patients (18% of participants), angiographic ISR was recorded in the long-term period. Results. The groups of patients with and without long-term restenosis were comparable in terms of initial VEGF-A levels: 481 (259; 674) and 560 (339; 766) pg/ml, respectively (p>0,05). Within 24 hours after stent implantation, a significant increase in VEGF-A level was found in patients who subsequently demonstrated angiographic ISR as follows: from 476 (267; 602) to 1117 (1089; 1573) pg/ml (p<0,05). A positive moderate correlation was established between the plasma VEGF-A content 24 hours after stent implantation and angiographic ISR in the long-term period (r=0,55; p<0,001). Conclusion. Initial plasma VEGF-A levels are not associated with angiographic ISR. Moreover, a sharp increase in VEGF-A level f within 24 hours after coronary stenting is associated with drug-eluting ISR.

Objective: To develop and test an algorithm for no-reflow phenomenon (NRP) prevention during endovascular treatment of patients with ST-elevation myocardial infarction (STEMI) Methods: A prospective single-center randomized study included 100 patients diagnosed with STEMI who underwent coronary artery stenting. Group 1 included 50 patients who were operated using an algorithm for the NRP prevention, while Group 2 included 50 patients who underwent routine transluminal balloon angioplasty and stenting of the coronary arteries. The NRP risk was assessed using the predictive model by Wang JW et al Results: Both groups were comparable in terms of anamnestic and clinical data, biochemical and instrumental examination results. High NRP risk was determined in 36% of Group 1 patients and 40% of Group 2 patients. NRP developed significantly less often in Group 1 patients compared to Group 2 (14% vs. 36%, p=0.01). Worsening of Killip class of acute heart failure was found significantly less common in Group 1 patients compared to Group 2 (2% versus 16%, p=0.03) Conclusion: The proposed algorithm for NRP prevention increased the effectiveness of treatment for STEMI Keywords: ST-elevation myocardial infarction, myocardial revascularization, percutaneous coronary intervention, no-reflow phenomenon.

Approaches to myocardial revascularization in patients with acute ST-segment elevation myocardial infarction remain controversial, both from the point of view of disaggregant therapy and from endovascular approaches to restoring the lumen of the affected vessels. We herein present the result of treating a 64-year-old male patient admitted to the Regional Vascular Center of the Aleksandrovskaya Hospital with a preliminary diagnosis of 'Acute coronary syndrome with ST segment elevation. Acute heart failure class IV according to Killip'. The findings of angiography revealed acute occlusions of the proximal segments of the right coronary artery and the anterior interventricular branch of the left coronary artery. Given a combination of prognostically unfavorable factors, a decision was made intraoperatively on preventive administration of eptifibatide, followed by manual thromboaspiration and implantation of stents without predilation, which, in our opinion, had a beneficial effect on the further course of the disease. This clinical case demonstrates the importance of risk stratification and an individual approach to myocardial revascularization in patients with the pathology concerned. In addition, this clinical example underlines an important role of preventive administration of IIb/IIIa glycoprotein receptor blockers and thrombus aspiration in relation to the development of reperfusion complications and the no-reflow phenomenon in a patient with an extremely high risk of their occurrence.

Исследование заключалось в определении влияния стентирования почечных артерий у пациентов с артериальной гипертензией в сочетании со стенозом почечных артерий на клинико-гериатрический статус по таким показателям, как число принимаемых препаратов, когнитивный статус, определяемый по шкале MMSE, распространенность частоты падений, психоэмоциональный статус по шкале Бека, качество сна по шкале ВАШ, индекс возрастной дискриминированности по опроснику эйджизма E. Palmore, качество жизни по опроснику SF-36. В исследовании приняли участие 72 пациента пожилого возраста с артериальной гипертензией в сочетании со стенозом почечных артерий. По итогам проведенного исследования, в результате стентирования почечных артерий отмечается уменьшение числа принимаемых препаратов, улучшение когнитивного статуса по шкале MMSE, уменьшение распространенности частоты падений, улучшение психоэмоционального статуса по шкале Бека и качества сна по шкале ВАШ, снижение уровня возрастной дискриминированности, повышение качества жизни по всем шкалам опросника SF-36. The study consists in determining the effect of renal artery stenting in patients with arterial hypertension in combination with renal artery stenosis on the dynamics of clinical and geriatric status in terms of such indicators as the number of drugs taken, cognitive status, determined by the MMSE scale, prevalence of the frequency of falls, psycho-emotional status by the Beck scale, the quality of sleep on the VAS scale, the index of age discrimination according to the E. Palmore ageism questionnaire, the quality of life according to the SF 36 questionnaire. The study involved 72 elderly patients with arterial hypertension in combination with renal artery stenosis. According to the results of the study, as a result of stenting of the renal arteries, there is a decrease in the number of drugs taken, an improvement in the cognitive status on the MMSE scale, a decrease in the frequency of falls, an improvement in the psycho-emotional status on the Beck scale, an improvement in the quality of sleep on the VAS scale, a decrease in the level of age discrimination, an increase in the quality of life according to questionnaire SF-36 on all scales.

Самым распространенным пороком клапанов сердца у лиц пожилого и старческого возраста является стеноз аортального клапана. Традиционным методом лечения тяжелого аортального стеноза (АС) считается открытая операция по замене аортального клапана. Более современным малоинвазивным методом коррекции АС является транскатетерная имплантация аортального клапана (TAVI). Данное вмешательство прежде всего показано пациентам старческого возраста и высокого хирургического риска, страдающим тяжелой ХСН, обусловленной АС. В настоящее время TAVI превратилась из сложной и опасной процедуры в эффективный и безопасный метод лечения благодаря разработке устройств нового поколения. При этом актуальными остаются вопросы использования TAVI в отдельных клинических случаях: применение TAVI в пожилом возрасте (60-75 лет), TAVI у долгожителей (90 лет и более), TAVI при старческой астении (frailty), целесообразность TAVI при низком хирургическом риске и другие, а также вопросы, связанные с долговечностью клапанов, применяемых для TAVI, и прогнозом в отношении качества и продолжительности жизни. The most common heart valve defect among the elderly and senile is aortic valve stenosis. The traditional method of treating severe aortic valve stenosis is open surgery to replace aortic valve. At the same time, a more modern, minimally invasive method of correcting aortic stenosis is transcatheter aortic valve implantation (TAVI). This intervention is primarily indicated for patients of old age suffering from severe chronic heart failure associated with aortic stenosis, who have a high surgical risk. Currently, TAVI has evolved from a complex and dangerous procedure into an effective and safe method of treatment thanks to the development of a new generation of devices. Currently, there are still topical issues of using TAVI in individual clinical cases (use of TAVI in the elderly (60-75 years), TAVI in centenarians (90 years or more), TAVI in frailty, the feasibility of performing TAVI with low surgical risk, etc.), as well as issues related to longevity valves used for TAVI and prognosis in terms of quality and life expectancy.

Despite the fact that the phenomenon of unrecovered coronary blood flow (no-reflow) has long been known, there is still no unanimous opinion about the predictors and, accordingly, the risk groups for its occurrence. This prevents predicting the further course of the disease and investigating the effectiveness of therapeutic and surgical methods for preventing the consequences of reperfusion in patients with ST-segment elevation myocardial infarction, which in turn worsens the postoperative and long-term prognosis in this group of patients. We used the search engines E-library, Google Scholar and Pubmed to search for studies on this issue. The article presents and analyzes research data covering the predictors of the no-reflow phenomenon. The difficulties in identifying them are also described, the issue of a diagnostic approach ans sampling for research is raised. A review of studies dedicated to the identification of predictors of the no-reflow phenomenon using optical coherence tomography and intravascular ultrasound is given.

Myocardial reperfusion syndrome is a complex set of pathological processes that occur in the heart muscle due to restoration of coronary blood flow in patients with ST-segment elevation myocardial infarction. Despite the fact that it has been known for a long time, there is still no unequivocal opinion about the predictors, and, accordingly, the risk groups for its occurrence. This prevents predicting the further course of the disease and studying the effectiveness of surgical and therapeutic methods for preventing the consequences of reperfusion in patients with ST-segment elevation myocardial infarction, which in turn significantly worsens the postoperative and long-term prognosis in this group of patients. We used the search engines such as E-lilbrary, Google Scholar and Pubmed to search for studies on this issue. The article presents research data highlighting predictors of myocardial reperfusion syndrome. In addition, the problems of verification of irreversible reperfusion injury and myocardial stunning are described.

Рассматриваются основы патогенеза, клиники и диагностики синдрома реперфузии миокарда. Дано определение синдрому реперфузии миокарда. Объяснена его актуальность как одного из самых малоизученных и грозных осложнений реперфузии сердца при инфаркте миокарда с подъемом сегмента S-T. Кратко рассмотрен исторический обзор по данной проблеме и такие виды проявления синдрома реперфузии миокарда, как диастолическая дисфункция миокарда, постреперфузионные нарушения сердечного ритма, феномен no-reflow и необратимое повреждение миокарда. Разобраны современные взгляды на паталогическую физиологию диастолической дисфункции миокарда, постреперфузионного повреждения миокарда, феномена no-reflow. Проведен обзор современных взглядов на паталогическую физиологию развития постреперфузионных нарушений сердечного ритма. Описаны клиническая картина и влияние на гемодинамику такого проявления синдрома реперфузии миокарда как диастолическая дисфункция миокарда. Дано краткое описание клинической картины необратимого постреперфузионного повреждения миокарда. Описана клиническая картина и виды постреперфузионных нарушений ритма. Подробно разобрана диагностика феномена no-reflow, графически показаны коронароангиографические шкалы оценки тромболизиса при инфаркте миокарда и оценки перфузии миокарда. Дано описание основ диагностики постреперфузионных нарушений сердечного ритма, диастолической дисфункции миокарда, постреперфузионного необратимого повреждения миокарда. Представлено краткое описание известных в мировой литературе предикторов развития синдрома реперфузии миокарда.

A comparative analysis of clinical and epidemiological data and results of treatment of 7 patients suffering from myocardial infarction without obstructive coronary artery disease (main group) and 54 patients with their lesions (control group) aged 45,69,3 and 62,714,2 years, respectively. Both groups were dominated by men (85,7% and 72,2%, respectively). In the main group, dyslipidemia and hypertension were less common (14,3 and 28,6%, respectively) than in the control group (61,1 and 72,2%, respectively). At the same time, the former had a more burdened history of early cardiovascular events in close relatives in 28,6% of cases, and the latter-only in 5,6% of cases. Surgical tactics and features of double antiplatelet therapy in myocardial infarction without obstructive coronary artery disease did not differ from the standard approach. In both groups, active surgical tactics prevailed, consisting in performing percutaneous coronary intervention and installing a coronary stent in the infarct-related artery (85,7 and 83,3%, respectively). The choice of dual antiplatelet therapy in the main group did not differ from the control group and was characterized by a significantly higher frequency of clopidogrel administration (71,4 and 72,2%, respectively). When comparing the left ventricular ejection fraction before and after percutaneous coronary intervention, it turned out that in patients of the main group, in contrast to the control group, the value of the left ventricular ejection fraction did not change significantly (52,56,4 and 51,39,5, respectively). The etiology and pathogenesis of myocardial damage in patients suffering from myocardial infarction without obstructive coronary artery disease is characterized by significant heterogeneity, which requires additional examinations and differential diagnostics to identify the underlying causes of this condition.

The basics of pathogenesis, clinic and diagnosis of myocardial reperfusion syndrome are considered. Myocardial reperfusion syndrome is defined. Its relevance as one of the most poorly studied and formidable complications of cardiac reperfusion in myocardial infarction with elevation of the S-T segment has been explained. A brief review of the historical review of this problem and such types of manifestations of myocardial reperfusion syndrome as: diastolic myocardial dysfunction, post-reperfusion disturbances of the heart rhythm, the phenomenon of no-reflow and irreversible damage to the myocardium are briefly reviewed. The modern views on the pathological physiology of diastolic myocardial dysfunction, post-reperfusion damage to the myocardium, and the no-reflow phenomenon are analyzed. A review of current views on the pathological physiology of the development of post-reperfusion disturbances in heart rhythm is carried out. The clinical picture and the effect on the hemodynamics of such a manifestation of myocardial reperfusion syndrome as diastolic myocardial dysfunction are described. A brief description of the clinical picture of irreversible post-reperfusion damage to the myocardium is given. The clinical picture and types of post-reperfusion rhythm disturbances are described. The diagnostics of the no-reflow phenomenon has been analyzed in detail, the coronary angiographic scales for assessing thrombolysis in myocardial infarction and for assessing myocardial perfusion are graphically shown. A description of the basics of diagnosing post-reperfusion disturbances in heart rhythm, diastolic myocardial dysfunction, and post-reperfusion irreversible damage to the myocardium is given. A brief description of the known in the world literature predictors of the development of myocardial reperfusion syndrome is presented.

Introduction. One of the most difficult and completely unsolved problems of modern interventional cardiology is bifurcation stenting of the coronary arteries. This problem requires a comprehensive study, including using the possibility of morphological analysis.Material and methods. Stenting of the bifurcation lesions of the coronary arteries on 46 cadaveric hearts was performed using the bifurcation and conventional stents with subsequent plating and study of the preparations obtained.Results. From the point of view of the safety of the lateral branch, T-stenting is optimal, especially when implanting a BIOSS stent. When using the Tryton stent with the culotte stenting technique, there was never a stenosis of the side branch, due to the stent in the lumen, but there was always an excessive metal saturation in the main branch before the bifurcation. When using conventional stent with a provisional T-stenting technique residual, stenosis of the mouth of the lateral branch was also observed. In addition, in all cases there was a deformation of the stent beams near the mouth of the lateral branch.Conclusions. Morphological studies of stented coronary arteries on anatomical preparations of the heart, plastized with epoxy resin, make it possible to obtain new results that cannot be obtained with traditional morphological and clinical research methods (histological, corrosive, radiological, etc.).

Introduction. One of the most difficult and completely unsolved problems of modern interventional cardiology is bifurcation stenting of the coronary arteries. This problem requires a comprehensive study, including using the possibility of morphological analysis. Material and methods. Stenting of the bifurcation lesions of the coronary arteries on 46 cadaveric hearts was performed using the bifurcation and conventional stents with subsequent plating and study of the preparations obtained. Results. From the point of view of the safety of the lateral branch, T-stenting is optimal, especially when implanting a BIOSS stent. When using the Tryton stent with the culotte stenting technique, there was never a stenosis of the side branch, due to the stent in the lumen, but there was always an excessive metal saturation in the main branch before the bifurcation. When using conventional stent with a provisional T-stenting technique residual, stenosis of the mouth of the lateral branch was also observed. In addition, in all cases there was a deformation of the stent beams near the mouth of the lateral branch. Conclusions. Morphological studies of stented coronary arteries on anatomical preparations of the heart, plastized with epoxy resin, make it possible to obtain new results that cannot be obtained with traditional morphological and clinical research methods (histological, corrosive, radiological, etc.).

A literature review of the publications of foreign authors on the treatment of non-varicose bleeding from the upper gastrointestinal tract of elderly and senile patients is presented. The authors showed a modern view of the possibilities of endovascular hemostasis in comparison with a surgical operation with inefficiency of endoscopic hemostasis and characterized patients in whom it is possible this will be most effective.

OBJECTIVE. Based on our own experience and analysis of the literature, we want to demonstrate the features of diagnosis and treatment of ascending deep phlebothrombosis of the lower limbs and pelvis.MATERIAL AND METHODS. During the period from October 2008 to September 2016, in the First Clinic of Surgery (postgraduate medical education) of ”Military Medical Academy named after S. M. Kirov” we analyzed the results of treatment of 44 patients with this pathology. Selective surgical tactics was based on the evaluating of general status, activity of the patient, the presence of concomitant pathology, complications of the disease. Implantation of the cava-filter was performed in 23 patients. In active patients, without significant concomitant pathology, open thrombectomy operations were performed from the deep veins of the lower limbs or from the inferior vena cava and iliac veins (21 patients). In some of these patients, a removable cava-filter was implanted before thrombectomy (8 patients). Thrombectomy from the deep veins of the lower limbs was supplemented in 12 patients by the plication of the main vein.RESULTS. This tactic made it possible to achieve favorable results in the majority of patients (27 patients, 87 %) – there were no signs of recurrence of venous thromboembolic complications, there was complete or almost complete (more than 90 %) recanalization of thrombosed veins, venous insufficiency was limited by the presence of transient edema. Small hemorrhagic complications were noted in 2 patients. Relapses of venous thromboembolic complications occurred in a distant period in 3 patients. In order to prevent fatal pulmonary embolism, patients with ascending deep phlebothrombosis need surgical treatment.CONCLUSION. The choice of surgical treatment (cava filter implantation, deep vein thrombectomy) should be determined depending on the general status, patient activity, the presence of concomitant pathology, complications of the disease, and also individually in each specific clinical situation.

This review article examines the possibilities of surgical treatment of one of the socially significant diseases of modern society - arterial hypertension. The reasons for the development of parenchymal arterial hypertension have been disassembled. The reasons for the development of renovascular hypertension are discussed. Illuminates the pathogenesis of nephrogenic hypertension, statistical data on its prevalence. The issue of embolization of renal arteries in the treatment of nephrogenic arterial hypertension is considered. The forms of nephrogenic arterial hypertension in which the use of embolization is indicated. The etiology and pathogenesis of arterio-venous fistulas of the kidneys are described. Details of the world literature concerning the treatment of arterio-venous fistula and malformations of the kidneys are considered in detail. A review of literature data on materials used in embolisation of renal arteries in patients with arteriovenous fistula and malformations of the kidney is given. The etiology and pathogenesis of arterio-venous malformations of the kidneys are highlighted. The goal of embolization of the renal arteries in the preparation of patients with terminal renal failure and resistant arterial hypertension to kidney transplantation is described. The issue of preoperative preparation of patients before embolization of the renal arteries, the choice of operative access is considered. Methods of embolization of the renal arteries, possible complications and methods of their prevention are described. The data of the world literature concerning application of selective and superselective embolization of renal arteries in patients with parenchymal arterial hypertension are covered. The issue of potential use of renal artery embolization in other forms of nephrogenic arterial hypertension is also highlighted.