[Predictors of Efficacy of Radiofrequency Ablation of Pulmonary Veins Performed During Coronary Bypass Surgery in Patients With Ischemic Heart Disease and Paroxysmal Atrial Fibrillation].

We performed simultaneous coronary artery bypass grafting (CABG) and radiofrequency ablation (RFA) ostia of pulmonary veins in 254 patients (147 men and 107 women) with ischemic heart disease and paroxysmal atrial fibrillation (AF). In-hospital mortality in patients with early recurrence of AF was 8.4%, in patients without recurrence of AF 1.9% (χ2 = 4.65; p = 0.03). The patients were followed-up during 12 months after operation. During follow-up 166 patients (69.5%) had no recurrence of AF without receiving antiarrhythmic drugs (AAP), 33 patients (13.8%) had recurrences of AF, and 40 patients (16.7%) receiving AAD had repeated rare paroxysms of AF. Main predictors of late AF recurrence were age > 65 years, AF duration > 5 years, preoperative atrial effective refractory period < 240 ms, frequency threshold of AF induction < 400 counts/min, anteroposterior left atrial size > 50 mm, glomerular filtration rate < 60 ml/min/1.73 m2. Reverse dynamics of structural, functional and electrophysiological parameters of the heart due to CABG and RFA, use of ß-blockers, angiotensin converting enzyme inhibitors and aldosterone antagonists were associated with the preservation of a stable sinus rhythm. The cardiovascular mortality during 12 months follow-up accounted for 2.1% and 1.2% in groups of patients with and without late recurrences of AF respectively (p > 0.05) to coronary artery bypass grafting surgery and RFA, taking drugs--ß-blockers, angiotensin converting enzyme inhibitors and aldosterone antagonists--were associated with the preservation of a stable sinus rhythm.

[Cardiorenal prognosis in kidney dysfunction patients undergoing cardiac surgery].

AIM: To evaluate the impact of cardiac surgical procedures on cardiac and renal functions within 12 months after surgery in patients with a history of chronic kidney disease (CKD). SUBJECTS AND METHODS: A total of 875 patients (464 men and 411 women) aged 32 to 68 years (62.3±5.2 years), including 396 patients who had undergone heart valve replacement under extracorporeal circulation, 422 who had aortocoronary and/or mammary coronary artery bypass, and 57 who had a combination of these operations, were examined. According to the baseline glomerular filtration rate (GFR), the patients were divided into 2 groups: 1) 508 patients with preserved kidney function (GFR, higher than 90 ml/min/1.73 m2); 2) 367 with CKD (GFR, 89 to 60 ml/min/1.73 m2). Results. In Group 2, early postoperative cardiovascular events were noted significantly more frequently and mortality proved to be higher than in Group 1. By the end of the first year of a follow-up, CKD was diagnosed in 5.4% of the patients in Group 1. In Group 2, CKD regressed in 54.1 % of the patients and, on the contrary, progressed in 9.5%. In Group 2, programmed hemodialysis was performed in 15 (4.4%) patients. Overall mortality was significantly higher in patients with a postoperative glomerular filtration fall in both Groups 1 and 2 (7.5 and 8.4%, respectively). Long-term cardiovascular events were significantly more common in patients with progressive CKD and postoperative kidney dysfunction. CONCLUSION: A slight decrease in glomerular filtration makes the immediate prognosis of cardiac surgery poorer. The late cardiorenal prognosis mainly depends on changes in kidney function; regression of CKD is noted in 50% of the cases.

[THE RISK OF ACUTE RENAL LESIONS AND ITS PROGNOSTIC SIGNIFICANCE IN PATIENTS WITH CHRONIC RENAL DISEASE UNDERGOING CARDIAC SURGICAL INTERVENTION].

AIM: to determine the frequency and risk factors of acute renal lesions (ARL) and their prognostic significance in patients with chronic renal disease (CRD) undergoing surgical intervention. MATERIALS AND METHODS: The study included 1122 patients (586 men and 536 women) aged 32-68 (mean 62.3 ± 5.2) years who underwent correction of valvular defects, aortocoronary bypass surgery or their combination). Initial glomerular filtration rate was higher than 90 ml/min/l.73 m2 in 656 patients (group 1) and 89-60 ml/min/l/73 m2 in 470 ones (group 2). ARL were diagnosed based on the serum creatinine level using RIFLE criteria. RESULTS: In the early postoperative period, ARL were diagnosed in 23.9% of the patients in group I and 38.7% of those in group 2 (p < 0.001). Intra-hospital lethality in group 1 was 4.9% (14.1% in patients with ARL) and 12.1% in group 2 (18.1% iin patients with ARL). In group 2, 47.9% of the patients with ARL experienced regress of renal dysfunction during 12 months compared with 56.9% ones without ARL. The progress of CRD was documented in 11% of group 2 patients with ARL and in (4.5% without AR (p = 0.013). 5.7% of the patients in group 1 developed CRD after ARL. 4.9% of the patients in group 2 needed programmed hemodialysis. CONCLUSION: The development of ARL in patients with CRD is associated with unfvouravle cardiovascular prognosis following cardiosurgery.

[Predictive Value of Renal Dysfunction for Early and Long-Term Outcomes of Coronary Artery Bypass Grafting].

AIM: to assess value of renal dysfunction for immediate and long-term prognosis after coronary artery bypass grafting (CABG). MATERIAL AND METHODS: We examined 657 patients (419 men and 238 women) aged 54-68 (60.6 ± 5.3) years before and after coronary artery bypass grafting (CABG). Patients with baseline glomerular filtration rate (GFR) > 90 and with GFR 89-45 ml/1.73 (n = 246) comprised groups 1 and 2, respectively. Acute kidney injury (AKI) was diagnosed using the AKI Network criteria. RESULTS: In early postoperative period AKI (perioperative AKI) was diagnosed in 97 (23.6%) and 102 (41.55) patients of group 1 and 2, respectively (χ² = 22.4; p < 0.001). Rate of early cardio-vascular complications and hospital mortality were significantly higher in patients with compared with those without perioperative AKI. During 12 months of follow-up 6.8% of patients in group 1 developed chronic kidney disease (CKD). In group 2 we noted progression of CKD in 14.7 and 5.4% (p > 0.05) and its regression in 45.1 and 61.4% (p = 0.004) of patients with and without perioperative AKI, respectively. Programmed hemodialysis was carried out in 12 patients of group 2, including 10 with perioperative AKI (p = 0.003). CONCLUSION: Presence of CKD and development of perioperative AKI was associated with unfavorable cardiorenal prognosis after CABG.

[Dynamics of parameters of systemic inflammation and hemocoagulation in early postoperative period in patients with heart valve prostheses].

In 42 patients with rheumatic heart defects before implantation of mechanical valves and on days 5 and 20 after surgery we measured parameters of hemostasis, levels of proinflammatory cytokines (interleukin 6 [IL-6], tumor necrosis factor- [TNF-] and C-reactive protein [CRP]) as well as activity of enzymes (alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine phosphokinase and its MB fraction). On day 5 after surgery we revealed substantial elevation of IL-6, TNF-, and CRP levels, increase of activity of the studied enzymes, contents of fibrinogen and soluble fibrin monomer complexes (SFMC), and to the contrary lowering of antithrombin III level and decrease of number of platelets. On day 20 IL-6 and TNF- levels remained significantly elevated compared to preoperative values. Concentrations of enzymes and parameters of hemostasis returned to baseline values while content of SFMC remained significantly decreased. In early postoperative period levels of IL-6 and TNF- significantly correlated with that of SFMC and platelet count what reflected interrelation ship of processes of inflammation and coagulation. Severity of systemic inflammatory reaction in patients with implanted prosthetic valves influenced optimal doses of warfarin.

[Effect of a fixed-dose perindopril and amlodipine combination on intrarenal hemodynamic and kidney functional parameters in patients with essential hypertension].

AIM: To evaluate the effect of prestans on intrarenal hemodynamic and kidney functional parameters and to study their correlations during 24-week therapy in patients with grade I-II essential hypertension (EH). SUBJECTS AND METHODS: Eighty-two patients (44 men and 38 women) with EH were examined and allocated to 3 groups according to glomerular filtration rate (GFR): 1) 31 patients with a GFR of > 90 ml/min/1.73 m2; 2) 28 with a GFR of 60-89 ml/min/1.73 m2; 3) 23 with a GFR of 59-30 ml/min/1.73 ml. RESULTS: Group 3 patients were found to show a preponderance of metabolic disturbances, such as dyslipidemia, obesity, as well as intrarenal arterial lesions and diminished kidney function. In addition, the most pronounced therapy-induced changes in the parameters under study were also observed in Group 3. In particular, resistive index, pulsatility index of interlobar arteries of the kidneys, and serum creatinine levels increased, the frequency of microalbuminuria episodes reduced, and GFR, endothelium-dependent dilation of the brachial artery, and systolic index rose statistically significantly. Group 3 also displayed statistically significant correlations of the resistive index of the interlobar arteries with GFR, urinary albumin excretion, endothelium-dependent vasodilation, and cardiac index. CONCLUSION: The fixed-dose perindopril and amlodipine combination in patients with EH and hypertensive nephropathy improves intrarenal hemodynamics and exerts marked nephroprotective and antihypertensive effects.

[Organoprotective effects of the combination of perindopril and amlodipine depending on the renal functional state in patients with arterial hypertension].

AIM: To estimate effect of combined perindopril/amlodipine therapy on structural and functional characteristics of the heart and blood vessels, intrarenal hemodynamics in patients with essential arterial hypertension (AH) depending on the degree of renal dysfunction. MATERIAL AND METHODS: 112 patients (63 men and 49 women) were included in the study; 35 of them (group 1) had the glomerular filtration rate (GFR) 90 ml/min/1.73 m2 or higher, 43 (group 2)--60-89 ml/min/1.73 m2 and 34 (group 3)--9-45 ml/min/i1.7 mi. The patients were treated with a fixed combination of dosage forms ofp erindopril and amlodipine at 10/5 mg/days or 10/10 mg/days for 24 weeks. RESULTS: Pronounced antihypertensive effect of therapy was comparable in all groups. However dynamics of structural and functional indicators of the left ventricle (LV) and a brachial artery was apparent only in group 3. Endothelium-dependent vasodilation, cardiac index and LV ejectionf raction increased significantly whereas myocardiumnmass index of L decreased .A reduction of resistance andpulsation indices was recorded in interlobar renal arteries especially in groups 2 and 3. Serunmcreatinine level and urinary albumin excretion were significantly decreased while GFR increased . CONCLUSION: Manifestations ofr emodeling ofc ardiovascular system and protective efficiencvyof the fixed combination ofp erin.opril and amlodipine correlate with the degree ofr enal dysfunction.

[Organoprotective and metabolic effects of S-amlodipine in patients with arterial hypertension].

We compared effects of racemic amlodipine and S-amlodipine in 127 patients with 1-2 degree arterial hypertension (AH) on structural-functional parameters of the left ventricle and brachial artery as well as on characteristics of carbohydrate, lipid, electrolyte, and purine metabolism. Racemic amlodipine was given to 66 and S-amlodipine--to 61 patients. Duration of therapy was 24 weeks. In all patients we observed positive and comparable hypotensive effect while doses of S-amlodipine were significantly lower than those of racemic amlodipine (7.5 +/- 0.8 and 11.6 +/- 1.4 mg/day, respectively, p < 0.01). Monotherapy with S-amlodipine resulted in complete regression of left ventricular hypertrophy in 55% and normalization of left ventricular diastolic function in 62.4% of cases; significant improvement of brachial artery vasomotor function was also observed. In addition treatment with S-amlodipine for 24 weeks in patients with hyperlipidemia led to significant lowering of levels of atherogenic lipoproteins and total cholesterol.

[The influence of vascular remodeling and endothelial vasomotor function on the efficacy of indapamide retard in patients with hypertensive disease].

The influence of vascular remodeling and endothelial vasomotor function on the efficacy of indapamide retard was studied in 92 patients (49 men and 43 women) with stage I-II hypertensive disease and grade I-II arterial hypertension by observation of dynamics of the results of 24 hour AP monitoring and heart rhythm variability (HRV), cardio- and vasoprotective efects. The patients were divided into comparable groups. Group 1 was comprised of 40 patients without structural changes of the humeral artery (HA), group 2 included 52 patients undergoing HA remodeling. It was shown that antihypertensive efect of indapamide was virtually identical in both groups. Dynamics of left ventricular and HA structural/functional characteristics in group 2 was more pronounced than in group 1. Conversely, changes of spectral and time-dependent characteristics of HRV in group I were more significant than in group 2; they included suppression of reciprocal hyperactivity of the sympathetic nervous system. In the absence of structural vascular changes, the anti-hypertensive, cardio- and vasoprotective effects of indapamide retard were realized via neurohumoral blockade whereas direct vascular action of the drug prevailed in case of vascular remodeling and endothelial dysfunction

[Impact of subclinical primary hyperparathyroidism on cardiovascular manifestations of essential arterial hypertension].

At 95 patients with essential arterial hypertension features of structural and functional remodeling of left ventricular and humeral artery depending on a level parathyroid hormone in blood are studied. It is shown that while increasing of plasma parathyroid hormone level frequency and expressiveness of left ventricular and humeral artery remodeling increases whereas diastolic function and endothelium-dependent vasodilatation considerably decrease. Subclinical primary hyperparathyroidism in patients with essential arterial hypertension is detected in 22.1% of cases.

[Selection of rational combinations of indapamide with various of calcium antagonists in patients with arterial hypertension].

We studied 89 patients with II degree arterial hypertension (age 43-67 years). Before and in 24 weeks after therapy we carried out 24-hour monitoring of arterial pressure and Doppler echocardiography. Patients were divided into 2 groups. Combination therapy with indapamide and verapamil retard, indapamide and amlodipine were prescribed to patients of group 1 and 2, respectively. At the background of therapy circadian rhythm was normalized in 82.8 and 76.9% of patients in groups 1 and 2, respectively. In group1 therapy was especially effective in patients with type 1 left ventricular diastolic dysfunction (LVDD), 24-hour nondipper profile, and hyperkinetic type of circulation. In group 2 pronounced changes of parameters were seen in II-III type of LVDD and hypokinetic type of circulation.

[Comparative efficiency of indapamide combinations with various derivaties of calcium antagonists in patients with arterial hypertension].

The study included 59 patients aged 42-65 yr with grade II AH. They underwent 24 hour AP monitoring and Doppler echocardiography before and 16 weeks after onset of the study. The patients were randomly allocated to 2 groups. In group 1, they were given combined therapy with indapamide and verapamil retard. Patients of group 2 were treated with indapamide and amlodipine. AP circadian rhythm returned to normal in 83 and 78.6% of the patients in groups 1 and 2 respectively. Combined therapy in group 1 was especially beneficial for patients with type 1 left ventricular diastolic dysfunction, daily non-dipper profile, and hyperkinetic type of blood circulation. In group 2, the most pronounced changes were documented in patients with type II-III left ventricular diastolic dysfunction and hypokinetic type of circulation.

[Efficacy of calcium antagonists depending on the functional state of parathyroid glands in patients with hypertensive disease].

Hypotensive and cardioprotective effects of amlodipine (normodipine) were evaluated in 65 patients (35 men and 30 women) with grade II essential arterial hypertension treated with regard for calcium-controlling parathyroid function. 24 hour Holter monitoring, Doppler-cardiography, and blood PTH measurement were performed before and 6 months after the onset of therapy. The patients were divided into 3 groups depending on PTH levels (0-25, 26-50, and over 51 pg/ml). Changes of structural and functional cardiac parameters and AD were most prominent in group 3 in the form of decreased left ventricular hypertrophy, improved ventricular diastolic function, and marked hypotensive effect. The group was significantly different from group 1 in terms of these characteristics. Univariate analysis revealed correlation of PTH levels with left ventricular mass, mean daily systolic and diastolic AD, and left ventricular diastolic function. It is concluded that evaluation of calcium-regulating parathyroid function is necessary for optimization of antihypertensive therapy with calcium antagonists.

[Dynamics of electrophysiological parameters of the heart in hypertensive patients depending on a 24-h profile of arterial pressure, left ventricular geometry and metabolic disorders].

AIM: To examine conduction system and repolarization in the ventricles and heart rate variability in hypertensive patients with consideration of 24-h blood pressure profile, left ventricular (LV) geometry and metabolic disorders. MATERIAL AND METHODS: 24-h monitoring of blood pressure, diagnostic transesophageal electrostimulation of the left ventricle, echocardiography were made and duration and dispersion of QT interval, variability of the intervals R-R (SDNN) were assessed in 73 untreated patients aged 42 to 57 years with essential hypertension of the second degree. RESULTS: It is shown that hypertensive patients having left ventricular hypertrophy (LVH), metabolic syndrome (MS) and pathologic 24-h blood pressure profile have also a depressed function of the sinus-atrial node and atrioventricular conduction, marked electric instability of the atria and ventricles. Such patients are at high risk to develop arrhythmia (3-5 times higher than patients without LVH, MS, with normal circadian blood pressure rhythm). CONCLUSION: Electric heart remodeling associated with LVH, MS and disturbances of circadian blood pressure pattern enhances electric instability and risk to develop cardiac arrhythmia.

[Efficacy of and tolerance to combined therapy with dihydropyridine and non-dihydropyridine Ca antagonists in patients with moderate arterial hypertension].

The authors of the article studied efficacy of combined therapy with dihydropyridine and non-dihydropyridine Ca antagonists, its influence on structural and functional condition of the heart in 53 patients (28 men and 25 women) with moderate arterial hypertension (AH), and their tolerance to the therapy. Before and during the treatment the patients underwent 24-hour arterial pressure (AP) monitoring and Doppler echoCG. Due to combined therapy with isoptin SR and corinfar retard complete hypotensive effect (AP < 140/90 mmHg) was achieved in 83% of cases, and partial effect (diastolic pressure lowered by 10 mmHg)--in 17%. The therapy significantly reduced left ventricular mass index (14.6% on the average; p < 0.01), and improved diastolic function: E/A increased by 10.3% (p < 0.05), and isovolumetric relaxation time decreased by 13.6% (p < 0.01). Combined therapy also resulted in a 1.5 to 4 time reduction in the frequency of side effects of isoptin SR and corinfar retard due to reduction in their doses and/or mutual neutralization of their side effects. The paper demonstrates high antihypertensive efficacy of and good tolerance to the combination of dihydropyridines and non-dihydropyridines when they are administered for prolonged therapy in patients with moderate AH.

[Assessment of coronary reserve in patients with hypertensive disease and without hypertrophy left ventricular].

AIM: To study relationship between coronary reserve and left ventricular geometry. METHOD AND MATERIAL: Transesophageal cardiac pacing was carried out in 53 patients with hypertensive disease. Thirty five patients (66%) had left ventricular hypertrophy which was eccentric in 16 and concentric in 19. RESULTS: Myocardial ischemia was induced during pacing in 79.2% of patients; it was painful in 45.2 and painless -- in 54.8% of patients. Test with esophageal pacing was positive in 91.4 and 55.6% of patients with and without left ventricular hypertrophy, respectively. In patients with concentric hypertrophy frequency of positive tests was higher and level of coronary reserve lower than in patients with eccentric left ventricular hypertrophy. There was negative correlation between pacing rate at myocardial ischemia induction and left ventricular myocardial mass index. Painless ischemia was more frequent among patients with left ventricular hypertrophy. Twelve of 42 patients (28.3%) with positive result of pacing had no clinical signs of ischemic heart disease. CONCLUSION: Left ventricular hypertrophy limits coronary reserve, increases prevalence of painless myocardial ischemia. Transesophageal pacing enables detection of preclinical signs of lowered coronary reserve.

[Effect of pacemaker implantation on clinical course of ischemic heart disease and choice of optimal pacing parameters].

Effect of cardiac pacing on clinical course of ischemic heart disease was assessed in 154 patients with class II-IV angina pectoris with implanted pacemakers. Improvement of symptoms (decrease of number of anginal attacks, increase of exercise tolerance, reduction of number and doses of antianginal drugs) occurred in 72 patients (46.8%). In 30 patients (19.5%) increase of frequency of angina was accompanied with changed character, localization and duration of attacks as well as response to nitroglycerin. This was believed to be caused by augmented myocardial oxygen consumption due to 1.5-2 fold heart rate elevation during pacing and psychocardial syndrome. In 52 patients (33.8%) pacing was not associated with any changes of character of angina. It was shown that reprogramming of pacing parameters aimed at optimization of coronary reserve should be performed with consideration of angina class and presence of chronic heart failure. Optimal pacing rate was supposed to be 55-65 and 75-85 per min in patients with low coronary reserve and heart failure, respectively.

[The incidence and pattern of cardiac rhythm and conduction disturbances in patients with different clinical and pathogenetic types of hypertensive disease]. / Chastota i kharakter narushenii ritma i provodimosti serdtsa u bol'nykh s razlichnymi kliniko-patogeneticheskimi variantami gipertonicheskoi bolezni.

In 237 patients with grades I-III hypertensive disease, the incidence and pattern of cardiac rhythm and conduction disturbances were studied in various clinical and pathogenetic types of the disease. By taking into account the known clinical, laboratory, and hemodynamic criteria, the patients were profiled by the following types: 62 (26.2%) patients with a hyperadrenergic type, 61 (25.7%) with a hyperhydration types, 60 (25.3%) with a hyperrenin type, and 54 (22.8%) with a calcium-dependent type. Bicycle ergometric exercise test, daily ECG monitoring, and a transesophageal electrophysiological study of the heart were performed to detect latent, routine ECG-unverified cardiac rhythm and conduction disturbances. In the total group of patients, cardiac arrhythmia and block occurred in 55.3% of the cases, including in 55.7% they are latent. Cardiac rhythm disturbances were most frequently detected in the hyperadrenergic and hyperrenin variants of the disease (50.0 and 43.3%, respectively). Premature beats and paroxysmal supraventricular tachyarrhythmias were predominantly diagnosed in the hyperadrenergic type of HD; intraventricular conduction disturbances and extrasystolic arrhythmia were in the hyperhydration type; the sick sinus syndrome and atrioventricular blocks were in the hyperrenin type. The above cardiac rhythm and conduction disturbances were equally characteristic for the calcium-dependent type of the disease. There was a direct correlation between the detection rate of cardiac arrhythmia and block and the degree of a risk for cardiac and cerebral events, as well as left ventricular hypertrophy. Thus, the study of the incidence and pattern of cardiac arrhythmias associated with hypertensive disease is of importance for choosing an effective and safe treatment; and their existence should be borne in mind to stratify a risk of prognosis.