[The association of growth differentiation factor 15 (GDF-15) level with extent of left atrial fibrosis in patients with nonvalvular atrial fibrillation].

Aim To study the relationship between the serum level of growth differentiation factor 15 (GDF-15) and clinical and functional characteristics and severity of left atrial (LA) fibrosis in patients with nonvalvular atrial fibrillation (AF).Material and methods The study included 87 patients with nonvalvular AF (62 patients with paroxysmal AF and 25 patients with persistent AF) aged 27 to 72 years (mean age, 56.9±9.2 years, 32 women). 85 % of these patients had arterial hypertension (AH), 33 % had AH and ischemic heart disease, and 12.6 % had isolated AF and were hospitalized for primary catheter ablation. General clinical evaluation, echocardiography, laboratory tests including measurement of GDF-15 and NT-proBNP concentrations in blood were performed. As a surrogate substrate of LA fibrosis during the electroanatomical voltage mapping, the area of low-voltage (<0.5 mV) zones in LA was calculated, including the total LA fibrosis area (Sf, cm2) and a percentage of fibrosis of the total LA area (Sf%).Results Median concentration of GDF-15 was 767.5 [590.0; 951.0] pg /ml. The GDF-15 level positively correlated with age, presence and severity of AH and chronic heart failure, body mass index, and degree of obesity, CHA2DS2 VASc score, level of NT-proBNP, and LA fibrosis area (Sf and Sf%) and negatively correlated with the indexes of left ventricular diastolic function, e' septal and e' lateral. The area of fibrosis increased with increasing GDF-15 concentrations divided into quartiles; Sf% exceeded 20 % at GDF-15 levels higher than median. After a comparative analysis of patients with Sf% ≤20 % and >20 %, statistically significantly different variables were included into a stepwise logistic regression analysis. Two independent predictors of LA fibrosis >20% were identified: a concentration of GDF-15 higher than median (odd ratio (OR), 3.318, 95 % confidence interval (CI): 1.184-9.298) and LA volume index (OR, 1.079, 95 % CI: 1.014-1.147). According to results of the ROC analysis, the area under the curve (AUC) was 0.762 (p=0.000), the model specificity was 72.3 %, sensitivity was 72.4 %, and the prediction accuracy was 72.4 %.Conclusion Blood levels of GDF-15 were associated with the presence and severity of major risk factors for AF and the area of LA fibrosis. In this study, a level of GDF-15 above the median and the LA volume index were independent predictors of LA fibrosis > 20% of the LA area.

[Predictors of Left Atrial Severe Fibrosis in Patients with Nonvalvular Atrial Fibrillation].

Objective The search for predictors of severe (>35 %) left atrial (LA) fibrosis in patients (pts) with nonvalvular atrial fibrillation (AF) directed for catheter ablation (CA).Materials and Methods 69 pts with nonvalvular AF (57 paroxismal and 12 persistent) aged from 32 to 69 years (mean age 57.1±8.4, 28 females) were included in the study, among them 59 pts (86 %) with arterial hypertension (AH), 24 (34.8 %) - with AH and CAD. Complete physical study, laboratory tests (including NT-proBNP level), comprehensive echocardiography were performed. As a surrogate substrate of LA fibrosis, the area of low-voltage (<0.5 mV) zones in LA was estimated in the process of voltage electroanatomic mapping, as the first stage of CA. The total square of LA fibrosis in absolute values (Sf, cm2) and in percent of total LA square (Sf%), as well as the degree of fibrosis: degree I - <5 %, II - 5-19 %, III - 20-35 %, IV - >35 % were calculated. Degree IV of fibrosis was considered as severe fibrosis.Results Extent of fibrosis didn't depend on sex, age, body weight, presence of diabetes, CHA2DS2VASc scores, duration of AF history. There was a tendency to smaller Sf in pts with spontaneous termination of AF compared to those who required cardioversion: 7.2 cm2 (4.4; 17.1) and 12.6 cm2 (4.2; 30.5), respectively (p=0.069). Although NT-proBNP level was normal in 62 % of pts (<125 pg / ml), it was higher in Sf% ≥20 % than in Sf% <5 %: 146.0 (48.0; 276.0) and 42.8 (24.2; 91.0) pg / ml, respectively (p=0.0216). The distribution of pts by left ventricular (LV) geometry types was as follows: normal geometry (t.1) - 34, concentric remodeling (t.2) - 16, concentric LV hypertrophy (t.3) - 8, eccentric LV hypertrophy (t.4) - 11. Compared to pts with t. 1 (reference level), pts with t.3 and t.4 had higher LA volume and LV myocardial mass index, and pts with t.4 had larger end-diastolic LV volume and lower LV ejection fraction. Pts with t.4 tended to have higher Sf% than t.1: 31.1 (10.2; 46.2) and 11.2 (5.1; 28.0), respectively (p=0.053). Using logistic regression 3 independent predictors of LA severe fibrosis were detected: type 4 geometry of LV - OR=8.893 (95 % CI 1.150; 68.78), NT-proBNP >128 pg / ml - OR=6.184 (1.01; 37.99), LA volume index >34 ml / m2 - OR=5.92 (1.05; 33.38). According to ROC analysis, the area of the curve AUC = 0.839 (p<0.001), model specificity - 85.1 %, sensitivity - 70.0 %, predictive accuracy - 82.5 %.Conclusion In pts with nonvalvular AF predictors of severe (>35 %) LA fibrosis were LV geometry type in the form of eccentric LV hypertrophy, LA volume index >34 ml / m2 and NT-proBNP >128 pg / ml.

[Chronic Mitral Regurgitation in Postmyocardial Infarction Patients: Gender Differences].

There are two mechanisms of mitral regurgitation formation in postmyocardial infarction patients: local myocardial remodeling with changing of mitral chord tethering, and global myocardial remodeling with dilatation of mitral ring. Analysis of data of the "Register of provided coronary angiography" showed that the first mechanism in preponderant in men, and the second - in women. Factors found to be associated with chronic moderate and pronounced mitral regurgitation in men and women after myocardial infarction are presented in this article.

[Chronic Mitral Regurgitation in Postmyocardial Infarction Patients: Gender Differences].

There are two mechanisms of mitral regurgitation formation in postmyocardial infarction patients: local myocardial remodeling with changing of mitral chord tethering, and global myocardial remodeling with dilatation of mitral ring. Analysis of data of the "Register of provided coronary angiography" showed that the first mechanism in preponderant in men, and the second - in women. Factors found to be associated with chronic moderate and pronounced mitral regurgitation in men and women after myocardial infarction are presented in this article.

[Predictors of high-grade ventricular arrhythmias in patients referred for the coronary angiography].

Ventricular arrhythmias (VA) are still the leading cause of sudden cardiac death (SCD). Therefore identification of predictors of high-grade (hg) VA and stratification of risk of fatal events remain important problems of cardiology. We analyzed data of 993 patients with and without hgVA according to 24 hours Holter monitoring referred for the coronary angiography. Patients with hgVA were older (57.2 ± 8.4 vs. 54.9 ± 8.3 years, p = 0.001), had lower left ventricular ejection fraction (LVEF) (51.6 ± 11.2 vs. 58.4 ± 7.6%, p < 0.001) and larger extent of LV wall motion abnormalities (10.8 ± 15.7% vs. 5.5 ± 10.9%, p = 0.001). Patients with hgVA more often had LV aneurysms and thrombi. These patients also had significantly greater LV end diastolic diameter (54.3 ± 7.4 vs. 49.9 ± 4.7 mm, p < 0.001), and more often had NYHA class III-IV chronic heart failure (28.1 vs. 15.5%, p < 0.001). According to multivariate analysis hgVA were independently associated with age, LV dilation and reduced LVEF (specificity and sensitivity of a mathematical model for prediction of hgVA were 78 and 49.5%, respectively). Each subsequent year of life increased risk of having hgVA by 1.2% (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.01-1.05, p = 0.002), while 1 mm increase of LV size elevated risk of VA by 4.2% (OR 1.08; 95% CI 1.04-1.13, p < 0.001), and 1% lowering of LVEF increased risk of VA by 7% (OR 0.95; 95% CI 0.92-0.98, p < 0.001).

[Mitral regurgitation and coronary stenosis in postmyocardial infarction patients].

The results of investigations devoted to relationship of mitral regurgitation (MR) and scars are contradictive, data on relationship of MR and localization of coronary lesions are few. Purpose. To determinate relationship of moderate or severe MR to localization of coronary stenosis in postmyocardial infarction patients. Methods. There were 1167 patients with no MR and 403 patients with moderate or severe MR. Results. Patients with MR had more severe New York Heart Association (NYHA) functional class (III-IV) (35.5 vs. 11.2%). Echocardiographic indices of left atrial dimension (23.5+/-2.9 vs. 20.3+/-2.1 mm/m) and extent of left ventricular (LV) wall motion abnormalities (32.8+/-14.9 vs. 23.6+/-12.7%) were higher in patients with MR as well as reduced LV systolic function (LV ejection fraction <50% - 63.7 vs. 25.6%) and LV dilatation (63.3 vs. 19.9%, all p<0.001). Rates of multivessel coronary artery involvement (three or more arteries) (27.5 vs. 18.3%, p=0.001), lesions in left main coronary artery (7.2 vs. 1.1%), circumflex (36.2 vs. 26.7), and right coronary artery (57.3 vs. 44.9%) were higher in patients with MR (all p<0.001). According to results of multivariate analysis MR was independently associated with LV dilatation, NYHA class of congestive heart failure, index of left atrial size, and extent of LV wall motion abnormalities. Moderate or severe chronic MR was not related to localization of coronary stenosis in these patients.

[Parameters associated with absence of significant coronary atherosclerosis by data of register of provided coronary angiography].

AIM OF THE STUDY: The study aimed to reveal the sign of coronary atherosclerosis absence using the factor analysis in patients referred for the coronary angiography. PATIENTS AND METHODS: 9409 patients suspected stable coronary artery disease (CAD) or with confirmed diagnosis of CAD from the "Registry of provided coronary angiography" were included in the study. RESULTS OF THE STUDY: Principal factor described about 59% of the variation and included the burdens of 4 parameters (gender, smoking, significant coronary atherosclerosis and hypothyroidism) and was interpreted as factor of coronary atherosclerosis. CONCLUSIONS: It was found that the absence of coronary stenosis was associated with female gender, non-smoking status and hypothyroidism.

[Specific features of left ventricular remodeling in patients with diabetes mellitus and coronary heart disease residing in the Far North].

This study enrolled 202 patients with diabetes mellitus and coronary heart disease residing in the Far North. They were selected from 8753 subjects included in the Registry of performed coronary angiographies. The control group contained 196 patients with CHD and DM2 residing in the south of Tyumen region. 76 (19%) patients had normal structural and functional characteristics of LV (LVMM = < N and LVRWT < 0.45), in 322 (81%) these characteristics were pathologically changed (eccentric and concentric LV hypertrophy, concentric LV remodeling). Groups 1 and 2 included 79.2 and 68.4% men respectively p = 0.014) of mean age 53.9 +/- 0.45 and 58.1 +/- 0.51 p < 0.001) having LV diameter 26.2 +/- 0.2 mm and 25.5 +/- 0.2 mm (p = 0.012). Other echocardiographic parameters, occurrence of asymmetric myocardial hypertrophy, and distribution of the patients by the types of LV geometric models were not significantly different. Odd ratios for the patients with pathological LV morphology revealed no dependence of LV remodeling on the site of residence. The structural and functional changes in myocardium of the patients residing in the North and South of Tyumen region were comparable in terms of severity. It is concluded that DM is a powerful factor influencing myocardial remodeling to the extent that masks even the effects of extreme ("northern") environmental conditions.

[Impact of cardiac resynchronization therapy on survival in patients with ischemic and nonischemic cardiomyopathy in clinical practice].

AIM: To compare the impact of cardiac resynchronization therapy (CRT) on survival in patients with ischemic and non-ischemic cardiomyopathy (CMP) in clinical practice. SUBJECTS AND METHODS: The study enrolled 206 patients with NYHA Functional Class II-IV chronic heart failure (CHF) and a left ventricular ejection fraction of < or = 35, including 107 patients implanted with CRT devices in combination with continuous drug therapy (DT). Among the 107 patients, 48 were diagnosed as having non-ischemic CMP (NCMP), 59 as coronary heart disease (CHD). The other 99 patients (12 with NCMP and 87 with CHD) were on DT only. Later on the patients from both groups were divided into subgroups according to the treatment policy of CHF: CRT + DT or DT only. The mean follow-up period was 24 +/- 18.1 months. RESULTS: The Kaplan-Meier survival analysis revealed that overall survival in the patients on CRT + DT was significantly higher than in those on DT (70 and 49%, respectively; p = 0.004). Analysis of the chosen treatment policy in the NCMP subgroup showed no significant differences in survival rates in the patients receiving CRT + DT or DT (74 versus 78%, respectively; p = 0.5). At the same time, the survival rates in the CHD patients on CRT + DT were significantly higher than those in the DT subgroup (68 versus 44%; p = 0.04). CONCLUSION: CRT significantly reduces overall mortality in patients with CHF in clinical practice. Our findings indicated that this effect was achieved mainly in patients with CHD, rather than in those with NCMP.

[Cryoballoon ablation for pulmonary vein isolation to treat atrial fibrillation: first experience in Russian Federation].

Cryoballon ablation (CBA) for pulmonary vein (PV) isolation is a new method for catheter-based treatment of patients with atrial fibrillation (AF). The purpose of our work is to describe the CBA technique and to report its short-term results. Methods. CBA was performed in 12 patients (8 men; age 53.1+/-5.7 years) with highly symptomatic drug-refractory AF. Paroxysmal AF was present in 11 and persistent AF - in 1 patient. CBA procedure was carried out under general anesthesia with intubation in 6 and under light sedation in 6 patients. After transseptal access and direct PV angiography, 28 mm-cryoballoon was introduced into the left atrium, and more or equal 2 cryoapplications were delivered to each PV, once good PV occlusion was obtained. PV isolation was verified utilizing a circular mapping catheter. Arrhythmia recurrences were monitored every 3 months after ablation using 24-hour Holter, and additional ECG registrations. Holter monitoring was also performed in a case of symptoms. Results. Complete electrical PV isolation was achieved by only cryoballoon ablation in 11 patients, and additional cryocatheter touch-up ablation was required in left PVs in 1 patient. Total procedure time was 203.1+/-34.2 min, fluoroscopy time - 50.5+/-14.0 min. There were no complications. During a mean follow-up period of 136.8+/-59.8 days 9 (75%) patients were free from arrhythmia recurrence after a single procedure. Redo ablation was required in 1 patient, in whom electrical reconnection to all PVs was documented. Conclusion. CBA is a novel promising technique for treatment of patients with AF, and now is available in Russian Federation. The method standardizes and facilitates interventional AF treatment with acute isolation of 96% PVs. The short-term follow-up shows freedom from atrial tachyarrhythmias in 75% of patients.

[Clinical features of coronary heart disease with concomitant diabetes mellitus at high latitudes].

Joint effect of diabetes mellitus (DM) and extreme natural conditions of the Far North on the clinical course of coronary heart disease (CHD) remains poorly known. Specific features of DM2 concomitant with CHD were studied in 243 of the 8573 subjects living in Far North areas of the Tyumen region and examined by coronarography (mean age 53.4 +/- 0.4 years). The control group comprised 139 patients (56.9 +/- 0.58 years) with CHD and DM2 living in the south of Tyumen region. Clinical and ECG observations were supplemented by measurement of total cholesterol and selective coronarography. Patients of the study group were younger (p < 0.001), more frequently consumed tobacco (p < 0.001) and alcohol (p = 0.001) and had obesity (p = 0.008). Most patients in both groups had a history of myocardial infarction, suffered functional class II or higher angina and circulatory insufficiency (according to NYHA), high cholesterolemia, and arterial hypertension further deteriorating effects of CHD and DM2. However, the two groups were not significantly different in terms of these characteristics. It is concluded that combination of CDH and DM2 has unfavourable effect in patients living in the Far North although severity of clinical and functional manifestations of CDH in DM2 patients is not significantly different between residents of northern and southern areas of Tyumen region.

[Effect of cardiac resynchronization therapy in the treatment of chronic heart failure].

As a result of cardiac resynchronization therapy in all 10 patients with chronic NYHA class III-IV heart failure at duration of observation from 2 to 20 months was noted positive dynamics: improvement of self feeling, increase of 6 min walking distance, decrease of heart failure class, and improvement of functional parameters of the heart according to echocardiography data. Implantation of biventricular cardiac pacemaker to patients with chronic heart failure is relatively safe and accomplish-able from technical point of view. Cardiac resynchronization in patients with pronounced chronic heart failure appears to be an effective supplementation of drug therapy.