[Progression of precerebral atherosclerosis and predictors of ischemic complications in cardiac patients]. / Progressirovanie pretserebral'nogo ateroskleroza i prediktory ishemicheskikh oslozhnenii u patsientov kardiokhirurgicheskogo profilya.

OBJECTIVE: To identify predictors of progression of precerebral atherosclerosis in long-term period after coronary artery bypass surgery. MATERIAL AND METHODS: There were 97 procedures of carotid endarterectomy in patients after previous coronary artery bypass grafting for the period from 2006 to 2017. Inclusion criteria were previous CABG, no significant (over 60%) stenosis of internal carotid arteries at discharge after CABG. The control group included 447 patients without progression of precerebral atherosclerosis in long-term period after CABG. RESULTS: Careful monitoring of progression of precerebral atherosclerosis and therapeutic prevention of ischemic stroke are required in patients with mild-to-moderate ICA stenosis after CABG. The most significant predictors of progression of precerebral atherosclerosis after CABG were AF (OR=1.97, 95% CI 1.04-3.73), previous occlusion of stent (OR=7.89, 95% CI=2.3-27.0), chronic brain ischemia grade II or III (OR=22.45, 95% CI=11.9-42.3), chronic kidney disease (OR=15.8, 95% CI=5.04-49.5). CONCLUSION: It was revealed that the majority of predictors of adverse ischemic cerebral and myocardial events are indirectly associated with atrial fibrillation.

[Long-term outcomes of coronary artery bypass surgery in young patients]. / Otdalennye iskhody koronarnogo shuntirovaniia u patsientov molodogo vozrasta.

OBJECTIVE: To analyze long-term outcomes of CABG in young patients, incidence and structure of adverse cardiovascular events depending on patients' age. MATERIAL AND METHODS: There were 175 young patients (up to 44 years old in accordance with WHO classification) who underwent CABG for the period from 2006 to 2016. The control group included 175 patients aged 45 years and older who were randomly selected among patients operated in the same period. Overall long-term follow-up period was 81.9±15.75 months (≈ 6.8 years). Data on long-term survival and adverse cardiovascular events were available in 86.3% of patients in general sample and 72.6% of young patients. RESULTS: Young patients undergoing CABG were usually characterized by the absence of severe concomitant diseases, moderate coronary atherosclerosis by SYNTAX Score scale, high percentage of left ventricular aneurysm and previous PCI. Incidence and structure of in-hospital and long-term adverse cardiovascular events in young and older patients confirmed satisfactory results of CABG regardless age.

[Predictors of long-term complications after carotid endarterectomy]. / Prediktory oslozhnenii v otdalennom periode posle karotidnoi éndarteréktomii.

AIM: To analyze the predictors of complications within 3 years after carotid endarterectomy (CEE). MATERIAL AND METHODS: The study included 1035 patients after CEE for the period 2011-2016. Long-term follow-up period was 42.4±18.6 months (≈ 3.5 years). The endpoints were such unfavorable cardiovascular events as death, myocardial infarction, stroke/transient ischemic attack, redo revascularization. Statistical analysis was carried out by using of Statistica for Windows 8.0 software package (StatSoft Inc., USA). Stepwise logistic regression was applied to identify risk factors of adverse outcomes and death in long-term postoperative period. RESULTS: Comprehensive analysis of numerous factors (anamnestic, instrumental-diagnostic, surgical) allowed us to identify predictors of long-term unfavorable outcomes in patients with occlusive-stenotic lesions of carotid arteries. Risk factors of long-term complications were SYNTAX score ≥33 (high risk), unstable plaque in the contralateral ICA, occlusion of contralateral ICA, LVEF <39%, ICA cross-clamping >40 min, previous CABG. CONCLUSION: These data are extremely important and can be used to create prognostic models. The last ones are necessary to determine optimal treatment strategy in patients with occlusive-stenotic lesions of supra-aortic vessels.

[Predictors of Progressive Course of Multifocal Atherosclerosis in Patients With Myocardial Infarction].

PURPOSE: Determination of clinical and instrumental predictors of progressive course of multifocal atherosclerosis (MFA) in patients one year after myocardial infarction (MI), initially having hemodynamically insignificant stenoses of carotid arteries. MATERIALS AND METHODS: From database of patients with acute coronary syndrome treated in the Kemerovo Regional Clinical Cardiac Dispensary in 2009-2010 we selected for this study 141 patients with verified diagnosis of MI and hemodynamically insignificant lesions in the internal carotid artery (ICA) (stenosis up ≤ 55 %). All patients had coronary atherosclerosis verified on coronary angiography at admission because of MI. A multivariate analysis of possible predictors of the progressive course of multifocal atherosclerosis was made based on assessment of the development of cardiovascular complications (CVC) (death, MI, stroke and transient cerebral circulatory attacks [TIA]), as well as revascularizations and negative dynamics of parameters of color duplex scanning (CDS) of ICA during one year after MI. RESULTS: One year after MI the overall incidence of CVC was 16.3 % (n=23). Structure of registered events was as follows: death from MI 7.1 % (n=10), deaths from stroke 2.1 % (n=3) and other causes 2.1 % (n=3), non-fatal MI 5.0 % (n=7), non-fatal stroke / TIA 2.1 % (n=3), carotid revascularization 2.8 % (n=4), coronary revascularization 14.9 % (n=21). CDC of ICAs was repeated in 125 patients. There were 17 (13.6 %) cases of progression of carotid atherosclerosis in the form of de novo bilateral stenoses in 14 (11.2 %) patients, stenoses in the left and right ICA 1 patient and 2 patients, respectively. The following predictors of progression of atherosclerosis of cerebral arteries were identified: family history of cardiovascular diseases (CVD),ICA stenosis ≥45 %, baseline circular atherosclerotic plaque (ASP). Predictors of high risk of stroke were family history of CVD, history of stroke,ICA stenosis ≥45 %, heterogeneous hypoechoic ASP. As predictors of lethal outcome, we identified history of MI, high functional class of angina preceding the index MI, severe coronary vascular bed involvement (SYNTAX score >23), presence of any bilateral atherosclerotic lesion in ICAs, and heterogeneous hypoechoic ASP. Assessment of the contribution of adherence to therapy in the prognosis 1 year after hospital discharge was fulfilled in 125 alive patients. It allowed to conclude that patients with progression of atherosclerosis and nonfatal CVC were characterized by insufficient adherence to standard therapy. CONCLUSION: Predictors of the progressive course of multifocal atherosclerosis during one year after MI were identified in this study. It is necessary to strengthen therapeutic and preventive measures aimed at minimization of the impact of these factors in this category of patients.

[In-hospital outcomes of transcutaneous coronary intervention and carotid endarterectomy in hybrid and staged regimens]. / Gospital'nye rezul'taty chreskozhnogo koronarnogo vmeshatel'stva i karotidnoi éndarteréktomii v gibridnom i poétapnom rezhimakh.

The aim of this study was comparative assessment of in-hospital outcomes after hybrid and staged surgical management of patients presenting with haemodynamically significant lesions of the coronary (CA) and brachiocephalic arteries (BCA) treated by means of either endovascular or surgical techniques. Over the period from 2010 to 2017, we operated on a total of 197 patients with stenotic lesions of the carotid and coronary arteries. The strategy of revascularization included transcutaneous coronary intervention (TCI) and carotid endarterectomy (CEA). Of these, 73 (37%) patients underwent staged revascularization of the brain and myocardium in various sequence (TCI-CEA or CEA-TCI), with a mean interval between the operations amounting to 9.89±7.36 months. Unfavourable outcomes were regarded as the development of such significant cardiovascular events as myocardial infarction (MI), acute impairment of cerebral circulation, death, repeat unplanned revascularization. For hybrid strategy (TCI+CEA) the index period of assessing the outcomes was the single in-hospital period, whereas for the staged strategy it was the time period beginning from the in-hospital period of the primary operation and ending by the in-hospital period of the second stage. The groups were comparable by the absolute majority of the parameters. More than half of the patients were elderly males. One third had a history of MI. The findings of coronary angiography most often revealed lesions of 1-2 CAs. The average parameters of carotid artery stenosis, according to the BCA angiography varied from 74.9 to 82.6%, with bilateral occlusive stenotic lesions being revealed in every third patient. In connection with more frequent involvement of 1-2 CAs the patients underwent implantation of 1-2 stents. In our sample we used a total of 247 stents. Of these, 119 were uncoated and 128 were drug-eluting stents. No between-group significant differences in the development of unfavourable cardiovascular events during the in-hospital postoperative period were revealed. However, despite this, a pronounced negative tendency of the complication rate was noted in the group of staged revascularization. Non-optimal time intervals between the stages of the operations in a third of cases exceeded one year on the patient's own initiative. Nearly a quarter of patients did not come for the second stage of revascularization. An important finding of our study was no increase in the risk of stent thrombosis in hybrid operations compared with the staged approach, despite administration of a loading dose of clopidogrel after CEA, but not before TCI. Another significant result was the fact of greater availability of revascularization of the myocardium and the brain within the framework of the hybrid strategy as compared with the staged one, which may play an important role in prevention of ischaemic unfavourable events in the remote period of follow up.

[In-hospital outcomes of carotid endarterectomy depending on severity of contralateral lesion]. / Gospital'nye rezul'taty karotidnoi éndarteréktomii v zavisimosti ot razlichnoi vyrazhennosti kontralateral'nogo porazheniia.

AIM: To compare in-hospital outcomes of carotid endarterectomy (CEE) in patients with different lesion of contralateral internal carotid artery (ICA). MATERIAL AND METHODS: There were 730 CEE procedures in patients with bilateral ICA lesion for the period 2011-2016. All patients were divided into 4 groups depending on contralateral ICA stenosis grade: group 1 - stenosis up to 60% (42.6%, n=311); group 2 - 60-90% (18.7%, n=137); group 3 - 90-99% (25.9%, n=189); group 4 - occlusion (12.7%, n=93). Endpoints were unfavorable cardiovascular events including death, myocardial infarction (MI), stroke/TIA, significant hemorrhage by BARC scale (Bleeding Academic Research Consortium). RESULTS: In-hospital mortality and incidence of MI, stroke/TIA were similar in all groups. However, there were no cardiovascular complications in patients with critical contralateral stenosis or occlusion. Bleeding followed by redo surgery was the most frequent complication. Overall incidence of adverse cardiovascular events did not exceed 1.23%. CONCLUSION: There was no correlation between contralateral ICA stenosis and incidence of in-hospital adverse events including death, MI, stroke/TIA. Currently, technique of CEE is well developed that is associated with low incidence of postoperative complications.