Two-Stage Revascularization in Patients with Acute Myocardial Infarction and Massive Coronary Thrombosis.

AIM: to investigate safety and angiographic efficacy of two-stage revascularization with percutaneous coronary intervention (PCI) with stenting delayed by one day in patients with acute myocardial infarction (MI) and massive coronary thrombosis. MATERIALS AND METHODS: We included in this study 12 patients with massive infarct related coronary artery thrombus which length was greater than thrice the vessel diameter in the presence of TIMI grade II-III blood flow as detected by coronary angiography (CAG). The emergency PCI was not performed, and conservative antithrombotic therapy continued for 24 hours. After this day, CAG was repeated. RESULTS: Repeat CAG in all patients showed thrombus regression which visually appeared as complete lysis in 8, and partial lysis - in 4 patients. Stenting of residual stenosis was performed in 11 patients without complications. In 1 patient residual stenosis was considered insignificant (<50 %) therefore stenting was not performed. No-reflowphenomenon and recurrent MI were not observed. CONCLUSION: These data suggest that in patients with massive coronary artery thrombosis conservative antithrombotic therapy for 24 hours followed by repeated CAG and, if required, by stenting of residual stenosis, is safe treatment tactics that might reduce the risk of the no-reflow phenomenon.

[Comparative efficacy of pharmacoinvasive strategy of myocardial reperfusion and primary angioplasty in patients with acute ST elevation myocardial infarction].

In order to assess comparative efficacy of pharmacoinvasive strategy of myocardial reperfusion and primary angioplasty in ST elevation acute myocardial infarction 289 patients were randomized at prehospital stage within first 6 hours of the disease into 2 groups: primary angioplasty (group 1), and prehospital thrombolysis with subsequent rescue or delayed angioplasty depending on efficacy of thrombolysis. We analyzed clinical and anamnestic characteristics of patients, efficacy of reperfusion measures, dimensions of myocardial necrosis, and clinical course of the disease. Pharmacoinvasive myocardial reperfusion with prehospital thrombolysis compared with primary coronary angioplasty decreased time of myocardial ischemia (224.65 +/- 71 vs. 278 +/- 184 min, p < 0.03), increased rate of achievement of TIMI grade 3 flow after percutaneous coronary intervention (80.5% vs. 71.4%, p = 0.002) and more effectively preserved left ventricular ejection fraction (60.0 +/- 14.9% vs. 54.9 +/- 12.3%, p < 0.01). Prehospital thrombolysis before coronary angioplasty compared with primary angioplasty was associated with lower rate of development of no-reflow syndrome (1.4% vs. 11.6%, p < 0.003).

[Thrombosis of stents with an antiproliferative coating. Review of the literature].

The authors analysed the findings concerning thromboses of sirolimus- and paclitaxel-eluting stents over the time period from 2004 to 2007, having singled out the following causes of a stent's thrombosis: 1 - an anatomical cause (bifurcation stenosis, a prolonged atherosclerotic plaque, and in-stent restenosis; 2 - the stent's failure to fit snugly to the arterial wall; 3 - dissection of coronary arteries during stenting; 4 - cocaine dependence; 5 - resistance to aspirin and clopidogrel therapy; 6 - discontinuation of anti-platelet therapy.

[Long-term results of coronary endovascular revascularisation with sirolimus-eluting stents in patients with ischemic heart disease comorbid with type-2 diabetes mellitus: data from 18-month prospective study].

AIM: To study long-term results of 3-42-month (mean 18.1 +/- 1.2 month) of a prospective clinically and angiologically controlled follow-up after coronary endovascular revascularisation with sirolimus-eluting stents (SES) in patients with coronary heart disease (CHD) comorbid with type 2 diabetes mellitus (DM). MATERIAL AND METHODS: A total of 108 CHD patients with angina pectoris resistant to antianginal therapy were divided into 2 groups: 51 CHD patients with mild and moderate type-2 DM (group 1); 57 CHD patients free of diabetes (group 2). All the patients have undergone successful coronary endovascular revascularisation with SES. Anti-ischemic efficacy and safety of stenting were studied in the course of 18-month prospective follow-up. RESULTS: An anti-ischemic effect of stenting in hospital setting was achieved in all the patients. 18 months after stenting frequency and severity of anginal attacks reduced in group 1 by 70.6%, daily need in nitroglycerine--by 71.9%, in group 2--by 87.1 and 93.1%, respectively. As a result, exercise tolerance improved in group 1 by 38.3%, in group 2--by 40.8%. Quality of life improved by 22.7 and 25.1%, respectively. Most of the patients showed no deterioration of carbohydrate and lipid metabolism compensation. Recurrent angina and symptoms of painless myocardial ischemia occurred in 39.3 and 14% patients of group 1 and 2, respectively. More frequent causes of the recurrence were progression of coronary artery atherosclerosis de novo and Cypher stent restenosis (11.8 and 3.5% in group 1 and 2, respectively). CONCLUSION: SES implantation provided good anti-ischemic efficacy in 60.7 and 86% CHD patients with and without DM, respectively. It significantly improved exercise tolerance and quality of life.

[Late results of endovascular coronary revascularization in patients with type 2 diabetes mellitus].

The aim of this work was to evaluate anti-ischemic and angiographic efficiency of endovascular revascularization of ischemic myocardium by implantation of Sirolimus-eluting stents from the results of a 18 moth-long prospective study of patients with coronary heart disease and/or type 2 diabetes mellitus (DM). The study included 108 patients with angina of effort randomized into two groups: CHD with DM (n = 51) and CHD without DM (n = 57). All of them received anti-ischemic and antihypertensive therapy and two desaggregants; DM patients also used oral hypoglycemic preparations. The patients underwent implantation of Sirolimus-eluting stents. The frequency of restenosis of the target arteries, development of serious cardio-vascular events (death, MI, cerebral stroke, and the need in repeat revascularization) were compared within 18 months after primary endovascular revascularization. Although Sirolimus-eluting stents markedly improved long-term prognosis in DM patients, results of their implantation were worse than in patients with CHD without DM.

Model testing of radioactive contamination by 90Sr, 137Cs and 239,240Pu of water and bottom sediments in the Techa River (Southern Urals, Russia).

This paper presents results of testing models for the radioactive contamination of river water and bottom sediments by (90)Sr, (137)Cs and (239,240)Pu. The scenario for the model testing was based on data from the Techa River (Southern Urals, Russia), which was contaminated as a result of discharges of liquid radioactive waste into the river. The endpoints of the scenario were model predictions of the activity concentrations of (90)Sr, (137)Cs and (239,240)Pu in water and bottom sediments along the Techa River in 1996. Calculations for the Techa scenario were performed by six participant teams from France (model CASTEAUR), Italy (model MARTE), Russia (models TRANSFER-2, CASSANDRA, GIDRO-W) and Ukraine (model RIVTOX), all using different models. As a whole, the radionuclide predictions for (90)Sr in water for all considered models, (137)Cs for MARTE and TRANSFER-2, and (239,240)Pu for TRANSFER-2 and CASSANDRA can be considered sufficiently reliable, whereas the prediction for sediments should be considered cautiously. At the same time the CASTEAUR and RIVTOX models estimate the activity concentrations of (137)Cs and (239,240)Pu in water more reliably than in bottom sediments. The models MARTE ((239,240)Pu) and CASSANDRA ((137)Cs) evaluated the activity concentrations of radionuclides in sediments with about the same agreement with observations as for water. For (90)Sr and (137)Cs the agreement between empirical data and model predictions was good, but not for all the observations of (239,240)Pu in the river water-bottom sediment system. The modelling of (239,240)Pu distribution proved difficult because, in contrast to (137)Cs and (90)Sr, most of models have not been previously tested or validated for plutonium.

[Coronary angioplasty in diabetic patients].

The authors present a review of clinical studies conducted and completed in 2001-2005. The review contains data on clinical trials of sirolimus- and paclitaxel-eluting stents in patients with diabetes mellitus and coronary artery disease. The authors analyze experimental data on mechanism of neointima formation in animals with experimental diabetes as well as clinical data on coronary angioplasty in patients with diabetes mellitus. In addition, they discuss data on the use of sirolimus-eluting stents in the treatment of in-stent restenosis in diabetic patients.

[Experience with primary coronary angioplasty in management of patients suffering from acute myocardial infarction].

The authors herein analysed the findings obtained in randomized studies carried out to compare the efficacy of percutaneous transluminal coronary angioplasty (hereinafter referred to as PTCA) and thrombolytic therapy for acute myocardial infarction (AMI). Some studies employed thrombolytic therapy with streptokinase, while others used plasminogen tissue activators as thrombolytic agents. Primary PTCA as compared with thrombolysis was noted to decrease the total lethality rate, lowering mortality related to cardiogenic shock, decreasing lethality amongst elderly and aged patients, decreasing the prevalence of stroke and secondary infarctions, as well as the incidence of repeat revascularizations. The obtained findings demonstrated that primary PTCA still remains a better means of management of patients with AMI as compared with thrombolytic therapy, irrespective of the thrombolytic agent used. The long-term forecasts in primary PTCA and coronary artery bypass are similar, with the average hospital stay in PTCA being, however, shorter as compared with that in coronary artery bypass and thrombolytic therapy. Hence, the authors came to a conclusion that primary PTCA is a more efficient method of management of AIM patients than thrombolytic therapy or coronary artery bypass. We also analysed the findings of randomized studies aimed at comparing the efficacy of primary balloon dilatation and stenting of the infarction-associated coronary artery, and came to a conclusion that primary stenting makes it possible to more efficiently, than balloon angioplasty, revascularize the infarction-affected myocardium, since stenting decreases the incidence rate of relapsing secondary revascularizations as compared with primary balloon dilatation. However, stenting possesses no advantages over angioplasty as regards the influence on the incidence rate of lethal outcomes and secondary myocardial infarctions. Using the syrolimus-containing stents may improve the long-term prognosis in patients presenting with AMI. Preliminary administration of absiximab was observed to decrease the lethality rate amongst the patients subjected to primary angioplasty during the first 30 days following the development of AMI, exerting however no influence on the lethality rate during one year after the onset of AMI. Intravenous administration of beta-adrenoblockers as compared with primary angioplasty improves survival in AMI patients. Aspirin treatment before and after primary angioplasty appears to improve the remote prognosis following PTCA as compared with the patients having received no aspirin. We believe that beta-adrenoblockers and aspirin should be used in management of patients having undergone angioplasty of the infarction-associated coronary artery.

[Problem of restenosis inside stents with an antiproliferative coating].

The article deals with a review of clinical studies carried out within the time period from 2003 to 2007. The review contains the data concerning restenoses of sirolimus- and paclitaxel-eluting stents, suggesting that the stents with an antiproliferative coating substantially diminished the acuity of the problem regarding restenoses but did not solve the problem completely. The incidence rate of restenoses remains high in patients with diabetes mellitus as well as in those with bifurcation stenoses, acute and chronic occlusions of coronary arteries. Analysing the published data the authors made a conclusion that during angioplasty of acute and chronic occlusions of coronary arteries preference should be given to sirolimus-eluting stents since they are most effective in prevention of restenoses inside stents in such lesions. Analysing the findings of clinical trials of drug-eluting stents showed efficiency and safety of such stents in treatment of in-stent restenoses. Patients with diabetes mellitus are exceptions to this rule, being poor candidates for drug-eluting stents, since the latter proved to exhibit low efficacy in these patients.

[Experience in using stents with an antiproliferative coating in treatment of stenoses and occlusions of coronary arteries. Review of the literature].

The authors analysed the data concerning sirolimus- and paclitaxel-eluting stents used for treatment of stenoses and chronic occlusions of coronary arteries. Also discussed herein are clinical outcomes following stenting of bifurcation stenoses, stenoses of the main trunk of the left coronary artery, diffuse stenoses and chronic occlusions. The authors concluded that introduction into clinical practice of stents with an antiproliferative coating made it possible to considerably improve the results of coronary angioplasty in the above-mentioned lesions of coronary arteries. At the same time, the incidence rate of restenoses, secondary revascularizations and unfavourable outcomes for drug-eluting stents in various lesions of the coronary bed remains sufficiently rather high and is 2-3 times greater than similar indices in focal stenoses.

[Paclitaxel-eluting stents in treatment of stenoses and chronic occlusions of coronary arteries].

The present review summarises the data obtained by analysing the publications dedicated to using paclitaxel-eluting stents in management of coronary heart disease. The stents containing paclitaxel (taxol) proved to have high clinical efficacy in both single and multiple stenoses of the coronary arteries. The feasibility of using taxol-eluting stents in patients suffering from diabetes mellitus and in patients diagnosed with chronic coronary occlusion does not admit of any doubt. However, the rate of restenoses development following implantation of the paclitaxel-eluting stents is higher than that after using the syrolimus-releasing stents. Unsolved as yet remains the issue concerning the efficacy of the paclitaxel-eluting stents intended for treatment of restenoses inside the stent, as well as concerning the feasibility of using these stents for stenting the main trunk of the left coronary artery.

[Cardiomyoplasty with autological mononuclear cells of the bone marrow in patients with acute myocardial infarction].

AIM: To study efficacy and safety of transplantation of bone marrow autologous mononuclear cells (BMAMC) in patients with acute myocardial infarction; to examine BMAMC distribution in the human body after intracoronary introduction. MATERIAL AND METHODS: The open controlled trial investigated 26 AMI patients (16 entered the study group and 10 were controls). Cell cardiomyoplasty with BMAMC was performed by intracoronary injection of the cells after stenting the coronary artery supplying blood to the infarction zone on AMI day 7-21. BMAMC were isolated by gradient centrifugation. Distribution of mononuclear cells was studied with radionuclear indication of the cells 99m-Tc-HMPAO. All the patients were examined with Tl-199 perfusion scintigraphy of the heart 2 weeks and 6 months after the treatment, echocardiography, 24-h ECG monitoring, 6-min walk test. RESULTS: All the patients were followed up for 6 months. Two patients (one in each group) developed recurrent myocardial infarction 3 months after the first. Radionuclide investigations revealed fixation of labelled mononuclear cells in the heart both in initial hours after the treatment and 24 hours after it. As shown by myocardial scintigraphy, intracoronary administration of the cells with short-term arterial occlusion was followed by much greater number of labeled cells. By follow-up month 6, in the study group, left ventricular ejection fraction increased more: 12.7 +/- 3.2% versus 10.4 +/- 2.5% in the control group (p = 0.09); moreover, a stable defect of myocardial perfusion reduced more (by 29 +/- 24% against 20 +/- 18%, respectively, p = 0.1). Malignant arrhythmia, complications during and after bone marrow aspiration, intracoronary administration of cell suspension were not registered. CONCLUSION: Intracoronary administration of BMAMC in AMI patients is safe and provides their transfer and fixation in the myocardium. BMAMC transplantation has a positive effect on recovery of perfusion and contractile function of left ventricular myocardium in AMI patients.

Cardiac contractility after transplantation of autologous mononuclear bone marrow cells in patients with myocardial infarction.

Autologous bone marrow mononuclear cells were transplanted by intracoronary infusion to patients with myocardial infarction after recovery of coronary perfusion. Controls received traditional therapy alone. Echocardiography was carried out before and 3 and 6 months after cell therapy. Cell transplantation did not appreciably improved left-ventricular contractility in comparison with the control group. In none patient cell therapy provoked malignant ventricular arrhythmias. Intracoronary infusion of bone marrow mononuclear cells in patients with myocardial infarction did not improve cardiac contractility and did not aggravate the course of the disease.

[The effects of intracoronary infusion of bone marrow mononuclears on myocardial contractility].

The effects of intracoronary infusion of bone marrow mononuclears (BMM) on myocardial contractility after myocardial infarction (MI) was studied in 16 post-infarction patients. The intracoronary infusion of autologic BMM during the subacute period of MI did not have a significant effect on myocardial contractility, the functional class of chronic heart failure, physical tolerance, and quality of life evaluated three and six months after the transplantation. Intracoronary BMM transplantation did not provoke ventricular tachycardia or ventricular fibrillation. BMM transplantation into an infarcted myocardium did not exacerbate coronary heart disease in post-infarction patients.

Sirolimus-eluting stents. (The results of the five-year use for the treatment of coronary artery disease).

This paper discusses the results of the five-year clinical trials of sirolimus-eluting stents in the treatment of coronary artery disease. Analyzes outcomes of revascularization of the coronary arteries in patients with single focal lesions of the coronal arteries, multi-vessel coronary stenoses, chronic occlusion of the coronary arteries, bifurcation stenoses, and diabetes mellitus. Reviews the results of the use of sirolimus-eluting stents for the treatment of in-stent restenoses. Discusses the mechanism of antiproliferative action of rapamycin.

[Revascularization interventions in the left coronary artery system: transesophageal Doppler ultrasound study].

AIM: To elucidate the role of evaluation of coronary reserve in coronary sinus by transesophageal doppler for assessment of efficacy of various revascularization interventions. MATERIAL AND METHODS: Patients with isolated stenoses of either left anterior descending or circumflex coronary artery subjected to stenting (n=14) and with two vessel disease subjected to bypass surgery (n=20). Dipyridamole was used as a stress agent. Coronary reserve was calculated as ratio of peak hyperemic to baseline antegrade coronary sinus blood flow velocity (CR(P)) and as ratio of hyperemic to baseline antegrade coronary sinus volume blood flow (CR(VBF)). RESULTS: In patients with atherosclerotic lesions in the system of left coronary artery normalization of CR(P) after stenting of single vessel stenoses and of CR(VBF) after bypass surgery in two vessel disease were markers of efficacy of revascularization with sensitivity 75 and 71%, respectively.

[Hyperinsulinemia in patients with microvascular coronary artery lesion as a possible diagnostic criterion of coronary heart disease].

The purpose of the study was to investigate the character of clinical and functional manifestations of ischemic cardiac dysfunction in patients with idiopathic coronary microangiopathy, and their correlation with insulin level, as a possible diagnostic criterion of coronary heart disease (CHD). The subjects were 115 men, including 35 individuals (mean age 41.8 +/- 1.2 years) with microvascular form (MVF) of coronary artery lesion, 60 patients with CHD with postinfarction cardiosclerosis (PICS), and 20 healthy individuals. Patients with glucose tolerance disorder, diabetes mellitus, arterial hypertension, and other severe pathology were not included in the study. The diagnostic tests included selective coronaroventriculography with right ventricle endomyocardium biopsy, and myocardial perfusion scintigraphy. Parameters of coronary, intracardial and system hemodynamics were evaluated; insulin and glucose serum levels were measured at rest and during stress-tests with physical exercise. Endocardial biopsy in MVF patients found plastic insufficiency of the endothelium of hemocapillars, prearteriols and cardiomyocytes. Alterations in the parameters of metabolism, intracardial and system hemodynamics, and physical exercise tolerance were found to be comparable in MVF and PICS patients. Insulin level at rest in both groups was equal to that in the control group. At threshold physical load during veloergometry insulin levels in MVF and PICS patients demonstrated comparable elevation (222.8% and 201%, respectively; p < 0.05-0.01). Glucose concentrations in patients with microangiopathy decreased by 28% (p < 0.05), while in patients with CHD it increased significantly by 27.3% (p < 0.05). The study shows that structural and functional lesion of hemocapillar endothelium underlies cardiac syndrome X It results in perfusion ability impairment, chronic hypoxia, impairment of myocardial contractility under the conditions of physical activity. Hyperinsulinemia, manifesting when ischemia is induced, is not caused by insulinresistence. Probably, it presents and adaptive and compensatory reaction to increase of myocardial glucose requirement, and may be one of early CHD markers.

[Effectiveness of external mechanical recanalization in the treatment of cardiogenic shock in patients with myocardial infarction].

Attempts of mechanical coronary artery recanalization (angioplasty) were undertaken in 52 patients with acute myocardial infarction and cardiogenic shock. In 28 patients (53.9%) recanalization was successful while in 24 it was not (in-hospital mortality 39.3 and 87.5%, respectively, p<0.001). Overall 11 and 21 patients died among those with (n=28) and without (n=24) successful recanalization, respectively. Among patients with successful recanalization survivors compared with nonsurvivors had shorter time from onset of myocardial infarction to recanalization (11.44+/-2.86 vs 16.8+/-3.4 hours, respectively). No serious complications occurred during invasive interventions.

[An experience of the use of stenting for recurrence of myocardial ischemia after coronary artery bypass grafting].

Coronary artery stenting was carried out in 18 patients with angina recurrence 29.3+/-7.6 after coronary artery bypass grafting. Paired bicycle exercise tests, (199)Tl single photon emission tomography and graft angiography were used in evaluation of patients. Occlusions of 1 or 2 venous grafts were found in 38.9%, stenoses of both previously bypassed and native arteries in 27.8% of patients. Implantation of stents in grafts and/or native coronary arteries was associated with 2.7 fold decrease of angina frequency, 3 fold decrease of nitroglycerine consumption, 72.5% increase of exercise tolerance. The use of statins resulted in obvious lowering of total and low density lipoprotein cholesterol.