[Catheter therapy of congenital cardiovascular defects]. / Kateternaia terapiia vrozhdennykh porokov serdtsa i sosudov.

The authors analyze the experience gained in catheter operations performed at their Department over the recent 28 years. A total of 500 balloon (Rashkind) and 35 knife (Park) atrioseptostomies were performed in critical patients with different "blue" congenital diseases over this period. An immediate hemodynamic effect at the operation table was attained in 95% of patients. Transluminal balloon valvuloplasty (TLBVP) was performed in 372 patients with valvular stenosis of the pulmonary artery. The results of this operation depend on the patient's age, anatomy of the defect, and correct choice of the diameter of balloon catheter. This intervention is particularly effective in patients aged under 1. In patients with combined valvular and infundibular stenosis the results of TLBVP depend on the severity of stenosis and age of patient. An attempt at TLBVP of congenital aortal stenosis was undertaken in 67 patients. Valvuloplasty was carried out in 57 patients. The operation was effective in 13 (62%) out of 21 patients aged under 1. The mortality in this group was 5.5%. Balloon valvuloplasty of the pulmonary artery was carried out in 71 patients with cyanotic congenital heart diseases. The intervention helped eliminate the critical state, rise the systolic pressure in the pulmonary artery, improve blood saturation with oxygen, and evade the operation for creation of a systemic-pulmonary anastomosis. Isolated and postoperative stenoses of pulmonary arteries were removed in 65 patients. Six Johnson and Johnson stents were effectively implanted to 3 patients with rigid postoperative stenoses; in 32 patients transluminal balloon angioplasty (TLBAP) for coarctation and recoarctation of the aorta brought about a satisfactory immediate hemodynamic effect. TLBAP of Blalock-Taussig's stenosed anastomosis were performed in 60 patients with various cyanotic congenital heart diseases. Its results were good in 39 (65%) patients, satisfactory in 19 (31.7%), and unsatisfactory in only 2 (3%) cases. Of the novel endocardial interventions, dilatation of the conduit following Rastrelli's operation, creation of a defect of the atrial septum after Fontain's operation, and embolization of the coronary-cardiac fistulas and of patent ductus arteriosus were carried out. This review demonstrates wide use of endocardial surgery methods in the treatment of some congenital heart diseases; in many cases such treatment may be an alternative to surgical interventions.

[The treatment of critical valvular stenosis of the pulmonary artery by the balloon valvuloplasty method in patients in the first 3 years of life]. / Lechenie kriticheskogo klapannogo stenoza legochnoi arterii metodom ballonnoi val'vuloplastiki u bol'nykh pervykh 3 let zhizni.

The work generalizes the experience of the Bakulev Institute of Cardiovascular Surgery in balloon valvuloplasty of valvular pulmonary stenosis in 58 children of the first 3 years of life: 8 were 1 to 6 months of age, 10 were 7 to 12 months of age, 18 were 13 to 24 months old, and 22 were 25 to 36 months old. Cyanosis was found in 27 of them. As the result of balloon valvuloplasty, the systolic pressure gradient between the right ventricle and the pulmonary artery reduced from 114.7 +/- 12.6 to 31.4 +/- 7.2 mm Hg in children under 1 year of age, from 143 +/- 12.6 to 40.1 +/- 8.3 mm Hg in children aged from 1 to 3 years. In patients with cyanosis, saturation of arterial blood with oxygen increased to 92%. The late-term results were studied in follow-up periods of 6 to 36 months in 35 patients, by means of catheterization and angiocardiography in 15 of them. Analysis showed balloon valvuloplasty to be effective. Balloon valvuloplasty was repeated in 5 patients with critical stenosis because a hemodynamic effect was not achieved by the first dilatation.

[Transluminal balloon valvuloplasty in the treatment of congenital critical aortic valve stenosis in infants in the 1st year of life]. / Transliuminal'naia ballonnaia val'vuloplastika v lechenii vrozhdennogo kriticheskogo klapannogo stenoza aorty u detei 1-go goda zhizni.

Balloon valvuloplasty was performed in 14 patients with congenital valvular aortic stenosis. Their age was 28 days to 12 months. All the patients had severe heart failure. Balloon valvuloplasty was successfully conducted in 8 patients. The systolic pressure gradient between the aorta and the left ventricle decreased, on the average, from 81.2 +/- 21.4 to 31.3 +/- 8.2 mm Hg, i.e. by 61.5%. Only 2 patients developed moderate aortic insufficiency after balloon valvuloplasty. The left ventricle could not be catheterised in 6 infants: in 4 patients due to critical valvular stenosis, in 2 due to a. lusoria. One of them died when the guide was attempted to be introduced through the narrowed aortic valve, which resulted in aortic sinus perforation. Long-term results were studied in 4 patients 3 to 24 months after surgery. Their clinical condition improved. The systolic pressure gradient between the left ventricle and the aorta was in agreement with the values obtained just after transluminal balloon valvuloplasty. Transluminal balloon valvuloplasty can be successfully performed in 1-year-old infants with congenital critical aortic valvular stenosis and yields good immediate results. A further accumulation of clinical findings, development of procedures for transluminal balloon valvuloplasty and study of long-term results will allow indications for this tool to be worked out in this group of patients.

[Complications of catheter-balloon valvuloplasty (analysis of their causes and the methods of prevention and treatment]. / Oslozhneniia kateternoi ballonnoi val'vuloplastiki (analiz prichin, sposoby profilaktiki i lecheniia).

The authors analyse the results of 1,404 operations of catheter-balloon valvuloplasty in stenoses of the pulmonary, aortic, and mitral valves. The experience was accumulated by the leading heart surgeons of the country from 1984 to 1990. The total number of complications was 77 (5.4%), 23 (1.6%) of them were fetal. The least number of complications (1.88%) occurred in catheter-balloon valvuloplasty in pulmonary stenosis, 1% were fetal. Complications in aortic stenosis were encountered in 11.3% of cases, 4.8% were fatal. The greatest number of complications (44) were recorded in mitral stenosis with a relatively low mortality (2.7%). The authors distinguish unspecific complications connected with the use of standard diagnostic catheters and instruments, and specific complications linked with the use of balloon catheters or caused by the course of the disease, and the character of the valve affection. As the result of analysis of the causes of complications, the authors suggest a system for preparation of patients for operation and the principles of its safe accomplishment and describe the order of the acts undertaken by the surgeon for the management of complications. Analysis of complications of catheter-balloon valvuloplasty demonstrates the efficacy and mild injurious character of this method, which makes it possible to rank it among the generally accepted cardiosurgical methods for the correction of heart valvular stenoses.

[The effect of contrast ventriculography of the left ventricle on intracardiac hemodynamics in patients with ischemic heart disease]. / Vliianie kontrastnoi ventrikulografii levogo zheludochka na vnutriserdechnuiu gemodinamiku u bol'nykh IBS.

The effect of left ventricular (LV) contrast ventriculography (VG) on the state of intracardiac hemodynamics during the administration of a contrast medium and 30-40 sec. after it was investigated in 48 CHD patients. It followed retrograde catheterization of the left ventricle by a parallel use of two catheters that permitted recording intraventricular pressure directly during LV VG. The performance of left VG with 76% urografin administered in a dose of 0.6-0.8 ml/kg with the rate of 13-15 ml/s produced no significant change in the state of intracardiac hemodynamics, relaxation and pumping function of the LV in the course of the first three contrasted cardiocycles. Transitory disorder of hemodynamics observed in the patients after contrast VG was restored by itself in 15-20 min.

[Effect of contrast ventriculography of the left ventricle on coronary hemodynamics in patients with ischemic heart disease]. / Vliianie kontrastnoi ventriculografii levogo zheludochka na vnutriserdechnuiu gemodinamiku u bolnykh IBS.

The effect of left ventricular (LV) contrast ventriculography (VG) on the state of intracardiac hemodynamics during the administration of a contrast medium and 30-40 sec. after it was investigated in 48 CHD patients. It followed retrograde catheterization of the left ventricle by a parallel use of two catheters that permitted recording intraventricular pressure directly during LV VG. The performance of left VG with 76% urografin administered in a dose of 0.6-0.8 ml/kg with the rate of 13-15 ml/s produced no significant change in the state of intracardiac hemodynamics, relaxation and pumping function of the LV in the course of the first three contrasted cardiocycles. Transitory disorder of hemodynamics observed in the patients after contrast VG was restored by itself in 15-20 min.

[Angiographic signs and pathophysiology of abnormal origin of the left coronary artery from the pulmonary trunk]. / Angiograficheskaia semiotika i patofiziologiia anomal'nogo otkhozhdeniia levoi koronarnoi arterii ot legochnogo stvola.

The results of intracardiac examination of 37 patients with anomalous origin of the left coronary artery from the pulmonary trunk were studied. On the basis of anatomo-angiographic++ comparisons the authors point out the characteristic features of coronary circulation and affection of the left ventricular myocardium which determine the clinical manifestations of its dysfunction. The functional condition of the left ventricle was appraised depending on the character of development of the intercoronary collaterals.

[Intravascular radiologically-guided surgery in the treatment of congenital heart defects]. / Endovaskuliarnaia rentgenokhirurgiia v lechenii vrozhdennykh porokov serdtsa.

The article discusses the experience of the Bakulev Institute of Cardiovascular Surgery, USSR AMS, in catheter endovascular radiologically-guided surgery of some congenital heart diseases in the period from 1967 to 1990. A total of 505 operations were performed at the department of radiologically-guided examination and treatment of the heart and vessels: 307 Rashkind's and 35 Park's operations in total transposition of the great vessels, 110 balloon dilatations in valvular stenosis of the pulmonary trunk and 13 in valvular stenosis of the aorta, 7 embolizations in coronary-cardiac fistulas, 2 balloon dilatations in constrictions of Blalock-Taussig anastomosis, 14 balloon dilatations in peripheral stenoses of the pulmonary arteries, etc. The methodical aspects and the results of endovascular interventions are discussed in detail. The data of foreign researchers on the promising methods of radiologically-guided surgery are also shown.

[Transluminal balloon angioplasty of pulmonary arteries after palliative reconstruction of the outflow tract from the right ventricle as a preparatory stage for radical surgery]. / Transliuminal'naia ballonnaia angioplastika legochnykh arterii posle operatsii palliativnoi rekonstruktsii putei ottoka iz pravogo zheludochka kak podgotovitel'nyi étap k radikal'noi operatsii.

The authors describe their experience in the use of transluminal balloon angioplasty (TBA) of the pulmonary arteries (PA) carried out in stenosed segments in the late-term period after operation for palliative reconstruction of the right ventricular outflow tract without closure of a ventricular septal defect (VSD) in 7 patients: in 6 with Fallot's tetrad after previously created systemic-pulmonary anastomoses and in one with PA atresia and VSD. TBA was conducted in 11 stenosed segments of the pulmono-arterial tree. The TBA method is suggested as a procedure for preparing the PA for the final stage of operative treatment.

[Tl-201 perfusion scintigraphy of the myocardium in patients with anomalous origin of the left coronary artery from the pulmonary trunk (clinico-anatomical comparisons)]. / Perfuzionnaia stsintigrafiia miokarda s 201Tl u bol'nykh s anomal'nym otkhozhdeniem levoi koronarnoi arterii ot legochnogo stvola (kliniko-anatomicheskie sopostavleniia]

The clinical significance of 201Tl myocardial perfusion scintigraphy was studied in 7 patients with abnormal branch of the left coronary artery from the pulmonary trunk and in 1 patient with that of the anterior interventricular artery from the pulmonary trunk. Radiological criteria for the defect were established on the basis of comparative analysis of the data of myocardial scintigraphy with those of electrocardiographic, coronary angiography and anatomic examinations. It was shown that it was feasible to make a differential diagnosis between abnormal left coronary artery branch and dilated cardiomyopathy and that the technique was of value for comparative assessment of the efficacy of various types of surgical treatment for abnormal left coronary artery ramus from the pulmonary trunk.

[Angiographic semeiotics and pathophysiology of congenital fistulas of the coronary arteries]. / Angiograficheskaia semiotika i patofiziologiia vrozhdennykh fistul koronarnykh arterii.

From analysis of the findings of intracardiac examination of 35 patients with congenital fistulas of the coronary arteries the authors discuss the angiographic semeiotics of the anomaly and the mechanism of disorders of coronary circulation. The pathophysiology of the anomaly is determined by the amount of blood shunted through the fistula, the location of the fistula (whether in the proximal or distal segment of the artery), and the perfusion deficit of the distal segment of the involved artery. Fistulas with a large volume of the shunt may be accompanied both with ischemic changes in the basin of the affected coronary artery and with regional disorders of myocardial perfusion in the adjacent basins (intact coronary arteries). The last named is due to the phenomenon of "stealing" the adjacent coronary trunk. The absence of electrocardiographic signs of focal disorders cannot be considered a sign of a hemodynamically insignificant fistula because an ECG of rest does not always reflect the state of the coronary blood flow in the basin of the involved vessel. Evidence of this are asymptomatic coronary insufficiency and disorders of myocardial perfusion which are revealed by exercise tolerance tests and scintigraphy of the myocardium in patients with a normal ECG.

[Comparative hemodynamic characteristics of Soviet-made mechanical heart valve prostheses in the mitral position]. / Sravnitel'naia gemodinamicheskaia kharakteristika otechestvennykh mekahnicheskikh protezov klapanov serdtsa v mitral'noi pozitsii.

The article deals with hemodynamic evaluation of Soviet-made, and heart valve prostheses in late-term periods after operation for mitral valve replacement. Fourty-six patients were examined: a ball prosthesis was implanted in 21 patients (1st group), as disk prosthesis--in 15 patients (2nd group) and a prosthesis--in 10 patients (3rd group). A good clinical result of the operation was achieved in all patients, they were referred to functional class I and II. Catheterization of the left and right parts of the heart, left ventriculography, and test with dosed physical exertion were carried out. Loading was continued till cardiac output increased approximately by 60 per cent in 6 patients of the 1st group, 12 patients of the second group, and in all 10 patients of the 3rd group. The study showed that the prostheses do not yield to foreign models of heart valves in hemodynamic characteristics and cause a lower stenosing effect than the prostheses do. No essential differences were detected between the prostheses.

[Left-ventricular relaxation in patients with ischemic heart disease, congestive cardiomyopathy and mitral and aortic valve defects]. / Relaksatsiia levogo zheludochka u bo'lnykh s ishemicheskoi bolez'niu serdtsa, zastoinoi kardiomiopatiei, porokami mitra'l- nogo i aorta'lnogo klapanov.

Left ventricular relaxation was studied in 105 patients with coronary heart disease (CHD), 42 with mitral and aortic valvular diseases, and 14 with congestive cardiomyopathy. To assess the left ventricular relaxation, the values of dP/dt and T time constants for isovolumic exponential fall in intraventricular pressure were defined in the patients. Depressed left ventricular relaxation was found in the majority of the patients with CHD whatever the status of global and segmental pumping function of the left ventricle. Abnormal left ventricular relaxation turned out to be a characteristic feature in patients with congestive cardiomyopathy and valvular diseases that contributed to the generation of left ventricular overload by its pressure and volume. In CHD patients, depressed relaxation was accompanied by lower volume and slower early diastolic filling of the left ventricle.

[Balloon valvuloplasty in congenital aortic stenosis]. / Ballonnaia val'vuloplastika vrozhdennogo aortal'nogo stenoza.

The authors discuss their experience with balloon valvuloplasty (BVP) in aortic valvular stenosis (AVS) in 3 patients aged 10 months, 15 and 16 years. BVP was carried out in all of them with exposure of the right subscapular artery. Left ventricular (LV) systolic pressure before BVP was 198 +/- 45 mm Hg on the average, systolic pressure gradient between the LV and the aorta was 102-32 mm Hg. After BVP systolic pressure in the LV reduced by 26.5% and was 146 +/- 27.8 mm Hg, the systolic pressure gradient between the LV and the aorta reduced by 64.8% and was 36.0 +/- 7.5 mm Hg. No increased regurgitation of contrasted blood through the valve into the LV was demonstrated by repeated aortography. Complications connected with BVP were not encountered. Thus, BVP may be an alternative to surgery in congenital AVS. This method is evidently indicated for patients of early age with AVS, which allows operations with extracorporeal circulation to be avoided. According to the authors, BVP is expedient in congenital AVS in older patients when the diameter of the aortic valvular ring is less than 20 mm.

[Transluminal balloon valvuloplasty and aortoplasty in the treatment of congenital heart defects]. / Transliuminal'naia ballonnaia val'vuoplastika i aortoplastika v lechenii nekotorykh vrozhdennykh porokov serdtsa.

The authors' experience in endovascular treatment of such congenital heart defects as pulmonary valvular stenosis (PVS), aortic valvular stenosis (AVS), and aortic coarctation (AC) is presented. Transluminal balloon dilatation was performed in 46 patients: in 30 patients with PVS, 11 patients with CA, and 4 patients with AVS, the patients' age ranging from 7 months to 45 years. Transluminal balloon valvuloplasty was performed using 'Schneider-Medintag' catheters (Switzerland). In PVS patients, the systolic pressure in the right ventricle (RV) was reduced after the procedure from 129 +/- 10.4 to 58 +/- 3.5 mm Hg, the systolic pressure gradient (SPG) between the right ventricle and pulmonary artery fell from 111 +/- 10.6 to 35 +/- 3.8 mm Hg, and the pulmonary valve opening was enlarged from 13.4 +/- 1.5 to 69 +/- 3.9 mm2. Late (6-18-month) results were studied in 5 patients. In CA and reversed CA patients, the SPG between the ascending and descending aorta was reduced from 47.0 +/- 1.7 to 16.0 +/- 3.7 mm Hg, the coarctation diameter increased from 4.5 +/- 0.6 to 8.2 +/- 2.3 mm. In congenital AVS patients, the SPG between the left ventricle and aorta was reduced from 106.5 +/- 35.1 to 39.5 +/- 8.1 mm Hg. Thus, the transluminal balloon valvuloplasty is an effective therapeutic intervention and might be an alternative to surgical treatment. Further experience will allow one to specify indications to its performance in congenital heart disease.

[Endovascular laser methods in the treatment of arteriosclerotic cardiovascular diseases]. / Lazerny éndovaskuliarnye metody lecheniia ateroskleroticheskikh zabolevanii serdechno-sosudistoi sistemy.

Employment of laser for restoration of adequate blood flow in atherosclerotic vessels is a radically new approach to treatment of cardiovascular diseases of atherosclerotic genesis. Since 1983, wide-scale experimental work has been done at A.N. Bakulev Institute of Cardiovascular Surgery, USSR Academy of Medical Sciences, which has formed the basis for transluminal laser angioplasty (vascular recanalisation with high-intensity laser beam), laser atherolysis (regression of atherosclerotic formations under low-intensity laser beam), and their combinations. Clinical application of these procedures was started in 1985. Sixty-two patients with ischaemic heart disease, Takayasu's and Leriche's syndromes, chronic occlusion of pelvic and lower-limb arteries, and with combined lesions of the arterial bed were exposed to targeted transluminal laser. Laser endovascular therapy alone and in combination with balloon angioplasty or bypass surgery was used. Application of these methods showed their high efficacy. Successful recanalisation and restoration of adequate flow (confirmed by Doppler echography and angiography) were achieved in 93 per cent cases; results were poor (no effect, complications) in 7 per cent cases.

[Hemodynamic mechanisms of ECG changes in congenital fistulas of the coronary arteries]. / Gemodinamicheskie mekhanizmy izmeneniia EKG pri vrozhdennykh fistulakh koronarnykh arterii.

ECG changes were analysed in 31 patients with congenital coronary arterial fistulas with reference to the site of coronary arterial lesion and the level and magnitude of blood discharge. Two hemodynamic factors, conditioning ECG changes, were identified as typical for coronary arterial fistulas: 1) volume strain on cardiac compartments making up the fistula receptacle chamber; 2) perfusion deficiency in the distal segment of the affected coronary artery. Fistulas with large-volume shunts may be accompanied by both ischemic changes in the affected-artery basin and regional perfusion disorders in adjacent basins, the latter being due to "stealing" of the adjoining coronary trunk or the type of coronary blood supply.

[Effect of the rheological properties of the blood on the intracardiac hemodynamics in patients with acquired mitral valve defects]. / Vliianie reologicheskikh svoistv krovi na vnutriserdechnuiu gemodinamiku u bol'nykh priobretennymi mitral'nymi porokami serdtsa.

A study of 17 patients with prevailing mitral stenosis and 10 patients with prevailing mitral insufficiency demonstrated a significant aspirin-induced improvement of blood rheologic characteristics in all patients that was accompanied with a heterogeneous shift of intracardiac hemodynamics and left-ventricular myocardial pumping activity. For instance, in patients with prevailing mitral stenosis, an improvement of blood rheologic properties is accompanied with a drop in mitral pressure gradient and a decrease in total pulmonary resistance and total peripheral resistance resulting in increased pumping capacity of the heart (increased minute volume, systolic index and stroke index). In patients with prevailing mitral insufficiency, the improvement of blood rheologic properties is accompanied by an increase of regurgitation volume, a reduction of effective ejection fraction and a rise in total pulmonary resistance. Therefore, a differential approach to the use of agents improving blood rheologic properties is needed.