Ukrainian Journal of Cardiovascular Surgery

From a Tandem of Cardiologists and Cardiac Surgeons to a Triad with a Multidisciplinary Rehabilitation Team

Vasyl V. Lazoryshynets — 2024-09-27

Patients with STEMI after Revascularization: Is There a Relationship Between Coronary Artery Lesion and Renal Function?

Anna V. Broniuk — 2024-09-27

The aim. To establish the relationship between coronary bed lesions and glomerular filtration rate (GFR) calculated on the basis of creatinine, cystatin C and urine albumin-creatinine ratio in patients with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention.

Materials and methods. We examined 286 patients with STEMI, aged 39 to 87 years (mean age 62.8 ± 9.8, median age 64, interquartile range 56 to 71 years), 202 (70.6%) were men and 84 (29.4%) were women. All the patients underwent general clinical tests, coronary angiography with subsequent percutaneous coronary intervention, and echocardiography.

Results. The most frequent infarct-related coronary artery (CA) was the anterior interventricular branch of the left coronary artery in the proximal and middle segments, and the right coronary artery in the proximal segment. In general, there was no significant difference in the number of affected CAs among the examined patients. The division of patients into groups according to the level of GFR, determined both on the basis of creatinine and cystatin C, did not reveal significant differences in the distribution of infarct-related CAs. At the same time, the number of patients with multivessel lesions significantly increases with decreased GFR. Depending on the level of the urinary albumin-to-creatinine ratio, a significant increase in the number of patients with two- and multivessel lesions of the CAs was noted.

Conclusions. Close correlations between multivessel lesions of CAs and gender, age, urinary albumin-to-creatinine ratio, GFR, left and right atrial size, duration of history of hypertension and diabetes mellitus, presence of II-III degree atrioventricular block and mortality were established.

Heart Rhythm Disturbances in Cardiac Surgery Patients with Coronary Artery Disease

Olena K. Gogayeva — 2024-09-27

The aim. To analyze arrhythmological complications in cardiac surgery patients with coronary artery disease (CAD).

Materials and methods. This was a retrospective data analysis of 354 cardiac surgery patients with various forms of CAD who were operated on and discharged from the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. The mean age of the patients was 61.9 ± 9.6 years. All the patients underwent laboratory examinations, electrocardiography, echocardiography, coronary angiography and cardiac surgery. The patients with uncomplicated forms of CAD (n = 194) underwent isolated surgical revascularization of the myocardium, in the case of complicated forms of CAD (n = 160), coronary bypass surgery was supplemented with valvular or ventricular correction.

Results. Postoperative atrial fibrillation (AF) occurred in 40 (20.6%) patients with uncomplicated CAD and 43 patients with complicated CAD (26.8%), p = 0.1667. Among patients with complicated forms of CAD, 2 (1.25%) had paroxysms of ventricular tachycardia, which required the implantation of a cardioverter-defibrillator, also in this group of patients complete left bundle branch block occurred more often (p = 0.0020). The postoperative period in patients with impaired glucose metabolism was characterized by more frequent development of AF in patients with type 2 diabetes mellitus (33.3%, p = 0.0006), with impaired glucose tolerance (24.8%, p = 0.0156) compared to patients with normoglycemia (12.6%).

Conclusions. There was no statistically significant difference in the frequency of postoperative AF in patients with various forms of CAD (p = 0.1667). In the occurrence of postoperative AF paroxysms, the negative influence of type 2 diabetes mellitus (p = 0.0006), impaired glucose tolerance (p = 0.0156), stage III-IV chronic kidney disease (p = 0.0015) and gouty arthritis (p = 0.0072) has been proven. The presence of postoperative AF was associated with acute encephalopathy (p = 0.0291) and panic attacks (p = 0.0043). The occurrence of postoperative AF increased the length of stay of cardiac surgery patients with CAD in the hospital from 8.2 ± 2.9 to 11.06 ± 6.8 days (p < 0.0001).

Clinical and Genealogical Research as a Method for Predicting the Development of Premature Ischemic Heart Disease

Oleg O. Zhurba — 2024-09-27

The aim. To establish the role of the hereditary factor in the risk of developing premature coronary heart disease (CHD) based on clinical and genealogical analysis of pedigrees.

Materials and methods. The study included patients with CHD. The total sample size was 286 people, the mean age of the patients was 58.8 ± 2.9 years. The material for the analysis was the data of a clinical and genealogical analysis, which included the collection of data from the proband about the number of relatives with an indication of consanguinity. On the basis of the obtained data, pedigrees were compiled and the coefficient of family aggregation (FA) was calculated. A comparative analysis was conducted between experimental (n = 108, 25-44 years old) and control (n = 178, 75-90 years old) groups.

Results. As a result of the analysis of pedigrees, it was established that in patients who had premature CHD, which developed at the age of 25-40 years, there was a FA of cardiovascular diseases, as evidenced by the determined frequency of the hereditary burden of family history for cardiovascular diseases of 50.9%. When compared with the corresponding frequency in the group of elderly patients, the determined frequency of family burden of 24.2% which was significantly lower than that in young patients, p = 0.0001; χ² = 33.12. The calculated coefficient of FA was 2.1, which indicates that the risk of premature CHD is two times higher in families with a burdensome family history of cardiovascular diseases. Analysis of the burdensome history of cardiovascular diseases considering the degree of kinship with the proband established that in patients of both groups, the burdensome history was observed with the highest frequency in relatives of the 1st degree of kinship: 86.2% in the experimental and 83.3% in the control groups.

Conclusions. It was found that in families with a burdensome family history of cardiovascular diseases, the risk of developing premature CHD is two times higher, as evidenced by the calculated coefficient of FA - 2.1; p = 0.0001; χ² = 33.12. It was found that in both groups of the study, the prevalence of family history of cardiovascular diseases prevailed, mainly among relatives of the first degree of consanguinity.

Association of β1- and β2-Adrenergic Receptor Gene Polymorphisms with the Effectiveness of Bisoprolol and Carvedilol in Patients with Heart Failure of Ischemic Etiology

Nadiia M. Kulaiets — 2024-09-27

The aim. To study the relationship between β₁-, β₂-adrenergic receptor (β-AR) gene polymorphisms and the effectiveness of bisoprolol and carvedilol in patients with heart failure (HF) and coronary heart disease.

Materials and methods. We examined 201 patients with HF on the background of post-infarction cardiosclerosis. Control group included 43 healthy individuals of comparable age and sex. Genotyping was carried out for 3 polymorphisms (rs1801253 and rs1801252 of the β1-AR gene; rs1042714 of the β2-AR gene). The patients were divided into 2 groups: the first group included 104 (51.7%) patients who took bisoprolol during the year of observation; 97 (48.3%) patients of the second group were treated with carvedilol. Statistical analysis was performed using Statistica 10.0 and SNPStats programs.

Results. In patients with HF, the mutant C-allele (rs1801253 polymorphism) of the β₁-AR gene was associated with a decrease in the probability of heart rate reduction >15 min^-1 against the background of the use of β-blocker during the year (odds ratio [OR] = 0.42 [0.16-0.98], p = 0.041, recessive inheritance model; OR = 0.62 [0.40-0.97], p = 0.038; log-additive inheritance model). The probability of positive dynamics of the left ventricular ejection fraction (LVEF) increased in carriers of the wild A-allele of the rs1801252 (Ser49Gly) polymorphism of the β₁-AR gene (OR = 4.86 [2.35-10.08], p < 0.0001, codominant model; OR = 5.18 [2.51-10.68], p < 0.0001, dominant model; OR = 4.68 [2.26-9.68], p < 0.0001, over-dominant model; OR = 5.05 [2.48-10.28], p < 0.0001, log-additive inheritance model). The probability of an increase in LVEF within a year increased with treatment with carvedilol in homozygous mutant G/G rs1042714 polymorphism (Gln27Glu) of the β₂-AR gene in patients with HF (OR = 6.09 [1.16-31.88], p = 0.038, dominant inheritance model).

Conclusions. Patients with HF of ischemic etiology, carriers of the mutant C-allele of rs1801253 polymorphism of the β₁-adrenoceptor gene, are worse responders to the use of β-blockers compared to patients with the wild G-allele (a lower proportion of patients with a decrease in heart rate >15 min^-1: 6.8% vs. 14.5%, respectively; OR = 0.42 [0.16-0.98], p = 0.041). The frequency of an increase in the value of the LVEF >10% was higher compared to patients with the mutant G-allele (39.3% vs. 11.1%, respectively; OR = 4.86 [2.35-10.08], p < 0.0001) against the background of application of β-blockers. The use of carvedilol was more appropriate in homozygous carriers of the mutant G-allele of the rs1042714 polymorphism (Gln27Glu) of the β₂-AR gene compared to bisoprolol (a greater proportion of patients with an increase in the LVEF: 17.6% vs. 9.1%, respectively; OR = 6.09 [1.16-31.88], p = 0.038). No probable associations of rs1801253 and rs1801252 polymorphisms of the β1-AR gene with the pharmacodynamics of bisoprolol and carvedilol in patients with HF of ischemic etiology were found.

The Role of Myocardial Ischemia in the Course of Heart Failure with Preserved Ejection Fraction in Patients with Cardiorenal Metabolic Syndrome

Yevhen Yu. Marushko — 2024-09-27

The aim. Analysis of the influence of myocardial ischemia treatment on the left ventricular diastolic function and the levels of N-terminal pro B-type natriuretic peptide (NT-proBNP) in patients with cardiorenal metabolic syndrome.

Materials and methods. The study included 97 patients: 76 with confirmed coronary heart disease (CHD) (treatment group) and 21 with excluded CHD (comparison group), all of whom were examined at the Ukrainian Children’s Cardiac Center from January 1, 2023 to December 31, 2023. The main inclusion criterium for the treatment group was the presence of cardiorenal metabolic syndrome (combination of heart failure, stage ≥3A chronic kidney disease and dysglycemia in the form of type 2 diabetes or prediabetes). In 44 (57.9%) patients of the treatment group, stenosing atherosclerosis of the coronary vessels was detected and percutaneous coronary intervention was performed, while the index of coronary blood flow reserve was determined using dipyridamole test in the remaining patients, after which the diagnosis of microvascular angina was made. Microvascular dysfunction was corrected using complex therapy including nicorandil.

Results. Patients with cardiorenal metabolic syndrome and CHD with normal indicators of left ventricular diastolic function at rest had disturbances in it during stress echocardiography. Patients also had elevated levels of NT-proBNP with normal left ventricular ejection fraction, indicating the presence of heart failure with preserved ejection fraction. There was a significant decrease in left ventricular diastolic dysfunction (E/e’) and serum NT-proBNP levels (p<0.05) in patients with CHD after revascularization or after correction of coronary microvascular dysfunction. The obtained data indicate the role of myocardial ischemia in the development of heart failure with preserved ejection fraction due to impaired left ventricular diastolic function.

Conclusions. In CHD patients with cardiorenal metabolic syndrome, myocardial ischemia disrupts the diastolic function of the left ventricle and leads to higher levels of NT-proBNP. Restoration of myocardial blood supply by percutaneous coronary intervention in coronary artery stenoses or by medication in microvascular angina improves left ventricular diastolic function and leads to a decrease in the serum level of NT-proBNP.

Analysis of Echocardiography Indicators Depending on the Type of Surgical Correction of the Mitral Valve in Patients with Ischemic Heart Disease

Volodymyr S. Moroz — 2024-09-27

The aim. To study the influence of echocardiography indicators on the choice of surgical intervention on the mitral valve in patients with mitral insufficiency and coronary heart disease.

Materials and methods. The study included patients with mitral insufficiency who underwent myocardial revascularization and mitral valve reconstruction (plasty or replacement). The mean age of the study participants was 65.9 ± 4.0 years. The material for analysis was data from the primary medical records: medical history, clinical and instrumental examination data and protocols of operations. The division into study groups was performed retrospectively, according to the mitral valve operation performed: plasty (experimental group) or replacement (control group).

Results. We identified the features of the main echocardiographic data that guide the cardiologist when choosing the tactics of surgical correction of the mitral valve. It was established that in patients of the research group, the following was reliably significant: moderate degree of mitral insufficiency (p = 0.02; χ² = 9.38), decrease in the systolic function of the left ventricle (p = 0.001; χ² = 10.75); it was found that calcium deposits on the fibrous ring of the mitral valve were insignificant. When analyzing the morphological changes in patients of the experimental group, we found a significantly lower frequency of anterior leaflet prolapse (p = 0.04; χ² = 4.21) and in general the frequency of all prolapses of any type, while in the control group the frequency of all prolapses was significantly higher (p = 0.04; χ² = 4.0). In patients of the control group, a significantly higher frequency of akinesis (p = 0.04; χ² = 4.21) and hypokinesis zones of the posterior-inferior-lateral wall (p = 0.001; χ² = 19.76) was established, which is an additional sign of involvement of the chordal-muscular apparatus of the mitral valve in pathological process.

Conclusions. As a result of the study, echocardiographic differences in the structure of the mitral valve were established, which influenced the selection of the intervention volume. It was found that in patients of the experimental group, the early postoperative mortality and the duration of inpatient treatment were significantly higher than in patients of the control group, which indicates the imperfection of the criteria used by cardiac surgeons when choosing the tactics of surgical correction of the mitral valve in an attempt to perform organ-preserving surgery.

Left Atrial Plasty in Surgical Treatment of Combined Mitral-Aortic-Tricuspid Valve Diseases Complicated by Left Atrial Dilation

Volodymyr V. Popov — 2024-09-27

The aim. To study the possibilities of various techniques of the left atrial (LA) plasty in the correction of combined mitral-aortic-tricuspid valve diseases (cMATVD) in the presence of left atrial dilation (LAD).

Materials and methods. The analysis included the results of surgical treatment of 360 patients with cMATVD combined with LAD, who were operated on at the National Amosov Institute of Cardiovascular Surgery from January 1, 2006 to January 1, 2023. The main group consisted of 73 patients who underwent cMATVD correction combined with original triangular plasty of LA. The comparison group included 287 patients who underwent only cMATVD correction in the presence of concomitant LAD.

Results. Of the 73 operated patients in the main group, 3 died at the hospital stage (mortality rate 4.1%). The dynamics of echocardiographic parameters at the stages of treatment were as follows: left ventricular (LV) end- systolic index (ml/m²): 69.1 ± 12.1 (before surgery), 59.3 ± 8.5 (after surgery), and 48.4 ± 9.5 (long-term period); LV ejection fraction (%): 51.0 ± 5.0 (before surgery), 54.0 ± 5.0 (after surgery), and 56.0 ± 4.0 (long-term period); LA diameter (mm): 64.8 ± 4.1 (before surgery), 50.3 ± 2.1 (after surgery), and 51.2 ± 2.2 (long-term period). Of the 287 operated patients in the comparison group, 9 died (mortality rate 3.1%). The dynamics of echocardiographic parameters at the stages of treatment were as follows: LV end-systolic index (ml/m²): 68.3 ± 11.3 (before surgery), 60.4 ± 9.3 (after surgery), and 52.7 ± 7.2 (remote period); LV ejection fraction (%): 52.0 ± 5.0 (before surgery), 53.0 ± 5.0 (after surgery), and 50.0 ± 4.0 (remote period); LA diameter (mm): 65.5 ± 3.7 (before surgery), 64.1 ± 3.3 (after surgery), and 72.5 ± 2.8 (remote period).

In the remote period, thromboembolic complications occurred in 5 (7.7%) patients of the main group (1 severe, 1 mild, and 3 fatal) and 25 (9.3%) patients of the comparison group (10 severe, 6 mild, and 9 fatal). The thromboembolic complications rates indicate the advisability of LA plasty simultaneously with resection of its appendage.

Conclusions. In the correction of LAD, all plastic reconstructions of the dilated LA are low-traumatic and effective procedures that lead to a significant improvement in the morphometry of the LA both at the hospital stage and in the remote period. The methods are associated with low risk of hospital mortality, as well as a low level of thromboembolic complications in the remote period. In all methods of LA plasty, its appendage was resected, which also excluded conditions for thrombus formation.

Development of Artificial Intelligence-Based Programs for the Diagnosis of Myocarditis in COVID-19 Using Chest Computed Tomography Data»

Ievgen A. Nastenko — 2024-09-27

It has been established that 7.2% of patients hospitalized with coronavirus disease (COVID-19) exhibit signs of heart disease, with 23% of these patients experiencing heart failure. Currently, there is a lack of data on chest computed tomography (CT) for diagnosing myocarditis associated with COVID-19.

The aim. To justify the feasibility and develop classification models for diagnosing myocarditis in COVID-19 patients based on chest CT data processing.

Materials and methods. A retrospective analysis of data from 140 COVID-19 patients was conducted. Chest CT scans were analyzed using DRAGONFLY software, with permission from Object Research Systems. The COVID-CT-MD database, which includes CT data from 169 confirmed cases of SARS-CoV-2 infection, was used to build classification models. The regions of interest were fragments of heart CT images. Texture analysis methods were employed to create diagnostic models.

Results. It was shown that the average density of the myocardium of a patient with a confirmed diagnosis of SARS-CoV-2 infection according to the Hounsfield scale does not essentially differ from the densitometric indicators of a healthy person. Therefore, the research was focused on finding structural changes in CT images for their use in constructing diagnostic models.

The use of different classification algorithms had little effect on classification accuracy, probably due to the informational content of the input data. However, the obtained accuracy of the diagnostic models is acceptable and allows them to be used to support medical decision-making regarding diagnosis and treatment.

Conclusions. Using classic methods, myocarditis was diagnosed in 7.1% of patients with severe pneumonia caused by the coronavirus. The global data closely aligns with the results of our clinical studies. The obtained results allowed for assessing structural changes in the myocardium characteristic of the acute form of SARS-CoV-2 infection. The constructed classification models indicate that specific changes in the myocardium during the acute form of SARS-CoV-2 infection can be identified using CT. The highest diagnostic accuracy on test samples reached 74%. The implementation of the developed diagnostic programs based on texture analysis of CT data and artificial intelligence technologies enables the diagnosis of myocarditis and the assessment of long-term treatment efficiency. Creation of these diagnostic programs using artificial intelligence technologies significantly simplifies the work of radiologists and improves the efficiency of myocarditis diagnosis in patients with SARS-CoV-2 infection.

Evaluation of the Results of Left Bundle Branch Pacing after Atrioventricular Junction Ablation in Patients with Chronic Atrial Fibrillation

Eugene O. Perepeka — 2024-09-27

Atrioventricular junction ablation (AVJA) together with the implantation of cardiac pacemaker has become a recognized and effective treatment strategy for patients with symptomatic tachysystolic atrial fibrillation that does not respond to heart rate control drug therapy. Left bundle branch pacing (LBBP) is a physiological alternative to right ventricular and biventricular pacing.

The aim. To analyze the clinical results of the average duration with the use of LBBP and AVJA.

Materials and methods. Over the period from January 2023 to July 2024, LBBP with subsequent AVJA was applied at the National Amosov Institute of Cardiovascular Surgery in 18 patients as a method of treatment of chronic tachysystolic atrial fibrillation to achieve heart rate control.

Results. Mid-term results (at least 1 month) could be monitored in 15 out of 18 patients (84%); in the other three (16%) patients the time between pacemaker implantation and AVJA was too short. The mean period from pacemaker implantation to control examination was 5.07 ± 2.79 months (minimum period 1 month, maximum 12 months). During the period from implantation and ablation to the control observation in the study group, it was possible to observe an increase in left ventricular ejection fraction from 39.12 ± 10.56% to 46.38 ± 7.09%, p = 0.035; decrease in the values of end-diastolic volume from 184.22 ± 76.76 to 167.85 ± 36.93 ml, p = 0.074; decrease in the right ventricular pressure from 43.07 ± 8.29 to 34.38 ± 4.78 mm Hg, p = 0.013. It was also possible to observe a decrease in the left bundle branch capture thresholds from 1.27 ± 0.58 to 0.7 ± 0.39 V at 0.4 ms, p = 0.016; and a decrease in the average LBBP endocardial lead resistance from 638 ± 172.83 to 529.4 ± 120.15 Ohm, p = 0.012.

Conclusions. Implantation of the LBBP pacemaker and AVJA was not associated with the occurrence of complications both in the intraoperative and postoperative periods, as well as in the remote period of the average duration in the studied group. The use of this approach in patients with chronic atrial fibrillation made it possible in a series of consecutive patients to improve the systolic function of the left ventricle, to reduce the values of the end-diastolic volume of the left ventricle and the right ventricular pressure at optimal pacing parameters.

Cytokine Storm in Pathogenesis of COVID-19 Complications

Olga V. Rasputniak — 2024-09-27

The aim. To explore the current literature and key findings concerning the cytokine storm contribution to pathogenesis of COVID-19 complications and mortality, and summarize clinical and pathologic features of cytokine storm in COVID-19 patients.

A cytokine storm is a hyperinflammatory state secondary to excessive production of cytokines by deregulated immune system. It manifests clinically as an influenza-like syndrome, which can be complicated by multi-organ failure and coagulopathy, leading in most severe cases even to death. Cytokine storm has recently emerged as key aspect in COVID-19 disease, as affected patients show high levels of several key pro-inflammatory cytokines, some of which also correlate with disease severity.

The current review describes the role of critical cytokines in COVID-19-mediated cytokine storm. Key findings of the studies are provided further. A cytokine storm is associated with COVID-19 severity and is also a crucial cause of death from COVID-19. Impaired acquired immune responses and uncontrolled inflammatory innate responses may be associated with the mechanism of cytokine storm in COVID-19. Cytokine storm is defined as acute overproduction and uncontrolled release of pro-inflammatory markers, both locally and systemically. In COVID-19 patients, pyroptosis triggers the release of proinflammatory cytokines and affects macrophage and lymphocyte functions, causing peripheral lymphopenia. Cytokine storm is characterized by a clinical presentation of overwhelming systemic inflammation, hyperferritinemia, hemodynamic instability, and multi-organ failure. The cytokine storm clinical findings are attributed to the action of pro-inflammatory cytokines like interleukin-1, interleukin-6, tumor necrosis factor alpha, vascular endothelial growth factor.

Incidental Finding of Subacute DeBakey Type II Aortic Dissection with Circular Intimal Tear in a Patient with Severe Aortic Insufficiency During the COVID-19 Pandemic

Barış Akça — 2024-09-27

We present a case of severe aortic insufficiency diagnosed in the pandemic period with the surgery being postponed due to hygiene concerns and suspicion of COVID-19. One month later the patient’s complaints worsened. Renewed preoperative examinations revealed no difference and no sign of dissection. The suspicion of COVID-19 was eliminated, so immediate aortic valve surgery was performed despite the pandemic. Surprisingly subacute DeBakey type II aortic dissection with complete circular intimal tear came across intraoperatively. Thus, the modified Cabrol procedure was performed successfully. The diagnosis of aortic dissection may be missed, and this rate may increase in natural disasters such as pandemics and earthquakes.

Surgical Treatment of Unusual Anatomy of the Tricuspid Valve in Ebstein’s Anomaly

Hanna V. Maistriuk — 2024-09-27

Ebstein’s anomaly is a congenital heart disease in which the septal and posterior leaflets of the tricuspid valve are displaced to the apex of the right ventricle, forming its atrialization. In contrast, the anatomical position of the anterior leaflet usually remains normal.

The aim. To present and analyze a case of surgical treatment of Ebstein’s anomaly with a rare anatomy – isolated displacement of the anterior leaflet of the tricuspid valve.

Case report. We present a rare clinical case of isolated displacement of the anterior leaflet of the tricuspid valve into the right ventricular cavity with the formation of a right atrial aneurysm. The diagnosis was made prenatally and confirmed after the birth of the child by echocardiography. Surgical intervention was postponed and successfully performed at the age of six years due to the progression of tricuspid insufficiency and increase in the right atrial aneurysm. We achieved a reduction in the size of the right atrium (diameter 31 mm, volume 25 ml and area 10 cm²) and minimized insufficiency at the tricuspid valve. The total duration of the surgical intervention was 270 minutes. The intra- and postoperative periods were uneventful. The duration of the patient’s stay in the intensive care unit was 4 days. We believe that this pathology of the anterior leaflet of the tricuspid valve should be interpreted as a variant of Ebstein’s anomaly.

Conclusion. Isolated tricuspid valve anterior leaflet displacement with right atrial aneurysm is amenable to surgical correction with good immediate and long-term results.