Ukrainian Journal of Cardiovascular Surgery

Military Aspects of Science and Practice of Ukrainian Cardiovascular Surgery

Vasyl V. Lazoryshynets — 2024-12-27

40 Years of Balloon Valvuloplasty for Pulmonary Valve Stenosis

Yurii Panichkin — 2024-12-27

Features of Myocardial Revascularization in Multifocal Atherosclerosis with Involvement of Coronary Arteries and Lower Limb Arteries

Artur V. Gabriyelyan — 2024-12-27

The presence of a combination of coronary artery disease (CAD) and peripheral artery disease (PAD) is associated with nearly double all-cause mortality rate, up to 4.6% per year, compared to the mortality rate for each of the conditions. Performing the first-stage intervention on the arteries of the lower limbs carries a high risk of the coronary blood flow worsening in the form of perioperative myocardial infarction, while isolated coronary artery bypass grafting (CABG) may exacerbate ischemia of the lower limbs. The following questions remain unresolved: What should be the sequence and timing of surgical interventions in the combination of CAD and PAD? Do simultaneous surgical interventions have advantages over staged interventions? What is the optimal graft choice for CABG? What is the optimal technique for myocardial revascularization?

The aim. To study the features of myocardial revascularization in patients with multifocal atherosclerosis affecting both coronary arteries and arteries of the lower limbs.

Materials and methods. We analyzed the treatment outcomes in 48 patients with combined coronary artery and lower limb artery disease from 2016 to 2023, as well as data from contemporary literature from 2018 to 2023, which covered over 14,000 patients. Surgeries were performed without cardiopulmonary bypass, both simultaneously and in stages. Venous and arterial grafts were used during the interventions.

Results. The patients who underwent simultaneous operations demonstrated a higher incidence of wound complications (p < 0.001). The patients who underwent staged procedures experienced more severe limb ischemia requiring intervention (p < 0.001) than those who had simultaneous procedures. No cases of acute cerebrovascular accidents were noted in either group. In both groups, early postoperative periods were marked by rhythm disturbances, specifically paroxysms of atrial fibrillation, which were successfully managed conservatively. There were no hemorrhagic complications associated with prolonged heparinization during simultaneous procedures compared to staged interventions. The patients who underwent either simultaneous or staged myocardial revascularization and vascular reconstruction of the lower limbs rarely experienced complications related to vascular graft thrombosis.

Conclusions. The choice of intervention sequence should prioritize CABG as the first step, both in simultaneous and staged interventions. Safe procedures for patients with multifocal atherosclerosis involving coronary and lower limb arteries require a multidisciplinary team. Simultaneous interventions help avoid ischemic complications associated with delaying the next stage of revascularization of other affected vascular territories. Delaying the revascularization of lower limb arteries in staged interventions may lead to the worsening of existing limb ischemia.

A Young Patient with Coronary Artery Disease: Fortuity or Regularity?

Olena K. Gogayeva — 2024-12-27

The aim. To analyze the reasons for hospitalization of young patients in the department of surgical treatment of coronary artery disease and to identify risk factors for premature progression of atherosclerosis.

Materials and methods. Retrospective analysis of data from patients younger than 45 years who were hospitalized in the department of surgical treatment of coronary artery disease of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from September 2023 to September 2024. All the patients underwent standard clinical and laboratory examinations, electrocardiography, echocardiography, and coronary angiography, based on the results of which the heart team decided on further treatment tactics.

Results. Among 1187 patients who were hospitalized in the department during the year, 78 (6.57%) were younger than 45 years (mean age 40.7 ± 4.04 years). The admission was elective in 57 (73.1%) patients and urgent in 21 (26.9%) patients. During coronary angiography, hemodynamically significant lesions of the coronary arteries were detected in 45 (57.7%) patients, moderate (up to 50%) lesions of the coronary arteries in 22 (28.2%), intramural course of the left anterior descending artery in 6 (7.7%), and in 5 (6.4%) cases, coronary lesions were not detected. Coronary artery stenting was performed in 27 (60%) patients, coronary artery bypass grafting in 12 (26.6%) patients, which in 3 (25%) cases was supplemented by left ventricular aneurysm resection; myocardial revascularization was delayed in 6 (13.3%) patients.

Conclusions. The frequency of hospitalization of patients younger than 45 years with suspected coronary artery disease is 6.57%, among which cardiac surgery is required in 57.7%. Among the factors of premature progression of atherosclerosis of the coronary arteries, the role of diabetes mellitus (p = 0.0440), long-term smoking experience of 20.7 ± 7.9 years (p = 0.0002) and history of cerebral blood circulation disorders (p = 0.0478) was proven.

Marital Status and Its Association with Leading Cardiovascular Risk Factors of Ischemic Heart Disease

Oleg O. Zhurba — 2024-12-27

The aim. To establish a relationship between marital status and frequency of cardiovascular risk factors: type II diabetes, hypertension, overweight, smoking, and hypodynamia.

Materials and methods. The study included patients with coronary artery disease (CAD) who underwent off-pump coronary bypass surgery. The total number of people in the sample was 3674, the mean age of the patients was 60.6 ± 0.8 years. Medical history, case records and results of general clinical and laboratory examinations provided for inpatient treatment became the material for analysis. The study design was based on the patient’s age according to the WHO age classification. The relationship between marital status and leading cardiovascular risk factors was calculated using the odds ratio and relative risk.

Results. As a result of studying the relationship between marital status as a leading factor in a person’s social status, it was established that the presence of a partner relationship was associated with a 1.50-fold increased risk of overweight (p = 0.0003, χ² = 21.59), 1.07-fold increased risk of hypertension (p = 0.005, χ² = 7.60) and 1.26-fold increased risk of type II diabetes (p = 0.04, χ² = 4.28). Taking into account the age of the patients, it was found that senile married people had an increased risk of overweight (p = 0.0001, χ² = 20.51) and elderly patients had an increased risk of hypertension (p = 0.002, χ² = 9.73). It was found that loneliness in patients with CAD was associated with a 4.97-fold increase in the frequency of obese people (p = 0.08, χ² = 3.02) and smokers (p = 0.0001, χ² = 182.60). It was also determined that young single patients were significantly more likely to smoke (p = 0.0001, χ² = 102.19).

Conclusions. As a result of the study, the associations of loneliness with leading cardiovascular factors regarding the risk of developing coronary heart disease were clarified. It was found that single persons, as a group with an unfavorable socio-economic status, had increased cardiovascular risks: obesity (p = 0.08, χ² = 3.02) and smoking (p = 0.0001, χ² = 121.16). It was also established that young single patients were significantly more likely to smoke (p = 0.0001, χ² = 102.19), and elderly family patients had a significantly higher risk of overweight (p = 0.0001, χ² = 20.51), and hypertension (p = 0.002, χ² = 9.73).

Coronary Artery Bypass Grafting in Patients with Reduced Left Ventricular Myocardial Contractility

Yurii V. Kashchenko — 2024-12-27

Coronary artery bypass grafting (CABG) is a crucial treatment for ischemic heart disease in patients with reduced left ventricular ejection fraction (LVEF). This approach improves survival and quality of life but carries a higher risk of complications. Off-pump CABG reduces the risk of strokes and bleeding, while on-pump CABG is beneficial for patients with complex anatomy. Planned use of cardiopulmonary bypass (CPB) stabilizes patients’ condition and reduces postoperative complications.

The aim. To determine the optimal surgical strategy in patients with reduced LVEF and the reasons for emergency conversion to CPB.

Materials and methods. The study included 210 patients with LVEF ≤ 35% who underwent CABG at the National Amosov Institute of Cardiovascular Surgery from January 1, 2015, to December 31, 2021. The patients were divided into three groups based on LVEF levels: 35–30%, 29–25%, and ≤ 24%. The frequency of elective and emergency CPB conversion was analyzed depending on LVEF. Postoperative complications and their frequency were also assessed based on the type of CPB conversion.

Results. The study analyzed 210 patients with LVEF ≤ 35% who underwent CABG. The frequency of emergency CPB conversion increased as LVEF decreased, reaching 50% in patients with LVEF ≤ 24%. Planned use of CPB reduced the risk of postoperative heart failure.

Conclusions. CABG is an effective treatment for ischemic heart disease in patients with reduced LVEF. Careful evaluation of preoperative and intraoperative factors is critical to minimizing complication risks.

Comparative Analysis of the Influence of Empagliflozin and Dapagliflozin on the Course of Heart Failure with Associated Pathology

Nadiia M. Kulaiets — 2024-12-27

The aim. To compare the effectiveness of empagliflozin and dapagliflozin on the course of heart failure (HF) in patients with concomitant pathology.

Materials and methods. We examined 398 Caucasian patients with HF on the background of post-infarction cardiosclerosis, aged 58 (54.00-67.00) years (198 women and 200 men). Of these, 226 (56.8%) had persistent atrial fibrillation (AF), 102 (25.6%) had type 2 diabetes mellitus (DM), and 52 (13.1%) had a combination of DM and AF. Reduced left ventricular ejection fraction (LVEF) of ≤40% was observed in 167 patients (42.0%); in 133 (33.4%) patients, LVEF was from 41% to 49%; 98 (24.6%) patients had preserved LVEF (≥50%). The levels of thyroid-stimulating hormone, free T3, free T4, blood glucose, glycated hemoglobin, galectin-3, ST-2, B-type natriuretic peptide, N-terminal pro B-type natriuretic peptide were determined. Registration of electrocardiogram, daily electrocardiography monitoring, and standardized echocardiographic examination were performed during hospitalization and after 1 year. From the first days of inclusion in the study, a sodium-glucose cotransporter 2 inhibitor was prescribed to all the patients, regardless of the presence of DM. The study participants were divided into two groups: the I group included 187 (47%) patients who took dapagliflozin 10 mg daily for a year, the II group included 211 (53%) patients who took empagliflozin at a daily dose of 10 mg. The groups did not differ in terms of the use of β-blocker with different pharmacological properties (bisoprolol or carvedilol) (p = 0.977). Over the course of the year, the patients were observed, taking into account the presence of rehospitalization due to HF decompensation. Statistical analysis was performed using the programs Statistica for Windows Release 10.0 and MedCalc® (Statistical Software version 22.020).

Results. In HF patients with moderately reduced LVEF with sinus rhythm without DM, who took empagliflozin, the risk of re-hospitalization was lower compared to those who took dapagliflozin (odds ratio [OR] = 0.136 [0.030-0.623]; χ² = 5.608, p = 0.018). In the group of HF patients with preserved LVEF with sinus rhythm without DM, who took empagliflozin, compared to the group of patients on dapagliflozin, there was a trend towards lower one-year mortality (χ² = 3.600, p = 0.058). The frequency of re-hospitalization in HF patients with AF and concomitant DM was lower (by 18.5%; χ² = 5.122; p = 0.024) when using empagliflozin. Analysis of Kaplan-Meier curves showed that HF patients with a concomitant combination of AF with DM who took empagliflozin, compared to those on dapagliflozin, had a lower probability of re-hospitalization during 12 months (by 18.5%; χ² = 6.938; p = 0.008). The mean time to the occurrence of the event in the group of HF patients who took empagliflozin was 5.3 ± 0.7 months against 3.1 ± 0.3 months in dapagliflozin patients (OR = 0.389 [0.193-0.786]; p = 0.008).

Conclusions. Empagliflozin compared to dapagliflozin is more effective in reducing the risk of re-hospitalization in HF patients with sinus rhythm with a moderately reduced LVEF without type 2 DM (OR = 0.136, p = 0.018) and in the concomitant combination of AF and type 2 DM (without taking into account the HF phenotype) (by 18.5%; p = 0.024). The mean time to re-hospitalization in patients with HF with a combination of AF and DM was 2.2 months longer in patients receiving empagliflozin compared to those receiving dapagliflozin (OR = 0.389; p = 0.008). In other groups of patients with heart failure, dapagliflozin and empagliflozin showed the same effectiveness.

Long-Term Results of Stenting of Left Main Coronary Artery Lesions: Experience of One Hospital

Olena V. Levchyshyna — 2024-12-27

The aim. To study the effectiveness of left main coronary artery (LMCA) stenting in patients with coronary heart disease and to optimize the choice of percutaneous coronary intervention technique based on the experience of one clinic.

Materials and methods. The study, which was conducted at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, included 107 patients with LMCA disease, who underwent stenting from January 2019 to December 2023. During the study, the patients were divided into two groups. One group underwent stenting using the single-stent method (44 patients, 41.1%), while the other group underwent stenting using the double-stent method (63 patients, 58.9%).

Results. In the group of surveyed patients after stenting, an analysis was conducted regarding adherence to drug therapy and achievement of target lipid spectrum levels. It was found that one of the reasons for the active progression of atherosclerosis can be considered low adherence to drug therapy. A group of patients with recurrence of angina after stenting, the cause of which was restenosis in the stented segment, was analyzed. In the analysis of the frequency of repeated interventions in patients with hemodynamically significant lesions of the LMCA, who initially underwent stenting, it was found that 24.5% of patients (n = 24) underwent stenting again at the second visit and only 4 patients (4.1%) underwent bypass surgery, which is statistically significant (p ≤ 0.001).

Conclusions. LMCA stenting is an effective way of treating patients with hemodynamically significant damage to it (effectiveness of the technique is 71.4%). Recurrence of angina was observed in 28 patients (28.6%). Both single-stent and double-stent procedures are effective: recurrence of angina was observed in 13.3% and 15.3% of cases, respectively. One of the main reasons for the recurrence of angina pectoris is the progression of atherosclerosis in new locations (39.3%) and restenosis in stenting segment (39.3%).

Mechanisms of Ischemic Heart Disease Development in Type 2 Diabetes Patients Based on Renal Function

Georgii B. Mankovskyi — 2024-12-27

Ischemic heart disease (IHD) remains a leading cause of mortality and disability in Ukraine and globally, primarily due to stenosing atherosclerosis of the coronary arteries. Type 2 diabetes mellitus (T2DM) is a significant factor accelerating atherogenesis, alongside with chronic kidney disease. Investigating the causes of myocardial ischemia in patients with IHD, T2DM, and cardio-renal-metabolic syndrome requires further exploration.

The aim. To investigate the prevalence of various causes of myocardial ischemia in patients with IHD and T2DM based on renal function.

Materials and methods. The study involved 103 patients with IHD and T2DM examined at the Ukrainian Children’s Cardiac Center in 2023. Participants were divided into two groups: 52 with IHD, T2DM, and stage 3A or higher chronic kidney disease; and 51 with IHD and T2DM. All the patients had angina pectoris; myocardial ischemia was confirmed in 47 (45.6%) cases by stress echocardiography and in 56 (54.4%) via exercise electrocardiography testing. Echocardio graphy with intravenous dipyridamole was performed to diagnose coronary microvascular dysfunction and determine coronary flow reserve. Renal function was assessed using estimated glomerular filtration rate (eGFR) based on the CKD‑EPI score.

Results. Demographic indicators were comparable: 32 (61.5%) / 20 (38.5%) men/women in the clinical group and 30 (58.8%) / 21 (41.2%) in the control group (p > 0.05); the mean age was 56.3 ± 0.3 and 57.1 ± 0.4 years (p > 0.05). Patients with eGFR <60 ml/min/1.73 m² had a lower frequency of single-vessel disease and a higher proportion of threevessel disease compared to those with eGFR ≥60 ml/min/1.73 m². In all patients without significant coronary artery disease, coronary flow reserve was less than 2. In the clinical group, significant atherosclerotic lesions were the cause of IHD more frequently (86.5%) compared to the control group (64.7%), while microvascular angina had a significantly higher frequency (13.5% vs. 35.3%).

Conclusion. In patients with IHD, T2DM and reduced glomerular filtration rate (eGFR <60 ml/min/1.73 m²), more aggressive coronary artery disease was observed. Consequently, the proportion of microvascular dysfunction as a cause of myocardial ischemia was higher in patients with eGFR ≥60 ml/min/1.73 m². Therefore, a comprehensive approach in managing patients with comorbid conditions becomes an even more relevant topic for further research aimed at improving prognosis.

Association of Microcirculation Parameters with Mortality in Patients with Coronary Artery Disease Combined with COVID-19

Vasyl Z. Netiazhenko — 2024-12-27

The aim. To investigate the association of microcirculation parameters with deaths in patients with coronary artery disease and COVID-19.

Materials and methods. From January 2020 to December 2022, 79 patients with coronary artery disease (CAD) without COVID-19, 127 patients with CAD and COVID-19, and 180 patients with COVID-19 without CAD were examined at the clinical sites of the Bogomolets National Medical University. The control group consisted of 37 healthy volunteers. Digital capillaroscopy (DC) was performed to assess the caliber and length of arterial and venous parts of the capillaries, as well as velocity of red blood cells therein. Laser Doppler flowmetry (LDF) was used to measure the microcirculation index and capillary blood flow reserve. Wavelet analysis of the basal LDF signal was also performed and the maximum amplitudes of fluxmotions were measured: endothelial, neurogenic, myogenic, respiratory, and cardiac. All the patients underwent transcranial Doppler monitoring to detect microembolic signals.

Results. The greatest damage to the microcirculatory bed was observed in patients with CAD and COVID-19. The risk of death was 6.3% in patients with CAD, 22% in those with CAD combined with COVID-19, and 6.1% in patients with COVID-19. According to the LDF, the risk of death increases at certain values of flux amplitudes, and according to the DC, with a decrease in capillary caliber and blood flow velocity. The index of mortality risk assessment was proposed with the consideration of amplitudes of neurogenic fluxmodes, caliber of venous part of the capillaries, velocity of red blood cells in arterial part of the capillaries, microcirculation index and presence of CAD and/or COVID-19.

Conclusions. In patients with CAD and COVID-19, deterioration of microcirculation regulation, decreased erythrocyte velocity and increased microembolic signals were found. It is proposed to use the index for assessing the risk of mortality in patients with COVID-19.

Decellularized Matrix Scaffolds for Vascular Transplantation: Addressing Immunogenicity, Sterilization, and Current Strategies for Long-Term Storage

Yevhen V. Shevchenko — 2024-12-27

Cardiovascular diseases are the leading cause of death globally, with their incidence rising rapidly. For obstructive cardiovascular diseases, definitive treatment options include surgical interventions such as vascular stenting, replacement surgery, or vascular bypass. Decellularized extracellular matrix scaffolds, designed through tissue engineering, hold great potential in addressing the donor shortage issue.

The aim. To conduct a comparative analysis of sterilization methods for decellularized matrix scaffolds used in vascular transplantation, based on information from open sources.

Materials and methods. Publications were selected from the databases PubMed, Clinical Key Elsevier, Cochrane Library, eBook Business Collection, and Google Scholar, focusing on sterilization methods for decellularized matrix scaffolds. The literature search used keywords such as tissue engineering, decellularization, extracellular matrix, sterilization, gamma sterilization, and acellular transplant.

Results. The transplantation of synthetic scaffolds into the human body triggers an immune response to foreign materials. Ideal sterilization or disinfection for decellularized extracellular matrix should effectively eliminate microorganisms while ensuring the sterilized material is non-toxic and preserves physical and chemical properties, as well as biological activity of the biomaterial. Radiation sterilization primarily involves gamma irradiation from Cobalt-60 isotopes and electron beams generated by electron accelerators. In addition to sterilization, decellularized tissue constructs require long-term preservation methods, including cryopreservation, lyophilization, and the use of antibiotics and antifungals stored at –20 °C to –80 °C.

Conclusions. Decellularized tissue is receiving significant attention as a potential biological scaffold, as it retains the structure and functions of the extracellular matrix. The application of sterilization methods, such as gamma irradiation from Cobalt-60, ensures deep penetration and preservation of physical properties of the materials.

Myocardial Protection in Combined Mitral-Aortic-Tricuspid Valve Diseases Correction under Cardiopulmonary Bypass

Oleksii M. Gurtovenko — 2024-12-27

The aim. To determine the optimal option for administering cardioplegic solution for myocardial protection in the correction of combined mitral-aortic-tricuspid valve diseases (CMAT) under cardiopulmonary bypass.

Materials and methods. We analyzed the results of surgical treatment of 251 patients with CMAT who were operated on at the National Amosov Institute of Cardiovascular Surgery from 01/01/2010 to 01/01/2023 and in whom 3 ways of applying crystalloid cardioplegic solution was used. There were three comparison groups: group A with antegrade (n = 47), group B with retrograde (n = 56), and group C with combined ante-retrograde administration of crystalloid cardioplegic solution (n = 148).

Results. Of the 251 operated patients, 10 died at the hospital stage (mortality rate 3.9%). The level of creatine kinase-MB (CK-MB) (U/L) at cross-clamping time ≤90 minutes for the groups was as follows: 72.3 ± 7.1 (p < 0.05) in group A, 64.0 ± 8.2 in group B, 67.5 ± 7.7 in group C. The level of CK-MB (U/L) at cross-clamping time ≥151 minutes for the groups was as follows: 115.2 ± 18.7 in group A, 97.4 ± 15.8 in group B, 96.3 ± 16.2 in group C. The dynamics of echocardiographic parameters at the stages of treatment were as follows. Group A (mortality rate 4.3%): left ventricular (LV) end-systolic index (mL/m²): 69.1 ± 13.5 (before surgery), 60.3 ± 9.7 (after surgery); left ventricular ejection fraction (LVEF): 51% ± 9% (before surgery), 54% ± 7% (after surgery). Group B (mortality rate 3.6%): LV end-systolic index (mL/m²) 66.5 ± 12.1 (before surgery), 57.4 ± 8.6 (after surgery); LVEF: 50% ± 8% (before surgery), 56% ± 7% (after surgery). Group C (mortality rate 4.1%): LV end-systolic index (mL/m²) 67.8 ± 11.3 (before surgery), 56.2 ± 8.9 (after surgery); LVEF: 50% ± 7% (before surgery), 56% ± 7% (after surgery). The dynamics of echocardiographic parameters at the stages of treatment were better in groups B and C than in group A (p < 0.05). Hospital mortality was lower in groups B and C than in group A (p > 0.05).

Conclusions. The three types of cardioplegic solution delivery used in complex pathology of surgical treatment of CMAT demonstrated the adequacy of heart protection using crystalloid cardioplegia. Taking into account certain advantages in the dynamics of restoration of the LV contractility and increase in the level of CK-MB (U/L) on the second day after surgery, groups C and B should be considered optimal compared to group A (p < 0.05). The widespread, branched venous system of the heart allows for adequate use of the retrograde route of cardioplegia delivery and complete penetration of cardioplegic solution into the heart cells, which provides a better clinical effect compared to the isolated antegrade route of crystalloid cardioplegia delivery.

TAVI Procedure Accesses: Our Experience and Comparison of Transapical Versus Transfemoral Routes

Glib I. Yemets — 2024-12-27

There is no denying the fact that surgical aortic valve replacement has been considered as the “gold standard” of treatment for patients with aortic stenosis (AS). However, approaches are changing. A particularly influential event was the first successful transcatheter aortic valve implantation (TAVI) from an antegrade transseptal approach in 2002.

The aim. To evaluate the results of TAVI performed using transapical and transfemoral access in patients over 60 years of age with severe AS.

Materials and methods. This single-center study was performed at the Ukrainian Children’s Cardiac Center in the period from 2016 to 2024. The study included 105 consecutive patients with a confirmed diagnosis of severe AS. All the patients met eligibility criteria, received a full package of basic and additional examinations and, based on the decision of the heart team led by a cardiac surgeon, were verified for the TAVI procedure from the appropriate access: transfemoral access in group 1 (n = 54 patients), transapical access in group 2 (n = 51 patients). Patients who had previously undergone aortic valve replacement were excluded from the study.

Results. All the patients were verified as high surgical risk patients according to the STS Adult Cardiac Surgery Risk Calculator, EuroSCORE II, ASA scales. Intraoperative mortality was 0.95% (n = 1). The postoperative period of hospital stay (from the time of operation to discharge) was 11.13 ± 10.45 days (from 3 to 54) in group 1 and 12.65 ± 11.68 days (from 0 to 71) in group 2. The procedure was performed under general anesthesia in both groups. Duration of the operation was 147.59 ± 113.46 minutes (from 110 to 810) in group 1, and 168.31 ± 93.61 minutes (from 76 to 690) in group 2. Early outcomes, assessed by echocardiography and aortography, were satisfactory in all the patients. In group 1, minimal paravalvular insufficiency was detected in 92.6% (n = 50), moderate paravalvular insufficiency was observed in 7.4% (n = 7) patients. In group 2, minimal deficiency was found in 90.2% (n = 46), moderate in 9.8% (n = 5) patients.

Conclusions. Early and long-term postoperative outcomes were satisfactory in both groups. There was no statistically significant difference between the groups in the level of complications. However, the pattern of complications differed between the groups: the transfemoral group had a lower rate of postoperative bleeding and cerebrovascular disorders, while the transapical group had a lower rate of pacemaker implantation and prosthesis repositioning.

Infective Endocarditis: Systemic Inflammatory Response in Preoperative Heart Failure

Hanna B. Koltunova — 2024-12-27

Surgical outcomes depend on several factors, including the choice of surgical procedure, surgical techniques and experience of medical center. Numerous nationwide population-based studies in Europe have shown an increase in the incidence of infective endocarditis (IE) by 4% per year. An important role in predicting the severity of the disease is played by the systemic inflammatory response, which is manifested by increased levels of inflammatory markers such as C-reactive protein and procalcitonin. The use of a complex of several inflammatory markers can potentially improve the analysis of the inflammatory response system and the assessment of treatment dynamics.

The aim. To evaluate the dynamics of systemic inflammatory response markers in patients with IE complicated by acute heart failure undergoing cardiopulmonary bypass surgery.

Materials and methods. The study included clinical data of 72 patients with IE complicated by preoperative acute heart failure (AHF) who underwent cardiac surgery at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine from 01/01/2019 to 12/30/2022. The diagnosis of IE was established in accordance with the Duke criteria. All the patients were classified as NYHA class IV.

Results. According to the analysis of systemic inflammatory response markers in patients with IE complicated by AHF at the preoperative stage, the leukocyte count was 10.1 × 10⁹/L (8.1; 14.1), while stab cells accounted for 6.0% (4.0; 8.0). Erythrocyte sedimentation rate was elevated – 27.5 mm per hour (17.0; 50.0). The median body temperature on admission was 37.3 °C (37.1; 38.3). In the early postoperative period, there was a sharp increase in the level of procalcitonin to 2.1 ng/mL, as well as increase in C-reactive protein to 69.33 mg/L. At the same time, an increase in lactate level to 2.24 mmol/L was recorded. On the 7th day of the postoperative period, a decrease in the levels of C-reactive protein and procalcitonin was detected – 34.15 mg/L and 0.2 ng/mL, respectively. In contrast, the lactate level increased to 2.43 mmol/L. Evaluation of biochemical markers of inflammation on postoperative day 14 showed a trend towards normalization: C-reactive protein 28.27 mg/L, procalcitonin 0.1 ng/mL, lactate 2.29 mmol/L.

Conclusions. Timely assessment of specific markers of organ dysfunction associated with infectious processes is the basis for diagnosis, risk stratification and ensuring the best treatment outcome. A comprehensive analysis of the levels of biochemical markers of inflammation creates the conditions for choosing a management strategy for patients with IE complicated by AHF.

Diagnosis and Optimal Surgical Treatment Strategy Selection for Asymptomatic Large Cardiac Myxomas: Review of Modern Approaches and Own Clinical Case Presentation

Vyacheslav V. Osaulenko — 2024-12-27

Cardiac myxoma (CM) is the most common primary tumor of the heart and can be asymptomatic for a long time. CMs have an increased risk of systemic embolization, intracardiac obstruction, transient ischemic attacks, and strokes, potentially leading to patient disability and/or sudden cardiac death.

The aim. To highlight the data of modern scientific literature and demonstrate a case of plastic reconstruction of the heart after resection of a large tumor.

Materials and methods. We report a case of incidentally discovered left atrial myxoma in a 67-year-old woman with no significant medical history. Transthoracic echocardiography revealed a large mass located in the left atrium. An open surgical intervention was performed, during which the giant CM was completely removed. Histopathological examination confirmed the diagnosis. The patient was discharged on the 7th day of the postoperative period without any complaints. Also, we carried out a comprehensive search and analysis of previously published cases of asymptomatic myxomas and methods of their surgical treatment in the scientific literature of the main electronic databases.

Results. In our proposed report, a satisfactory clinical outcome was obtained in a patient with giant myxoma who underwent open cardiac surgery. According to the current literature, transthoracic echocardiography, computed tomography and magnetic resonance imaging of the heart are the gold standards for the diagnosis of heart neoplasms, which corresponded to our diagnostic algorithm. In the opinion of most specialists, the minimally invasive approach is a promising and attractive treatment method for surgeons, however, a complete median sternotomy remains the standard approach in patients with CMs.

Conclusions. Asymptomatic CM is a rare incidental finding with a high probability of serious adverse cerebral and cardiovascular events. Early diagnosis of CM is crucial to prevent life-threatening complications, and the most valuable tool is transthoracic echocardiography. The strategy of surgical treatment varies depending on their size and anatomical localization, in particular, resection of large and septal myxomas is usually performed through median sternotomy.

Reverse Left Ventricular Remodeling after Aortic Valve Replacement for Aortic Disease: TAVR and Minimally Invasive Cardiac Surgery

Oleksandra V. Telehuzova — 2024-12-27

The aim. To examine the difference in left ventricular (LV) reverse remodeling parameters in elderly patients (65 years and more) who underwent transcatheter aortic valve replacement (TAVR) and minimally invasive cardiac surgery aortic valve replacement (MICS-AVR).

Materials and methods. This study analyzed data from a consecutive series of 159 patients who underwent TAVR (n = 109) and MICS-AVR (n = 50) due to severe or critical aortic stenosis between January 2018 and August 2023. We also included the data from follow-ups: 30 days, 60 days and 1 year after replacement.

Results. Five deaths (4.0%) occurred during the follow-up period of 3.1 ± 2.0 years. The causes of late death were stroke (n = 2), sepsis, interstitial pneumonia, and cancer. The 6-year survival rate was 86.0% and the 6-year freedom from cardiac death rate was 93.8%. After 1 year (1.3 ± 0.6 years) of follow-up, postoperative left ventricular ejection fraction increased significantly from 48.5 ± 19.6% to 55.4 ± 7.2% (p < 0.0001), LV end-systolic dimension index decreased significantly from 29.3 ± 11.8 to 18.5 ± 3.1 mm/m² (p < 0.0001). Specifically, LV end-diastolic dimension decreased from 65.4 ± 22.6 mm to 60.84 ± 0.21 mm (p = 0.023) in the TAVR group vs. 67.3 ± 22.4 mm to 62.99 ± 0.29 mm (p = 0.204) in the MICS-AVR group. There was a steady and significant improvement in post-procedural LV septal thickness in both groups at different evaluation times. There was also a slight but significant improvement in LV dimensions (LV end-diastolic dimension and LV end-systolic dimension) in the TAVR group at 1 year compared with the MICS-AVR group.

Conclusion. Favorable long-term outcomes, including 6-year freedom from cardiac mortality and no need for reoperation, were similar in both groups. Both TAVR and MICS-AVR are effective treatments for patients with aortic stenosis, allowing for the potentiation of postoperative LV remodeling and achieving satisfactory long-term outcomes and improved quality of life.

Mitral Valve Surgical Treatment with Mini-Invasive Access (Five-Year Results)

Vasyl V. Fylypchuk — 2024-12-27

In the world, minimally invasive mitral valve surgery (MIMVS) has a recognized role in the surgical treatment of mitral valve (MV) diseases, however, this technique has not yet been widely used in our country. Due to the lack of clear clinical guidelines and recommendations in the choice of access to MV, many cardiac surgery centers implement a minimally invasive technique insufficiently often, and this procedure is characterized by complex learning curve.

The aim. To analyze the results of MV surgical treatment using a minimally invasive approach.

Materials and methods. Between 2020 and 2024, surgical treatment of MV insufficiency through a right-sided minithoracotomy was performed in 34 patients aged 18 to 67 at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, forming the primary study group. The comparison group included 36 consecutive patients (aged 25 to 81) who underwent isolated MV insufficiency correction through the classic approach, i.e. median longitudinal sternotomy (between 2023 and 2024).

Results. The studied groups did not differ in terms of echocardiographic parameters. It was established that blood loss in the operating room was significantly higher with median longitudinal sternotomy compared to minithoracotomy (268.06 ± 14.3 mL and 192.50 ± 12.1 mL, respectively; p = 0.001). However, duration of operation and time of aortic compression were significantly longer in patients in the main group compared to controls, which is consistent with data from other researchers. Patients after minithoracotomy had a likely lower number of hours of analgesia, compared to those after median longitudinal sternotomy (88.35 ± 12.9 hours and 148.11 ± 16.6 hours, respectively; p = 0.009). Complications occurred less often in patients after minithoracotomy than in controls (8.8% and 11.1%, respectively; p > 0.05).

Conclusions. MIMVS was associated with less blood loss in the operative period and reduced the severity of early postoperative pain. The effectiveness of surgical treatment using MIMVS was 100%, while complications occurred less often than in controls.

Extracranial Carotid and Vertebral Artery Dissection

Ihor I. Kobza — 2024-12-27

Cervical artery dissection (CAD) is a rare vascular pathology that causes stroke in 2.0% of cases and is the most common cause of ischemic stroke among young patients. Today the choice of optimal treatment of CAD remains controversial, especially the issue of choosing antiplatelet and anticoagulant therapy, the expediency of endovascular and surgical approaches.

The aim. To analyze the results of management of extracranial carotid and vertebral artery dissection.

Materials and methods. Retrospective and prospective analysis of the results of comprehensive examination and treatment in 40 patients (17 [42.5%] men and 23 [57.5%] women, mean age 48.7 ± 13.4 years) with CAD was performed. Of these, 14 (35.0%) patients underwent surgical management, 26 (65.0%) received conservative treatment.

Results. Etiology of CAD included: atherosclerosis in 13 (32.5%), fibromuscular dysplasia in 12 (30.0%), trauma in 3 (7.5%), and nonspecific aortoarteritis in 1 (2.5%) patient. Spontaneous CAD was observed in 11 (27.5%) patients. The choice of surgical tactics in patients with carotid artery dissection was justified due to lesion of proximal extracranial segment with unstable ulcerative atherosclerotic plaque, critical stenosis, dissecting aneurysm. The choice of optimal anticoagulant and antiplatelet therapy in conservative group was predicted by individual approach, including the risk of bleeding and ischemic stroke. Long-term results were evaluated among 22 patients who received conservative treatment. Complete resolution of dissection was noted in 15 (68.2%), partial in 4 (18.2%), recurrence of dissection in 1 (4.5%) patient. In 9 (40.9%) patients, complete resolution of dissection was observed within 6 months of treatment.

Conclusion. The choice of anticoagulant and antiplatelet therapy of CAD requires an individual approach with evaluation of the risk of bleeding, ischemic stroke, duration of the disease, lumen recanalization, atherosclerotic lesion, patient’s comorbidity. Novel oral anticoagulants and their combination with antiplatelets allow to achieve effective results of treatment of CAD and prevent the recurrence of ischemic events.

Closed Cardiac Trauma: Literature Review and Case Series of Combat Trauma

Viktoriia V. Petrushenko — 2024-12-27

The aim. Analysis of the causes, diagnosis and treatment methods of closed heart injuries through the examples of literary sources and our own clinical cases.

Russia’s full-scale invasion of Ukraine led to massive hostilities. This war not only changed the geopolitical situation in Europe, but also presented new challenges to the medical community, particularly in the field of military medicine. Among many types of combat injuries, heart injury, which can be both open and closed, requires special attention. Although both types of injuries are life-threatening, the closed heart injury becomes more relevant in the conditions of modern warfare. A closed heart injury often accompanies any chest injuries, has a hidden course, and its real prevalence exceeds the number of diagnosed cases. Among the closed injuries of the heart, concussion is accompanied by the least damage to the structures and the mildest consequences, while heart rupture has an intensive clinical manifestation, an extremely difficult course, and often fatal consequences. Most often, a heart bruise occurs with a chest injury. The proper diagnosis of heart bruise at the pre-hospital stage is accompanied by difficulties. They are associated with the conditions of the history taking and physical examination of the wounded person. The mentioned conditions include the lack of time, impaired consciousness of the victim (for example, when combined with a craniocerebral injury), lack of additional laboratory and instrumental diagnostic methods as well as different levels of training of medical personnel. The article presents a detailed description of the types of closed heart trauma, clinical, laboratory and instrumental characteristics of each type, as well as a generalized scheme of treatment tactics. In addition, three clinical cases of heart bruise with different severity of clinical manifestation are provided.

Conclusion. In the conditions of modern warfare, a closed heart injury is more relevant than an open type of the combat heart trauma. This requires military and civilian physicians to pay more attention to the possible presence of this type of injury, to improve diagnostics and treatment approaches, and to develop effective field care protocols.

Endovascular Treatment of the Tentorial Dural Arteriovenous Fistulas. Case Series and Literature Review

Dmytro V. Shchehlov — 2024-12-27

Dural arteriovenous fistulas (DAVFs) are vascular anomalies where arteries from the carotid or vertebral arteries directly drain into the dural venous sinuses. Symptoms can range from asymptomatic to severe, including hemorrhage, venous hypertension, and neurological deficits. Tentorial dural arteriovenous fistulas (TDAVFs), a rare subset occurring in the tentorium, represent up to 4% of all DAVFs. Traditionally, DAVFs have been treated surgically, but recent advancements in endovascular embolization have made it a first-line treatment, although the optimal approach is still debated.

The aim. To evaluate the efficacy and outcomes of endovascular treatment for TDAVFs.

Materials and methods. Between 2012 and 2024, 174 patients with DAVFs were treated at the ScientificPractical Center of Endovascular Neuroradiology of the NAMS of Ukraine, including 8 patients with TDAVFs (mean age 58.5 years). All the patients with TDAVFs were symptomatic, with symptoms including hemorrhage (37.5%), headache, tinnitus, and seizures (62.5%). Endovascular treatment used liquid embolic agents and coils when required. Outcomes were assessed using postoperative angiograms and the modified Rankin Scale.

Results. Nine embolization sessions were performed; of these, 8 (88.9%) using n-butyl cyanoacrylate Histoacryl and 1 (11.1%) using Onyx. Complete shunt elimination was achieved in 75% of sessions; 25% had residual lowflow shunting, with vessels unsuitable for further catheterization. No neurological deterioration occurred. The mean length of hospital stay was 5.5 days. Follow-up angiography in 7 patients showed one case of symptom worsening and vessel recruitment, which was later fully treated with repeat transvenous embolization.

Conclusions. Endovascular embolization is an effective and safe treatment for TDAVFs. This case series indicates its efficacy but underscores the need for further randomized trials to compare all treatment modalities for tentorial and other deep-seated dural vascular lesions.