Endovascular Closure of Secundum Atrial Septal Defects with Complex Anatomy

According to European guidelines, endovascular closure is the method of choice for defects with favorable anatomy. However, there are no clear criteria for determining favorable anatomy and this issue requires additional investigation. According to literature data, only 24.2% of secundum atrial septal defects (ASDII) have a central location, others have complicated anatomy. The aim. To analyze the experience of endovascular closure of ASDII with complex anatomy. Materials. In the period from 2003 to 2021, 1732 transesophageal echocardiographies and intracardiac echocardiographieswereperformedinpatientswithASDIIinitiallydiagnosedaccordingtotransthoracicechocardiography, and only 1408 (91.8%) were selected for endovascular closure. Mean age was 19.9±18 years, mean weight was 45±26.68 kg. Methods. The standard closure technique was primarily used in 100% of cases, and only when it was ineffective, we used modified techniques. Results. Modified techniques were used in 478 (33.9%) of 1408 patients and were effective in 460 (96.2%) patients with the complex anatomy. Based on previous statement, 460 (32.6%) of 1408 patients (one third of all) had modified techniques utilized and avoided open surgery. In 18 (1.3%) cases, it was impossible to close the defect. The overall technical success of transcatheter closure was 98.7% (1390 patients). Nineteen (1.3%) patients with poor visualization of inferior rim on transesophageal echocardiography had intracardiac echocardiography; in two of them inferior rim was present, others had open surgery. The rate of complications in immediate periprocedural period was 1.9% (27 patients). One death was recorded in the period of introduction of percutaneous interventions in our institution. Mean follow-up period was 5.41±3.28 years. In the follow-up period two complications were observed: 1 case of erosion, 17 (1.9%) cases of new-onset atrial fibrillation. Conclusion. The majority (90.6%) of ASDII can be closed percutaneously. Modified techniques improve the efficacy of the procedure enabling to close 32.6% of the defects. Safe procedure for the defects with complex anatomy is possible only with surgical and arrhythmological services back-up.

HEIGHT AND WEIGHT CHARACTERISTICS OF MILITARY SERVICEMEN OF MOBILIZATION AGE WITH DISEASES OF THE CARDIOVASCULARY SYSTEM

OBJECTIVE

The aim establish the height and weight characteristics of servicemen of mobilization age with cardiovascular diseases, the frequency and etiological fraction of excess body weight and obesity in the risk of developing cardiovascular diseases.

PATIENTS AND METHODS

Materials and methods: The study included military personnel, exclusively male (n=127), who made up the observation group. The age of the study participants varied from 19 to 64 years, the average age - 43.06±4.07. All study participants were undergoing inpatient examination and treatment with cardiovascular diseases. The material for the study was the results of anthropological examinations and data from primary accounting medical documentation (medical history, primary medical card, evacuation ticket, etc.).

RESULTS

Results: It was established that the prevalence of obesity in the observation group was 26.0%, which is significantly higher compared to the frequency of obesity in the control group of 13.2% (χ2=17.02; P=0.0003). It was found that obesity of the III stage degree occurred significantly more often in the experimental group - 3.03% compared to the control group - 0.4%, (χ2=5.73; #=0.01). The calculated value of the etiological share (EF of obesity) was equal to 51-66%, which indicates a high contribution of obesity to the development of cardiovascular diseases.

CONCLUSION

Conclusions: It was established that the prevalence of obesity of various degrees among servicemen with diseases of the cardiovascular system is significantly higher compared to the frequency of obesity in the male population of Ukraine.

Endovascular Closure of Secondary Septal Defect in Children with Low Body Weight

The aim. To assess the effectiveness and safety of transcatheter closure of a secondary atrial septal defect (ASD) using an occluder in symptomatic children weighing ≤10 kg. Materials and methods. In the period from November 2014 to June 2021, on the basis of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, closure of secondary ASD using an occluder was performed in 18 patients, among them 13 women (72.2%) and 5 men (27.8%). Th e mean age of the patients was 18.94±9.44 months (the youngest patient was 12 months, the oldest was 4 years). The mean weight was 9.294±1.170 kg (6.4 kg to 10 kg), the mean Z-score was -1.7±1.5 (-4.6 to 0.46), the mean height was 80 cm (71 cm to 88 cm). According to the measurements by transesophageal echocardiography (TEE), the average size of the defects was 13.7 mm±3.6mm (the largest 18.0 mm, the smallest 6.0 mm). Results and discussion. In our publication, the effectiveness of the method was 100% (18/18), while the world statistics show 94-95%. Th e frequency of complications was 5.6% (n=1). We suggest that this is associated with the use of a sizing balloon and careful selection of the device. When choosing treatment tactics for symptomatic children weighing ≤10 kg, the decisive factor was the determination of the presence of edges and the size of the defect. Defects were considered suitable for closure, according to TEE data, when all margins of the defect were ≥4 mm, except for the aortic margin. Although the total length of the interatrial membrane was taken into account, it was not of decisive importance, since for most occluders with the presence of all edges, the fields of the implant could not interfere with the work of the anatomical structures of the heart. To determine the real size of the defect, we recommend a measuring balloon under TEE control. The following devices were used to close the defect: MemoPart ASD occluder, Amplatzer Septal Occluder, LifeTech HeartR Occluder, LifeTech HeartR Multi-Fenestrated Atrial Septal Defect (MF-ASD) Occluder.   Conclusion. After the study, we are convinced that the endovascular method of closing a hemodynamically significant secondary ASD for the treatment of children with a body weight of ≤10 kg has proven to be an effective method, with successful implantation of the occluder in 100% of cases.

Arrhythmias in Pregnancy. Experience of the Multidisciplinary Team

Arrhythmia is the main cause of pregnancy-related hospitalizations. Potential risk of arrhythmias during pregnancy is associated with hypercoagulation and increased risk of thromboembolism. The aim. To increase patients’ safety and to improve maternal and perinatal outcomes by choosing the optimal medical strategy. Methods. We present the experience of multidisciplinary care for 54 pregnant and parturient women (32 with tachy-, 20 with bradyarrhythmia and 2 with ventricular asynchrony) who were admitted to the cardiac surgery facility from December 2013 to February 2022. Pacemakers were implanted in 15 cases of complete atrioventricular block radiofrequency ablation was performed in 12 cases. Results. There were no near misses and maternal losses in our group of patients. Two programmed perinatal losses were provided in patients with rhythm disorders and complex congenital heart defects. Type and place of delivery were chosen by the multidisciplinary team. There were nine childbirths at a specialized cardiac surgery clinic. There were no perinatal losses among patients who underwent rhythm interventions. In our group of patients, electrical cardioversion was performed in three cases, the pregnancies ended successfully with the birth of healthy newborns. Conclusions. Arrhythmias in all trimesters of pregnancy and the postpartum period are a common reason for seeking medical attention and hospitalization during pregnancy.Most of the arrhythmias are hemodynamically insignificant and don’t require hospitalization. Maternal risk stratification of major cardiac events during pregnancy, childbirth and the postpartum period is the cornerstone for choosing a strategy of medical care for pregnant women with arrhythmias. Patients with hemodynamic manifestations of tachy- and bradyarrhythmias, as well as patients with life-threatening types of rhythm disturbances are in the focus of attention of pregnancy heart team. Preconceptional management of patients with life threating arrhythmias is the best type of care in these patients. Pregnancy and delivery in high-risk class patients should be managed in an experienced center with on-site interventional electrophysiology techniques. Rhythm interventions have extremely limited indications and can be conducted when less invasive treatment strategy is unsuccessful.

CARDIOPULMONARY BYPASS IN PREGNANCY. A SINGLE-CENTER EXPERIENCE

OBJECTIVE

The aim: Presentation of a single-center experience of cardiac surgery with cardiopulmonary bypass (CPB) in pregnant women with critical cardiac pathology. The possibility of minimally invasive technique in this group of patients were presented.

PATIENTS AND METHODS

Materials and methods: The present study included 19 cases of multidisciplinary care with CPB surgery in pregnant women in single center from December 2013 to December 2020. 8 patients underwent J-form median mini-sternotomy. Maternal and neonatal outcomes depending on the type of surgery (urgent or elective) were reviewed.

RESULTS

Results: There were no negative maternal consequences; there were 4 perinatal losses (21%): three after urgent and one after elective interventions. All other pregnancies (n=15) finished successfully with the birth of healthy newborns. We compared some values in two groups (urgent and elective) of patients who underwent CPB surgery during pregnancy. Despite the variability in some parameters the difference between the groups was not significant. Follow-up was from 5 to 72 months (39.7±16.9) without negative consequences.

CONCLUSION

Conclusions: Multidisciplinary team management is an effective strategy for pregnant women with cardiac pathology. Elective cardiac surgery in expert centers during pregnancy is a safe and effective option. Urgent CPB cardiac surgery during pregnancy increases the risk for the fetus. J-form median mini-sternotomy is a good option during pregnancy in high-experienced centers.

NON-INVASIVE CORONARY ARTERIES ATHEROSCLEROSIS CT-VISUALIZATION: UP-TO-DATE STANDARDS AND OWN CLINICAL EXPERIENCE STUDY

Non-invasive coronary arteries (CA) visualization experiences fast progress recently. Existing evidence-based dataand trials show that there is a great need in non-invasive technologies able to trustworthy and accurately identifyCA high risk atherosclerotic plaques (AP) and provide more insights into atherosclerosis pathophysiology in individ-ual patents, being accurate qualitative and quantitative methods of primary diagnosis and answer to therapeuticintervention indicators in patients with coronary artery (CAD). Until now in Ukraine there were no studies evaluat-ing accuracy of last generation 640-sliced computed tomography coronary angiography (CTCA) in diagnosing of dif-ferent CAD forms.Objective of the study was to study diagnostic accuracy of CTCA compared to invasive coronary angiography (iCAG)in the patients with different forms of chronic CAD before surgeon revascularization.Materials and methods. From I.2019 to V.2021 we prospectively studied 201 patients with different chronic CADforms (76.6 % men and 23.4 % women) aged (61.8 ± 9.2) years hospitalized to our center for diagnostic work-upand decision about primary or secondary revascularization (coronary aortic bypass (CABG) or percutaneous (PCI)intervention). All patients underwent planned CTCA and iCAG.Results and conclusions. There were no significant complication duing procedures performed. Totally 2412 coro-nary segments were visualized and studied. Coronary calcium index (CI) highly significantly correlated with overallburden and severity of atherosclerotic process (r = 0,73, р < 0.0001). CTCA compared to iCAG showed no false-nega-tive results and only 6 (2.99 %) false positive results in cases of insignificant lesions. There was no significant dif-ference in diagnostic accuracy for significant stenoses with very high accuracy for overall vessels lesions quantityand burden (r = 0.95, р < 0.0001) with very high prognostic method accuracy (AUC 0.99; OR >>1000, р < 0.0001),making high multi-sliced CTCA safe and extremely accurate method for qualitative and quantitative diagnosis of ath-erosclerotic CA lesions absolutely comparable to iCAG, including hemodynamic significance evaluation.

THE PLACE OF CARDIAC COMPUTED TOMOGRAPHY IN PREOPERATIVE PLANNING OF EXTENDED SEPTAL MYECTOMY IN PATIENTS WITH OBSTRUCTIVE FORM OF HYPERTROPHIC CARDIOMYOMATHY

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy. Extended septalmyectomy (ESM) is one of the priority methods of treatment of drug-refractory obstructive HCM. In recent years,hospital mortality during surgical correction of obstructive HCM in expert centers does not exceed 1-2 %. However,typical threatening complications of septal myectomy, such as iatrogenic ventricular septal defect (VSD) and rupture of the anterior or posterior walls of the left ventricle (LV), remain a topical issue in surgery of HCM.

OBJECTIVE

to show the role of preoperative CT-planning to predict and reduce possible technical problems associated with ESM, including iatrogenic VSD.

METHODS AND MATERIALS

This study includes 217 symptomatic patients with obstructive HCM, who from April 2016to October 2019 as one of the steps of preoperative planning underwent cardiac CT prior to ESM. Cardiac CT was performed to delineate the left ventricular myocardium, assess the distribution of hypertrophy and the presence ofcrypts. Special attention was also paid to the anatomy of the mitral valve (MV) and subvalvular apparatus. Coronaryartery patency was assessed by CAD-RADS, a standardized method for reporting the results of coronary CT angiography to determine tactics for further management of the patient.

RESULTS AND DISCUSSION

In the study group, the average age of patients was (49 ± 15) years, 48 % - men. All patientshad a symptomatic, drug-refractory obstructive form of HCM. The mean maximum wall thickness of the interventricular septum (IVS) was (20 ± 5) mm (range 16-33). The average LV mass was (118 ± 23) g/m2. 195 patients (89.9 %)had systolic anterior motion ( SAM) of the MV. MV and subvalvular apparatus anomalies were detected in 62 patients(28.6 %). A zone of scarring and regression of IVS after alcohol septal ablation (ASA) was detected in 7 patients(0.3 %) with residual LV outflow gradient. Coronary arteries atherosclerosis was detected in 32 patients (14.7 %).

CONCLUSIONS

Preoperative CT-planning of septal myectomy allows to obtain information on morphology of the LV,IVS, MV and subvalvular apparatus, and gives the surgeon the advantage to form a more accurate plan for the location and volume of septal resection, and avoid complications when correcting obstructive HCM. No iatrogenic VSDwas detected in any of the patient in the study group.

[SURGICAL TREATMENT OF THE ACQUIRED HEART FAILURES, USING BIOLOGICAL PROSTHESES]

Possibilities of application of bioprostheses for correction of acquired heart failures in condition of artificial blood circulation were studied. Examination and treatment of 235 patients, suffering failures of mitral valve (MV) and aortal valve (AV), was performed. In 89 patients a MV prosthesis was made, and in 146 — the AV prosthesis. In 94 patients bioprostheses were applied, and in 141 — mechanical prosthesis was implanted. Indices of the left heart portions morphometry and of survival, stability of good postop* erative results in remote period have witnessed high efficacy of the bioprostheses application and expediency of their application in the aged patients.

[PULMONARY COMPLICATIONS IN CHILDREN, OPERATED ON FOR INBORN HEART FAILURES IN THE ARTIFICIAL BLOOD CIRCULATION ENVIRONMENT]

The risk factors of pulmonary complications occurrence were analyzed in children, operated on for inborn heart failures in atrificial blood circulation environment. Pulmonary complications rate and the risk factors of their occurrence were analyzed.

[PLASTY OF THE INTERVENTRICLE SEPTUM DEFECT, USING A PATCH WITH A VALVE IN PATIENTS, SUFFERING HIGH PULMONARY ARTERIAL HYPERTENSION AND ENHANCED RESISTANCE OF PULMONARY ARTERIES]

Right ventricle insufficiency due to pulmonary hypertensive crysis or persisting pulmonary arterial hypertension (PAH) in patients after the interventricle septum defect (IVSD) closure with the heightened resistance of pulmonary arteries (RPA) constitutes an actual problem and associates with a high risk for a life-threatening complications and high lethality. Experience of the IVSD plasty conduction in a patient with high PAH, using a patch with a valve for right ventricle decompression while pulmonary hypertensive crysis in early postoperative period and nonreversible PAH in the remote period of observation, was presented. In the clinic 38 children were operated on for big IVSD, complicated by high PAH and heightened RPA, using a patch with a valve in 1996 - 2014 yrs. Hospital lethality have constituted 2.6%. Postoperatively a pressure in pulmonary artery (PA) have lowered trustworthy from (93.4 ? 14.9) to (49.2 ? 22.9) mm Hg. In a remote period of observation all the patients were alive. In 6 (16.2%) patients in terms from 4 mo to 18 yrs postoperatively a PAH have occurred, a pressure in PA was by 50% higher, than a systemic one. The IVSD plasty in patients with high PAH and heightened RPA may appear successful if a patch with a valve are applied.

[DIAGNOSIS OF ISCHEMIC HEART DISEASE CAUSED BY TORTUOSITY OF CORONARY ARTERIES]

This article is devoted to the problems of diagnostics of coronary artery tortuosity phenomenon. Given the lack of literature about the role of phenomenon tortuosity of coronary arteries in the genesis of ischemic myocardial damage, the purpose of study was to determine the clinical relevance as well as necessity for prevention and treatment of this vascular anomaly. Therefore were analyzed medical history, laboratory and clinical database as well as data functional studies of the heart and cardiovascular system in 1404 patients which were divided into four groups on the results of coronary angiography. The results of the study indicate tortuosity of coronary arteries may be independent and additional burdening factor in the development of ischemic heart disease.

[PUBLIC ADMINISTRATION OF PERSONNEL POLICY IN REFORMING OF UKRAINIAN HEALTH CARE SYSTEM USING THE EXAMPLE OF DERMATOVENEREOLOGICAL SERVICE]

The health care system, its modernization and optimization are among the most important functions of the modern Ukrainian state. The main goal of the reforms in the field of healthcare is to improve the health of the population, equal and fair access for all to health services of adequate quality. Important place in the health sector reform belongs to optimizing the structure and function of dermatovenereological service. The aim of this work is to address the issue of human resources management of dermatovenereological services during health sector reform in Ukraine, taking into account the real possibility of disengagement dermatovenereological providing care between providers of primary medical care level (general practitioners) and providers of secondary (specialized) and tertiary (high-specialized) medical care (dermatovenerologists and pediatrician dermatovenerologists), and coordinating interaction between these levels. During research has been found, that the major problems of human resources of dermatovenereological service are insufficient staffing and provision of health-care providers;,growth in the number of health workers of retirement age; sectoral and regional disparity of staffing; the problem of improving the skills of medical personnel; regulatory support personnel policy areas and create incentives for staff motivation; problems of rational use of human resources for health care; problems of personnel training for dermatovenereological service. Currently reforming health sector should primarily serve the needs of the population in a fairly effective medical care at all levels, to ensure that there must be sufficient qualitatively trained and motivated health workers. To achieve this goal directed overall work of the Ministry of Health of Uktaine, the National Academy of Medical Sciences of Ukraine, medical universities, regional health authorities, professional medical associations. Therefore Ukrainian dermatovenereological care, in particular fixed, needs a deep and objective medical and social audit. A necessary condition for the harmonious development of dermatovenereological service is adequate staffing to ensure it to reflect changes in the structure of the provision of the assistance at various levels, as well as their effective coordination throughout the natient's medical route.

[Microalbuminuria as a marker of endothelial dysfunction in the long-term follow-up patients after surgical correction of aortic coarctation]

1170 patients after surgical correction of aortic coarctation during the period from 1988 to 2002 were studied. The median period of medical supervision after coarctation repair was 13,8 years, maximum age - 24 years. For diagnostics of the Microalbuminuria (MAU) it were used the special test-strings Microalbu PHAN (PLIVA-Lachema Diagnostica). MAU were discovered in 62.6% of and 34.9% of normotesive patients. Credible decrease of MAU of hypertensive patients with corrected coarctation of the aorta were defined after 3 months-long treatment by Losartan.

[Contractility and energy metabolism in human myocardium in normal state and in various stages of cardiac insufficiency]

Contractile function and metabolism of byoptates of human myocardium were investigated in the control group and at early stages of heart failure development. Support of the myocardial contractile function at the early stage of the heart failure is provided by intensive use of macroergic phosphates and their insufficient resynthesis. At the late stages of myocardial failure deterioration of the heart muscle relaxation was observed as a result of disturbances in transport of high-ergic phosphates to the sites of their utilization.