Abstract: Introduction: pulmonary arterial hypertension (PAH) is a pathophysiological syndrome that can occur in a variety of clinical conditions. Percutaneous balloon dilatation and stent implantation are methods for creating or expanding atrial communication in a variety of conditions to improve cardiac output. It should be kept in mind that creation of an inadequate size of the shunt leads to an excess of right-left shunt, worsening of pulmonary blood flow, severe hypoxemia, and acute left ventricular failure. Possibility of a calculated determination of required size of shunt in the interatrial septum will increase the effectiveness and safety of atrioseptostomy, which is especially important in this severe category of patients. Aim: to substantiate a method of determining of optimal diameter of the atrial communication during atrioseptostomy in patients with PAH for increase of exercise tolerance, prevention of syncope and reducing the risk of sudden death. Materials and methods: the choice of the diameter of the interatrial communication during atrioseptostomy operation in patients with PAH is as follows: before the operation, patient undergoes an invasive measurement of pressure in right and left atrium and determination of stroke volume of left ventricle. Then calculation the diameter of the interatrial communication according to the formula is performed. We performed calculation according to presented formula in 4 patients with PAH. In 2 patients, a fenestrated occluder was implanted, in 1 patient atrial septum stenting was performed, and 1 patient underwent open atrioseptostomy. Results: in all patients after atrioseptostomy, an improvement in quality of life was observed: decreased dyspnea, increased exercise tolerance, decreased edema of lower limbs, and the absence of syncopal conditions. Thus, after the operation, there was a positive dynamics in clinical status of patients, indicators of test with a six-minute walk, as well as changes in echocardiographic indicators: a decrease in the size of the right ventricle and square area of right atrium, an increase in the end-diastolic size of the left ventricle, which indicates an improvement in function of both ventricles. Conclusion: a mathematical model based on principles of intracardiac hemodynamics, demonstrates the importance of choosing of size of foramen to create a certain Qp/Qs. Size of foramen, depending on the pressure in atrium, in conditions of high pulmonary hypertension has a small range of values (from 6 to 8 mm). Therefore, the use of the 7 mm size, previously obtained empirically by other authors, is physically justified. Our first experience testifies to applicability of the developed model, but due to the small number of observations associated with the rarity of the pathology, it requires further research. Referenses 1. Micheletti A, Hislop AA, Lammers A, et al. Role of atrial septostomy in the treatment of children with pulmonary arterial hypertension. Heart. 2006; 92: 969-72. http://doi.org/10.1136/hrt.2005.077669 2. Baglini R, Scardulla C., Reduction of a previous atrial septostomy in a patient with end-stage pulmonary hypertension by a manually fenestrated device. Cardiovasc Revasc Med. 2010; 11(4). http://doi.org/10.1016/j.carrev.2009.11.005 3. St?mper O, Gewillig M, Vettukattil J, et al. Modified technique of stent fenestration of the atrial septum. Heart. 2003; 89: 1227-30. http://doi.org/10.1136/heart.89.10.1227 4. Sivaprakasam M, Kiesewetter C, Veldtman GR, et al. New technique for fenestration of the interatrial septum. J Interv Cardiol. 2006; 19: 334-6. 5. Alekyan BG, Pursanov MG. Atrial septal stenting. Textbook of endovascular surgery for cardiovascular diseases. AN Bakulev National Medical Research Center of Cardiovascular Surgery. 2008; 2: 57-65 [In Russ]. 6. Gorbachevsky SV, Belkina MV, Pursanov MG, et al. Atrial septostomy as a long bridge to lung transplantation in patients with idiopathic pulmonary arterial hypertension. J. Cardiovasc. Surg. 2012; 53(2): 11 [In Russ]. 7. Alekyan BG, Gorbachevskiy SV, Pursanov MG, et al. Atrial septal stenting with idiopathic pulmonary hypertension. AN Bakulev National Medical Research Center of Cardiovascular Surgery. Thoracic and Cardiovascular Surgery. 2016; 58(5): 258-314 [In Russ]. 8. Pardaev DB, Alekyan BG, Gorbachevskiy SV, et al. Atrioseptostomy with atrial septum stenting in patients with idiopathic pulmonary hypertension. AN Bakulev National Medical Research Center of Cardiovascular Surgery. 2017 [In Russ]. 9. Weimar T, Watanabe Y, Kazui T, et al. Impact of differential right-to-left shunting on systemic perfusion in pulmonary arterial hypertension. Cathet. Cardiovasc. Interv. 2013; 81(5): 888-95. http://doi.org/10.1002/ccd.24458 10. Sandoval J, Arroyo JG, Gaspar J, et al. Interventional and surgical therapeutic strategies for pulmonary arterial hypertension: Beyond palliative treatments. J. Cardiol. 2015; 66: 304-4. http://doi.org/10.1016/j.jjcc.2015.02.001 11. Lammers AE, Derrick G, Haworth SG, et al. Efficacy and long-term patency of fenestrated Amplatzer devices in children. Cathet. Cardiovasc. Interv. 2007; 70(4): 578-84. http://doi.org/10.1002/ccd.21216 12. Shmaltc АА, Nishonov NА. Atrioseptostomy in patients with pulmonary hypertension. Thorax and Cardiovascular Surgery. 2015; 57(5): 18-25 [In Russ]. 13. Chiu JS, Zuckerman WA, Turner ME, et al. Balloon atrial septostomy in pulmonary arterial hypertension: effect on survival and associated outcomes. J Heart Lung Transplant. 2015; 34(3): 376-380. http://doi.org/10.1016/j.healun.2015.01.004 14. Hirsch R, Bagby MC, Zussman ME. Fenestrated ASD closure in a child with idiopathic pulmonary hypertension and exercise desaturation. Congenit Heart Dis. 2011; 6(2): 162-166. http://doi.org/10.1111/j.1747-0803.2010.00472.x 15. Kurzyna M, Dabrowski M, Bielecki D, et al. Atrial septostomy in treatment of end-stage right heart failure in patients with pulmonary hypertension. Chest. 2007; 131(4): 977-983. http://doi.org/10.1378/chest.06-1227 16. Patel MB, Samuel BP, Girgis RE, et al. Implantable atrial flow regulator for severe, irreversible pulmonary arterial hypertension. EuroIntervention. 2015; 11(6): 706-709. http://doi.org/10.4244/EIJY15M07_08 17. Kapoor A, Khanna R, Batra A, et al. Inoue balloon atrial septostomy in severe persistent pulmonary hypertension following surgical ASD closure. J Cardiol Cases. 2012; 6(1): 1-3. http://doi.org/10.1016/j.jccase.2012.02.002 18. Rajeshkumar R, Pavithran S, Sivakumar K, et al. Atrial septostomy with a predefined diameter using a novel occlutech atrial flow regulator improves symptoms and cardiac index in patients with severe pulmonary arterial hypertension. Catheter Cardiovasc Interv. 2017; 90(7): 1145-1153. http://doi.org/10.1002/ccd.27233 19. Baglini R, Scardulla C. Reduction of a previous atrial septostomy in a patient with end-stage pulmonary hypertension by a manually fenestrated device. Cardiovasc Revasc Med. 2010; 11(4). http://doi.org/10.1016/j.carrev.2009.11.005 20. Alekyan BG, Gorbachevsky SV, Pursanov MG, et al. Stenting of the interatrial septum for the treatment of idiopathic pulmonary arterial hypertension. J. Invasive Cardiol. 2015 [In Russ]. 21. Koval PV. Hydraulics and hydraulic lines of mining machines: Textbook for universities in the specialty «Mining machines and complexes». Engineering. 1979.
Abstract: Introduction: pulmonary arterial hypertension (PAH) is a disease characterized by a progressive increase in pulmonary vascular resistance that leads to the development of right ventricular heart failure and premature death of patients. Today, there are several ways to create an atrial communication: balloon dilatation, Park procedure, balloon knife atrial septostomy, atrial septum stenting and implantation of fenestrated occluder. The main problem with positioning of the device is that the atrial septum is not visible on fluoroscopy, where the stent is visible throughout. And the stent is not visible throughout on echocardiography, where the septum is visible. Exactly for this operation, the combination of echo- and fluoroscopic image in real time is very useful in order to accurately place in the middle at the level of stent in the septum and to avoid its dislocation with embolization of right or left heart chambers, or vessels of pulmonary and systemic circuit. Material and methods: we present a case report of atrial septostomy with stent implantation into the atrial septum using the EchoNavigator® hybrid imaging system in a patient with pulmonary arterial hypertension.Surgical intervention was performed on a patient with PAH: atrial septostomy with intubation anesthesia under the control of fluoroscopy and transesophageal echocardiography (TEE) using the EchoNavigator® system. The procedure was performed using a Palmaz stent, that was implanted without additional fixation. Results: patient with pulmonary hypertension underwent an atrial septostomy using the EchoNavigator® hybrid imaging system, which was used for positioning and implantation of stent into the atrial septum as quickly and accurately as possible. This surgical intervention significantly improved patient's clinical condition, cardiac hemodynamics and, accordingly, increased the quality of life. Conclusion: atrial septostomy is a surgical method for patients with severe pulmonary arterial hypertension. Carrying out this operation under the control of the EchoNavigator® system with the function of hybrid imaging in real time greatly facilitated the procedure for positioning and implanting of stent, facilitated the safe implementation. References 1. Gali? N, Rubin L. Pulmonary arterial hypertension. Epidemiology, pathobiology, assessment and therapy. Journal of the American College of Cardiology. 2004; 43:1–90. 2. Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines. Chest. 2007; 131:1918–28. http://doi.org/10.1378/chest.06-2674 3. Reichenberger F, Pepke-Zaba J, McNeil K, et al. Atrial seprostomy in the treatment of severe pulmonary arterial hypertension. Thorax. 2003; 58:797–800. http://doi.org/10.1136/thorax.58.9.797 4. Law M, Grifka RG, Mullins CE, et al. Atrial septostomy improves survival in select patients with pulmonary hypertension. Am Heart J. 2007; 153:779–84. http://doi.org/10.1016/j.ahj.2007.02.019 5. Kurzyna M, Dabrowski M, Bielecki D, et al. Atrial septostomy in treatment of end-stage right heart failure in patients with pulmonary hypertension. Chest. 2007; 131:977–83. http://doi.org/10.1378/chest.06-1227 6. Gorbachevsky SV, Belkina MV, Pursanov MG, et al. Atrial septostomy as a long bridge to lung transplantation in patients with idiopathic pulmonary arterial hypertension. J. Cardiovasc. Surg. 2012; 53:11. 7. Alekyan BG, Gorbachevsky SV, Pursanov MG, et al. Atrial septal stenting in idiopathic pulmonary hypertension. Journal of thoracic and cardiovascular surgery. 2016; 58(5): 258-314 [In Russ]. 8. Schmaltz АА, Nishonov NА. Atrioseptostomy in patients with pulmonary hypertension. Journal of thoracic and cardiovascular surgery. 2015; 57(5): 18-25 [In Russ]. 9. Sandoval J, Gaspar J, Pena H, et al. Effect of atrial septostomy on the survival of patients with severe pulmonary arterial hypertension. Eur. Respir. J. 2011; 38: 1343–8. http://doi.org/10.1183/09031936.00072210 10. Chiu S, Zuckerman WA, Turner ME, et al. Balloon atrial septostomy in pulmonary arterial hypertension: Effect on survival and associated outcomes. J. Heart Transplant. 2015;34(3):376-80. http://doi.org/10.1016/j.healun.2015.01.004 11. Fraisse A, Chetaille P, Amin Z, et al. Use of Amplatzer fenestrated atrial septal defect device in a child with familial pulmonary hypertension. Pediatr. Cardiol. 2006; 27: 759–62. 12. O’loughlin AJ, Keogh A, Muller DW. Insertion of a fenestrated Amplatzer atrial septostomy device for severe pulmonary hypertension. Heart Lung Circ. 2006; 15: 275–7. http://doi.org/10.1016/j.hlc.2006.02.002 13. Prieto LR, Latson LA, Jennings C. Atrial septostomy using a butterfly stent in a patient with severe pulmonary arterial hypertension. Cathet. Cardiovasc. Interv. 2006; 68: 642–7. http://doi.org/10.1002/ccd.20745 14. Althoff TF, Knebel F, Panda A, et al. Longterm follow-up of a fenestrated Amplatzer atrial septal occlude in pulmonary arterial hypertension. Chest. 2008; 133; 283–5. http://doi.org/10.1378/chest.07-1222 15. Troost E, Delcroix M, Gewillig M, et al. A modified technique of stent fenestration of the interatrial septum improves patients with pulmonary hypertension. Cathet. Cardiovasc. Interv. 2008; 73: 173–9. https://doi.org/10.1002/ccd.21760 16. Roy AK, Gaine SP, Walsh KP. Percutaneous atrial septostomy with modified butterfly stent and intracardiac echocardiographic guidance in a patient with syncope and refractory pulmonary arterial hypertension. Heart Lung Circ. 2013; 22(8):668–71. https://doi.org/10.1016/j.hlc.2013.01.005 17. Alekyan BG, Pursanov MG. Atrial septal stenting. Guide to endovascular surgery of the heart and blood vessels. 2008; 2:57–65 [In Russ]. 18. Sager JS, Ahya VN. Surgical therapies for pulmonary arterial hypertension. Clin. Chest Med. 2007; 28: 187–202. https://doi.org/10.1016/j.ccm.2006.11.003 19. Unger P, Stoupel E, Vachiery JL, et al. Atrial septostomy under transesophageal guidance in a patient with primary pulmonary hypertension and absent right superior vena cava. Intensive Care Med. 1996; 22:1410–11. https://doi.org/10.1007/BF01709560 20. Bidoggia H, Maciel JP, Alvarez JA. Transseptal left heart catheterization: usefulness of the intracavitary electrocardiogram in the localization of the fossa ovalis. Cathet. Cardiovasc. Diagn. 1991; 24:221–5. https://doi.org/10.1002/ccd.1810240318 21. Moscucci M, Dairywala IT, Chetcuti S, et al. Balloon atrial septostomy in end-stage pulmonary hypertension guided by a novel intracardiac echocardiographic transducer. Cathet. Cardiovasc. Interv. 2001; 52:530–4. https://doi.org/10.1002/ccd.1116 22. Sorajja P, Cabalka AK, Hagler DJ, et al. Long-term follow-up of percutaneous repair of paravalvular prosthetic regurgitation. J Am Coll Cardiol. 2011; 58:2218–2224. https://doi.org/10.1016/j.jacc.2011.07.041 23. Zorinas A, Janusauskas V, Davidavicius G, et al. Fusion of real-time 3D transesophageal echocardiography and cardiac fluoroscopy imaging in transapical catheter-based mitral paravalvular leak closure. Advances in Interventional Cardiology. 2017; 13(3):263-268. https://doi.org/10.5114/aic.2017.70200 24. Corti R, Biaggi P, Gaemperli O, et al. Integrated x-ray and echocardiography imaging for structural heart interventions. EuroIntervention. 2013; 9:863-869. https://doi.org/10.4244/EIJV9I7A140 25. S?ndermann SH, Biaggi P, Gr?nenfelder J, et al. Safety and feasibility of novel technology fusing echocardiography and fluoroscopy images during MitraClip interventions. EuroIntervention. 2014; 9:1210-1216.
Abstract Background: in patients with congestive heart failure (CHF), there is a change in indicators of heart mechanics against the background of myocardium remodeling. Currently, magnetic resonance imaging (MRI) and speckle tracking echocardiography provide additional options for assessing changes in heart mechanics. Evaluation of mechanics of the myocardium rotational movement according to coronarography (CAG) has not been found in available literature. In this regard, there is a need to develop a methodology that allows to obtain a mathematical description of rotation processes and heartbeat during the CAG. Material and methods: study included 90 patients aged 30-71 to assess indicators of heart rotation mechanics. Subjects were divided into groups: with dilated cardiomyopathy (DCMP, n=30), left ventricular aneurysm (LVA, n=30) and patients with autonomic nervous system disorder (ANSD, n=30) without heart failure (control group). Mechanics of heart rotation was studied using the CAG technique, modified by us, based on mathematical calculations of the rotation angle in motion of points on the heart surface, determined on the coronary angiogram in two projections. Results: study found out, that in patients with DCMP and LVA with chronic heart failure, the angle of rotation of the heart was significantly lower than in patients with ANSD who do not have heart disease (p <0,05). The link between impaired myocardial contractile function in patients with DCMP and LVA with chronic heart failure and a decrease in the heart rotation angle was confirmed (DCMP: ?2=9,774; df=1; P <0,05), (LVA: ?2=9,600; df=1; P <0,05). Conclusion: coronarography technique that we modified, makes it possible to quantify changes in parameters of the heart mechanics in examined patients. This makes it possible to determine the presence or absence of heart failure, depending on results. References 1. Fomin IV. Chronic heart failure in the Russian Federation: what we know today and what we should do. Russian Journal of Cardiology. 2016, 8(136): 7-13 [In Russ]. 2. Belenkov YuN, Mareev VYu. Principles of rational treatment of heart failure.M. 2000. 266 [In Russ]. 3. Popescu BA, Beladan CC, Calin A, et al. Left ventricular remodelling and torsional dynamics in dilated cardiomyopathy: reversed apical rotation as a marker of disease severity. EurJHeartFail. 2009;11(10): 945-51. 4. Pavlyukova EN, Kuzhel' DA, Matyushin GV, Savchenko EA, Filippova SA. Rotation, twisting and spinning of the left ventricle: physiological role and significance in clinical practice. Regional pharmacotherapy in cardiology. 2015; 11(1): 68-78 [In Russ]. 5. Mondillo S, Galderisi M, Mele D, et al.; Echocardiography Study Group Of The Italian Society Of Cardiology (Rome, Italy). Speckle-tracking echocardiography: a new technique for assessing myocardial function. J Ultrasound Med. 2011;30(1):71-83. 6. Sergio Mondillo, MD, Maurizio Galderis, et al. Speckle-tracking echocardiography - a technique for assessing myocardial function. June 2, 2016. The international online community of specialists in ultrasound diagnostics [In Russ]. 7. Leitman M, Lysyansky P, Sidenko S et al. Two-dimensionalstrain - a novel software for real-time quantitative echocardiographic assessment of myocardial function. J. Am. Soc. Echocardiogr. 2004; 17(10): 1021-1029. 8. Amundsen BH, Helle-Valle T, Edvardsen T et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging. J. Am. Coll. Cardiol. 2006; 47(4): 789-793. 9. Buckberg G.D., Weisfeldt M.L., Ballester M. [et al.] Left ventricular form and function: scientific priorities and strategic planning for development of new views of disease. Circulation. 2004; 110: 333-336. 10. Mirsky I., Parmley W.W. Assessment of passive elastic stiffness for isolated heart muscle and the intact heart. Circ. Res. 1973; 33: 233-243. 11. Pouleur A., Knappe D., Shah A. [et al.] Relationship between improvement in left ventricular dyssynchrony and contractile function and clinical outcome with cardiac resynchronization therapy: the MADIT-CRT trial. Eur. Heart J. 2011; 32:1720-29. 12. Vermes E., Tardif J.C., Bourassa M.G. [et al.] Enalapril decreases the incidence of atrial fibrillation in patients with left ventricular dysfunction: insight from the Studies of Left Ventricular Dysfunction (SOLVD) trials. Circulation. 2003; 931: 2926-2. 13. Victor Mor-Avi et al. The consensus decision of the American Echocardiographic Society and the European Association of Echocardiography on the methodology and indications, approved by the Japanese Society of Echocardiography. Articles. 07/07/2015 [In Russ]. 14. Roberto M Lang, Michelle Bierig [et al.] Roberto M Lang, Michelle Bierig [et al.]Recommendations for quantifying the structure and chambers of the heart.. Russian Journal of Cardiology 2012; 3(95). This edition of guidelines is published in Eur J Echocardiography 2006; 7: 79-108 [In Russ].
