Abstract:

In recent years, with the growth of number of patients with multifocal atherosclerosis, revascularization of the brain and myocardium through hybrid intervention is gaining popularity. Although, in the world literature there are practically no results of significant randomized researches concerning percutaneous coronary intervention and carotid endarterectomy in hybrid mode, this technique is becoming more and more preferable and promising in comparison with other methods of treatment.

Aim: was to demonstrate results of revascularization of the brain and myocardium with staged and hybrid strategies, on the base of evaluation of advantages and disadvantages of these strategies on the example of case reports.

Materialsand methods: article presents two case reports, demonstrating different approaches to surgical treatment in patients with combined lesions of arteries of the brain and myocardium. Both patients were over 65 years age, at the time of treatment, had a history of acute cerebral circulation disorders, coronary heart disease and arterial hypertension. At the outpatient stage, they received antiplatelet, hypotensive, and hypolipidemic therapy. During further examination, both patients were found to have unilateral hemodynamically significant stenoses of internal carotid arteries and isolated stenoses of coronary arteries. In first case, patient was selected for hybrid surgical tactics in the volume of carotid endarterectomy and stenting of coronary artery, which was performed with a further favorable prognosis. In the second case, tactics was determined in favor of a staged procedure: first performing carotid endarterectomy, then stenting the affected coronary artery. However, taking into account subjective and objective factors, none of planned interventions were performed.

Results: hybrid revascularization allows to perform correction in two arterial of different regions in a short period of time using surgical and endovascular techniques. An important advantage of this method is the one-time performance, that means correction of MFA manifestations for one hospitalization, or even one anesthesia, with increasing in the availability of revascularization. In the first case report, the successful implementation of a hybrid approach in the treatment of combined vascular pathology in an elderly patient with a burdened anamnesis and significant comorbidities was demonstrated. Within one day, we managed to complete the planned volume of myocardial and brain revascularization and avoid the development of adverse events both in the early postoperative and long-term follow-up periods. The second clinical example clearly shows disadvantages of staged strategy, when the patient is at risk of developing adverse cardiovascular events while waiting for staged interventions, or for subjective reasons may refuse to be hospitalized in a clinic for performimg a particular operation, that as a result, led to negative dynamics and fatal outcome due to acute stroke.

Conclusions: thus, demonstrated case reports show significant potential and effectiveness of hybrid myocardial and brain revascularization using percutaneous coronary intervention and carotid endarteectomy in treatment of patients with combined lesions of two vascular regions. This method of treatment is especially promising in patients with burdened anamnesis and additional risk factors. It not only prevents adverse cardiovascular events in brain and myocardium, but also has greatest availability and implementation of the planned volume of treatment, completely excluding the influence of subjective factors (change of tactics, failure of patient to attend the next stage of treatment, etc.).

References

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Abstract:

Aim: was to evaluate the prognostic effectiveness of the method of cardiac magnetic resonance imaging (MRI) in patients with ischemic heart disease (IHD) with dysfunctional myocardium after endovascular interventions

Materials and methods: a total of 114 patients were included in the study Inclusion criteria: myocardial infarction in previously; myocardial ischemia according to stress tests; occlusion or subtotal stenosis of one or more coronary arteries according to digital angiography (SYNTAX score <32); viable myocardium in the zone of the occluded/stenotic artery; heart failure of I-III functional class (NYHA); left ventricular ejection fraction (LVEF) less than 50%. Patients were randomized into 2 equivalent groups: in the I group, myocardial viability was determined by cardiac magnetic resonance imaging (MRI) with delayed contrast, in the II group - by stress-echocardiography with dobutamine. All patients underwent stenting of coronary arteries in the zone of the viable myocardium with drug-eluting stents. Long-term results of treatment were followed to 12 months after endovascular intervention in all patients.

Results: all patients had a significant improvement in the local contractility of the myocardium after performed endovascular myocardial revascularization. After 12 months, a significant decrease in the mass fraction of ischemic viable myocardium in the peri-infarction zone was noted among patients from group I, compared with preoperative data (32.8 ± 2.4 and 24,3±2,3%, respectively, p<0.05). Thus, in I group the volume of ischemic myocardium decreased by 26%. In all studied groups, there was a significant increase in LVEF, compared with data obtained when the patient was discharged from the hospital. Survival in the I group was 100%, whereas in the II group - 97.3% (p> 0.05). The incidence of non-fatal MI was 0.88 and 3.5% in groups I and II, respectively (p <0.05).

Conclusion: cardiac MRI with delayed contrast is more effective and sensitive for diagnosis of myocardial viability and patient prognosis after endovascular intervention, compared with stress echocardiography with dobutamine. 

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Abstract:

Aim: to study the contractility of left ventricle (LV) and left atrium (LA) by speckle tracking imaging (STI), vector analysis and the diagram method in patients with mitral regurgitation (MR).

Materials and methods: we examined 63 patients (39 males, 24 females), mean age 53±11 years with 3-4 degree MR and control group of 26 healthy volunteers (15 males, 11 females), mean age 39±7 years. Transthoracic echocardiography was performed by a standard technique at rest. Sizes and volumes of LV, LA, ejection fraction (EF), degree of MR, pulmonary artery (PA) pressure were evaluated. LV and LA images were analyzed by STI with LV global longitudinal strain (GS), peak atrial longitudinal (PALS) and contraction strain (PACS), and by vector analysis of myocardial displacement and «Flow-Volume» diagrams. Rates of volume change in LV (dVol/dt) and LA (LAdVol/dt), rates of long axis change in LV (dLA/dt) and LA (LAdLA/dt), LA long axis size (LA) were calculated in systole (reservoir phase) and diastole (conduit phase). Statistical analysis (Statistica,10.0; JMP).

Results: left heart sizes and volumes, PA pressure compared to the norm were increased(p<0,(0)), but the EF was preserved. GS and PACS in patients with MR was normal, but PALS was reduced (p<0,(0)), while dVol/dt and LAdVol/dt were increased and shown in «Flow-Volume» diagrams. But, dLA/dt was normal, LAdLA/dt was reduced in the conduit phase, LA size was increased (p<0,(0)).

Conclusion: STI, vector analysis and diagram method parameters are the criteria for efficiency of LV and LA function in patients with MR.

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Abstract:

Diseases of the circulatory system in a few decades are one of the major causes of death and disability in the population in many countries around the world. In Russian Federation, a number of newly diagnosed cases of coronary heart disease and mortality of the working population of this pathology is growing. In clinical practice at the present time, various radiological techniques assess the condition of the heart and coronary vessels, determine the location and volume of lesions. In the available literature, however, we found no data on methods of research that would reveal the correlation between the X-ray anatomy of coronary vessels and structural and functional state of the heart muscle. Thus, the need for comprehensive scientific research is obvious. Results of this study will, on the basis of survey data, using the methods of radiation diagnosis, objectively assess the level of metabolic and structural and functional state of the cardiomyocytes in cardiac patients. This will improve the accuracy and informativeness of diagnosis, as well as the increase of the control of effectiveness of therapy and quality of patients' life with cardiac diseases. 

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