Aim To study the relationship between the type of circulation, severity and localization of atherosclerotic damage of coronary arteries, results of laboratory and instrumental tests, and historical data in patients with multivascular coronary lesions and atrial fibrillation (AF) that developed after coronary bypass surgery.Material and methods This was a novel, retrospective study of data of patients after elective coronary bypass surgery at the Cardiac Surgery Department #1 of the N.V. Sklifosofsky Research Institute of Emergency Care from December, 2018 through December, 2020. The study included 100 patients. The main group consisted of 20 patients whose early postoperative period (first 7 days after surgery) was complicated with postoperative atrial fibrillation (POAF) (mean age, 65.15±9.7 years). The comparison group included 80 patients without the POAF complication during the early postoperative period (mean age, 62.0±9.16 years). Prior to the coronary bypass surgery, all patients underwent clinical, laboratory, and instrumental examination. Based on data of selective coronary angiography, localization, severity of coronary atherosclerotic damage (according to angiographic classification), number of affected arteries, and the type of circulation were taken into account.Results Intergroup differences in the incidence and localization of myocardial infarctions in history, severity of arterial hypertension in history, class of chronic heart failure (according to the New York Heart Association, NYHA, classification), and heart rate were absent. 100 % of patients had left atrial (LA) dilatation not correlated with the development of AF in the early postoperative period. According to data of coronary angiography, there was no statistically significant association between the type of circulation and the development of POAF. The right type of myocardial blood supply prevailed in patients of both groups. There was no correlation between the severity and localization of coronary atherosclerotic lesions and the development of AF in the early postoperative period.Conclusion The development of AF following coronary bypass surgery was not associated with features of coronary atherosclerotic lesions, which may indicate active development of inter- and intra-systemic anastomoses in patients with long-term history of chronic coronary atherosclerosis.
INTRODUCTION The cause of heart failure in patients with coronary artery disease after anterior myocardial infarction may be dilatation of the cavity of the left ventricle (LV) with subsequent unfavorable course of the disease. In the case of early reperfusion, which prevents transmural myocardial necrosis, the damaged segment more often becomes akinetic than dyskinetic. Surgical remodeling of the left ventricle (SRLV) is aimed at reducing the volume and restoring its elliptical shape by eliminating scars in the akinetic and/or dyskinetic segments.AIM OF STUDY To evaluate the survival of patients with chronic heart failure (CHF) who had anterior wall myocardial infarction in the early and late periods after surgical remodeling of the left ventricle, in combination with coronary bypass grafting and/or interventions on the mitral valve.MATERIAL AND METHODS The study included 99 patients with coronary artery disease (CAD) who had myocardial infarction of the anterior LV wall and with severe heart failure, who underwent surgical LV remodeling in the period from 2002 to 2020. The analysis of early and long-term results was carried out. The risk factors influencing lethality were determined.The mean age of the patients was 56.0±10.2 years (from 23 to 81 years). The vast majority of patients (90%) were men. LV ventriculoplasty was combined with coronary bypass grafting in 97 (98%) patients, with mitral valve repair in 2 (2%) patients, with mitral valve replacement in 2 (2%) patients.RESULTS In the early postoperative period, all patients showed an improvement in global LV systolic function. The ejection fraction (EF) of the left ventricle increased from the average preoperative average value of 34.2±3.7% to 43±4.2% in the postoperative period (р<0,001). Left ventricular end systolic volume index (LVESV) decreased from 71.4±15.3 ml/m2 to 43.8±9.6 ml/m2, respectively (р<0,001). In the early postoperative period, 5 (5%) patients used the following means of mechanical hemodynamic support: intra-aortic balloon pump (IABP), non-implantable device for temporary support of the left ventricle (LVAD) and extracorporeal membrane oxygenation (ECMO). The 30-day mortality rate after LVESV was 6%. Prior to surgery, all patients had NYHA functional class (FC) III or IV. In the postoperative period, all patients experienced regression of heart failure symptoms and improved exercise tolerance. NYHA functional class improved to I and II in 100% of cases. Using univariate analysis, it was possible to determine that EF ≤30%, LVESV ≥80 ml/m2 and pulmonary artery pressure (PAP) >60 mm Hg. were risk factors for hospital mortality. The overall fifteen-year survival rate was 59.8±0.13%. The absence of readmission to the hospital due to recurrent angina pectoris, mitral valve dysfunction and progression of heart failure (HF) was 72% among surviving patients.CONCLUSION Surgical remodeling reduces the volume of the dilated left ventricle and restores its elliptical shape in patients with CAD after anterior myocardial infarction. The results of our study demonstrate an improvement in LV systolic function in all patients in the early postoperative period and low mortality, an acceptable fifteen-year survival rate, and a low readmission rate due to the progression of chronic heart failure (CHF).
Ischemic heart disease holds the leading position in the structure of cardiovascular diseases. Early reperfusion therapy for acute myocardial infarction led to a decrease in mortality and severe complications of coronary artery disease. Despite advances in the treatment of coronary artery disease, dilatation and remodeling of the left ventricle develop in 20% of patients who have had a heart attack, leading to mitral insufficiency and systolic dysfunction of the left ventricle. Aneurysm of the left ventricle is a delayed severe complication of myocardial infarction, which significantly worsens the prognosis. Large aneurysms of the left ventricle cause progressive dilatation of the left ventricle, its volumetric overload with an increase in wall tension in the non-infarction zone, decreased functional characteristics of the left ventricle, thrombosis in the aneurysm cavity, life-threatening arrhythmias, and sudden death. Postinfarction left ventricular remodeling can lead to secondary mitral regurgitation, which is an independent predictor of mortality in the longterm period. Surgical treatment of coronary heart disease and its complications is one of the main problems of modern cardiovascular surgery.
Atrial fibrillation (AF) after coronary bypass surgery is recorded in 20- 60% of patients and increase the early and long-term postoperative mortality. The aim of the review is to analyze the studies on causal relationships between damaging factors and the development of myocardial inflammation at each stage of surgical treatment in patients with multivessel coronary artery disease. In the review, myocardial inflammation is considered from the point of view of a continuum — a chronic process that originates from the coronary endothelium damage and continuously proceeds within the AF pathogenesis after coronary bypass surgery. For the first time, the concept of inflammatory continuum for postoperative AF is introduced. The review discusses the main and latest laboratory and instrumental markers of local and systemic inflammatory response, which are informative in terms of severity and promising for improving approaches to the diagnosis and prevention of postoperative AF. The review was prepared using available materials from Russian and foreign library databases (PubMed, Medline, Web of Science and Cochrane Library). The search depth was >25 years since 1996. Based on the analysis of available studies, we concluded that inflammation is not just evidence of AF, but plays a causal role in its pathogenesis at each stage of surgical myocardial revascularization.
Aim. To evaluate changes of left ventricular (LV) diastolic function in patients with multivessel coronary artery disease before coronary artery bypass grafting (CABG) and in the early postoperative period (7-10 days), as well as to assess the relation- ship between diastolic LV dysfunction and postoperative atrial fibrillation (POAF).Material and methods. This original prospective study of included 50 patients undergoing CABG at the Cardiac Surgery Unit № 1 of the N. V. Sklifosovsky Research Institute for Emergency Medicine from December 2020 to December 2021. All patients underwent standard echocardiography before and after surgery. Diastolic function was assessed using the following parameters: septal mitral annulus velocity (e’septal), lateral mitral annulus velocity (e’lateral), the ratio of the peak early transmitral velocity to peak early diastolic velocity of the mitral annulus movement (E/e’), left atrial volume index (ml/m2), peak tricuspid regurgitation velocity (m/s), the ratio of the peak early to late filling velocity (E/A).Results. After CABG, 35 patients maintained sinus rhythm in the early postoperative period (group 1), while 15 patients had POAF (group 2). According to echocardiography, type 1 diastolic dysfunction prevailed in both groups; types 2 and 3 LV diastolic dysfunction were not identified. Among the parameters characterizing myocardial relaxation, in group 1 after CABG, a significant increase in the peak E (p=0,001) was noted, and due to this, the normalization of the E/A ratio was recorded (p<0,0001). An increase in e’lateral (p=0,05) was also revealed, in connection with which an increase in the E/e’ (p=0,02) was noted. In the group of patients with POAF, such changes were not detected. Left atrial volume index (ml/ m2) was significantly higher in the POAF group (p=0,02).Conclusion. Surgical myocardial revascularization has a positive effect on LV diastolic function. Improvement in LV diastolic function after CABG may be a sign of the restoration of hibernating myocardium function, while the absence of LV diastolic function improvement, together with left atrial dilatation, may be predictors of early POAF.
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