Vol 47, No 4 (2019)

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The potential and limitations of standard electrocardiography for the differential diagnosis of wide QRS complex tachycardias

Salami H.F., Shlevkov N.B., Sokolov S.F.


The possibility to identify potentially life-threatening ventricular arrhythmias by analysis of standard electrocardiography (ECG) parameters without the use of sophisticated and expensive diagnostic techniques, such as electrophysiological heart studies, has been an important achievement of the last decades. Current differential diagnostic methods for wide QRS complex tachycardias can be categorized into 4 groups: 1) identification the ECG signs diagnostic of ventricular tachycardia, such as atrioventricular dissociation and/or sinus captures and/or fusion QRS complexes; 2) analysis of the distinct morphological features of QRS complexes during wide QRS complex tachycardias; 3) analysis of the ECG characteristics in between wide QRS complex tachycardia attacks; 4) comparison of the morphological QRS features during wide QRS complex tachycardia and during sinus rhythm periods. The list of ECG algorithms for differential diagnosis of wide QRS complex tachycardias has been growing and updated year after year; however, all of them have their limitations. Most frequently, the differential diagnosis between ventricular and aberrant supraventricular tachycardias is based on the morphological criteria of wide QRS complexes developed by H.J. Wellens et al., P. Brugada et al., M. Griffith et al., K.E. Kindwal et al., A. Vereckei et al. At the same time, there is a continuous search for new algorithms or criteria that could be easily used without decreased specificity and/or sensitivity of the diagnosis of ventricular tachycardia. The aim of this review is to comprehensively analyze the literature data and results of our own studies on the potential and limitation of standard ECG for the differential diagnosis of ventricular and various aberrant supraventricular tachycardias.
Almanac of Clinical Medicine. 2019;47(4):350-360
pages 350-360 views


Surgical repair of the moderately dilated ascending aorta combined with bicuspid aortic valve replacement

Uspenskiy V.E., Malev E.G., Gavriliuk N.D., Salavatov B.K., Ermolov S.A., Cvetkova J.V., Malashicheva A.B., Gordeev M.L.


Background: Ascending aortic (AA) dilatation is common in patients with bicuspid aortic valve (BAV). In BAV replacement, surgery of the AA is indicated in the case if AA diameter exceeds 45 mm. Aortic valve replacement combined with an AA intervention is associated with increased risk of complications. The feasibility of the reduction ascending aortoplasty for correction of the dilated AA remains disputable.

Aim: To analyze the results of BAV surgical replacement with simultaneous surgical correction of the borderline AA dilatation (45-50 mm) by the reduction aortoplasty (RAP) or supracoronary AA replacement (SPR).

Materials and methods: This single center prospective non-randomized study included 53 patients with significant BAV stenosis and AA dilatation (45-50 mm), divided into 2 groups: BAV surgical replacement combined with RAP AA replacement (group 1, 36 patients) and BAV replacement with SPR (group 2, 17 patients). There were no significant differences between the patients of the two groups in their characteristics of the underlying disease, complications and comorbidities.

Results: Hospital mortality was 0%. No between-group differences in the early postoperative course were found. At later term, 44 (81.5%) patients were assessed; median (dispersion) of the follow-up was 36 (25; 50) months. Two patients from the group 2 died during the follow-up. The long-term survival was better in the group 1 (p = 0.028). No differences in the combined adverse event rate were observed between the groups (p = 0.633). The median (dispersion) of the AA absolute increment and the rate of dilatation after RAP were 1.0 (0.0; 3.0) mm and 0.24 (0.00; 0.95) mm/year, respectively. The predictor of AA increment rate ≥ 2 mm/year was the baseline blood pressure level (odds ratio 1.321, 95% confidence interval 1.050-1.662; p=0.017). The threshold preoperative blood pressure value for the increased risk of the long-term AA expansion rate was 138 mmHg.

Conclusion: The efficacy and safety of RAP and SRP combined with BAV replacement in AA borderline dilatation are similar. Combined BAV surgery and RAP is effective and safe in patients with systolic blood pressure level ≤ 135 mmHg. Combined BAV replacement with SRP seems reasonable in patients with arterial hypertension.

Almanac of Clinical Medicine. 2019;47(4):299-309
pages 299-309 views

The way to control the interventricular septum thickness during septal myectomy. An experimental study

Gurshchenkov A.V., Selivanov M.V., Mukhin E.A., Sukhova I.V., D'yachenko Y.A., Agaev R.S., Maystrenko A.D., Novikov V.K., Kucherenko V.S., Gordeev M.L.


Background: At present, there are no methods for intraoperative monitoring of the interventricular septum (IVS) thickness in a stopped and empty heart. This might be an obvious reason for unsatisfactory results after a number of septal myectomies.

Aim: To provide an experimental background for the method to control the IVS thickness (that we had proposed) during septal myectomy.

Materials and methods: The proposed technique is based on the transillumination method. The experimental models were cadaveric porcine hearts, as well as fragments of the human myocardium removed during septal myectomies. The thickness of the translucent myocardium was estimated depending on the local illumination value at the entrance to the myocardium and the external illumination of the surgical field. We compared the results of 67 septal myectomies performed in the clinic of the Almazov National Medical Research Centre with the results of 35 similar experimental procedures with cadaveric porcine hearts using the proposed way of measurement.

Results: A graph of the illumination at the entrance to the myocardium against the thickness of the translucent myocardium was constructed. After conventionally performed septal myectomies the median variation of the myocardial thickness was 4 [3; 6] mm. In the experiment using the proposed control method, the median variation was 1 [1; 2] mm, i.e. significantly less than with the conventional approach (p = 3 x 10-10).

Conclusion: The method to control the IVS thickness when performing septal myectomy makes it possible to achieve the required myocardial thickness the resection area with much greater accuracy than with the conventional one.

Almanac of Clinical Medicine. 2019;47(4):310-317
pages 310-317 views

Surgical treatment for coronary artery disease with concomitant carotid stenosis: one-center experience

Schneider Y.A., Tsoi V.G., Fomenko M.S., Pavlov A.A., Shilenko P.A.


Background: Coronary artery disease (CAD) in 16.6% of cases is associated with concomitant carotid arterial involvement, with this proportion reaching up to 40% in the elderly patients. According to the guidelines on myocardial revascularization and surgical treatment of brachycephalic artery (BCA) stenosis, the surgical strategies in this patient cohort remains uncertain, with advantages of various techniques being debated.

Aim: To evaluate efficacy and safety of the staged or simultaneous surgery of patients with multifocal atherosclerosis (CAD with BCA atherosclerosis).

Materials and methods: Patients were recruited into this single center study retrospectively with "continuous follow-up". From September 2012 to March 2019, 3718 CAD patients underwent coronary artery bypass grafting. Concomitant BCA involvement was found in 574 (15.4%) of the cases (the study group). The mean age of the patients in the study group was 65.9 ± 14.2 years (38 to 84 years). There were 171 (29.8%) patients over 70 years of age and most of the patients were male (412, 71.8%). Bilateral BCA involvement was found in 104 (18.1%) of the cases. The staged surgical intervention (1st step, carotid endarterectomy and 2nd step, coronary artery bypass grafting) was performed in 441 (76.8%) of the cases (group I), whereas simultaneous interventions in 133 (23.2%) (group II).

Results: There was no difference between the groups I and II in the hospital mortality (0.2% vs. 0%, p = 1.000). No between-group differences were found in the rates of complications, such as early postoperative bleedings (n = 8, 1.8% vs. n = 2, 1.5%; p = 1.000), wound infections (4, 0.9% vs. 2, 1.5%; p = 0.410), acute cerebrovascular accidents (n = 1, 0.2% vs. n = 1,0.8%; p = 0.36), and acute myocardial infarction (n = 1, 0.2% vs. 0; p = 1.000). The longest total duration of in-hospital stay (considering all hospitalizations taken together) was in patients who had undergone staged interventions (p < 0.001).

Conclusion: Surgical treatment of CAD with concomitant BCA involvement can be effectively and safely performed both as separate procedures, as well as simultaneously, based on the patient's comorbidities and special aspects of the underlying disorders.

Almanac of Clinical Medicine. 2019;47(4):318-325
pages 318-325 views

Venous thrombosis in patients after intracardial catheter interventions: incidence, risk factors, special aspects of the diagnosis

Loginova A.I., Kropacheva E.S., Titaeva E.V., Maykov E.B., Balakhonova T.V., Golitsyn S.P.


Rationale: Thrombosis of the puncture site in the femoral veins is one of the potentially dangerous complications of intracardial catheter interventions associated with thromboembolic risk related to its proximal location. According to the literature, the incidence of symptomatic venous thrombosis (VT) is 1–3%. No special studies on the assessment of risk factors for this complication, its diagnosis and treatment have been conducted.

Aim: To study the incidence, risk factors and special aspects of VT diagnosis in patients undergoing intracardial electrophysiological studies (EFI) and/or catheter ablation.

Materials and methods: This prospective study included 408 patients (194  men and 214  women, with median age of 51±10.1 years), who were admitted to the hospital with various cardiac rhythm disorders for intracardial EFIs and/or catheter ablations from 2016 to 2018. Before the interventions, in addition to common laboratory and instrumental work-up, all the patients underwent ultrasound duplex scanning (USDS) of the iliac-femoral segment; in 269  patients the level of D-dimer was measured. Latest at 24 hours after the intervention, all patients underwent a control ultrasound scan of the femoral vein puncture site. In case of VT occurrence anticoagulant therapy was started in all patients and they were followed up till complete VT resolution and at least for 3  months (the study endpoint). The VT incidence and its risk factors including the prognostic value of D-dimer levels were evaluated.

Results: The VT incidence after catheter interventions was 11.7% (n=48). There was a significant correlation between VT occurrence and such risk factors as diabetes mellitus (p=0.001) and obesity (p<0.001). No association between elevated baseline D-dimer values (>500 ng/mL) and subsequent VT development was found (p>0.05). The quartile analysis revealed an association between baseline D-dimer levels exceeding 434  ng/mL (which corresponds to the range of 75 to 100%) and the presence of the following risk factors: age over 65  years (p<0.001), female gender (p=0.001), arterial hypertension (p=0.003), chronic coronary heart disease (p=0.044).

Conclusion: In this study, all VTs (11.7%) detected after catheter transvenous interventions by USDS were asymptomatic. VTs were most frequent in patients with diabetes mellitus and obesity. D-dimer had no predictive value in the development of VT; however, its increased baseline values were more common in women, patients over 65 years, and in patients with arterial hypertension and chronic coronary heart disease.

Almanac of Clinical Medicine. 2019;47(4):326-333
pages 326-333 views

Comparative analysis of the immediate results of the off-pump versus on-pump myocardial revascularization in the elderly patients

Yusupov A.I., Vitsukaev V.V., Sushkov A.I., Makalskiy P.D., Zavgorodniy V.N.


Aim: To evaluate efficacy and safety of surgical myocardial revascularization with two internal thoracic arteries in the elderly patients and to identify special aspects and immediate results of the interventions on a working heart and with the use of cardiopulmonary bypass and on a working heart.

Materials and methods: This retrospective single center study included patients over 65 years of age with multivessel coronary artery disease who underwent coronary artery bypass grafting with two internal thoracic arteries in a  working heart without cardiopulmonary bypass at the Federal Clinical Center of High Medical Technologies of FMBA of Russia from 2015 to 2017  (the study group, n=50) and with cardiopulmonary bypass and cardioplegia (the comparison group, n=51). We analyzed demographic characteristics, preoperative state severity, and special aspects of myocardial damage, operational parameters, rates, and structure of postoperative complications.

Results: None of the patients died. Median intraoperative parameters in the study group were better than those in the comparison group: blood loss, 300  vs. 800  mL (p<0.001), duration of the surgery, 190  and 240  min (p<0.001), duration of mechanical ventilation, 3  and 5  hours (p<0.001), respectively. Early postoperative acute renal failure was less frequent in the patients who had undergone surgery without cardiopulmonary bypass (median serum creatinine levels 90  vs. 125  µmol/L (p<0.001)). Postoperative complications were observed in the group of patients operated with cardiopulmonary bypass: three cases of acute cerebrovascular accidents (stroke) and one deep wound infection of the sternum. Mean duration of the hospital stay in the patients operated on a working heart without the use of cardiopulmonary bypass was 7  days versus 9  in the comparison group.

Conclusion: Myocardial revascularization without cardiopulmonary bypass is associated with lower rates of postoperative complications, decreased duration of the procedure, decreased blood loss, time on mechanical ventilation and acute renal failure rate, which all results in decreased duration of hospital stay. Bimammary myocardial revascularization without cardiopulmonary bypass could be the method of choice in the elderly patients. 

Almanac of Clinical Medicine. 2019;47(4):334-341
pages 334-341 views

The role of hemodynamic limitations in the reduction of exercise capacity in patients with sarcoidosis

Gudim A.L., Postnikova L.B., Boldina M.V., Bychkova E.V.


Aim: To perform comprehensive evaluation of the Cardiopulmonary Exercise Testing (CPET) parameters with gas analysis in patients with pulmonary sarcoidosis (PS) and to assess the effects of hemodynamic limitations on the reduction of exercise capacity (EC).

Materials and methods: We examined 42 PS patients (25 men, 17 women) aged from 22 to 62 years (34.5 [29; 41.5] years old). PS had been verified histologically in 33 (78.6%) patients. The group 1 included patients with decreased oxygen consumption per minute at the peak load (n = 20) with VO₂ peak pred ≤ 84%, i.e. with decreased EC. Group 2 consisted of 22 patients with normal VO₂ peak pred (> 84%). In all patients, echocardiographic and CPET parameters were assessed that characterize response of the cardiovascular system to physical exercise, such as oxygen consumption at the anaerobic threshold (VO₂ AT, % of predicted value); oxygen pulse (VO₂/HR, abs/% of predicted), the chronotropic-metabolic index (CMI), and blood pressure.

Results: Thickening of the left ventricular posterior wall (p = 0.012) was found in the group 1, together with decreased VO₂ AT (р < 0.001), VО₂/HR (р < 0.001), and systolic blood pressure (p = 0.037) at the peak load during CPET, compared to the parameters in the group 2. Twelve patients from the group 1 demonstrated their VO₂ AT < 43%, 6 patients had decreased VО₂/HR < 80% of predicted, and 3 patients were diagnosed with the chronotropic incompetence phenomenon.

Conclusion: Decreased EC was identified by CPET in 47.6% of PS patients without any functional abnormalities at rest. The reduction of EC in 17/20 PS patients from the group 1 was associated with abnormalities in CPET parameters, corresponding to the hemodynamic limitations (reduction of cardiac output and chronotropic incompetence).

Almanac of Clinical Medicine. 2019;47(4):342-349
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Penetration cardiac wound associated with anterior mitral leaflet perforation: a case report and review of the literature

Basarab D.A., Ustyuzhin E.D., Perutskiy D.N., Basarab A.I.


The paper presents a  rare case of successful correction of an anterior mitral leaflet perforation. A 28-years old patient was referred with progressive heart failure symptoms at 18  weeks after he had a penetrating stab wound of the right ventricle. Massive pericardial effusion with cardiac tamponade risk and severe mitral valve insufficiency were found at examination. By the time of referral, spontaneous closure of the ventricular septal defect, which is an inevitable component of the “unhappy triad”, had happened. Accurate topical ultrasound diagnosis of the intracardial lesion that resulted from the penetrating wound of the left ventricular outflow allowed for a successful urgent mitral valve reconstruction with a xenopericardial patch and the insertion of a  28  mm MedEng annuloplasty band. To prevent any future pericardial constriction, subtotal pericardectomy by Cooley was performed.

Conclusion: Perioperative echocardiography and subsequent follow up by cardiologist are obligatory in all cases of precordial wounds after discharge from hospital. Timely surgery for traumatic mitral leaflet perforation allows for a successful valvuloplasty.

Almanac of Clinical Medicine. 2019;47(4):361-369
pages 361-369 views

Progression of chronic lower limb ischemia in a patient with occlusion of the infrarenal aorta after myocardial revascularization using the internal thoracic artery: a clinical case

Lar'kov R.N., Shilov R.V., Sotnikov P.G., Zagarov S.S., Kolesnikov Y.Y., Petrakov K.V., Kazanskii M.Y., Vishnyakova M.V., Nikonov R.Y., Mirzemagomedov G.A.


Background: The main cause of mortality in patients with atherosclerosis of aorta and peripheral arteries of the lower extremities is ischemic heart disease. The presence of peripheral artery atherosclerosis suggests a high probability of simultaneous coronary involvement. To reduce the risk of cardiac complications, these patients are offered myocardial revascularization as the first step of the intervention; however, the choice of a conduit for coronary artery bypass in these patients remains challenging.

Case report: A 58-year old man with combined coronary artery stenoses, high occlusion of the aorta and common iliac arteries underwent autoarterial myocardial revascularization with the right internal thoracic artery (ITA) and left radial artery ("off pump”). In the early postoperative period, significant progression of the right leg ischemia was observed, related to partitioning of the main collateral flow between the right ITA and the inferior epigastric artery, that had contributed to blood supply to the right lower extremity. Taking into account the lack of efficacy of medical treatment and progression of the leg ischemia, at day 4 postoperatively the patient underwent resection of the infrarenal aorta with aortobifemoral bypass grafting and restoration of blood supply to the lower extremities and resolution of ischemia.

Conclusion: ITA has been recognized as the conduit of choice for surgical treatment of ischemic heart disease; however, its use may result in significant progression of ischemia. When choosing a conduit, ITA at the side of less ischemic lower extremity is preferred. ITA imaging by computed tomography-angiography or by selective ITA angiography can be helpful for assessment of the ITA significance at the side of less ischemic leg. Also, the appearance of retrograde flow in the inferior epigastric artery at Doppler ultrasound examination can be a conditional valuable criterion.

Almanac of Clinical Medicine. 2019;47(4):370-375
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Surgical treatment for the single ventricle with subaortic obstruction. Clinical case of the Damus-Kaye-Stansel procedure

Bykov S.E., Kovalev S.A., Gryaznov D.Y., Korosan E.I., Novick W.M.


We present a case of hemodynamic correction for the single ventricle combined with subaortic obstruction and coarctation in an infant. The Damus-Kaye-Stansel procedure with modified double-barrel technique was performed. The pulmonary flow was provided with modified Blalock-Taussig shunt. The early postoperative period was characterized by multiple organ failure. Subsequently, the infant underwent the next stages of hemodynamic correction with good long-term results.

Almanac of Clinical Medicine. 2019;47(4):376-379
pages 376-379 views

Comment on "Surgical treatment for the single ventricle with subaortic obstruction. Clinical case of the Damus-Kaye-Stansel procedure"

Tarayan M.V.


Almanac of Clinical Medicine. 2019;47(4):380-381
pages 380-381 views

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