The study demonstrates the safety, feasibility and effectiveness of a comprehensive approach to minimize fluoroscopy and contrast use during Watchman left atrial closure device implantation.

Background. The introduction of Watchman left atrial appendage occlusion device (WM) has provided an effective alternative to anticoagulation for patients with a high risk of cerebrovascular accidents (CVA) and high risk of bleeding and who are unable to take long-term anticoagulation therapy. Since its introduction, WM has been implanted more than 50,000 times worldwide. While the implant procedure is relatively safe, it involves the use of fluoroscopy and contrast and, as such, poses some associated risk to patient safety. The adoption of procedural techniques which reduce fluoroscopy exposure and contrast use have the potential to provide clinical patient benefit without compromising safety or efficacy. Aim To demonstrate that WM implant can be performed with minimal exposure to both ionizing radiation and IV contrast without compromising safety or efficacy.

Methods. A retrospective chart review of all 75 consecutive Watchman implantations by a single operator at a single center between December 2015 and December 2017. Every effort to optimize the WM implant procedure and minimize radiation and contrast exposure was incorporated as implant techniques evolved. Contrast and radiation exposure data were collected and analyzed year-over-year.

Results. Charts from 75 consecutive cases were reviewed with all cases at index procedure (100%), and included the majority of patients presenting in paroxysmal AF (63%). Baseline patient characteristics were consistent across years. Procedural characteristics also were consistent over time. The median absorbed radiation dose was low (75 mGy in 2015) and did not change significantly over time. Similarly, the median fluoroscopy time used after the initial case was low (2.8 minutes) and did not vary. 73 of 75 (97%) of procedures resulted in successful implantation. There were no procedural complications; notably, no cases resulted in stroke, death, pericardial effusion, vascular accidents or device embolization.

Conclusion.The current generation of WM can be successfully implanted using low fluoroscopy and contrast without compromising safety or efficacy using the techniques described.

Aim. To evaluate the impact of the atrial ectopic activity and left ventricular diastolic dysfunction on predicting the effectiveness of pulmonary vein isolation (PVI) in patients with paroxysmal and persistent atrial fibrillation (AF).

Methods. 54 patients with paroxysmal and persistent AF and the normal left ventricular ejection fraction were included in the study. Patients underwent Holter monitoring and echocardiography prior to the intervention to identify the predictors of successful PVI. The follow-up was 12 months after the indexed procedure. The effectiveness of treatment was assessed from the third month of the postoperative period. The criterion of the successful treatment was the absence of the AF paroxysms lasting more than 30 seconds, confirmed by Holter, diurnal and / or multi-day monitoring. The Student's t-test was used to assess the reliability of the differences between the variables characterizing the treatment results in the study groups. The discriminant analysis was performed to develop an algorithm that allows predicting the PVI result. A p value <0.05 was considered statistically significant.

Results. Premature atrial contraction over 70 per hour can be considered as the predictor of the successful PVI in patients with normal left atrial size. The severe LA enlargement should be considered as a predictor of poor ablation efficacy. The obtained discriminant function allows predicting the effectiveness of PVI in patients with paroxysmal and persistent AF depending on Holter monitoring and echocardiography. Its sensitivity is high for both predicting success and failure of the intervention.

Conclusion. Holter monitoring and echocardiography allow predicting the effectiveness of PVI. The intervention's efficacy in the groups of patients with severe LA enlargement and the combination of normal left atrial size with over 70 PAC per hour should be addressed in the further studies.

Aim. To estimate the efficacy of catheter ablation in patients with type 2 diabetes mellitus (T2D) present with atrial fibrillation and sick sinus syndrome (SSS) undergoing permanent pacemaker implantation.

Methods. 56 patients (34 females) with persistent AF and SSS were enrolled in the study. The mean age of patients was 67.7±10.7 years. Dual chamber cardiac pacemaker with remote monitoring function were implanted in all patients. All the patients were assigned to two groups: Group 1 comprised 31 patients aged 67.3±9.6 years, and Group 2 comprised 25 patients aged 72.6±9.9 years, including 22 (39.2%) diabetic patients. 2-3 days after pacemaker implantation, group 1 patients underwent intracardiac electrophysiology study and RFA of the pulmonary vein ostia, mitral isthmus and the left atrial posterior wall. Group 2 patients received antiarrhythmic drug therapy.

 Results. 3 patients (9%) in Group 1 had recurrent AF within the 6-month follow-up. The efficacy of the RFA for AF was 55% (n = 17) 1 year after the indexed hospitalization. 8 patients had short paroxysmal attacks which gradually lessened and stopped after. 5 patients (21%) in Group 2 did not have any AF paroxysms within the 1-year follow-up (Х2 = 5.52, р = 0.02). All these patients received amiodarone as antiarrhythmic drug therapy, whereas the others had paroxysmal attacks. Frequent attacks in 10 patients (40%) led to a change in antiarrhythmic drug use. Hospital readmission rates for AF were 16% and 52%, respectively (Х2 = 4.15, р = 0.04). The impact of atrial and ventricular stimulation on the development of recurrent AF was statistically insignificant (atrial stimulation – X2 = 0.01, cc = 1, p = 0.90; ventricular stimulation – X2 = 0.15, cc = 1, p = 0.69). None paroxysmal attacks were recorded in 10 diabetic patients (45%) after the RFA within the 1-year follow-up.

Conclusion. Catheter ablation for persistent AF and SSS treated with permanent pacemakers is highly effective and safe method. In addition, it is superior to pharmacological approach. The presence of T2D likely did not significantly affect the efficacy of RFA for persistent form of AF. 

Aim. To study the clinical and genetic aspects of the influence of polymorphic variants of the genes of endothelial NO-synthase (NOS3), the receptor of endothelin-1 type A (EDNRA) and NADPH-oxidase on the development of cardiotoxic remodeling of the left ventricle and heart failure during anthracycline-based regimens for patients with breast cancer.

Methods. 176 women with breast cancer receiving anthracycline antibiotics as part of multiple drug chemotherapy regimens were examined. According to the results of the examination, 12 months after the end of multiple drug chemotherapy, all the patients with the main disease in remission were divided into 2 groups: patients with cardiac remodeling caused by cardiotoxicity (Group 1 = 52) and those with preserved heart function (Group 2 = 124). All patients underwent echocardiographic assessment before chemotherapy, during the treatment regimen with anthracyclines and after the therapy. Genetic material (buccal cells) was collected from all patients for the subsequent typing of alleles of genes NOS3 (rs1799983), EDNRA (rs5335) and NADPH-oxidase (rs4673).

Results. Analysis of echocardiographic parameters in patients 12 months after the completion of multiple drug chemotherapy in comparison with those before treatment showed a statistically significant difference between end-systolic and end-diastolic dimensions, as well as a significant reduction in the left ventricular ejection fraction in the group of women who developed cardiotoxicity with anthracycline cardiotoxicity. An association between the development of cardiotoxic lesions with the presence of mutant allele of NOS3 rs1799983 and NADPH-oxidase rs4673 genes has been determined. The presence of the T/T genotype of the NOS3 rs1799983 gene was associated with myocardial damage during multiple drug chemotherapy, along with the T/T genotype of the NADPHoxidase gene rs4673. Importantly, the genotype G/G of the gene NOS3 rs1799983 was more frequently determined in Group 2, suggesting its protective effect against cardiotoxic myocardial damage.

Conclusion. The development of the strategy aimed at preventing or reducing the risk of cardiovascular complications in the treatment of cancer is a crucial problem. Genetic typing is an effective measure to predict the increased risk of cardiotoxic effects of anthracyclines.

Aim. To assess effectiveness, safety and adherence to treatment of patients with type I atrial flutter who were previously excluded from the clinical trials evaluating the potential benefits of rivoroxaban for thromboembolism prevention.

Methods. 27 medical records of patients with type I atrial flutter were retrospectively reviewed and assigned to the study group. The control group consisted of 100 patients with atrial fibrillation. Both groups received rivoroxaban. All patients underwent thromboembolism risk assessment with the CHA2DS2-VACs score, bleeding risk assessment with HAS-BLED score. Data were collected by telephone.

Results. No thromboembolic events were registered in the atrial flutter group, whereas one case of ischemic stroke was in the atrial fibrillation group. There were no major bleedings in both groups. Four patients with atrial flutter and 2 patients with atrial fibrillation had hemorrhages. Patients’ adherence to rivoroxaban was 75–80%.

Conclusion. Rivoroxaban therapy was found to be effective and safe in patients with type I atrial flutter including those who underwent cardioversion. High adherence to rivoroxaban therapy was demonstrated.

Aim. To assess the comparative 30-day effectiveness of percutaneous coronary intervention (PCI) with bioresorbable vascular scaffold (BVS) versus minimally invasive direct coronary artery bypass (MIDCAB) for left anterior descending coronary artery disease.

Methods. 130 patients with significant (≥70%) LAD disease were recruited in the study. Patients were randomized either to PCI with BVS (n = 65) or MIDCAB (n = 65). The groups of patients were comparable in baseline demographic, clinical and angiographic parameters. The endpoints included adverse cardiovascular events (all-cause mortality, myocardial infarction, stroke, target vessel revascularization) and scaffold thrombosis and were measured on day 30 after the indexed intervention.

Results. At 30-day follow-up, there were no significant differences in the incidence of the adverse cardiovascular events between the study groups (0% MIDCAB vs. 3.1% PCI, р = 0.151), myocardial infarction (0% vs. 3.1%, p = 0.151), target vessel revascularization (0% vs. 1.5%, p = 0.32) and scaffold (graft) thrombosis (0% vs. 1.5%, p = 0.32).

Conclusion. PCI with BVS and MIDCAB in patients with stable coronary artery disease and isolated left anterior descending lesions demonstrated comparable outcomes at 30-days follow-up.

Background. Acute coronary syndrome remains the leading cause of death worldwide. The rupture of vulnerable atherosclerotic plaque in the coronary artery is a common pathogenetic mechanism contributing to the onset of acute coronary syndrome. Therefore, one of the main goals of the practical cardiology is to ensure the development of sensitive early diagnostic methods and set preventive and treatment strategies for acute coronary event. Aim To evaluate the incidence of vulnerable plaques in the non-target coronary arteries in patients with stable coronary artery disease.

Methods. 58 patients with stable coronary artery disease were included in a prospective observational cohort study. After the target vessel had been stented, virtual histology intravascular ultrasound (VH-IVUS) of the proximal and middle segments (6–8 cm) of one non-target artery (i.e. without any significant stenotic lesions on coronary angiography) was performed.

Results. The mean age of patients was 60.4±6.6 years. In addition to the targeted hemodynamically significant lesions subjected to stenting, 56 patients had 58 lesions (96.5%) in the non-target coronary arteries. Of them, 5 lesions (8.6%) were with >70% luminal stenosis (including >70% luminal stenosis + lumen area <4 mm2 in 4 cases), 10 lesions (17.2%) – with minimum lumine area <4 mm2 and without any other signs of vulnerable plaque, 12 lesions (20.7%) – with a large necrotic core and a thin cap (including thin-cap fibroatheroma + >70% luminal stenosis in 2 patients; thin-cap fibroatheroma + lumen area <4 mm2 – 2 cases, thin-cap fibroatheroma + >70% luminal stenosis + lumen area <4 mm2 – 2 cases).

Conclusion. In vivo evaluation of the plaques in the non-target vessels ensures the detection of vulnerable plaques in stable patients. The long-term follow-up of the study group allows assessing the risk of developing adverse cardiovascular events in those patients who have vulnerable coronary plaques.

Aim. To evaluate the clinical efficacy of gradual sinus rhythm restoration, including the bioprosthetic mitral valve replacement combined with maze radiofrequency ablation, external cardioversion and catheter ablation.

Methods.102 medical records of patients with mitral valve disease and long-standing atrial fibrillation (4,7±2,7 years) were restrospectively reviewed. Maze procedure was performed under extracorporeal circulation before the mitral valve replacement. The endpoints were monitored at the day of surgery, at discharge, and 3, 6 and 12 months after surgery.

Results.Sinus rhythm was recorded in 65.7% of patients at discharge from the hospital. The completeness of the follow-up was 80.4%. Steady regular rhythm was maintained in 64.6 % of patients in the study group. Other patients (35.4%) underwent cardioversion with the efficacy rate of 41.4%. Anticoagulation therapy was withdrawn in 65.9% of patients three months after surgery. 18.3% of patients with symptomatic arrhythmia underwent catheter ablation, which allowed to restore sinus rhythm in 73.3% of cases. Sinus rhythm was recorded in 92.7% of cases within the 1-year follow-up. Importantly, 79.3% of patients were discontinued of indirect anticoagulants.

Conclusion. Discontinuation of indirect anticoagulants proved its beneficial effects and safety on the restoration of sinus rhythm in patients after bioprosthetic mitral valve replacement.

Aim. To compare transradial (TR) and transfemoral (TF) approach for carotid artery stenting (CAS) with an emphasis on the detection of micro-embolization with diffusion-weighted magnetic resonance imaging (DW-MRI).

Methods. 96 patients were included in the study in the period from January 2015 to October 2017 with further randomized 1 : 1 to the TR and TF groups. The inclusion criteria were the following: symptomatic stenosis ICA >70%; or asymptomatic stenosis ICA >80%. The positive history of stroke, myocardial infarction or open heart surgery <1 month were the exclusion criteria for the study. The primary endpoint was the incidence of new cerebral ischemic lesions as assessed by DW-MRI. All CAS procedures were performed by two experienced operators according to the approved protocol.

Results. Procedural success with TR approach was 46 (96%) versus 48 (100%) with TF approach (p = 0.495). Crossover rate was 4% in the TR group. The rate of primary endpoint in the TR and TF groups was 50 and 52%, respectively. The absolute risk difference was -2% (95% CI [-0.21, 0.17], p (non-inferiority) = 0.03). An «on-treatment» analysis revealed a tendency towards a reduced microembolic foci when intervening on the right ICA via TR approach compared to TF (44% vs. 68%, p = 0.478), and a reverse trend when intervening on the left ICA via TR compared to TF approach (57% versus 36%, respectively, p = 0.437).

Conclusion. Carotid stenting via transradial approach is noninferior for cerebral embolism to transfemoral approach. The rates of MACCE and vascular complications were similar in both groups. There was no significant difference in the procedural success rate in the transfemoral and transradial groups. The fluoroscopy time during transradial carotid stenting was higher in comparison with transfemoral carotid stenting, though the procedure duration was similar in both groups.

Aim. To assess safety and effectiveness of opioid-free anesthesia in patients with polyvascular disease undergoing carotid endarterectomy for early mobilization and hemodynamic stability in the perioperative period.

Methods. 28 consecutive male patients with polyvascular disease and internal carotid artery stenoses were included in a single-center, randomized observational study. The control group (n = 12) received conventional intravenous anesthesia of fentanyl 0.1 mg bolus every 20 minutes with continuous sedation with propofol at a rate of 4 mg / kg / h. The study group (n = 16) received conventional anesthesia followed by introvenous nefopam 20 mg with continuous infusion of 40 mg/h. Invasive monitoring of blood pressure, sedation depth, and the analgesia nociception index were measured. The marker of brain damage, S100 protein, was measured in blood plasma. All patients underwent neuropsychological testing in the perioperative period.

Results. There were no reliable hemodynamic derangements during anesthesia in both study groups. There were no cases with worsening of the initial coronary circulation according to the ECG. No alterations in the initial neurological status were registered. BIS values were maintained at 56±19 in both groups without increasing the dose of propofol. All patients in the study group versus 5 patients (41.7%) in the control group were extubated in the OR unit.

Conclusion. Opioid-free anesthesia in patients with polyvascular disease undergoing CEA allows achieving adequate pain management in the perioperative period, ensuring early extubation in the OR unit and postoperative mobilization while maintaining stable hemodynamic parameters and ensuring safe cognitive status.

The article provides new insights to cardiac resynchronization therapy (CRT), a method of treating chronic heart failure with cardiac biventricular pacing. The article covers the history of its development starting with the first attempts to eliminate heart dyssynchrony up to the present advances. Over the last decades, CRT has significantly improved, including both implantable devices and electrodes, and current CRT guidelines and indications. The article discusses serial changes in indications and selection criteria for patients based on the results of the recent clinical trials assessing its effectiveness. Evidence-based knowledge is presented for the CRT application in the routine clinical practice. Novel approaches and technologies aimed at improving the effectiveness of CRT are presented.

Patients with Wolff-Parkinson-White syndrome (WPW), neonates, and patients with major structural cardiac pathology who suffer from supraventricular tachycardia are at higher risk of sudden cardiac death. The review article accumulates evidence-based knowledge provided in the recent guidelines and expert consensus on the prevention of sudden cardiac death in adults and children with different SVT types. The review provides current data on the risk of sudden cardiac death in patients with supraventricular tachycardia, possible pathogenetic patterns of sudden cardiac death in this patient population, current guidelines on catheter ablation for supraventricular tachycardia to prevent sudden cardiac death in adults and children.

We report herein, successful thoracoscopic management of a patient who had a foreign body in the superior vena cava. Foreign body in the superior vena cava in this patient was accompanied by thrombosis, thus limiting the use of endovascular extraction. The impacted foreign bode was successfully removed by minimally invasive thoracoscopic approach without any major or minor traumas. This clinical case proved that thoracoscopic removal is a safe alternative in this group of patients. Given the low prevalence of this type of complications and excellent postoperative outcome, thoracoscopic removal should be considered as one of the routine management approaches to treat patients with these complications.

We are presenting a case of endovascular repair of critical mitral stenosis of rheumatic genesis complicated by decompensated congestive heart failure and massive thrombosis of the left atrium. According to the clinical status of the patient, the patient was found to be inoperable. Despite the extremely high risk of endovascular intervention, the patient underwent balloon mitral valvuloplasty using intracardial and transthoracic echocardiography. The analysis of technical and clinical aspects of the intervention and its results during the in-hospital period and a 9-month follow-up was performed. We concluded on the appropriateness of the chosen treatment strategy.

Adequate guide support is crucial for percutaneous coronary interventions complicated by unfavorable coronary artery anatomy, pronounced calcification, or the presence of chronic total occlusion. A clinical case presents a novel technique for guide support during stenting chronic coronary occlusion via transradial approach originally proposed in the TransRadial Ultra Support Technique trial.