[Immune checkpoint inhibitors related cardiovascular toxicity: 3‑mounth follow-up]

AIM

To analyze the condition of the cardiovascular system in oncological patients receiving immune antitumor therapy with immune checkpoint inhibitors (CPIs) based on results of laboratory and instrumental examinations during a 3-month follow-up.

MATERIAL AND METHODS

This multicenter prospective observational study included 49 patients (25 men and 24 women aged 65.6±8.7 and 64.3±9.6 years, respectively). A laboratory screening (C-reactive proteins, troponin I, N-terminal pro-brain natriuretic peptide), EchoCG, and carotid ultrasound were performed for all patients. 27 patients were followed up at 3 months after the antitumor therapy initiation. Statistical analysis was performed with the StatPlus 8.0.3 software.

RESULTS

Incidence of cardiovascular complications was 16.3 %. The following significant changes in EchoCG parameters were observed: LV EF; (p=0.017), increased LV end-systolic volume (ESV) (р=0.023), and increased LV index of myocardial performance (LIMP; р=0.016). The degree of changes in ESV (ΔESV) depended on a history of chronic heart failure (р=0.03), whereas the degree of changes in EF (ΔEF) depended on the patient's age at the initiation of antitumor therapy (р=0.006). Ultrasound showed an increase in maximum carotid stenosis (р=0.018).

CONCLUSION

The study showed a high incidence of newly developed cardiovascular complications associated with the CPI treatment as well as the presence of changes in EchoCG parameters and data of carotid ultrasound.

Cardiopulmonary exercise testing for treatment effect assessment in chronic thromboembolic pulmonary hypertension patients

Aim      To determine possibilities of the cardiopulmonary stress test (CPST) as an unbiassed, noninvasive method for evaluation of the effect of managing patients with chronic thromboembolic pulmonary hypertension (CTEPH).Material and methods  This study included 37 patients with CTEPH, 24 men (mean age, 53±15 years) and 13 women (mean age, 58±8.5 years). The diagnosis was verified and theCoperability was assessed according to 2015 European Society of Cardiology Clinical Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension (PH). The surgical treatment was used in 65 % (n=24) of CTEPH patients: the group with pulmonary thromboendarterectomy constituted 35 % (n=13); the group with balloon pulmonary angioplasty 30% (n=11); and the conservative tactics was used in 27 % (n=10) of patients.Results Baseline CPST parameters significantly correlated with parameters of right heart catheterization (RHC): mixed venous oxygen saturation (SvO2) significantly positively correlated with V´O2peak (r=0.640, p<0.05), V´O2 / heart rate (HR) (r=0.557; p<0.001), PETCO2 peak (r=0.598, p<0.05), and V´E / V´CO2 (r=0.587; p<0.001); cardiac output (CO) correlated with V´O2 / HR (r=0.555, p<0.001), PETCO2peak (r= -0.476; p<0.05 and r=0.555, p<0.001 for ´E / V´CO2). In repeated testing, the physical working capacity (V´O2peak) increased only in patients after the surgical treatment of CTEPH. Importantly in this process, significant correlations remained between a number of CPST and RHC parameters: SvO2 correlated with V´O2peak (r=0.743; p<0.05), V´O2 /HR (r=0.627; p<0.001), PETCO2peak (r=0.538; p<0.05), and V´E / V´CO2 (r=0.597; p<0.001); V´O2 / HR, PETCO2peak, and V´E / V´CO2 significantly correlated with CO (r=0.645, p<0.001; r= -0.516, p<0.001, and r=0.555, p<0.001, respectively.Conclusion      CPST can be used as a noninvasive instrument for evaluation of the effect of CTEPH treatment, particularly in the absence of echocardiographic data for residual PH.

Thrombotic and hemorrhagic complications during pregnancy, delivery and the postpartum period in females with prosthetic heart valves

Background/Introduction

Women with mechanical prosthetic heart valves are at greatest risk of developing complications.The main reason is that mechanical prosthetic heart valves require lifelong anticoagulation to reduce the high risk of associated thrombotic and hemorrhagic complications.

Purpose

The main goal of this study was to estimated risk factors and frequency of thrombotic and hemorrhagic complications during pregnancy, delivery and the postpartum period in women with prosthetic heart valves

Methods

According to retrospective cohort analyses in this study were included 70 patients with prosthetic heart valves who delivered in a specialized perinatal center from October 2010 to February 2020. All the patients were divided into two groups depending on prosthesis type: mechanical prostheses (44 deliveries in 44 patients), biological prostheses (22 deliveries in 19 patients). All patients were performed ECHO (Vivid 7, GE, USA). The average age were 30.7±5.2 years. The N-terminal brain natriuretic propeptide (NT-proBNP) concentration was determined by the quantitative electrochemiluminescence method using a Cobas E 411 analyzer (Roche, Switzerland). The activity of the anti –Xa factor was measured by chromogenic assays.

Results

In 9 (21.4%) pregnants with a mechanical valve prosthesis (MVP), prosthetic thrombosis was recorded until 2016. In 1 patient with mechanical valve prosthesis (2%) during pregnancy was complicated by an acute cerebral circulation disorder. Since 2016 there were monitored the activity of the anti –Xa factor. In 7 patients on the background of a change in anticoagulant therapy, pregnancy stopped in the early stages. Before pregnancy, 31.4% of the patients didn't have heart failure clinical manifestations, but in 12 (17.1%) patients during pregnancy had increase in NYHA Class maximum to NYHA Class III.

The average NT-proBNP concentration was 912.3±1586.6 pg / ml. The frequency of the cesarean section in both groups was high: in patients with mechanical valve prosthesis in 78.5% and in the group of patients with biological valve prostheses in 68.1% of cases. There were not registered any new cases of prosthetic thrombosis after delivery, however, 9 patients had hemorrhagic complications in the early postpartum period, which required relaparotomy and blood transfusions. Regardless of frequent complications during pregnancy and in the postpartum period, no fatal outcomes have been reported.

Conclusion

The absence of mortality over the 9-years old observation and delivery in patients with valvular prostheses demonstrates the feasibility of monitoring and delivery of this category of patients in a specialized multidisciplinary medical center with experience in managing patients during pregnancy with valvular prostheses on anticoagulant therapy.

Funding Acknowledgement

Type of funding sources: None.

Treatment Strategy Options in Inoperable Chronic Thromboembolic Pulmonary Hypertension Patients

This review presents an analysis of recent publications on the principles of diagnosis and management of patients with chronic thromboembolic pulmonary hypertension (CTEPH). The authors emphasize the importance of patient's operability assessment regarding the possibility of performing pulmonary thrombendarterectomy - a radical treatment option due to complete post-thrombotic material removal from the branches of the pulmonary artery. In the case of an inoperable type of CTEPH, such a method of transcatheter treatment as step-by-step balloon angioplasty of the pulmonary artery (BPA) is proposed. The article clearly outlines the principles of selection, patient training and techniques for BPA. The authors demonstrated their own patented method of the peripheral vascular bed visualization in the case of recanalization of chronic occlusions, which increases the safety of this intervention. Particular attention is paid to hybrid approaches using a soluble guanylate cyclase stimulator, riociguate in combination with BPA for high risk CTEPH patients. The review presents the data of the post hoc analysis of the CHEST-1 study and the data of real clinical practice of the use of riociguat in combination with the endovascular method of treatment on the example of the leading expert groups in Europe, who demonstrated in their studies the positive effect of riociguat on the hemodynamic parameters and the frequency of perioperative complications.

Modeling of Acute Pulmonary Arterial Hypertension in Pigs Using a Stable Thromboxane A2 Analogue (U46619): Dose Adjustment and Assessment of Hemodynamic Reactions

U46619, a synthetic analogue of thromboxane A2 was used for modeling acute stable and reversible pulmonary arterial hypertension. Administration of U46619 in high doses led to vascular collapse and inhibition of cardiac function. The doses of U46619 were empirically selected that allow attaining the target level of pulmonary hypertension without systemic hemodynamic disturbances. The possibility of attaining the target level of pulmonary hypertension and reversibility of changes after termination of U46619 infusion make this model attractive for evaluation of the efficiency of different therapeutic methods of treatment of pulmonary hypertension in large animals.

Idiopathic recurrent pericarditis - a new orphan autoinflammatory disease? A retrospective analysis of cases of idiopathic recurrent pericarditis and a design of а double-blind, randomized, placebo-controlled study to evaluate the efficacy and safety of RPH-104 treatment in patients with idiopathic recurrent pericarditis

Aim To analyze cases of idiopathic recurrent pericarditis (IRP) in the structure of pericardial diseases of various origins from patient visits to the Multidisciplinary Federal Center.Material and methods A retrospective analysis of case records was performed for patients admitted to the V.A. Almazov National Medical Research Center from January 1, 2015 through January 1, 2020 for pericardial effusion of different etiologies.Results For the study period, 4 981 new cases of pericardial damage of different etiologies were found. Among these cases, postpericardiotomy syndrome accounted for 4 360 cases and pericarditis for 621 cases. IRP was detected in 34 cases, which amounted to 5.4 %. Based on the study data, the estimated IRP prevalence in the Russian Federation can be 1.1 cases per 100 thousand population.Conclusion IRP should be regarded as a new autoinflammatory disease, the prevalence of which borders on that of adult Still disease and should be addressed within the concept of orphan diseases. Current knowledge of the pathogenesis and data from recent studies demonstrated a great importance of interleukin-1 blockade as a leading mechanism for achieving remission. This has justified conduction of a randomized clinical study at the Center.

Soluble Guanylate Cyclase Stimulators for Chronic Thromboembolic Pulmonary Hypertension Patients Treatment: New Data

This narrative review describes and appraises some relatively new studies investigating the efficacy and safety profile of soluble guanylate cyclase stimulator riociguat in patients suffering from pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). It has been a while since the publication date of pivotal CHEST-1 trial in 2013. New studies available complement existing evidence, expound on specific questions and open new frontiers for CTEPH investigations going forward. In this paper authors attempted to present data from post-hocanalysis of the CHEST-1 study and real-world data on riociguat treatment, confirming the positive effect of the drug on hemodynamic parameters of the pulmonary circulation and the functional status of patients. This effect was shown previously in large randomized trials. The extremely important positive effect of riociguat demonstrated both in the group of inoperable patients with CTEPH and in patients with residual pulmonary hypertension after pulmonary thrombendarterectomy. Of great interest are the presented some authors results of reverse remodelling of the right heart chambers during riociguat therapy in CTEPH patients, including using unique imaging methods (magnetic resonance imaging and positron emission tomography) to evaluate targeted medicinal therapy in terms of right heart remodelling. The safety profile of the drug was analyzed in the long-term post-registration international, multicenter, prospective, observational study EXPERT (NCT02092818), which confirmed the good tolerability and safety of riociguat therapy in PAH and CTEPH patients.

[Experience with Selexipag to Treat Pulmonary Arterial Hypertension]

Aim To present an own experience in using a medication selexipag in patients with pulmonary arterial hypertension (PAH) included into the V. A. Almazov National Medical Research Center registry and participating in the GRIPHON and GRIPHON OL clinical studies.Material and methods 26 patients with PAH were included into this study since 2010: 20 patients with idiopathic PAH, 4 patients with PAH associated with systemic scleroderma, and 2 patients with corrected congenital heart defects. At the time of randomization, 19 patients had been receiving therapy with phosphodiesterase type 5 inhibitors for at least one month. Among the patients treated with selexipag (n=14), 4 patients reached a high individual maintenance dose (1200-1600 µg b.i.d.), 4 patients reached a medium dose (600-1000 µg b.i.d.), and 6 patients reached a low dose (200-400 µg b.i.d.).Results The selexipag therapy exerted a positive effect on secondary endpoints, specifically, on changes in the functional class of pulmonary hypertension, serum concentration of NT-proBNP, and physical working capacity of patients. Adverse events associated with the selexipag treatment, which resulted in termination of study participation, were observed in one patient.Conclusion To achieve the main goal of drug therapy, low risk of death with selexipag it is critical to observe the titration schedule and to aim at reaching the highest individual maintenance dose.

[Clinical significance of different assesment methods of myocardial fibrosis in patients with hypertrophic cardiomyopathy.]

Objective To evaluate prospects for clinical use of circulating biomarkers for characterizing fibrotic changes in the myocardium of patients with hypertrophic cardiomyopathy (HCMP) with left ventricular (LV) outflow tract obstruction.Materials and Methods This was a prospective study with a 12-month follow-up period. The study included 47 patients (29 females and 18 males) with obstructive HCMP who were selected for septal reduction. Echocardiography (EchoCG), cardiac magnetic resonance imaging (MRI) and measurements of serum C-reactive protein, N-terminal pro-brain natriuretic peptide, and relevant circulating markers of fibrosis (TGF-β1, MMP-2,-9, TIMP-1, galectin-3, sST2, CITP, PICP, and PIIINP) were performed for all patients. All patients were evaluated at baseline and at 7 days, 6 and 12 months following surgical treatment. Morphometrical analysis of intraoperative biopsy samples was performed for evaluation of the degree of fibrotic changes. Patients received beta-blockers (95.7%), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (34%), loop diuretics (68.1%), aldosterone antagonists (34%), and statins (66%).Results Women with HCMP were older and more frequently had additional risk factors (arterial hypertension). Men had a higher risk of sudden cardiac death. Histological study of intraoperative myocardial biopsy samples showed that the area of fibrotic changes was 13.9±6.9%. According to cardiac MRI mean area of delayed contrast enhancement was 8.7±3.3% of LV myocardial mass. No association was established between traditional cardiovascular risk factors and severity of myocardial fibrotic changes or levels of circulating fibrosis markers. Perhaps that was due to the modifying effect of the drug therapy received by HCMP patients. According to EchoCG maximum pressure gradient in the LV outflow tract before the surgical treatment was 88 (55; 192) mm Hg, and interventricular septal thickness was 22 (16; 32) mm. A considerable decrease (p=0.0002) in the LV outflow tract gradient was observed after myectomy in all patients. At the same time, the left ventricular dimension, which tended to decrease in the early postoperative period, returned to baseline values by the 6th month of follow-up.Conclusion The study confirmed the increase in relevant circulating markers of fibrosis in patients with obstructive HCMP. At the same time, no correlation was observed between levels of circulating biomarkers and severity of fibrosis according to data of histology and cardiac MRI, which was probably due to the modifying effect of drug therapy and limited sampling.

[The Case of Fulminant Myocarditis]

Fulminant myocarditis (FM) is a severe form of inflammatory myocardial injury rapidly developing as acute heart failure, cardiogenic shock, or life-threatening disturbances of cardiac rhythm. FM requires intensive treatment including drug therapy, mechanical circulatory support, and in some cases - heart transplantation. Echocardiography can be used as a screening method of diagnostics. Magnetic resonance imaging of the heart often cannot be performed because of hemodynamic instability of a patient, therefore endomyocardial biopsy with histological and immunohistochemical studies as well as molecular-genetic analysis of obtained samples is required for final diagnosis. Prognosis of the disease is determined by histological picture. In most cases, after cessation of acute stage of the inflammatory process, FM has a favorable long-term prognosis. In this article we present a clinical case of FM and review of current literature on diagnosis and treatment of this disease.

[Expression of osteoprotegerin and soluble ligand of receptor of kappa-B transcription factor activator in the calcification of aortic valve]

The mechanism of valve calcification that is the main cause of aortic stenosis formation and progression is not yet clear. In recent years, the role of the OPG/RANKL/RANK system is considered as one of possible variants of pathogenesis of valve calcification. In presented work the differences in OPG and sRANKL levels involved in the calcification processes in tissues of patients with severe aortic stenosis have been examined. The study was performed using three groups of patients: group 1 - patients with aortic stenosis, group 2 - patients with aortic aneurysm, and group 3 - patients with aortic stenosis and aortic dilatation. In patients with aortic stenosis, the level of RANKL was significantly higher, and the level of RANKL was higher in valve than in tissue. The negative correlation between aortic dilatation and RANKL level indicated the lack of RANKL influence on pathogenesis of aortic dilatation. The obtained data confirm the increased expression of RANKL in patients with aortic valve calcification. The results of this study confirm importance of the OPG/RANKL/RANK system in calcification in patients with aortic stenosis. Athough patients of all groups had comparable values of OPG (including patients with aortic dilatation), the RANKL level increased only in patients with aortic stenosis. This suggest involvement of some additional mechanisms influencing the increase of RANKL expression.

Left main coronary artery compression by pulmonary artery aneurism in patients with long standing pulmonary arterial hypertension

This review focuses on a rare complication of pulmonary arterial hypertension (PAH), extravasation compression of the left coronary artery (LCA) dilated by the pulmonary artery. The review described clinical manifestations and methods for diagnostics of LCA compression, and advantages of the endovascular correction of this complication in patients with pulmonary hypertension. Selection of a device to be implanted during the endovascular intervention in these patients was discussed with due account for concomitant treatment with oral anticoagulants. As an illustration of the issue under discussion, a clinical case of acute coronary syndrome in a female patient from the PAH Registry of the V. A. Almazov National Medical Research Center was provided.

EXPERIENCE OF USING THE NON­SELECTIVE ENDOTHELIN RECEPTOR ANTAGONIST MACITENTAN IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION

Aim. To present the results of treatment with macitentan of patients included in the clinical trial SERAPHIN in Almazov National Medical Research Centre and define target therapy of pulmonary arterial hypertension (PAH) in real clinical practice.

Material and methods. The article presents the results of the 151 patients with PAH followed­up in Almazov National Medical Research Centre from 2009 to 2016.

Results. Five­year survival of PAH patients included in the register of Almazov National Medical Research Centre reached 77% for idiopathic PAH, 52% for PAH associated with systemic scleroderma, 81% for PAH associated with non­repaired congenital heart disease, 82% for patients with repaired congenital shunts and 100% for PAH associated with human immunodeficiency virus infection. The group that received PAH specific monotherapy consisted of 47% (n=71) of patients among which phosphodiesterase type 5 inhibitor (PDE­5i) sildenafil was undoubtedly the most prescribed drug — 74% (n=53). The group that received combined PAH specific therapy consisted of 66 (44%) patients: 48 patients received various two­component therapy, 18 patients — threecomponent therapy with endothelin receptor antagonist in combination with PDE­5i and prostanoids. 11 patients with PAH were included in SERAPHIN study of which 9 patients had been already receiving generic PDE­5i therapy. In macitentan group, a statistically significant increase in the 6­minute walk distance (+50 meters) and a decrease in hemodynamic parameters such as mean right atrial pressure (­2,3 mm Hg) and pulmonary vascular resistance (­445 dyn­sec/cm5) were observed after 6 months. No patient had a clinically significant increase in liver transaminases or a decrease in hemoglobin levels.

Conclusion. Improvement of prognosis in PAH patients according to the register of the Centre is connected both with early detection of the disease, thanks to the development of specialized healthcare, and more frequent use of combination therapy. Macitentan proved its long­term efficacy and safety as monotherapy and in combination with PDE­5i.

[Interventional treatment in patients with myocarditis: Pro and Contra]

AIM

Ventricular tachyarrhythmias (VTs) are often encountered in patients with inflammatory heart diseases. VT can become lifethreatening in patients with myocarditis, and the management may vary in different types of myocarditis. Purpose of the study is to describe VT characteristics in patients with verified myocarditis, and to evaluate the efficacy and safety of VT management, when tailored to the type of myocarditis.

MATERIALS AND METHODS

Study population comprised: 56 patients with morphologically verified myocarditis; 18 patients with primary cardiomyopathy (control group). All patients underwent full clinical evaluation, endomyocardial biopsy (including immunohistochemical analysis). Forty (54 %) patients underwent radiofrequency catheter ablation of VT. An implantable cardioverter-defibrillator (ICD) was inserted in 17 patients.

RESULTS

There was no statistically significant difference between myocarditis and primary cardiomyopathy groups by demographic and echocardiographic data. In myocarditis group, nonsustained VT and/or frequent premature ventricular beats were seen in 59 % of patients; sustained VT in 12,5 % subjects, 1 patient had a history of ventricular fibrillation. VT ablation was associated with a significant decrease in VT recurrence (p=0,0009) during the follow-up period. Active myocarditis was associated with a higher VT recurrence rate (67 % in active vs. 19 % in borderline myocarditis). Among patients with ICD implantation, only one subject (with active myocarditis at admission) had life-threatening ventricular arrhythmia.

CONCLUSION

In this selected group of patients with verified myocarditis and clinically significant VTs, catheter ablation seems at least partly effective. Patients with borderline myocarditis and symptomatic VTs may benefit from ablation. Therefore, morphological diagnostic of myocarditis can be a key point in choice of treatment.

[Perspectives of using pulmonary arterial stiffness indicators to evaluate the prognosis of patients with pulmonary arterial hypertension]

OBJECTIVE

the aim of the study was to characterize the mechanical properties of the pulmonary arterial wall (PA) in patients with pulmonary arterial hypertension (PAH) using magnetic resonance imaging (MRI) of the heart, and to determine their diagnostic and prognostic value.

MATERIALS AND METHODS

57 patients with PAH were examined. The diagnosis of PAH was verified according to the recommendations of the ERS/ESC from 2015. All patients underwent a detailed echocardiographic (ECHO) study, MRI of the heart and right heart catheterization (RHC). To calculate the stiffness of the pulmonary artery wall, the MRI and RHC data were used.

RESULTS

We identified a correlation between the functional class of PAH and the parameters of hemodynamic, physical performance, ECHO parameters of the right chambers. There were no differences in the stiffness of the pulmonary artery wall, depending on the functional class of PAH. Among the six stiffness indicators, only pulsation index was associated with the structural and functional parameters of the right ventricle and pulmonary vascular resistance.

CONCLUSION

The MRI pulsation index is the simpleststiffness index of the pulmonary artery wall and the most promising one for evaluating the prognosis of patients with PAH.

Cellular Mechanisms of Aortic Valve Calcification

Comparative in vitro study examined the osteogenic potential of interstitial cells of aortic valve obtained from the patients with aortic stenosis and from control recipients of orthotopic heart transplantation with intact aortic valve. The osteogenic inductors augmented mineralization of aortic valve interstitial cells (AVIC) in patients with aortic stenosis in comparison with the control level. Native AVIC culture of aortic stenosis patients demonstrated overexpression of osteopontin gene (OPN) and underexpression of osteoprotegerin gene (OPG) in comparison with control levels. In both groups, AVIC differentiation was associated with overexpression of RUNX2 and SPRY1 genes. In AVIC of aortic stenosis patients, expression of BMP2 gene was significantly greater than the control level. The study revealed an enhanced sensitivity of AVIC to osteogenic inductors in aortic stenosis patients, which indicates probable implication of OPN, OPG, and BMP2 genes in pathogenesis of aortic valve calcification.

[Pharmacoeconomic aspects of macitentan in the therapy of pulmonary arterial hypertension]

AIM

To provide a pharmacoeconomic estimate of macitentan versus bosentan in therapy for pulmonary arterial hypertension (PAH).

SUBJECT AND METHODS

An analysis was carried out on the basis of a social perspective for patients, whose mean age was 50 years. A budget impact analysis was performed without discounting; with the time horizon of the study being 5 years. Assessing the cost- effectiveness of endothelin receptor antagonists used a Markov model based on the meta-analysis of clinical trials. The cost of bosentan was calculated from the 2016 registered prices with VAT. That of macitentan was estimated from the expected price of 170,000 rubles per 10-mg dose pack #28 if the drug is included in the List of Essential Medicines with VAT. The cost of sildenafil and iloprost was consistent with the January-to-November 2016 auctio.

RESULTS

At cost-effectiveness assessment costs and outcomes were both discounted at an annual rate of 3,5%.

RESULTS

After 5 years of therapy with macitentan in patients with baseline Functional Class (FC) II PAH, the proportion of patients with FC I-II was shown to be 2.6% more than that during therapy with bosentan (20.1 and 17.5%, respectively), and that of the died patients was 1.5% lower (69.5 and 71%, respectively). In baseline FC III PAH following 5 years, the proportion of patients with FC III PAH on initial macitentan treatment was 1% more than that on bosentan therapy (8.1 and 7.1%, respectively), and that of the died patients was 0.5% lower (87.2, and 87.7%, respectively). The cost-effectiveness analysis shows that therapy with macitentan versus bosentan not only causes some increase in life expectancy in terms of quality of life (by 0.414 and 0.230 QALYs in FC II and III PAH, respectively), but also results in a small cost decrease in FC II and III PAH (by 11,000 and 16,000 rubles per patient, respectively). Thus, macitentan is a dominant alternative versus bosentan. The budget impact analysis indicates that when bosentan is replaced with macitentan, the reduction in health care costs in the Russian Federation will amount to 1.9 million rubles over 5 years, and in all budgetary costs will be 14.7 million rubles.

CONCLUSION

Treatment with macitentan in patients with FC II-III PAH is more cost-effective than that with bosentan and does not require an increase in budget costs.

[Autoimmunity and Prognosis of Patients With Morphologically Documented Myocarditis]

AIM

to assess clinical and prognostic value of circulating cardiospecific autoantibodies (AAB) and CD4+ T-regulatory cells in patients with myocarditis.

MATERIAL AND METHODS

We included into this study 47 patients with lymphocytic myocarditis verified by analysis of histological and immunohistochemical data. Comparison group consisted of 30 practically healthy persons. Content of marker cardiotropic AAT were measured with the help of standardized immune enzyme test-systems. Number of circulating CD4+CD25+ and CD4+CD25+FoxP3+ T-lymphocytes were evaluated by flow cytometry.

RESULTS

Among factors determining prognosis of patients with lymphocytic myocarditis factors of key significance were the presence of clinically overt heart failure at the disease debut, and degree of reduction of left ventricular ejection fraction. Distinctive feature of active myocarditis was elevation of titer of AABs to sarcomeric, cytoskeleton, and cytoplasmic proteins of cardiomyocytes, as well as elevated level of AABs to various epitopes of adenine nucleotide translocator. Elevated level of AAB to 1-adrenoreceptors was an independent predictor of unfavorable outcome in patients with lymphocytic myocarditis. Increased population of circulating CD4+CD25+ T-regulatory cells was as sociated with elevated concentration of of natriuretic peptide.

CONCLUSION

Abnormalities in the system of autoimmunity play key role not only in pathogenesis but also in prognosis of inflammatory myocardial diseases. Changes of profile of circulating cardiospecific AABs and T-regulatory cells can bear a protective function.

A 6-YEAR EXPERIENCE OF HEART TRANSPLANTATION IN FEDERAL ALMAZOV NORTH-WEST MEDICAL RESEARCH CENTRE

Aim. To estimate the results of 6-year experience of heart transplantation (HT) in Federal Almazov North-West Medical Research Centre. Methods. From 2010 to 2015 we have performed 65 HT. Mean age was 44.3 ± 14 years old (from 10 to 64 years old). We used biventricular assist device (BIVAD, Berlin Heart Excor) support in 7 heart transplant candidates before HT. 19 patients (29%) received thymoglobulin, whereas 46 patients (71%) had basiliximab to induce immunosuppression.

Results.Extracorporeal membrane oxygenation machines were implanted in 5 patients (7.7%) after HT due to acute right ventricular failure. Suture annuloplasty (the Batista procedure) for tricuspid valve repair was carried out in 3 cases (4.6%). Venovenous hemodiafi ltration was used in 11 patients (16.9%). A total of 598 endomyocardial biopsies (EMB) were performed after HT. Evidence of cellular rejection (R1 and R2) was presented in 286 biopsies (48%). The 30-day in-hospital mortality rate was 3.1%. The 6-month survival rate after HT was 92%, 1-year – 91% and overall survival for the 6-year period of observation – 89.2%. Maximum observation period was 71 months.

Conclusions.The 6-year experience of HT in our Center has shown a high level of survival. BIVAD Excor support can be effectively used as a «bridge» to HT. Prevention of graft loss due to acute rejection in heart transplant recipients can be achieved only through regular EMB monitoring. The rate of viral infection increased in 2 months after HT.

ANESTHETIC MANAGEMENT AND INTENSIVE CARE DURING PERIOPERATIVE PERIOD OF ABDOMINAL DELIVERY IN PREGNANT WOMEN WITH PULMONARY ARTERIAL HYPERTENSION

Background The presence ofpulmonary arterial hypertension (PAH) in pregnant women increases mortality up to 12- 30% and up to 50% when PAH is associated with Eisenmenger syndrome. Due to low prevalence of PAH in pregnancy many aspects ofperioperative management are still unclear.

THE AIM

To summarize our approaches to the anesthesia and intensive care in pregnant women with PAH.

MATERIALS AND METHODS

21 pregnant women with PAH (systolic pulmonary artery pressure (SPAP) higher than 60 mm Hg)-who underwent delivery by Caesarean section in 2010 - 2015 were included in the one-centre retrospective study. Data are presented as median (25th, 75th percentile).

RESULTS

The median age was 27 (23; 29) years. Among the patients, there were 4 (19%) cases of idiopathic PAH and in 17 (81%) women PAH was associated with congenital heart disease (CHD); 12 (57%) patients'demonstrated Eisenmenger syndrome. Baseline SPAP was 90 (82; 103) mm Hg. SpO2 90 (85,95)%. All women taken PAH-specific therapy (sildenafil) before delivery. Caesarean section (CS) were performed at 32 (28; 34) weeks. In 20 cases CS was perfofined under epidural anesthesia and in one case under general anesthesia due thrombocytopenia. Inhaled nitric oxide (NO) was administered intraoperative to all women in a dose of 40-60 ppm. Postoperative period was uncomplicated in five women (23?8%). Decompensation with PAP rise, acute right ventricular failure and hypoxemia developed in 16 (76,2%) cases 30 (24, 40) h after abdominal delivery. These patients required combined PAH-specific therapy (NO, sldenafil, iloprost) and inotropic agents, additionallyrespiratory support was used in four patients. The median ICU stay was 13 (9; 22) days. 3 patients died (14?2%); mortality in Eisenmenger syndrome cases was 25% (3/12). 18 healthy babies.

[Left ventricular noncompaction: A clinical and morphological study]

The data of clinical, macro- and micrometric, histological, and immunohistochemical studies of the heart were analyzed in patients with left ventricular noncompaction (LVNC). Materials from 7 patients: 5 hearts of recipients after heart transplantation, one heart of a dead patient, and one endomyocardial biopsy specimen were investigated. The investigations showed that this disease was accompanied by a preponderance of a noncompact layer with its ratio to a compact layer (2.4:6.6) in the left ventricle and by myocardial hypertrophy and fibrosis in all cases, by endocardial fibroelastosis and discomplexation of muscle fibers by more than 15% of the specimen area in 6 of the 7 cases, by right ventricular hypertrabeculation and myocarditis in 5 cases, and by lipomatosis and impaired connexin 43 expression in 4 cases. Only one of the four patients was found to have MYH 7 gene mutation. The results of MRI of the extracted heart coincided with morphological findings in 100% of cases. The comparative study demonstrated that this disease had simultaneously morphological features of both LVNC and restrictive, hypertrophic, dilated cardiomyopathy. The findings may suggest that the LVNC phenotype may be formed under the influence of various modifying factors (hemodynamic and inflammatory ones).

[Value of Two Dimensional Echocardiography for Assessment of Disease Severity in Patients With Pulmonary Hypertension]

AIM

To carry out complex assessment of the right ventricular (RV) function with two-dimensional echocardiography (2D-EchoCG) for detection of most informative markers of the disease severity in patients with pulmonary hypertension (PH).

MATERIAL AND METHODS

We examined 63 patients with PH (38 with idiopathic PH, 7 with corrected congenital heart defects, 6 with systemic scleroderma, 12 with chronic inoperable thromboembolic PY). Examination included right heart catheterization, 2D-EchoCG, and cardiac magnetic resonance tomography (MRT).

RESULTS

2D-EchoCG revealed dilation of right chambers of the heart, hypertrophy of RV anterior wall, increase of ratio of right to left ventricular end-diastolic dimensions (RV:LV), reduction of LV stroke volume, diminution of amplitude and velocity of tricuspid annular plane systolic excursion, and significant increase of myocardial performance index Tei. MRT data evidenced for lowering of RV ejection fraction. Canonical correlation was found between integral characteristic of 2D-EchoCG and integral hemodynamic characteristic (r=0.77; p=0.007). We also determined threshold values of RV: LV to be used for stratification of risk in patients with PH.

CONCLUSION

In patienns with PH calculation of simple 2D-EchoCG parameters provides information important for determination of disease severity, selection of optimal method of treatment, and monitoring of patients condition.

[Pulmonary Hypertension in Takayasu Arteritis]

Takayasu arteritis is well-known rare form of large vessel vasculitis. Pulmonary involvement is observed in 50% of cases. However, pulmonary hypertension is a rare complication of pulmonary artery stenosis. In this article we present a rare clinical case of Takayasus arteritis with typical stenosis of subclavian, carotid arteries, and involvement of pulmonary arteries with development of severe pulmonary hypertension. The article also contains discussion of current methods of diagnosis and treatment of pulmonary artery stenosis in Takayasus arteritis with special focus on effectiveness and complications of angioplasty and surgery.

[MODIFICATION OF MESENCHYMAL STEM CELLS AS A WAY TO IMPROVE THE EFFECTIVENESS OF CELL THERAPY OF ISCHEMIC MYOCARDIAL INJURY]

Acute myocardial infarction remains to be one of the most important problems of health care. Cardiac cell therapy is a new therapeutic strategy focused on repair of the injured cardiac muscle. Mesenchymal stem cells (MSC) are considered as the most suitable candidates for cardiac cell therapy. MSC transplantation in the myocardium after ischemic injury has been shown to be cardioprotective in animal models and clinical trials. However, the beneficial effects of MSC in humans are limited because of both poor survival and impaired function of the cells in ischemic tissue. To address these issues, a number of approaches to the modification of MSCs with the aim to improve their survival and proliferation, reduce the immune reaction, enhance transdifferentiation, and optimize the profile of secreted paracrine factors have been tested. In this review, we provide detailed discussion of different methods of MSCs modification, including targeted gene overexpression, conditioning of MSCs using physical and chemical factors, and application of multicellular units for transplantation. The effectiveness of these strategies in preclinical studies is also discussed.

[The metabolic and protein markers of dysfunction of mitochondria in patients with cardio-vascular diseases.]

The article deals with study concerning content of cytochrome C (CytC) and protein PGC1α (1alpha-co-activator of gammareceptor, activating proliferation of peroxisomes) in blood of patients with pathology of left ventricular outflow tract conjointly with low-molecular metabolites characterizing dysfunction of mitochondria and endothelium. The samples of blood plasma were analyzed taking from healthy persons (n=34), patients with aortic aneurysm (n=69), aortic stenosis (n=25) and without pathology of aorta (n=16). In the group of patients with disturbed blood circulation increasing of level of metabolic markers of dysfunction of mitochondria (lactate, ratio lactate/pyruvate) and endothelium (asymmetric dimethylarginine, total homocysteine) was established. The occurrences of cells death were detected according to increasing of level of CytC in 17% 0f patients. The evaluation of level of intermediates of energy metabolism and simultaneously of protein PGC1α permits detecting at least three degrees of dysfunction of mitochondria depending on stage of its progression: 1) without lactoacidemia but with detection of PGC1α in blood, 2) with lactoacidemia up to 2.2 mM and increased level of PGC1α in blood (more than 61 ng/l), 3) with lactoacidemia and loss of cells capacity to transfer this protein in blood. The application of common metabolic indicators of disorder of function of mitochondria supplemented by determination of level of CytC and PGC1α in blood permits evaluating more comprehensively development of dysfunction of mitochondria in patients with disorders of blood circulation of various genesis.

[Selection of reference genes for transcription analysis for myocarditis studies]

Myocarditis is defined as myocardial inflammation, followed by cardiomyocyte necrosis. Diagnostics of myocarditis is based on unsafe and complicated method of endomyocardial biopsy (EMB). Development of myocarditis might alter gene expression not only in cardiac but in peripheral blood cells (PBC) as well. So, transcription profiles can be considered as possible biomarkers for the given pathology. At the moment, there are no reference genes defined for expression analysis in myocarditis studies. In this study, we analyzed mRNA content of six housekeeping genes in EMB and PBC samples. An algorithm for processing qPCR results obtained under the limited amount of sample is proposed. Set of GAPDH and HPRT1 genes has been selected for normalization of gene expression profiles in cardiac tissue and blood cells under the studies of myocarditis.

[Concentration of osteoprotegerin and RANKL in blood serum of patients with aortic stenosis]

PURPOSE

to compare blood serum levels of osteoprotegerin (OPG) and soluble receptor activator of nuclear factor B ligand (sRANKL) in patients with different morphological variants of stenosis.

MATERIAL AND METHODS

We included in this study 57 patients with aortic stenosis: 29 with bicuspid aortic valve (BAV) and 28 with tricuspid aortic valve (TAV). Subjects without heart diseases (n=32) were also examined. In all patients we determined lipid profile and measured serum levels of C-reactive protein, OPG and sRANKL.

RESULTS

OPG levels were evaluated in all patients with aortic stenosis while evaluated sRANKL was found only in patients with BAV. Age and arterial hypertension were key risk factors for OPG/RANKL/RANK system activation.

CONCLUSION

Despite differences in pathogenesis of aortic stenosis in patients with BAV and TAV processes of calcification may have common mechanisms. The data obtained correspond to the conception of importance of OPG/RANKL/RANK system activation for development and progression of degenerative aortic stenosis.

[Comparative characteristics of the stem cells isolated from subcutaneous and subepicardial adipose tissue]

BACKGROUND

Stem cells (SCs) considerably vary in morphological, immunophenotypic, proliferative, and differentiation characteristics depending on their tissue source. The comparative analysis of their biological properties is essential for the optimal choice of SCs for regenerative therapies.

METHODS

Using immunocytochemistry, flow cytometry, histochemistry and real-time RT-PCR, we have investigated SCs obtained from human subepicardial (SEC-AT) and subcutaneous (SC-AT) adipose tissue and cultured under similar culture conditions without any differentiation-promoting factors.

RESULTS

The cultures were similar in the high proportion of proliferating cell nuclear antigen (PCNA)-positive cells. In both cultures, immunophenotyping has revealed high expression of mesenchymal stem cell surface markers CD29, CD44, CD73, and CD105, low expression of CD31, CD34 and CD45, and wide variability in CD117, CD146 and CD309 expression. The only distinction in CD marker profile was significantly lower expression of CD90 in SCs from SEC-AT. Histochemical analysis has shown the lack of Oil Red O-positive cells in both cultures and about ten-fold higher number of alkaline phosphatase-positive cells among SCs from SC-AT. In the both cultures, immunocytochemistry has detected similar low expression of slow myosin heavy chain marker MAB1628 and smooth muscle actin marker α-hSMA. Gap junctional protein Connexin-43 expression was markedly higher in SCs from SC-AT, and epithelial cell marker Cytokeratin-19 expression was detected only in these cells. By RT-PCR, GATA4 mRNA was found to be highly expressed only in SCs from SEC-AT.

CONCLUSIONS

Our results suggest that SC-AT, as compared with SEC-AT, is richer in epithelial cell and osteogenic progenitors. In turn, SEC-AT possesses cardiomyogenic SCs, and can be considered as an alternative to SC-AT as a source of SCs for cell cardiotherapy.

[Functional properties of smooth muscle cells in ascending aortic aneurysm]

Thoracic aortic aneurism (TAA) develops as a result of complex series of events that dynamically alter the structure and composition of the aortic vascular extracellular matrix (ECM). The main elements that alter the composition of aortic wall are smooth muscle cells (SMC). The purpose of the present work was to study alteration of smooth muscle cell functions derived from the patients with TAA and from healthy donors. As it is supposed that TAA associated with bicuspid aortic valve (BAV) and with tricuspid aortic valve (TAV) differ in their pathogenesis, we compared the SMC and tissues samples from BAV-, TAV-patients and healthy donors. We compared TAA patients' derived tissues and SMC to healthy donors' ones in several parameters: SMC growth, migration and apoptotic dynamics; metalloproteinase MMP2 and MMP9 activity (zymography) and elastin, collagen and fibrillin content (Western blot) in both tissue samples and cultured SMC. Proliferation ability of both BAV and TAV SMC was decreased comparing to donors cells; migration ability in scratch tests was increased in TAV-derived SMC comparing to donor cells. BAV-cells migration ability was not changed comparing to donor-SMC. Elastin content was decreased in TAA SMC comparing to donor cells whereas the content of fibrillin and collagen was not altered. At the same time elastin and collagen protein level was significantly higher in tissue samples of TAA patients comparing to donor-derived samples. SMS proliferation and migration ability is differently affected in TAV and BAV-associated TAA that supports the idea of different nature of these two groups of TAA. Also our data show that SMC functional properties are altered in TAA patients and these alterations could play a significant role in the disease pathogenesis.

[Profile of autonomous regulation of circulation in patients with severe left ventricular myocardial hypertension]

The possibility of concomitant hypertrophic myopathy (HCMP) and hypertensive disease (HD) in the same patient is debatable. This study aimed at estimating peculiarities of autonomous regulation of circulation and clinic-pathogenetic features of the disease in patients with marked hypertrophy of interventrucular septum (IVS) depending on the presence of arterial hypertension (AH). The patients with manifest left ventricular hypertrophy (MLVH) were divided into those with and without AH. Clinical examination included assessment of the vasomotor cardiopulmonary baroreflex (VM CPBR). Valsalva maneuver, sensitivity of spontaneous arterial baroreflex (ABR), cardiac rhythm variability at rest and orthostasis. Hemodynamic parameters were determined by continuous non-invasive recording using a Finometer arterial pressure monitor. Patients with HCMP showed reduced VM CPBR, preserved ABR, Valsalva and sympatovagal indices. Similar but less pronounced changes were documented in patients with MLVH, AH and HD. Profile of autonomous regulation of circulation in patients with manifest left ventricular myocardial hypertension and AH was significantly different from that in HCMP patients but similar to the profile in the patients with HD.

[First experience of the study "Intramyocardial Multiple Precision Administration of Mononuclear Bone Marrow Cells in the Treatment of Myocardial Ischemia"]

Study aim - to elucidate possibilities of the use of precision administration of mononuclear bone marrow cells (MBMC) for the treatment of myocardial ischemia and heart failure. "Intramyocardial Multiple Precision Administration of Mononuclear Bone Marrow Cells in the Treatment of Myocardial Ischemia" was a double blind randomized placebo controlled study in which we included patients more or equal 6 months after Q-wave myocardial infarction with systolic myocardial dysfunction (ejection fraction <35%), not requiring myocardial revascularization, receiving stable optimal medical therapy for more or equal 8 weeks, and with implanted cardioverter-defibrillator. Transplantation of MBMC was guided by fluoroscopy and tridimensional NOGA XP Cardiac Navigation System. For assessment of efficacy of the method we used surrogate end points: decrease of number of fixed perfusion defects according to SPECT data and improvement of regional myocardial contractility according to data of echocardiography. Results of dynamic observation of the first experience of MBMC administration are presented in this paper.

Contemporary treatment of pulmonary arterial hypertension: the North-West Registry data analysis

Aim. Using the prospective Registry data, to assess the effects of conventional and specific therapy on the clinical course and survival of the patients with pulmonary arterial hypertension (PAH). Material and methods. The study included 124 patients (mean age 38,2±13,7 years; 34 men and 78 women): 31 with idiopathic PAH (IPAH), 52 with Eisenmenger syndrome, 17 with inoperable chronic thromboembolic pulmonary hypertension, 9 with PAH and corrected congenital heart disease, 6 with PAH and systemic scleroderma, and 6 with PAH and HIV infection. Results. The cumulative one-year and three-year survival rates were 94% and 75%, respectively. Irrespective of the absence of right heart catheterisation and vasoreactive testing, 42,7% of the patients were treated with calcium antagonists. PAH-specific therapy was administered to 40,3% of the participants (64,5% and 21% of those with IPAH and Eisenmenger syndrome, respectively). PAH-specific therapy was associated with an increase in survival time. Conclusion. In PAH patients, the prognosis is linked to early administration of specific monotherapy and possible combination therapy. Developing a national registry of pulmonary hypertension will facilitate the assessment of the real-world demand for specific therapy and the related costs.

[Comparative analysis of the serum level of autoantibodies as a diagnostic tool of myocardial inflammatory diseases]

AIM

To assess whether the serum levels of autoantibodies (auto-Abs) interacting with myocardial and vascular wall antigens might be used for the differential diagnosis of myocardial inflammatory diseases. Subjects and methods. Seventeen patients with morphologically documented myocarditis were examined. A comparison group comprised 9 patients with acute myocardial infarction (AMI). A control group included 18 apparently healthy individuals and 8 patients with chronic erosive gastritis (CEG). Serum auto-Abs levels were estimated by the ELI test systems standardized for enzyme immunoassay.

RESULTS

The individual profiles that reflect relative changes in the levels of 16 study auto-Abs and characterize the integral autoreactivity of a patient have clear intergroup differences. Using the profiles of auto-Abs could confirm the diagnosis of myocarditis in 94% of cases or assign the patient to a group of apparently healthy individuals. The informative value of the method in patients with AMI and CEG was 81.8 and 87.5%, respectively.

CONCLUSION

The proposed method may be used for the noninvasive screening diagnosis of myocardial inflammatory diseases.

[Surgical treatment of chronic thrombo-embolic pulmonary hypertension with floating thrombi in the right heart ventricle]

A 31 years old male patient was admitted to a resuscitation unit with severe dyspnea (MMRC 4 grade). The patient had the dyspnea for 3 months.The diagnosis of chronic thrombo-embolic pulmonary hypertension with floating thrombi in the right heart ventricle was established. On the sixth day of admission after IVC filter insertion, the patient underwent thromboectomy with pulmonary endarterectomy. For an access to segmentary pulmonary arteries during operation SVC and the aorta had been cross-clamped. The duration of deep hypothermic (20 degrees C) circulatory arrest was 54 minutes. The patient was discharged in satisfactory condition on the 17th day. At the check-up at 3 months the dyspnea was absent and heart hemodynamic parameters had been normalized.

[The first experience with heart transplantation in the Federal Center of the Heart, Blood and Endocrinology named after V. A. Almazov]

At the present time heart transplantation is considered to be the operation of choice in treatment of patients with terminal stage of chronic heart failure. Results of the first 5 heart transplantations made in the Federal Center of the heart, blood and endocrinology named after V. A. Almazov are assessed. There were no perioperational lethality and complications at the hospital stage. An analysis of the long-term results has shown effectiveness of heart transplantations in treatment of severe heart pathology.

[The study of circulating endothelial precursor cells in patients with chronic heart failure]

We examined 41 patients with ischemic heart disease (n=26) and dilated cardiomyopathy (DCM) (n=15). Control group comprised 15 practically healthy subjects. We found no substantial differences in the presence of CD34+CD133- and CD34+CD133-VEGFR-2+ cells in peripheral blood of patients with chronic heart failure (CHF) but noted lowering of level of CD34-CD133+VEGFR-2+ cells mainly in DCM group. Most significant factors determining lowering of number of circulating endothelial precursor cells (EPC) were age, level of low density lipoprotein cholesterol, and intima media thickness of common carotid arteries. We found lowering of colony forming ability of EPC in patients with CHF first of all in the group of patients with DCM. Abnormality of qualitative and quantitative composition of EPC can be considered as one of risk factors of endothelial dysfunction, pathological remodeling of cardiovascular system and CHF progression.

[Laboratory methods for the diagnosis of postpericardiotomy syndrome]

The paper analyzes the diagnostic value of methods for the laboratory diagnosis of postpericardiotomy syndrome (PPS) in patients who have undergone open heart surgery. The prospective study included 63 patients, of whom 53 had the clinical manifestations of PPS. Ultrasensitive assay of serum procalcitonin and the determination of relative albumin levels in pleural and pericardial fluids are noted to be of high diagnostic value.

[Postpericardiotomy syndrome: risk factors and methods of diagnosis]

This study was designed to identify major risk factors of PCTS and elucidate the possibility of early laboratory diagnosis of this syndrome for the choice of optimal therapeutic strategy. Retrospective analysis covered medical records of 500 patients who had experienced open heart surgery. Prospective studies included 60 patients of whom 50 had clinical manifestations of PCTS. Risk of its development depended on the severity of the underlying disease and increased after mechanical revascularization of myocardium. Urgency surgical intervention and greater extent of coronary shunting increased the probability of PCTS. Results of the measurement of serum procalcitonin by a highly sensitive method and of relative content of different protein fractions in serum and pleural/pericardial fluid suggest high informative value of these methods as diagnostic tools for PCTS. Preventive treatment with non-steriodal anti-inflammatory agents decreased the incidence of PCTS by 53%.

[Effect of therapy with rosuvastatin on circulating endothelial progenitor cells in patients with chronic heart failure]

We assessed effect of therapy with HMG--CoA reductase inhibitor rosuvastatin on the number of circulating hemopoietic stem CD34+, CD133+ cells in peripheral blood of patients with systolic left ventricular dysfunction of ischemic genesis. Number of circulating hemopoietic stem CD34+, CD133+ cells in patients with chronic heart failure did not differ from their number in control group, however we revealed tendency to increase of number of endothelial CD34+, CD133+, VEGFR-2+ progenitor cells. We confirmed presence of relationship between quantity of circulating stem and progenitor cells and traditional risk factors of cardiovascular events: age, excessive body mass, arterial hypertension, and intima media thickness of common carotid arteries. Besides lipid lowering effect therapy with rosuvastatin was associated with lowering of C-reactive protein level and increase of number of circulating CD34+, CD133+ cells.

[The density of myocardial and pericardial rat mast cells in isoproterenol-induced heart failure]

Myocardial mast cells (MC) respond to cardiovascular pathology. The behavior of MC population in myocardium and pericardium of rats has been studied 24 h, 14, 28 and 60 days after two isoproterenol injections (at 24 h intervals). The extent of heart failure has been estimated by supersonic inspection 28 and 60 days after isoproterenol injections. The density of MCs of different degrees of maturity was estimated on paraffin sections stained with Alcian blue--Safranin. The MC density in myocardium of intact and experimental rats was relatively low: from 4 to 6 cells/mm2. The MC density in pericardium of intact rats was several times higher than in myocardium: 48.6 +/- 13.0 cells/mm2. In 24 h and 14 days after isoproterenol injections the pericardial MC density was 1.5 times higher than in control rats (P < 0.05) at the expense of increase in the number of mature MCs with Safranine-positive granules without the increase in the number of immature cells with Alcian blue-positive granules. In 28 days the pericardial MC density was 2 times higher than in intact rats (P < 0.05) at the expense of increase in number of immature and mature cells. In 60 days after isoproterenol injections the pericardial MC density and the ratio of immature and mature cells compared with control did not reach statistical significance. The changes in pericardial MC population corresponded to severity of heart failure according to functional indices. The findings show active reaction of pericardial MCs on myocardium dysfunction that stimulates the maturation of resident immature MCs in pericardium and migration of immature cells to pericardium of damage heart.

[Immunolocalization of ANP in mast cells of rat and human pericardium]

It is known that many heart diseases are accompanied by a significant increase in the level of atrial natriuretic peptide (ANP), a regulator of cardiovascular homeostasis, in the pericardial fluid. Cellular sources of ANP in pericardial cavity remain uncertain. By EM immunocytochemistry, we have examined the presence and localization of ANP in rat and human pericardium. ANP-immunoreactive material was revealed in granules of mast cells (MCs) situated in connective tissue of the pericardium. MCs have an oval form and measure about 6.5 x 12.5 and 9.1 x 13.6 microm in the rat and human pericardium, respectively. Density of MC population makes up about 50 and 10 cells/mm2 in the rat and human pericardium, respectively. Our data suggest possible participation of the pericardial MCs in endocrine function of pericardium and in control of the ANP level in pericardial cavity.

[Matrix metalloproteinases: significance in remodeling of the myocardium in valvular heart disease]

AIM

To assess concentration of metalloproteinase (MMP) -9 and its inhibitor in blood serum of patients with defects of left cardiac chambers, associated with pressure or volume overload.

RESULTS

Elevation of MMP-9/TIMP-1 ratio at the account of MMP-9 was characteristic for patients with volume overload while elevation of blood serum level of TIMP-1 was characteristic for patients with pressure overload. MMP-9/TIMP-1 coefficient was directly related to left ventricular myocardial mass index and negatively related to myocardial contractile capacity. In patients with aortic stenosis elevation of TIMP-1 content was associated with lowering of global left ventricular contractility. Concentration of MMP-9 in blood serum and MMP-9/TIMP-1 ratio depended on etiology of valvular heart disease. Values of the given parameters were maximal in patients with mesenchymal dysplasia and sclerodegenerative calcinosis of the aortic valve.

CONCLUSION

Serum levels of MMP-9 and TIMP-1, as well as MMP-9/TIMP-1 ratio reflect type and severity of hypertrophy of the myocardium and can be looked upon as markers of myocardial remodeling.

[Cardial fibrosis and the functional activity of leukocytes in patients with essential arterial hypertension]

The study revealed an increase in the serum levels of TGF-beta1 and the N-terminal peptide procollagen type III in patients with essential arterial hypertension (EAH), as well as an association between this increase and the duration of the disease, mean day arterial pressure profile, and left ventricular hypertrophy. An increased leukocyte functional activity is associated with disturbances in left ventricular diastolic function and an increase in TGF-beta1 serum concentration in EAH. The authors conclude that leukocytes participate in the development of myocardial hypertrophy and cardial fibrosis through the secretion of pro-inflammatory cytokines and peptide growth factors within the process of their activation.