Vol 14, No 2 (2023)

Background: Atrial fibrillation (AF) and coexistent typical atrial flutter (AFL) interventional treatment strategy remains unresolved in cardiology and cardiovascular surgery. Results of this approach remain suboptimal. There are several approaches to the interventional treatment of patients with coexistent AF and AFL: simultaneous pulmonary vein isolation (PVI) and cavotricuspid isthmus (CTI) radiofrequency catheter ablation (RFCA), PVI or CTI RFCA only and two-stage approach. To our knowledge, cumulative efficacy of two-stage approach has not been previously reported.

The aim. This study aimed to evaluate the efficacy of two-stage approach for interventional treatment of coexistent AF and AFL for sinus rhythm maintenance in long-term.

Methods: Patients (pts) (n=34) with AF and AFL aged 41–82 years (11 women) were divided into two groups (1:1): «One-stage Approach» (group 1; n=17): PVI+СTI RFСA and «Two-stage approach» (group 2; n=17): first stage — CTI RFCA (group 2.1); second stage — PVI in case of AF recurrence after RFCA (group 2.2). Primary endpoint (PEP) was defined as any recurrent atrial tachyarrhythmia at the end of follow-up; group 2 events have been considered after PVI. Secondary endpoint (SEP) — recurrent any atrial tachyarrhythmia in groups 1 and 2 after CTI RFCA in group 2. PEP and SEP were evaluated at the end of the «blind period» (3 months after procedure).

Results: Registered recurrent atrial tachyarrhythmia in pts who reached PEP or SEP was AF. AFL has not been detected in any cases. PEP was noted in 8 (47.06%) pts in group 1 and 1 (5.88%) pts in group 2. Further, SEP was observed in 3 pts (17.65%) in group 1 and in 4 (23.53%) pts in group 2 (p=0.671). The probability of long-term maintenance of sinus rhythm was significantly higher in «Two-stage approach» than in «One-stage approach» (94.12% and 52.94%, respectively, p=0.001). Significant differences in procedure length and fluoroscopy time have been found. Those were longer in group 1 compared to group 2.1 (p <0.001) and in group 2.2 compared to group 2.1 (procedure duration — p <0.001; fluoroscopy time — p=0.013). No differences were noted in length of procedure and fluoroscopy time between groups 1 and 2.2 (p=0.374 and p=0.028, respectively).

Conclusion: The «two-stage approach» for interventional treatment of coexistent AF and AFL results in better long-term arrhythmia-free survival than «one-stage approach» (94.12% and 52.94%, respectively, p=0.001). CTI RFCA alone in pts with coexistent AF and AFL cause 23.53% AF recurrence rate and associated with shorter procedure duration and fluoroscopy time compared to simultaneous PVI and CTI RFCA (p <0.001).

Background: There is a need for the systematization, generalization and analysis of the structural changes of the myocardium, occurring in patients with myocarditis. This disease is rare; therefore, structured information in the field of radiological diagnostics is still insufficient within national publications.

Aim: The study purpose was to determine the significance and specificity of changes observed in cardiac magnetic resonance images in patients with myocarditis, and to compare the obtained results with the literature data.

Methods: 7 patients, including children aged 4 and 6, with a verified diagnosis of myocarditis were retrospectively examined.

Results: The analysis of the obtained images revealed the most common changes related to myocarditis, such as myocardial edema, impaired myocardial contractility, increased delayed accumulation of the contrast agent. The pathophysiological mechanisms of the found structural changes were analyzed and described.

Conclusion: Magnetic resonance imaging is the most important non-invasive method for diagnosing myocarditis, which allows one to identify the lesion of the heart muscle, to assess the extent of its damage, to differentiate myocarditis from other diseases, as well as to assess the dynamics when evaluating the effectiveness of therapy.

Background: Dislocations of the forearm are rare injuries with the annual incidence of 6.1 cases per 100 000 population. Postero-lateral rotational instability is the most common complication after the conservative treatment of forearm dislocations. To restore the congruency and provide early movements in the elbow joint, the primary repair or reconstruction of the damaged ligaments of the elbow are required.

Aim: to evaluate the clinical and functional results after the surgical repair of the elbow joint ligaments in acute postero-lateral rotational instability.

Methods: The study was based on a retrospective analysis of a series of clinical cases, including 17 patients with acute postero-lateral rotational instability, among them 5 simple forearm dislocations, 9 fracture-dislocations of the forearm and 3 fractures of the radial head. Refixation of the lateral ulnar ligament was performed with anchor fixation or bone tunnels. The evaluation was performed using the clinical aspects (the «lateral pivot shift» test, the range of motion), according to the scale for the evaluation of the elbow joint functional condition (MEPS), Oxford scale of the elbow joint evaluation (OEC), the X-ray results were also estimated.

Results: In all the cases the elbow joint stability had been achieved, according to the X-ray and clinical aspects. In 4 cases, additional plasty of the medial collateral ligament was needed and performed after the restoration of the lateral ligament complex. According to the MEPS scale, 58% of the achieved results were excellent, 35% were good and 5.8% were satisfactory.

Conclusion: The restoration of the lateral ulnar collateral ligament complex is a safe and effective procedure, which restores the elbow joint stability and allows the patients to return to full physical activity and avoid the development of postero-lateral rotational joint instability.

Despite the success of modern conservative therapy of severe spinal instability, surgical methods still retain their importance in the treatment of this pathology, but even the most successful operation may be in vain without subsequent adequate rehabilitation. This report summarizes the features of rehabilitation of patients after surgery for injuries of the cervical spine using methods and means of physiofunctional treatment.

Sepsis is an unregulated host response to infection resulting in life-threatening organ dysfunction. As one of the most catastrophic surgical complications, sepsis remains a major public health problem worldwide, with increasing incidence despite sterile preoperative prophylaxis and administration of antibiotics. Sepsis mortality has remained unchanged for over a decade, and early recognition continues to be the most crucial factor in survival outcome. Early and accurate diagnosis of infection and organ dysfunction remains problematic, as evidenced by numerous interventional trials that have not resulted in improved outcomes. These failures are partly because of the belated intervention, when the patient developed multiple-organ failure and the therapeutic window of opportunity closed. The success of immunomodulatory and other therapeutic strategies, which is often achieved in preclinical models of sepsis, depends on their use in the early stages of sepsis development or even proactive action. Predicting the development of sepsis in surgical patients using laboratory analysis of plasma may be useful for doctors in the intensive care unit and resuscitation. Significant efforts are being made to develop biomarkers for the early stages of sepsis with high sensitivity and specificity. For early and accurate diagnosis, effective treatment of sepsis requires a deep understanding of the pathogenetic mechanisms. Dysregulation of the patient’s response to infection leading to sepsis and septic shock is studied using ohmic approaches: proteomics, transcriptomics, and metabolomics. Owing to the complexity and large volume of data sets, special data analysis tools, the so-called machine learning, become necessary.

Background: Еndoscopic neurolysis of the sciatic nerve has proven itself as a low traumatic and effective technique of treatment for deep gluteal pain syndrome and sciatic nerve neuropathy. Until now, there have been no publications dedicated to the parietal peritoneum damage after endoscopic sciatic nerve decompression.

Clinical case description: A 70-year-old female patient with deep gluteal pain syndrome and sciatic nerve neuropathy on the right side and failure of a conservative treatment. According to the VAS scale, the severity of pain syndrome was 10 cm. The severity of the motor dysfunction, according to the BMRC scale, was 4 points. The severity of the sensitive dysfunction, according to the Seddon scale, was 3 points. The functional activity of the lower limb, according to the LEFS scale, was 48 points. The instrumental investigation of the sciatic nerve included MRI, ultrasound, and ENMG. Endoscopic sciatic nerve decompression was performed in the prone position with saline irrigation using the technique published before. After the surgery, an ultrasound study and a CT scan were performed, which determined the presence of a free fluid in the abdominal cavity, and edema of the right retroperitoneal space. The patient underwent laparoscopy, which revealed the area of the parietal peritoneum damage in the lower floor, with a free saline fluid detected in the abdominal cavity, which was evacuated. The patient was discharged from the hospital on the 10th day after the surgery. 6 months after the surgery, the functional activity of the lower extremity, according to the LEFS scale, was 52 points. Pain syndrome, according to the VAS scale, was 8 cm. The severity of the motor dysfunction, according to the BMRC scale, was 4 points. The severity of the sensitive dysfunction, according to the Seddon scale, was 3 points. The performed surgical endoscopic treatment was rendered ineffective.

Conclusion: The method of endoscopic sciatic nerve decompression with saline pumping has a risk of the following complication: damaging the parietal peritoneum, saline penetration into the abdominal cavity, edema of the retroperitoneal space. To decrease the risk of this complication, it is necessary to observe the specific surgical conditions such as: controlled hypotension in a patient and a low pressure in the arthroscopic pump, the time of surgery not exceeding 1 hour, and the saline consumption not exceeding 10 liters. It is also crucial not to perform the dissection and neurolysis too proximal to the piriformis area.

Background: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary autosomal dominant vascular injury of the brain. Currently, the clinical diagnosis of CADASIL is based on the following criteria: the onset of the condition at a relatively young age (40–50 years), recurrent lacunar infarcts, gradual progression of encephalopathy with the development of pseudobulbar syndrome and dementia, various emotional disorders, and autosomal dominant inheritance. Having a family history of relatives with similar symptoms. The diagnosis is verified on the basis of the results of the following studies: neuroimaging, instrumental, morphological, and laboratory. The presence of leukoaraiosis and multiple small bilateral infarctions in such anatomical structures as the basal ganglia and white matter of the cerebral hemispheres, visual tubercles and the pons, and brain stem during MRI diagnostics. Histologically, transmission electron microscopy reveals granular osmiophilic inclusions in the adventitial membrane of the blood vessels of the brain, and on the periphery — in the adventitia of the vessels of skeletal muscles and somatic nerves and in vascular biopsies of skin flaps. A mutation in the Notch3 gene determines the clinic of the disease and morphological changes in blood vessels and is detected by a molecular genetic method. The article presents a clinical case, which was a manifestation of this rare hereditary microangiopathy.

Clinical case description: A 43-year-old patient was admitted to the Department of Neurology of the Republican Clinical Hospital in Simferopol for ischemic stroke in the basin of the left middle cerebral artery. According to the anamnesis, the patient suffered from migraine without aura from a young age and lacunar strokes; examination revealed a decrease in cognitive function, and MRI showed signs of microangiopathy of cerebral vessels. For final diagnosis, the patient underwent an intravital pathomorphological examination of the biopsy of the musculoskeletal flap; the results obtained made it possible to make a reliable diagnosis of CADASIL.

Conclusion: Understanding and knowledge of such a rare pathology as CADASIL is crucial for the rapid recognition of a characteristic clinical picture for further appointment and interpretation of the results of morphological and molecular genetic diagnostics, making it possible to make the correct diagnosis and treatment.

Background: In clinical practice, drug-induced arterial hypertension (AH) often remains undiagnosed, since the identification of an ethical disease in this form of AH avoids the initiation of antihypertensive therapy. A critical part in the differential diagnosis of hypertension and planning of long-term strategies for managing a patient requires a thorough study of the properties of the drugs taken and the pathophysiological mechanisms that depend on the increase in high blood pressure against the background of taking one or another substance.

Clinical case description: Assumption of pregnancy in a random 57-year-old Caucasian female patient with AH syndrome and history of AD crisis during the year. Against the background of two-component antihypertensive therapy, indapamide 2.5 mg + telmisartan 80 mg, increased blood pressure. From the anamnesis of life, it is noteworthy that the patient should keep records with a hepatologist; with a diagnosis of chronic viral hepatitis C with moderate activity, she takes Phosphogliv. Physical examination confirmed the presence of grade 2 hypertension; no signs of target organ detection were found. Laboratory and instrumental research showed cytolytic syndrome of minimal activity (AST, 74.8 U/l; ALT, 60.5 U/l), hypokalemia (K+ 2.1 mmol/l), unknown etiology, aldosterone within the normal range, metanephrine (80.4 pg/ml at a rate of <64 pg/ml), and normetanephrine (276 pg/ml at a rate of <176 pg/ml) in blood plasma are increased. MSCT of the kidneys and adrenal glands revealed no enlarged formations. Drug-induced arterial hypertension was clinically diagnosed. Concomitant diseases: Chronic viral hepatitis C, moderate activity. Varicose veins, venous infection of the extremities. Dynamics and outcome. After the abolition of glycyrrhizic acid, blood pressure and potassium levels in the blood plasma returned to normal, which is not recommended to take antihypertensive drugs.

Conclusion: An exceptional clinical situation is a pronounced manifestation of a rare side effect of glycyrrhizic acid in the form of drug-induced hypertension.