Vol 30, No 3 (2022)

INTRODUCTION: Dual-chamber cardiac pacing permits to maintain permanent atrial-ventricular synchronization. Physiological sequence of propagation of the impulse from atria to ventricles is provided with an artificial delay analogous to delay of propagation of excitation through the atrioventricular (AV) node of a heathy individual. The delay interval is formed so that to minimize stimulation of the right ventricle. This preserves the left ventricular ejection fraction, reduces the risk of development of the chronic heart failure (CHF) and of atrial fibrillation, and increases functional abilities of the patient. On the other hand, critical increase in the atrioventricular delay leads to pacemaker syndrome: impairment of circulation function, shortness of breath, reduced tolerance to exercise, dizziness, syncopal state. The question of the influence of the permanent electrical pacing on the AV node conduction remains unsolved.

AIM: To study the effect of trimetazidine dihydrochloride on the AV node conduction in conditions of permanent cardiac pacing, to determine the effect of cardiac pacing on the AV node in the studied time period.

MATERIALS AND METHODS: The study involved 86 patients. The AV node activity was assessed by antegrade intraoperative determination of Wenckebach point on the basis of electrocardiography data in 24–48 hours after pacemaker implantation, in 6–8 hours, 7, 14, 9 and 180 days after intake of trimetazidine dihydrochloride and in 7, 14, 21 and 30 days after its cancellation. To compare the extent of influence of the studied drug on the AV node activity, the patients were divided to three groups depending on the basic pathology: group 1 ― patients with the sick sinus node syndrome (n = 38, 44.2%); group 2 ― patients with II degree AV block (n = 25, 29.1%); group 3 ― patients with III degree AV block (n = 23, 26.7%).

RESULTS: Trimetazidine dihydrochloride improved the electrophysiological properties of the AV node in the first and second groups: increase in the mean value of Wenckebach point antegrade in the first group was in total 3.26% (р = 0.022), in the second group 4.68% (р = 0.001). In the third group of patients no improvement was noted, but it should be said that under the action of this drug, in 4 of 23 patients with III degree AV block, antegrade AV conduction appeared (р = 0.236).

CONCLUSION: Trimetazidine dihydrochloride has a positive effect on the AV node activity as early as in 6–8 hours of intake, which reaches maximum in 3 weeks. Cardiac pacing had no effect on AV node within the follow-up period (6 months).

INTRODUCTION: Spinal muscular atrophy (SMA) is a rare hereditary disabling disease and the most common hereditary cause of infant deaths. The timely comprehensive diagnosis of SMA permits to plan therapeutic tactics and preserve the quality of patients’ life. One of the objectives of the given work is a review of the actual literature data on etiopathogenesis, clinical presentation, valid diagnosis and modern effective tactics of SMA management.

AIM: To evaluate the management tactics of patients with SMA taking into account neuropsychiatric symptoms, to analyze problems of proposal and organization of measures aimed at improvement of the quality of medical care, on the basis of the practical experience of the Samara region and with consideration of the current state of the problem.

MATERIALS AND METHODS: In the work, the data of the archive of Seredavin Samara Regional Clinical Hospital were analyzed, 132 medical histories of 77 patients were processed with discharge dates from January 2008 to February 2022 with the following diagnoses (according to the code of the International Classification of Diseases and Health Related Problem, 10^th revision (ICD-10)): G12.0 (spinal muscular atrophy, type I [Werdnig–Hoffmann disease], G12.1 (other hereditary SMA), G12.8 (other SMA and related syndromes) and G12.9 (unspecified SMA). The analysis of the results of clinical, laboratory, instrumental and neuropsychiatric diagnostic methods was performed in comparison with the tactics of therapeutic management of these patients. For statistical processing of the data, methods of descriptive statistics were used.

RESULTS: Socio-demographic data. As of February 2022, 58 patients were registered (mean age 38.4 (41.3) years, of them 32 (55.2%) were individuals of female gender including 21 children (mean age 12.3 (7.4) years, 14 (24.1%) girls), with the following diagnoses according to ICD-10: G12.0 (n = 7; 12.0%; only children), G12.1 (children: n = 14; 24.1%; adults: n = 29; 50.0%), G12.8 (n = 6; 10.3%; only adults), G12.9 (n = 2; 3.4%; only adults). Clinical data. Motor disorders from a mild proximal lower paraparesis (n = 13; 22.4%) to pronounced tetraparesis (n = 7; 12.0%). The study of mental status was limited to evaluation of the state of consciousness and effectiveness of contact. Data on therapy. Until 2021, symptomatic therapy of SMA was conducted in the region, since March 2021, 8 children (13.8% of the total sample) aged 7.3 (8.8) years received nusinersen, another 8 children (13.8%) aged 9.5 (6.9) years received risdiplam; parents of 3 more children (5.2%) refused taking drugs. Of adult patients (n = 37; 63.8%; 35.3 (23.6) years) with confirmed SMA 5q (n = 10; 17.2%, 35.3 (19.0) years), 1 patient received nusinersen, the rest 9 patients (15.5%) did not receive therapy, 3 (5.2%) were achieving the right to receive drugs (at the moment of the analysis).

CONCLUSION: The data analysis revealed deficit of early SMA diagnosis (at the moment of the diagnosis, all the patients were already having pronounced symptoms), of assessment of affective and cognitive disorders, monitoring of treatment effectiveness (absence of validated scales for motor skills assessment), and also showed low availability of treatment for adult patients, which requires reorganization of care of patients with SMA in the region taking into account the revealed factors).

INTRODUCTION: The factors and mechanisms of progression and recurrence of the palmar fascial fibromatosis with formation of severe Dupuytren’s contracture, remain insufficiently studied.

AIM: To identify probable mechanisms of progression of the palmar fascial fibromatosis based on the comparative analysis of clinical and morphological characteristics of patients with Dupuytren’s contracture of different extent of severity.

MATERIALS AND METHODS: Objects: medical histories and histological preparations of surgical material of patients with I–II (group 1, n = 121) and III–IV (group 2, n = 135) degree Dupuytren’s contracture. Methods: clinical, histological, statistical.

RESULTS: Clinical markers of hereditary predisposition to Dupuytren’s disease (the percentage of patients under 50 at the time of onset of the disease and the frequency of involvement of both hands) were comparable in the study groups. The incidence of diseases of the circulatory system was reliably higher in group 2: 57.0% against 41.3% (p < 0.01). A prolonged course of the disease (> 8 years) was identified only in half of the patients of group 2. The median of the content of hyperplastic connective tissue in the palmar aponeurosis in patients of groups 1 and 2 was 22.9% and 11.3%, respectively (p < 0.001), interquartile range 0%–67.8% and 0%–56.7%, respectively. In the capillary network and in the intima of larger vessels, CD34-positive endothelium was identified in patients of both groups. Around the blood vessels supplying fibromatous nodules and cords, cells expressing CD34 were found. Thickness of adventitia and Kernogan index in the arteries perforating the palmar aponeurosis, were higher in group 2.

CONCLUSION: A higher frequency of comorbid diseases of the circulatory system, more evident thickening of adventitia of arteries perforating the palmar aponeurosis, and reduction of their throughput capacity in patients with severe Dupuytren’s contractures indicate the significance of systemic and regional vasogenic mechanisms of progression of the palmar fascial fibromatosis. The content of hyperplastic connective tissue (histological predictor of recurrence) varies individually with each degree of contracture.

INTRODUCTION: One of the parameters of the functional reserves of the human body is the level of physical fitness, which depends not only on the improvement of various methods used in the education of students in physical culture, but also on the individual characteristics of students, including parameters of their functional lateralization.

AIM: To establish the character of the interrelations between the parameters of functional lateralization and the parameters of physical fitness in medical university students.

MATERIALS AND METHODS: Functional lateralization was determined by both the conventional test methods and by the method of neuro-energo mapping in 120 practically healthy medical university students of male gender aged 18 to 23 years. Physical fitness was assessed in conventional tests for determination of strength fitness, speed-strength fitness, speed endurance. All the data were processed using non-parametric statistical methods and correlation and cluster analysis.

RESULTS: Based on the criterion of physical fitness, young men were divided to two groups: a group with a relatively high level of speed and strength endurance and flexibility (cluster 1, n = 71), and a group with a relatively high level of strength fitness (cluster 1, n = 49). Both the integral (coefficient of lateral organization profile C_LOP) and partial parameters (manual and sensory asymmetry) of the functional lateralization were higher in the representatives of cluster 2, with this, the analysis of changes of the permanent potential level (method of neuro-energo mapping) in functional tests showed only an emerging tendency in the differences between the clusters. Also, in cluster 1, weak (r < 0.3, р < 0.05) negative relationships between the parameters of functional lateralization were found in behavioral tests, and between changes in the permanent potential level of the left and right cerebral hemispheres (Td–Ts lead) in load tests. In the representatives of the second cluster, no correlations were found.

CONCLUSION: The results of the performed comprehensive analysis evidence, in the authors’ opinion, the differences in the central-peripheral relationships in the systemic organization of physiological functions that determine non-uniform physical fitness in young men with a relatively high level of speed-strength endurance and flexibility (cluster 1) and those with a relatively high level of strength fitness (cluster 2).

INTRODUCTION: PNonspecific aortoarteritis is a rare autoimmune disease with the involvement and narrowing of the aorta and its branches leading to ischemia of the respective arterial region. In the territory of the Russian Federation, the most common manifestation of Takayasu nonspecific aortoarteritis is lesion of the branches of the aortic arch, which in rare cases leads to development of the so called “bald arch” syndrome. In response to hypoxia, intersystemic collaterals are formed through the neoangiogenesis or redirection of the blood flow from the occluded vessels to small-diameter vessels. In patients with “bald arch” syndrome, the key role in blood supply to the brain is played by the vertebral arteries. Here, collateral blood supply is realized through the intersystemic anastomoses, most often through the anastomotic leaks between the intercostal and internal thoracic arteries. In the literature, single cases of formation of collaterals between coronary and bronchial arteries are reported. The article presents a clinical case of coronary-vertebral anastomoses in a patient with extremely severe course of Takayasu arteritis with occlusion of the brachiocephalic trunk, right common carotid artery (CA), left common CA, right internal CA, left internal CA (“bald arch” syndrome). The probable cause of such course of the disease was late referral for medical help by the patient and lack of adequate basic therapy.

CONCLUSION: The demonstrated case is the fourth case in the world literature describing the existence of collaterals between the coronary arteries and cerebral arteries, and the first case in the world describing the existence of collaterals from the right and left coronary arteries to the vertebral artery. Such unusual pathway of collateral blood supply in the patient is explained by the absence of the possibility for collateral compensation from the systems of subclavian and intercostal arteries, severe chronic cerebral ischemia. Usually, the causes of angina pectoris in patients with nonspecific aortoarteritis are spread of arteritis to the coronary arteries, insufficiency of the aortic valve, hypertrophy of the left ventricle. In the described case, none of these conditions was present, and angina can only be attributed to the existence of unusual collaterals and the development of a transient steal syndrome.

INTRODUCTION: Despite the efforts of the cardiologic communities to introduce approaches to treatment of heart failure (HF) based on the highest level of evidence, HF remains one of the “least satisfied demands in the therapy of cardiovascular diseases” due to high prevalence, poor prognosis and insufficient use of treatment methods with clinically proven effectiveness. The article considers chronology of study and introduction of sodium-glucose cotransporter 2 inhibitors (syn.: gliflozins; SGLT2is) in clinical practice from the moment of creation of the first drug of this group ― florizin ― and further, stepwise with the change of the therapeutic paradigm as the result of performed clinical trials. Thus, EMPAREG OUTCOME, CANVAS, DECLARE-TIMI 58 studies demonstrated that SGLT2is not only produce a glucosuric effect, but also reduce the development and progression of HF and increase the life expectancy of patients with type 2 diabetes mellitus (DM2) and with reduced left ventricular ejection fraction (LFEF). DAPA-HF, EMPEROR-Reduced studies proved a possibility of improving the outcomes for patients with HF with reduced LVEF irrespective of the presence or absence of DM2, thereby significantly expanding the potential target group for SGLT2is. EMPEROR-Preserved study is the only study of SGLT2is to date (the study drug ― empagliflozin) that has demonstrated high effectiveness of the drug in prevention of cardiovascular mortality and hospitalizations for HF, probably irrespective of LVEF and the existence of DM2. In result, on September 9, 2021, FDA (Food and Drug Administration, USА) assigned the “breakthrough therapy” status to Jardiance® (empagliflozin) drug for treatment of HF with preserved LFEF. EMPA-REG OUTCOME, DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved, DAPA-CKD studies have shown SGLT2is to slow down the development of the terminal stage of chronic kidney disease. Finally, the main result of EMPULSE study completed in 2022, was the proven clinical benefit of empagliflozin in hospitalized and stabilized patients with acute HF decompensation irrespective of HF status and existence of DM2.

CONCLUSION: From the moment SGLT2is have been introduced in the clinical practice, they rapidly and successfully passed the way from the second-line antidiabetic drugs for which it was just enough not to worsen the prognosis for serious cardiovascular complications, to independent and effective class of drugs for treatment of HF (with class I and IIa recommendations). The totality of clinical trials of empagliflozin showed that empaflorizin is so far the only drug of the SGLT2is group with the proven safety and clinical effectiveness including the influence on the prognosis, in patients with HF irrespective of the LVEF status, presence or absence of DM2, for use in outpatient treatment and in stabilized patients in hospital.