Aim. Optimal revascularization strategy in multivessel (MV) coronary artery disease (CAD) eligible for percutaneous management (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR), or MV-PCI. Methods. Consecutive MV-CAD patients (n = 155) were randomized (1 : 1 : 1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization midterm efficacy and an independent predictor of long-term prognosis) preceded routine angiographic control. Results. Data are given, respectively, for the CABG, HCR, and MV-PCI arms. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.71). Hospital stay was 13.8 vs. 13.5 vs. 4.5 days (p<0.001), and sick-leave duration was 23 vs. 16 vs. 8 weeks (p<0.001). At 12 months, RI was 5 (2, 9)% vs. 5 (3, 7)% vs. 6 (3, 10)% (median; Q1, Q3) with noninferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). Rates of angiographic graft stenosis/occlusion or in-segment restenosis were 20.4% vs. 8.2% vs. 5.9% (p=0.05). Clinical target vessel/graft failure occurred in 12.0% vs. 11.5% vs. 11.3% (p=0.62). Major adverse cardiac and cerebral event (MACCE) rate was similar (12% vs. 13.4% vs. 13.2%; p=0.83). Conclusion. In this first randomized controlled study comparing CABG, HCR, and MV-PCI, residual myocardial ischemia and MACCE were similar at 12 months. There was no midterm indication of any added value of HCR. Hospital stay and sick-leave duration were shortest with MV-PCI. While longer-term follow-up is warranted, these findings may impact patient and physician choices and healthcare resources utilization. This trial is registered with NCT01699048.

The aim of this study was comparative assessment of in-hospital outcomes after hybrid and staged surgical management of patients presenting with haemodynamically significant lesions of the coronary (CA) and brachiocephalic arteries (BCA) treated by means of either endovascular or surgical techniques. Over the period from 2010 to 2017, we operated on a total of 197 patients with stenotic lesions of the carotid and coronary arteries. The strategy of revascularization included transcutaneous coronary intervention (TCI) and carotid endarterectomy (CEA). Of these, 73 (37%) patients underwent staged revascularization of the brain and myocardium in various sequence (TCI-CEA or CEA-TCI), with a mean interval between the operations amounting to 9.89±7.36 months. Unfavourable outcomes were regarded as the development of such significant cardiovascular events as myocardial infarction (MI), acute impairment of cerebral circulation, death, repeat unplanned revascularization. For hybrid strategy (TCI+CEA) the index period of assessing the outcomes was the single in-hospital period, whereas for the staged strategy it was the time period beginning from the in-hospital period of the primary operation and ending by the in-hospital period of the second stage. The groups were comparable by the absolute majority of the parameters. More than half of the patients were elderly males. One third had a history of MI. The findings of coronary angiography most often revealed lesions of 1-2 CAs. The average parameters of carotid artery stenosis, according to the BCA angiography varied from 74.9 to 82.6%, with bilateral occlusive stenotic lesions being revealed in every third patient. In connection with more frequent involvement of 1-2 CAs the patients underwent implantation of 1-2 stents. In our sample we used a total of 247 stents. Of these, 119 were uncoated and 128 were drug-eluting stents. No between-group significant differences in the development of unfavourable cardiovascular events during the in-hospital postoperative period were revealed. However, despite this, a pronounced negative tendency of the complication rate was noted in the group of staged revascularization. Non-optimal time intervals between the stages of the operations in a third of cases exceeded one year on the patient's own initiative. Nearly a quarter of patients did not come for the second stage of revascularization. An important finding of our study was no increase in the risk of stent thrombosis in hybrid operations compared with the staged approach, despite administration of a loading dose of clopidogrel after CEA, but not before TCI. Another significant result was the fact of greater availability of revascularization of the myocardium and the brain within the framework of the hybrid strategy as compared with the staged one, which may play an important role in prevention of ischaemic unfavourable events in the remote period of follow up.

Adipose tissue (AT) is an endocrine and paracrine organ that synthesizes biologically active adipocytokines, which affect inflammation, fibrosis, and atherogenesis. Epicardial and perivascular fat depots are of great interest to researchers, owing to their potential effects on the myocardium and blood vessels. The aim of the study was to assess the expression and secretion of adipocytokine genes in the AT of patients with coronary artery disease (CAD) and patients with aortic or mitral valve replacement. This study included 84 patients with CAD and 50 patients with aortic or mitral valve replacement. Adipocytes were isolated from subcutaneous, epicardial (EAT), and perivascular AT (PVAT), and were cultured for 24 h. EAT exhibited the lowest level of adiponectin gene expression and secretion, regardless of nosology, and high expression levels of the leptin gene and interleukin-6 (IL-6). However, EAT adipocytes in patients with CAD were characterized by more pronounced changes in comparison with the group with heart defects. High leptin and IL-6 levels resulted in increased pro-inflammatory activity, as observed in both EAT and PVAT adipocytes, especially in individuals with CAD. Therefore, our results revealed the pathogenetic significance of alterations in the adipokine and cytokine status of adipocytes of EAT and PVAT in patients with CAD.

ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ МУЛЬТИФОКАЛЬНОГО АТЕРОСКЛЕРОЗА: ПАТОЛОГИЯ КОРОНАРНОГО И БРАХИОЦЕФАЛЬНОГО БАССЕЙНОВ И ПРЕДИКТОРЫ РАЗВИТИЯ РАННИХ НЕБЛАГОПРИЯТНЫХ СОБЫТИЙ

To analyze the predictors of complications within 3 years after carotid endarterectomy (CEE). The study included 1035 patients after CEE for the period 2011-2016. Long-term follow-up period was 42.4±18.6 months (≈ 3.5 years). The endpoints were such unfavorable cardiovascular events as death, myocardial infarction, stroke/transient ischemic attack, redo revascularization. Statistical analysis was carried out by using of Statistica for Windows 8.0 software package (StatSoft Inc., USA). Stepwise logistic regression was applied to identify risk factors of adverse outcomes and death in long-term postoperative period. Comprehensive analysis of numerous factors (anamnestic, instrumental-diagnostic, surgical) allowed us to identify predictors of long-term unfavorable outcomes in patients with occlusive-stenotic lesions of carotid arteries. Risk factors of long-term complications were SYNTAX score ≥33 (high risk), unstable plaque in the contralateral ICA, occlusion of contralateral ICA, LVEF 40 min, previous CABG. These data are extremely important and can be used to create prognostic models. The last ones are necessary to determine optimal treatment strategy in patients with occlusive-stenotic lesions of supra-aortic vessels.