Prompt diagnosis of pulmonary embolism (PE) remains challenging, which often results in a delayed or inappropriate treatment of this life-threatening condition. Mobile thrombus in the right cardiac chambers is a neglected cause of PE. It poses an immediate risk to life and is associated with an unfavorable outcome and high mortality. Thrombus residing in the right atrial appendage (RAA) is an underestimated cause of PE, especially in patients with atrial fibrillation. This article reviews achievements and challenges of detection and management of the right atrial thrombus with emphasis on RAA thrombus. The capabilities of transthoracic and transesophageal echocardiography and advantages of three-dimensional and two-dimensional echocardiography are reviewed. Strengths of cardiac magnetic resonance imaging (CMR), computed tomography, and cardiac ventriculography are summarized. We suggest that a targeted search for RAA thrombus is necessary in high-risk patients with PE and atrial fibrillation using transesophageal echocardiography and/or CMR when available independently on the duration of the disease. High-risk patients may also benefit from transthoracic echocardiography with right parasternal approach. The examination of high-risk patients should involve compression ultrasonography of lower extremity veins along with the above-mentioned technologies. Algorithms for RAA thrombus risk assessment and protocols aimed at identification of patients with RAA thrombosis, who will potentially benefit from treatment, are warranted. The development of treatment protocols specific for the diverse populations of patients with right cardiac thrombosis is important.

BACKGROUND: Adequate glycemic control can significantly reduce the risk of developing cardiovascular events. However, until now, glycaemic targets in aged patients remain a subject of discussion, especially in the conditions of the combined development of Type 2 Diabetes Mellitus (T2DM) and ischemic heart disease (IHD).AIMS: To examine the structural and functional heart parameters in patients with IHD associated with T2DM and the rhythmoinotropic responses of their isolated myocardium depending on glycated hemoglobin level.MATERIALS AND METHODS: The study included 44 patients with a diagnosis of "chronic IHD associated with T2DM", of which 2 groups were formed. Patients with glycated hemoglobin level (HbA_1c) <8% were included in the 1^st group, and patients with HbA_1c ≥8% were included in the 2^nd group. The structural and functional heart parameters obtained with ultrasonography, and the rhythmoinotropic responses of myocardium in patients ex vivo were analyzed using the right atrial appendage fragments obtained during elective coronary artery bypass graft. The inotropic response of muscle strips at a basic stimulation frequency of 0,5 Hz to testing influences was assessed. An extrasystolic test and post-rest test were performed.RESULTS: It was found that extrasystolic contractions of isolated myocardial strips in patients of the 2^nd group appeared at shorter extrasystolic intervals, which indicates a greater excitability of the myocardium in patients of this group. Postextrasystolic muscle contractions in patients of the 2^nd group had significant potentiation. The amplitude of the muscle strips contractions in patients of both groups was potentiative after short rest periods. However, with an increase in the rest duration, potentiation of contractions was observed only in the group with a higher HbA_1c level. According to the ultrasonography data, it was found that the values of the endsystolic and diastolic volumes, the interventricular septum thickness and the left ventricular (LV) myocardium mass were significantly lower in the patients of the 1^st group compared with the corresponding indicators in the patients of the 2^nd group. The early LV filling velocity (peak E) was significantly lower in the patients of the 1^st group, which indicates a slower LV relaxation. At the same time, the rapid LV filling velocity did not have a significant intergroup difference, but this indicator exceeded the reference values in both groups.CONCLUSIONS: With a moderately increased glycemic level (9,2 [8,0; 10,3]%), the structural and functional heart parameters are preserved both at the level of the isolated myocardial tissue and at the level of the whole heart.

Introduction. Type 2 diabetes is the most common form of endocrine disease. Diabetes is a well-established risk factor for stroke. Carotid endarterectomy (CEE) is the main method of preventing a serious complication of stroke in patients with carotid stenosis. Consequently, the assess of type 2 diabetes on the results of CEE is an urgent problem of angiosurgery.Aim: To assess effect of type 2 diabetes on cerebrovascular reserve capacity and brain structure in patients with carotid atherosclerosis by ultrasound and magnetic resonance diagnostic.Material and Methods. 44 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), who underwent ultrasound and magnetic resonance examinations of the carotid arteries at the pre- and postoperative stages were included in this study. Two groups were formed: group I (n =15) – with a verified diagnosis of type 2 diabetes, group II (n = 29) – without diabetes. To assess the cerebrovascular reserve, functional hypercapnic and hyperoxic tests were performed.Results. The analysis of the results showed statistically significant differences in the ICA blood flow in both groups. Intergroup comparison before surgery in the middle cerebral artery on the side of hemodynamically significant stenosis revealed a statistically significant difference in pulsation and peripheral resistance index. In the common carotid arteries on both sides, significant intergroup differences were found in the velocity parameters of blood flow after the CEE operation. The reactivity index in patients with surgical stenosis with type 2 diabetes in the hyperoxic test was statistically significantly different on the side of the stenosis compared to the same indicator in the group without diabetes. There were no statistically significant differences in the hypercapnic test. The value of reactivity index indicates a negative or paradoxical reaction.Conclusion. The use of simple and accessible functional tests to assess cerebrovascular reserve, plaque structure and changes in the brain in patients with type 2 diabetes at the stage of preoperative preparation according to ultrasound and MRI studies allows us to correct the treatment and subsequent protection of the brain at the stage of surgery to prevent possible complications.

Сопряженность уровня гликемии и функциональных показателей миокарда у больных ишемической болезнью сердца на фоне сахарного диабета 2-го типа

Background. Currently there is no holistic view of the influence of metabolic factors and endocrine pathology on the development of thromboembolic complications, both arterial and venous, which is probably due to wide clinical variability, as well as the imperfection of diagnostic strategies. In many cases, echocardiography helps to solve the main problem and determine further therapeutic tactics. In connection with the foregoing, in patients with metabolic syndrome (MS), it is especially important to conduct echocardiography, which makes it possible to identify markers of subclinical myocardial dysfunction. The presence of MS in patients with pulmonary embolism (PE) is associated with a significantly higher recurrence rate of PE, confirming the importance of recognizing this risk factor and initiating appropriate therapy to reduce the risk of relapse.Aim: To carry out a comparative assessment of cardiac hemodynamic parameters in MS and non-massive PE.Material and Methods. The study included 82 patients: the first group – 52 patients with PE with a submassive or segmental lesion within 6 months before the study; the second group – 14 patients with metabolic syndrome; the third, control, group consisted of 16 patients who did not have diseases of the cardiovascular and respiratory systems.Results. In a comparative analysis of the data of patients with MS, patients with subsegmental PE and the control group, statistically significant differences were revealed in a number of parameters: the sizes and volumes of the right heart sections were statistically significantly smaller in the MS group than in the PE group, RVSP in patients with MS was statistically significantly lower in comparison with PE, the volume of RA in systole and diastole, the transverse dimension of the right ventricle in systole and diastole was larger in the group of PE and did not differ between patients with MS and controls. Significant differences in the value of a number of TDI indicators in individual segments of the right and left areas were revealed in the group with MS: in the group with MS, the ivct of the RA, LV, and LV was statistically significantly shorter than in the other groups. Compared to the control group, the values of e′ (early diastole) according to TDI from the fibrous ring of the mitral valve (from the septal and lateral walls) were found to be lower in patients with MS and PE, and peak A (late-diastolic filling) was statistically significant lower in the MS group than in the PE group. At the tissue level, a statistically significant slowing of the synchronization time in the LV was noted in the MS, 1st degree obesity and PE groups compared to the control group. At the same time, the isovolumic contraction time of RA and LV was significantly shorter in patients with MS than in patients with PE and the control group. It is worth noting that in patients with MS, although there were changes in the right parts, the changes in the left parts of the heart reliably prevailed. Whereas in patients with subsegmental PE, the changes in the right parts of the heart were more significantly expressed.Conclusion. A number of echocardiographic parameters have been identified to distinguish between patients with metabolic syndrome and non-massive PE. Echocardiographic indicators that allow to distinguish patients with metabolic syndrome and non-massive PE are: the time of isovolumic contraction of the left and right atria, the left ventricle according to TDI, the size and volume of the right heart, RVSP.