Aim. To assess a relationship of left bundle branch block (LBBB) patterns defined by electrocardiography (ECG) and echocardiography with super-response (SR) to cardiac resynchronization therapy (CRT).

Material and methods. Sixty patients (mean age, 54,5±10,4 years) were examined at baseline and during follow-up (10,6±3,6 months). Patients were divided into groups: group I (n=31) — decrease of left ventricular end-systolic volume (ESV) ≥30% (super-responders) and II group (n=29) — decrease of LV ESV <30% (non-super-responders). Three strain-markers of LBBB assessed by tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) were used: early contraction of basal or midventricular segment in the septal wall and early stretching of basal or midventricular segment in the lateral wall (marker 1); early peak contraction of the septal wall occurred in the first 70% of the systolic ejection phase (marker 2, septal flash (SF)); early stretching wall that showed peak contraction after aortic valve closure (marker 3). The classical LBBB pattern was defined if all three strain-markers were present. The heterogeneous LBBB pattern was defined if two from three strain-markers were present.

Results. At baseline, groups did not differ in main clinical characteristics, including QRS width and LBBB assessed by ECG. Mechanical abnormalities were found only in group I: SF (32,3% vs 0,0%; p=0,001) and apical rocking (19,4% vs 0,0%; p=0,024), as well as classic LBBB mechanical pattern (20,8% vs 0,0%; p=0,05). The complex of heterogeneous LBBB mechanical pattern (odds ratio (OR), 7,512; 95% CI, 1,434-39,632; р=0,025), interventricular mechanical delay (OR, 1,037; 95% CI, 1,005-1,071; р=0,017) and longitudinal strain of interventricular septum mid segment (OR, 0,726; 95% CI, 0,540-0,977; р=0,035) had an independent relationship with SR. According to the ROC analysis, the sensitivity and specificity of model in SR prediction were 77,3% and 91,3% (AUC=0,862; p<0,001).

Conclusion. SR is associated with both LBBB mechanical patterns assessed by STE and TDI. LBBB defined by ECG did not have significant association with SR to CRT.

Aim. To assess the effect of cardiac contractility modulation (CCM) in patients with heart failure (HF) and atrial fibrillation (AF) on left ventricular (LV) myocardial cellular perfusion using perfusion single photon emission computed tomography (SPECT).

Material and methods. 99mTc-MIBI SPECT gated myocardial perfusion imaging was performed in 60 patients with HF and AF before implantation of CCM device and after 6-months follow-up. All patients received long-term optimal medication therapy for HF. Results. The results obtained indicate a significant positive effect of CCM use in patients with HF and AF on LV ejection fraction (increase from 22 [18;30] to 25,5 [19;38] (p=0,002)), LV volume (decrease in LV end-systolic volume from 187 [114;238] to 154 [100;201] (p=0,001), end-diastolic volume from 229 [174;290] to 209 [159;259] (p=0,007)), as well as myocardial perfusion values. There is a favorable myocardial perfusion dynamics, which was more pronounced in nonischemic HF: increase in SRS from 6 [5;9] to 8,0 [6;11] after 6 months (p=0,01)). The extent of impaired perfusion significantly decreases from 12 [9;17] to 9 [6;16] (p=0,04). An indicator reflecting the total impairment of LV myocardial perfusion significantly decreases: total perfusion deficit decreased from 10 [8;14] to 7 [6;14] after 6 months (p=0,02), compared with ischemia-related HF.

Conclusion. Perfusion SPECT makes it possible to assess the myocardial cellular perfusion during CCM therapy in patients with HF of various origin and AF. CCM therapy improves myocardial contractility and perfusion in patients with HF and AF.

Aim. To study the predictive value of growth differentiation factor 15 (GDF-15) in patients with atrial fibrillation (AF) after elective percutaneous coronary intervention (PCI).

Material and methods. The study included 150 patients (men, 69,3%) with AF receiving direct oral anticoagulants in combination with two (89,3%) or one antiplatelet agent (10,7%) after elective PCI. Median age was 71,0 [interquartile range, 66,0; 77,0] years. The median follow-up was 11,5 months [interquartile range, 8,0; 12,0]. The efficacy endpoint was the sum of cardiovascular events (CVEs), including cardiovascular death, ischemic stroke, venous thromboembolism, peripheral arterial thrombosis, acute coronary syndrome, and the need for emergency PCI. The safety endpoint was considered to be BARC type 2-5 bleeding. Prior to PCI, blood plasma samples were taken from patients to determine GDF-15 and D-dimer by enzyme immunoassay.

Results. The incidence of CVEs was 16%. The incidence of BARC type 2-5 bleeding was 24,7%. The median GDF-15 level was 1270,0 pg/ml [953,0; 1778,0]. According to multiple regression, the GDF-15 level is associated with D-dimer (t=3,20; p=0,0018), diabetes (t=3,97; p=0,0001) and SYNTAX score II (t=4,77; p<0,0001). In patients with single-vessel coronary artery disease, the GDF-15 level was significantly lower than in patients with three-vessel disease (p=0,0119). According to the ROC analysis, a GDF-15 >1191 pg/ml (p=0,0076) increases the likelihood of CVE (area under the curve, 0,647; confidence interval (CI), 0,5650,723). According to Kaplan-Meier survival curves, significant differences were found in terms of absence of CVEs during the follow-up period between the groups of patients with a GDF-15 >1191 and those with GDF-15 <1191 pg/ml (76% vs 94%, p=0,0032; relative risk, 4,36; CI 1,50-7,48). The relationship of GDF-15 level with BARC type 2-5 bleeding was not revealed.

Conclusion. GDF-15 is a novel marker of CVE in AF patients after elective PCI.

Aim. To study the myocardial morpho-functional abnormalities, the incidence and nature of cardiac arrhythmias in patients 3 months after the coronavirus disease 2019 (COVID-19).

Material and methods. The study included 77 patients (mean age, 35,9 years) treated for coronavirus infection, which underwent echocardiography and 24-hour Holter monitoring 3 months after COVID-19. The patients were divided into 3 groups: group 1 — 31 patients with upper respiratory tract involvement; group 2 — 27 patients with bilateral pneumonia (CT grade 1, 2), 3 — 19 patients with severe pneumonia (CT grade 3, 4). Statistical processing was carried out using Statistica 10.0.

Results. According to echocardiography, the peak tricuspid late diastolic velocity and isovolumetric contraction time in all groups increased (P<0,001). The tricuspid and mitral Em/Am ratio decreased depending on the disease severity. In group 3, the right ventricular and atrial size increased (P<0,001). The pulmonary artery systolic pressure, left atrial volume in patients of the 2nd and 3rd groups was higher than in the control one (P<0,001). In group 1 and 2 patients, the regional strain in basal and basal/middle segments decreased, respectively, while, in group 3, not only regional but also global left ventricular (LV) strain decreased (P<0,001). In all groups, cardiac arrhythmias and pericardial effusion were found. The relationship was established between coronavirus activity and the structural and functional myocardial parameters (P<0,001).

Conclusion. Cardiovascular injury 3 months after COVID-19 was found in 71%, 93%, and 95% of patients with mild, moderate and severe course. In mild course patients, a decrease in regional myocardial strain in LV basal segments, signs of past pericarditis, and various cardiac arrhythmias were noted. In patients of moderate severity, these changes were more pronounced and were accompanied by an additional decrease in regional strain in LV middle segments, impaired right ventricular diastole and increased pulmonary artery pressure. In severe patients, in addition to the above changes, dilatation of the right heart and inferior vena cava was recorded, as well as LV diastolic and global systolic function decreased.

Aim. To develop an algorithm for selecting predictors and prognosis of atrial fibrillation (AF) in patients with coronary artery disease (CAD) after coronary artery bypass grafting (CABG).

Material and methods. This retrospective study included 886 case histories of patients with CAD aged 35 to 81 years (median age, 63 years; 95% confidence interval [63; 64]), who underwent isolated CABG under cardiopulmonary bypass. Eighty-five patients with prior AF were excluded from the study. Two groups of persons were identified, the first of which consisted of 153 (19,1%) patients with newly recorded AF episodes, the second — 648 (80,9%) patients without cardiac arrhythmias. Preoperative clinical and functional status was assessed using 100 factors. Chi-squared, Fisher, and Mann-Whitney tests, as well as univariate logistic regression (LR) were used for data processing and analysis. Multivariate LR and artificial neural networks (ANN) were used to develop predictive models. The boundaries of significant ranges of potential predictors were determined by stepwise assessment of the odds ratio and p-value. The model accuracy was assessed using 4 metrics: area under the ROC-curve (AUC), sensitivity, specificity, and accuracy.

Results. A comprehensive analysis of preoperative status of patients made it possible to identify 11 factors with the highest predictive potential, linearly and nonlinearly associated with postoperative AF (PAF). These included age (55-74 years for men and 60-78 years for women), anteroposterior and superior-inferior left atrial dimensions, transverse and longitudinal right atrial dimensions, tricuspid valve regurgitation, left ventricular end systolic dimension >49 mm, RR length of 1000-1100 ms, PQ length of 170-210 ms, QRS length of 50-80 ms, QT >420 ms for men and >440 ms for women, and heart failure with ejection fraction of 4560%. The metrics of the best predictive ANN model were as follows: AUC — 0,75, specificity — 0,73, sensitivity — 0,74, and accuracy — 0,73. These values in best model based on multivariate LR were lower (0,75; 0,7; 0,68 and 0,7, respectively).

Conclusion. The developed algorithm for selecting predictors made it possible to verify significant predictive ranges and weight coefficients characterizing their influence on PAF development. The predictive model based on ANN has a higher accuracy than multivariate HR.

Aim. To determine quantitative criteria for assessing the therapeutic benefits and the most informative time frames after cardiac resynchronization therapy (CRT) to assess its long-term effectiveness (1, 2, 3 years of follow-up) based on retrospective analysis. To assess the CRT effectiveness, parameters of left ventricular (LV) reverse remodeling and signs characterizing the clinical CRT response were considered.

Material and methods. This single-center, retrospective, non-randomized study included data from 278 patients with implanted CRT devices. Quantitative criteria for assessing CRT effectiveness were determined using a two-step cluster analysis of patients 1, 2, and 3 years after CRT by LV reverse remodeling parameters.

Results. In the dataset with satisfactory division accuracy, after the first year, two clusters were identified, which are conventionally named as “non-responders” and “responders”. Two and three years after therapy, patients were classified into three clusters: “non-responders”, “responders” and “super-responders”. For the obtained clusters, we found cutoff values for LV reverse remodeling parameters, which can be used as criteria for response to therapy.

The study identified the most informative time frames for assessing the postoperative CRT effectiveness 1, 2, 3 years after the surgery. At the same time, the clinical response to therapy is manifested earlier in comparison with the reverse LV remodeling.

Despite the high divisibility of patients into responders and non-responders, predictive models of CRT effectiveness created using the available data from standard diagnostic protocols for heart failure patients have insufficient accuracy to be used for making decisions on therapy appropriateness. This circumstance indicates the need to receive additional data to improve the forecasting quality.

Conclusion. The study revealed a period for assessing the clinical response and changes in LV reverse remodeling after CRT surgery, which is important for the optimal choice of postoperative therapy. It has been shown that in most cases, one year after surgery is sufficient to assess the clinical response, and the process of LV reverse remodeling can last up to two years on average.

When assessing the CRT effectiveness by reverse remodeling, along with a change in LV end-systolic volume (ESV), it is necessary to take into account LV end-diastolic volume (EDV) changes. The change in LV ejection fraction showed a significantly lower value among the analyzed parameters in assessing the CRT effectiveness. Based on the cluster classification of patients, a dividing rule was established for responders and non-responders in the first and second years after surgery with an accuracy of 97%: a decrease in LV ESV and EDV by 9% or more compared to preoperative values.

Aim. To determine the features of left atrial electroanatomic structure and the arrhythmia substrate in patients with atrial fibrillation (AF) after coronavirus disease 2019 (COVID-19).

Material and methods. The pilot study included 20 patients with AF who underwent catheter radiofrequency ablation. Ten patients had COVID-19 and 10 patients were included as a control group. AF substrate was identified using anatomic and bipolar mapping. Zones with following amplitudes were analyzed: <0,25 mV, <0,5 mV, from 0,5 to 0,75 mV inclusive, and >0,75 mV. Left atrial volume was determined based on anatomic map.

Results. The groups were homogeneous in AF type, number of patients after prior pulmonary vein isolation, and heart rate during mapping. In the COVID-19 group, there was a higher area of fibrous zones with an amplitude of <0,25 mV (51,5±16,6% vs 29,1±16,1% in the control group, p=0,007), <0,5 mV (76,7±11,5% vs 45,6±22,7% in the control group, p=0,001) and a lower area of intact myocardium with an amplitude >0,75 mV (11,6±8,0% vs 45,0±25,0% in the control group, p=0,001). In 7 COVID-19 patients, the posterior wall was isolated due to low-amplitude zones. Of these, three patients underwent surgery for the first time. According to ROC analysis, in patients after COVID-19, fibrous tissue (<0,5 mV) occupies more than half of the area, while normal tissue (>0,75 mV) — ~30% or less.

Conclusion. This study shows that SARS-CoV-2 infection may cause left atrial remodeling in the form of diffuse fibrosis. The arrhythmia substrate in patients after COVID-19 can be localized not only in pulmonary vein mouths, but also in other left atrial areas. This must be taken into account before ablation, even if the procedure is being performed for the first time. It is recommended to perform amplitude mapping for all patients who have had SARS-CoV-2 infection in order to identify fibrous zones and plan the operation extent.

Aim. To determine the blood concentration of fibrosis biomarkers in patients with atrial fibrillation (AF) in combination with metabolic syndrome (MS) and to analyze the relationship with myocardial fibrosis.

Material and methods. This cross-sectional case-control study included 547 patients aged 35 to 65 years: experimental group — patients with MS (n=373), of which 202 patients had AF; comparison group — AF patients without MS (n=110); healthy subjects without cardiovascular diseases and metabolic disorders (n=64). Patients with AF and MS who underwent electroanatomic mapping before pulmonary vein isolation (n=79) were assessed for left atrial (LA) fibrosis severity.

Results. It was found that the blood concentration of circulating profibrogenic biomarkers in patients with AF and MS is higher than in patients with AF without MS: aldosterone (135,1 (80,7-224,1) and 90,1 (68,3-120,3) pg/ml, p<0,0001), galectin-3 (10,6 (4,8-15,4) and 5,8 (4,8-8,3) pg/ml, p=0,0001), GDF15 (938,3 (678,3-1352,1) and 671,0 (515,7-879,5) pg/ml, p=0,001), TGF-beta-1 (4421,1 (2513,5-7634,5) and 2630,5 (2020,7-3785,4) pg/ml, p=0,001), CTGF (167,8 (78,9-194,3) and 124,3 (74,4-181,9) pg/ml, p<0,0001), PIIINP (88,5 (58,6120,4) and 58,9 (40,7-86,1) ng/ml, p<0,0001), PINP (3421,4 (1808,1-4321,7) and 2996,1 (2283,8-3894,3) pg/ml, p<0,0001). Patients with paroxysmal AF have higher concentrations of TGF-beta1, CTGF and PINP than patients with persistent and permanent AF. In patients with persistent AF and MS, the concentrations of galectin-3, aldosterone, and PIIINP were higher than in patients with paroxysmal AF, while in patients with permanent AF, they were significantly lower. The plasma concentration of galectin-3 positively correlated with levels of PINP (p=0,465, p<0,0001), PIIINP (p=0,409, p<0,0001), GDF-15 (p=0,369, p<O,O001), CTGF (p=0,405, p<0,0001). According to multivariate regression, of all studied biomarkers, GDF-15 had a greater effect on PIIINP concentration (в=0,234, p=0,038), and galectin-3 — on PINP (в=0,248, p<0,021). Positive correlations of the severity of left atrial fibrosis with the concentration of galectin-3 (p=0,563, p<0,0001), PINP (p=0,620, p<0,0001), TGF-beta-1 (p=0,390, p<0,0001) and CTGF (p=0,551, p<0,0001). According to linear multivariate regression, the most significant effect on LA fibrosis severity among the studied biomarkers is exerted by galectin-3 (в=0,432, p<0,0001), PINP (в=0,343, p=0,001) and PIIINP (в=0,286, p=0,008).

Conclusion. An increase in the blood concentration of profibrogenic biomarkers galectin-3, TGF-beta-1, CTGF, PIIINP, and PINP is associated with an increase in LA fibrosis severity and probably has a pathogenetic role in increasing the AF risk in patients with MS.

The course of hypertension is often complicated by left ventricular hypertrophy (or hypertensive heart disease, HHD). The main “corridor” of natural HHD is development of heart failure with preserved ejection fraction (HFpEF). With HFpEF, the bioavailability of natriuretic peptides (NP) is significantly reduced, as a result of which the activity of cGMP-PKG signaling pathway, which plays a key role in maintaining normal diastolic function, weakens. It is possible to increase the activity of this pathway using the neprilysin inhibitor sacubitril. In case of HFpEF, the greatest efficacy from valsartan+sacubitril therapy should be expected in patients with severe concentric LVH, who have the most pronounced natriuretic peptide deficiency. Valsartan+sacubitril therapy has a clear hypotensive effect, causes a reversal of left ventricular hypertrophy and fibrosis. Since no effective treatment has yet been found for HFpEF, the main way for HHD treatment should be to prevent the diastolic dysfunction progression, which justifies valsartan+sacubitril therapy starting from the early/ asymptomatic stages.

Coronary artery disease (CAD) is the most common cardiovascular disease and the leading cause of morbidity and mortality. Acute coronary syndrome (ACS) as an abrupt destabilization of CAD, multiplies the risk of cardiovascular events. To reduce the incidence of recurrent cardiovascular events, timely tackling potentially reversible risk factors such as hypertension and/or hyperglycemia is imperative. However, a solid basis for a secondary prevention lies in the treatment of dyslipidemia and begins in the first hours of hospital admission. Despite considerable evidence regarding the efficacy and safety of lipid-lowering therapy, averagely only one third of patients maintain control of lipids. The main challenges are low adherence, poor continuity of medical care, and the lack of an ambulatory routine follow-up. Telehealth solutions are believed to address these barriers and may be considered as an add-on to in-person patient care. Telemonitoring of vital and laboratory parameters, remote patient counseling can be introduced into routine care delivery. Telemedicine shows promise for fostering better clinical effect, and provides health-related quality of life improvement.

It is planned to conduct a pilot observational study aimed to create and to test an integrated solution, i.e. telemonitoring and remote counseling in patients of very high cardiovascular risk with ACS followed by myocardial revascularization. The goal is to determine the clinical effectiveness, i.e achievement of target values of blood pressure, lipid profile and glycemia, and patient-centeredness of this approach.

Aim. To compare the efficacy and safety of prasugrel, ticagrelor, or clopidogrel as part of dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) due to myocardial infarction (MI).

Material and methods. The observational study included 74 patients who underwent PCI due to MI within the first 24 hours after the onset. The patients were devided into 3 groups: group 1 — patients who received ticagrelor as part of DAPT; group 2 — clopidogrel, group 3 — prasugrel. The follow-up period was 28 days. To assess the efficacy and safety of therapy, a composite endpoint was assessed (death + nonfatal recurrent MI (and/or stent rethrombosis) + nonfatal ischemic stroke (IS). Additional secondary endpoints were any moderate and severe (major) bleeding according to the GUSTO and/or TIMI scales. We assessed the incidence of reperfusion arrhythmias, an opening of an infarct-related coronary artery (IRCA), and non-ST elevation myocardial infarction (non-STEMI).

Results. The analysis showed no significant differences in the cumulative incidence of adverse outcomes in the study groups within 28 days. The prevalence of secondary endpoints over a 28-day follow-up period was 3,1% in the ticagrelor group and 5,9% in the clopidogrel group, while no moderate and life-threatening bleeding was recorded in the prasugrel group during. There were no significant differences in the incidence of reperfusion arrhythmias, opening of an IRCA, and non-STEMI between the groups.

Conclusion. The obtained results suggest the comparable efficacy and safety profiles of prasugrel, ticagrelor and clopidogrel as a part of DAPT in patients undergoing PCI due to MI. There were no significant differences in endpoint event rates. In particular, prasugrel has been shown to be as effective and safe as ticagrelor.

Introduction. Persistent atrial standstill is a rare syndrome characterized by absence of mechanical and electrical atrial activity. The article presents a unique case of atrial standstill in the newborn patient with tachyarrhythmia.

Brief description. The first manifestation of atrial standstill in the patient was heart failure (HF) manifestations and wide-complex tachycardia according to electrocardiography, which was identified as ventricular tachycardia. At the local outpatient clinic, the child was prescribed with antiarrhythmic therapy (AAT), which decreased heart rate. Three months later, a transesophageal electrophysiological study was carried out in our center in order to determine the arrhythmia origin. A multiform idioventricular rhythm with a heart rate of 46-119 beats per min was diagnosed, atrial pacing spike (A waves) was not recorded. Given bradyarrhythmia, hemodynamic abnormalities on echocardiography (significant atrial enlargement, decreased contractility), the patient, in order to prevent the risk of sudden cardiac death, underwent implantation of single chamber pacemaker in VVIR mode and bipolar ventricular lead. Anticoagulant therapy was prescribed. After 6-month follow-up, relief of HF symptoms and an increase in left ventricular contractile function was noted.

Discussion. Timely diagnosis and implantation of pacemakers allowed avoiding AAT and minimizing the HF symptoms. Continuous ventricular pacing and anticoagulant therapy are important in HF prevention.

Atrial fibrillation (AF) is one of the most common tachyarrhythmias, contributing to both environmental and genetic factors, a clear understanding of which can be extremely important for determining management tactics and predicting the disease course. The article provides a brief overview of studies on genetic predictors of AF, in particular, SNP markers found on chromosome 10. Establishing a relationship between the identified SNPs on chromosome 10 and functional genes, changes in the structure or regulation of which can affect the development of AF, opens the veil of understanding how these SNPs affect the pathogenesis of AF.

The use of direct oral anticoagulants minimized the risks associated with vitamin K antagonist (warfarin) therapy. Currently, direct oral anticoagulants have priority over warfarin for the prevention of thromboembolic events in patients with atrial fibrillation and a number of other conditions requiring anticoagulant therapy. Direct oral anticoagulants along with antiarrhythmic therapy are the accepted strategy for atrial fibrillation treatment. At the same time, the effect of drug-drug interactions (DDI) between direct oral anticoagulants and antiarrhythmic drugs, which have common points of metabolic application, has not been fully elucidated. In order to provide effective and safe anticoagulant and antiarrhythmic therapy in patients with AF, it is important to understand the mechanisms and severity of DDI of direct oral anticoagulants and antiarrhythmic agents. This review discusses the issues of DDI of direct oral anticoagulants and antiarrhythmic drugs used to treat atrial fibrillation.

Russian Society of Cardiology (RSC).

With the participation of Russian Scientific Society of Clinical Electrophysiology, Arrhythmology and Cardiac Pacing, Russian Association of Pediatric Cardiologists, Society for Holter Monitoring and Noninvasive Electrocardiology.

Approved by the Scientific and Practical Council of the Russian Ministry of Health.

Russian Society of Cardiology (RSC).

With the participation of Russian Scientific Society of Clinical Electrophysiology, Arrhythmology and Cardiac Pacing, Russian Association of Cardiovascular Surgeons.

Approved by the Scientific and Practical Council of the Russian Ministry of Health.