Frequent Ventricular Extrasystoles Research Articles

Structure of cardiac rhythm disorders in patients with obesity and associated with it dyslipidemia as an arrhythmogenic factor

Obesity is a global public health problem in the twenty-first century. The most adverse it’s effects are associated with visceral type, with accumulation of epicardial fat, showing high metabolic activity, dysfunction and important role in the development of lipotoxic cardiomyopathy linked with significant morphological and functional myocardial changes, accompanying by high risk of heart rhythm disorders. The aim of the study: to identify structure (frequency and character) of cardiac arrhythmias in men of employable age with visceral obesity, to establish the relationship of arrhythmias with features of the blood lipid spectrum of these patients. Material and methods. 98 men with abdominal obesity and 46 overweight patients were examined. The control group consisted of 40 healthy patients with normal body weight. All the patients were undergone ECG monitoring, echocardiography and analysis of serum lipid levels. Results. The presence of obesity is statistically significantly associated with the risk of supraventricular couplets, frequent ventricular extrasystoles, sinus arrhythmia and atrial fibrillation. The increase in the severity of obesity was accompanied by a tendency to a greater frequency of arrhythmias: in obesity of I degree, the frequency of atrial fibrillation was 12.3%, II–III degree — 21.2%, p = 0.25; frequent ventricular extrasystoles with similar degrees of obesity — 13.8% and 21.1%, respectively. Atrial fibrillation was significantly more often detected against the background of lipid disorders, mainly with a decrease in HDLP. Conclusion. The main type of heart rhythm disturbance in patients with obesity are supraventricular arrhythmias, mainly atrial fibrillation, the frequency of which increases in proportion to the increase in the patient's body weight. Abdominal obesity leads to an increase in ventricular ectopic activity. Dyslipidemia is the one of risk factors for arrhythmias in these patients.

Arrhythmic variant of post-covid myocarditis: spectrum of rhythm and conduction disorders, treatment approaches

Aim. To study the spectrum of rhythm and conduction disorders in patients with arrhythmic variant of postcovid myocarditis and determine the treatment approaches.Methods. The study included 23 patients with post-COVID-19 по абстракту разное написание. Post-COVID arrhythmias who had at least two of the three Lake-Louise criteria for myocarditis on magnetic resonance imaging of the heart and/or elevated anticardiac antibody (ACA) titers. The period of occurrence of post-COVID arrhythmias was 4.0 [2.0; 8.0] months, from 2 to 34 months. Echocardiography, Holter monitoring, and ACA study were performed. Cardiac magnetic resonance imaging was performed in 70% of patients (n=16). Coronary artery disease was excluded in 9 patients with risk factors.Results. In all patients’ arrhythmias were associated with COVID-19. Rhythm and conduction disturbances occurred within 2 to 34 months after infection. Echocardiography revealed no left ventricle systolic dysfunction. In all patients, an increase in ACA by 3 or more times was noted, in 65.2% (n=15) a specific antinuclear factor (ANF) was detected, reflecting the high immunological activity of myocarditis. Ventricular arrhythmias in most cases were represented by frequent ventricular extrasystole. Among supraventricular arrhythmias, frequent extrasystoles, non-sustained tachycardia, paroxysmal form of atrial fibrillation were detected. In one case, a transient atrioventricular block II-III degree developed. Treatment approaches included antiarrhythmic and immunosuppressive therapy. All patients underwent Holter monitoring, which showed regression of arrhythmias. Patients with high immunological activity of myocarditis underwent immunosuppressive therapy with methylprednisolone 8-16 mg/day (n=13), with moderate - mild immune-suppressive therapy with hydroxychloroquine 200 mg/day (n=10). When controlling the ACA titers, their decrease was noted. The decrease in the specific ANF titer was close to statistically significant (p=0.057). Interventional treatment of arrhythmias was performed in three patients.Conclusions. Arrhythmias that first developed after COVID-19 require the exclusion of subacute/chronic myocarditis that develops 2-8 months after COVID-19. The spectrum of arrhythmias in patients with post-COVID myocarditis is mostly represented by frequent symptomatic extrasystoles. Basic therapy of the arrhythmic variant of post-COVID myocarditis with methylprednisolone and/or hydroxychloroquine makes it possible to increase the effectiveness of antiarrhythmic drugs with the opportunity of their complete withdrawal in some patients.

КЛИНИЧЕСКИЙ СЛУЧАЙ ВАЗОСПАСТИЧЕСКОЙ СТЕНОКАРДИИ У ПАЦИЕНТА С ГАСТРОЭЗОФАГЕАЛЬНОЙ РЕФЛЮКСНОЙ БОЛЕЗНЬЮ

Introduction. The combination of CAD and GERD is a common clinical situation. In recent years, more and more information has appeared indicating that the coexistence of both diseases is not accidental. Clinical example. A 51-year-old man was admitted to the KGBUZ "AKKD" by transfer from the Central District Hospital with complaints of burning, pressing pains behind the sternum without a clear connection with physical activity, more often in the early morning hours, lasting up to 5 minutes, stopped by sitting, drinking cold water. Upon admission, the state of the average degree. BMI 23.9 kg/m2. Temperature 36.6 0С. NPV 16 per min. SpO2 - 96%. Heart rate 55 beats. in min. AD = 110/60 mm. rt. Art. Vesicular breathing in the lungs, no wheezing. The heart sounds are clear, the rhythm is correct. There are no edema. The abdomen is soft and painless. ECG at admission: sinus rhythm with a heart rate of 55 per minute. Negative T wave II, III, aVF, V7-V9. From the anamnesis: he had not previously controlled blood pressure, he did not take regular medications. Long history of smoking. During the year, he began to notice rare episodes of burning behind the sternum lasting up to 10 minutes without a clear connection with physical activity. He was examined at the place of residence, EGD was performed, where a hernia of the esophageal opening of the diaphragm, chronic atrophic gastritis were diagnosed. During the week before hospitalization, the condition worsened in the form of a decrease in exercise tolerance, an increase in burning sensation, pressing pain behind the sternum. On May 11, 23, due to a long-term pain syndrome behind the sternum, he called an ambulance, was hospitalized at the Central District Hospital, and then transferred to the AKKD. Upon admission to the AKKD, emergency coronary angiography was performed, where subocclusion of the circumflex artery (OA) was diagnosed, stenting of the OA with a drug-eluting stent. Echocardiography revealed hypokinesis along the lateral wall, the ejection fraction of the left ventricle was 59%. Laboratory: troponin I at admission and in dynamics within the reference values; dyslipidemia. After PCI in the department, daily recurrences of burning in the epigastrium and behind the sternum more often at night. Repeated EGD - reflux gastritis with metaplasia, cardiac insufficiency. HMECG recorded episodes of ST segment elevation in II, III, aVF, V5-V6, duration up to 70 minutes; frequent polymorphic ventricular extrasystole. Taking into account recurrent pains, the results of HMECG, a control coronary angiography was performed - the coronary arteries were without pathology, the OA stent was passable. Treatment was corrected, antianginal therapy was increased with beta-blockers, dihydropyridine calcium antagonists and long-acting nitrates, as well as therapy with proton pump inhibitors. During therapy, the condition improved, anginal pain did not recur. According to HMECG in dynamics - no ischemic changes. Discharged from the hospital in a satisfactory condition with recommendations. Conclusion. To date, a number of pathophysiological mechanisms have been established, both causing the pathogenetic relationship between IHD and GERD, and contributing to their mutual aggravation. The basis of the occurrence of associated angina pectoris is the esophagocardial reflex, caused by irritation of the esophagus and the development of coronary spasm as a result. In patients with variant angina pectoris, a time relationship was found between periods of esophageal spasm and episodes of ECG-registered ischemia. At the same time, it was found that with impaired esophageal motility in patients with coronary artery disease, a vicious circle may form: esophagospasm provokes myocardial ischemia, which, in turn, contributes to new episodes of esophageal spasm.

Endomyocardial substrate of ventricular arrhythmias in patients with autoimmune rheumatic diseases.

Delayed enhancement-magnetic resonance imaging (DE-MRI) has demonstrated that nonischemic cardiomyopathy is mainly characterized by intramural or epicardial fibrosis whereas global endomyocardial fibrosis suggests cardiac involvement in autoimmune rheumatic diseases or amyloidosis. Conduction disorders and sudden cardiac death are important manifestations of autoimmune rheumatic diseases with cardiac involvement but the substrates of ventricular arrhythmias in autoimmune rheumatic diseases have not been fully elucidated. 20 patients with autoimmune rheumatic diseases presenting with ventricular tachycardia (VT) (n = 11) or frequent ventricular extrasystoles (n = 9) underwent DE-MRI and/or endocardial electroanatomical mapping of the left ventricle (LV). Ten patients with autoimmune rheumatic diseases underwent VT ablation. Global endomyocardial fibrosis without myocardial thickening and unrelated to coronary territories was detected by DE-MRI or electroanatomical voltage mapping in 9 of 20 patients with autoimmune rheumatic diseases. In the other patients with autoimmune rheumatic diseases, limited regions of predominantly epicardial (n = 4) and intramyocardial (n = 5) fibrosis or only minimal fibrosis (n = 2) were found using DE-MRI. Endocardial low-amplitude diastolic potentials and pre-systolic Purkinje or fascicular potentials, mostly within fibrotic areas, were identified as the targets of successful VT ablation in 7 of 10 patients with autoimmune rheumatic diseases. Global endomyocardial fibrosis can be a tool to diagnose severe cardiac involvement in autoimmune rheumatic diseases and may serve as the substrate of ventricular arrhythmias in a substantial part of patients.

Carbamazepine in Ventricular Extrasystoles Management: Clinical Case

Carbamazepine is a drug that has been used for a long time to treat various neurological and psychiatric disorders. The drug has effect on many body systems and, in particular, on the cardiovascular. The cardiovascular effect of carbamazepine depends on several factors such as the presence/absence of any comorbidities and its plasma concentration. The drug’s antiarrhythmic effect was demonstrated previously in a number of experimental and clinical studies. In this article, we would like to present the clinical case of pediatric patient with frequent ventricular extrasystoles and arrhythmogenic myocardial dysfunction. Several antiarrhythmic drugs were ineffective in this patient, while carbamazepine administration contributed to the decrease in ectopic activity up to minimal values.

C79 NEGATIVE T WAVES ON ECG: NOT JUST HYPERTROPHIC CARDIOMYOPATHY

Abstract Background Arrhythmogenic cardiomyopathy is still considered a rare and difficult–to–diagnose condition, yet a well–founded clinical–instrumental suspicion and proper diagnostic procedure can unveil this condition early from common instrumental findings. Clinical Case In September, a 34–year–old man presented to our center for the presence on the electrocardiogram of ventricular repolarization changes (negative T waves in D1, inferior site and in all precordial leads with mild ST elevation in V1– V2). He denied family history of cardiological events. In 2018, following a suspected preoperative EKG, he performed an echocardiogram and cardiac magnetic resonance imaging (CMR); these examinations showed mild left ventricular hypertrophy with preserved systolic function. Clinically, the patient reported rare episodes of palpitation presented on ambulatory EKG with the same repolarization changes as mentioned above. In consideration of the clinic–instrumental findings, a diagnostic workup with echocardiogram and CMR was started for suspicion of hypertrophic cardiomyopathy in the first hypothesis. On echocardiogram, an non dilated left ventricle was found with left ventricular ejection fraction, parietal thicknesses, and segmental kinetics within normal limits, in the absence of significant valvulopathy; however, frequent ventricular extrasystoles were reported during the examination. Given the EKG–graphic alterations, although there weren‘t any echocardiographic changes, a CMR was performed, showing extensive irregularity of the epicardial profile of the lateral and infero–lateral mid–apical wall, site of adipose infiltration, in which evidence of intramyocardial late gadolinium enhancement (LGE) was also present; the right ventricle showed extensive microbulging of the mid–basal free wall in the absence of adipose replacement or LGE. In view of the clinical–instrumental pattern, the diagnosis of "left dominant" arrhythmogenic cardiomyopathy with initial involvement of the right ventricle was made. Conclusions EKG–graphic interpretation may in some cases be the only instrumental data underlying clinical suspicion of arrhythmogenic cardiomyopathy, allowing early diagnosis of a condition at high risk of sudden cardiac death.

P387 “THE IMPORTANCE OF NEW ADVANCED IMAGING TECHNIQUES IN SINE CAUSA VENTRICULAR ARRHYTHMIAS”

Abstract Case Presentation A 61–years–old woman was referred to our center after her 33 years old daughter suffered a sudden cardiac death. Cardiovascular risk factors: dyslipidemia and family history of ischemic cardiomyopathy. Diagnostic and Therapeutic Work Up Patient’s ECG was normal. Holter ECG showed frequent ventricular extrasystoles (2000/die) isolated and not premature, with LBB morphology, associated with not sustained ventricular tachycardias with LLB and low axis morphology (HR mean 140–170 beats/min). Exercise Stress Test did not show a clear correlation between physical activity and arrhythmias. Beta blocker therapy was started and was only partially effective in reducing ventricular arrhythmias, and a loop recorder was implanted. In 2019 a cardiac MRI with adenosine was performed, showing a mild globular shaped left ventricle with a non–specific linear distribution of LGE in the middle septum. Genetic analysis for channelopathies and cardiomyopathies resulted negative. In the last advanced echocardiogram (2022) with 3D reconstruction and strain analyses, characteristics suspected for arrhythmic mitral valve prolapse (MAD and curling of inferolateral wall) were identified. Accordingly, it has been decided to perform a second cardiac MRI to better characterize the underlying cardiac condition and to define the appropriate risk stratification algorithm. Conclusions Arrhythmic mitral valve prolapse is defined by ventricular arrhythmias in the absence of other known causes and it is present in up to 13% of sudden cardiac deaths in female patients. According to the recent consensus document by EHRA, sudden cardiac death risk stratification is complex and based firstly on the evaluation of arrhythmic burden, and secondly on symptoms and additional risk factors (i.e. MAD, left ventricle disfunction, flap redundancy, LGE in specific areas and so on). This case shows the importance of advanced imaging techniques and multimodal approach in ventricular arrhythmias evaluation.

Relationship of the White Coat Effect with Endpoints and Several Prognostic Indicators in Hypertensive Patients Treated with Regular Antihypertensive Therapy

Aim of the study was to evaluate in a prospective cohort study the relationship between the severity of the white coat effect (WHE) in patients with hypertension, who treated with regular antihypertensive therapy, and the composite endpoint, several prognostic indicators, in a routine clinical practice.Material and Methods. We analyzed the data of a prospective cohort study, which included 125 patients with hypertension who received regular antihypertensive therapy. The study consisted of three visits (baseline, 6 and 12 months) and an outcome data collection period (30.1±7.6 months of follow-up after the third visit). This study included three visits every 3 months: 1 visit – screening, ambulatory blood pressure monitoring (ABPM) session, Echo; 2 – assessment of the patient’s status and the therapy effectiveness; 3- assessment of the patient’s status, ABPM session, Echo (the total number of ABPM was 239, Echo - 240). The primary composite endpoint included death for any reason angina pectoris, transient ischemic attack, development of chronic heart failure, arterial revascularization, frequent ventricular extrasystoles, atrial fibrillation, secondary - deterioration of the cardiovascular diseases course and tertiary endpoint – deterioration of the arterial hypertension, concomitant diseases course.Results. The study involved 125 patients: 28 men (22%), 97 women (78%), mean age was 62.6±0.8 years, duration of hypertension 11.6±0.8 years, height 163.6±0.7 cm, body weight 83.1±1.4 kg. The baseline mean daytime systolic BP (SBP) was 125.1±9.8 and diastolic (DBP) – 76.1±7.0 mm Hg, age was 62.8±9.0 years, the WCE level for SBP was 16.5±1.4, for DBP 10.9±0.7 mm Hg. We identified a positive correlation between tertiary composite endpoint data and WCE: for systolic WCE (SWCE) (F = 4.7, p<0.031). We found correlations between WCE and Echo parameters: 1) SWCE level had with LVMI (r = 0.16. p<0.017); 2) diastolic WCE (DWCE) had negative relationship with LV contractility parameters.Conclusions. Thus, only systolic WCE level had correlation with composite endpoint data and LVMI. DWCE level had negative associations with echocardiography LV contractility parameters.

АССОЦИАЦИЯ АНЕМИИ С ЭКСТРАСИСТОЛИЕЙ У ПАЦИЕНТОВ СО СТАРЧЕСКОЙ АСТЕНИЕЙ

According global population aging there is an increase in the absolute and relative numbers of people in older age groups. Therefore, senile asthenia (SA) is very relevant. An association between SA and cardiovascular disease has been proven. In addition, there is an increase of aging anemia. At the same time, mortality in patients with anemia, including anemia, which is caused by cardiovascular diseases, increases. Purpose of the study: To study the association of anemia with cardiovascular pathology in patients who have SA syndrome. 168 over 65-year-old patients were examined. The main group contains 60 patients with SA syndrome (37 men, 23 women); control group includes 108 people (68 men, 40 women) without SA syndrome. The median age of patients in the main group did not statistically significantly differ from the median age of people in the control group (82 years ±7.4 [75.00; 84.00] years versus 78 years ±7.1 [65.00; 82.00] years, p=0.605). All patients had a comprehensive geriatric assessment (CGE). Statistically, anemia in patients with SA is diagnosed more frequently in comparison with patients without SA (51.67% vs. 33.33%, p<0.001). Statistically, significant negative correlations were determined among the hemoglobin level and senile asthenia (r=-0.222; p<0.001), hematocrit and senile asthenia (r=-0.224; p<0.001). There are statistically significant direct correlations between anemia in patients with SA with frequent supraventricular extrasystole (r=0.152; p=0.049) and frequent ventricular extrasystole (r=0.154, p=0.047). Conclusion: The association of SA with anemia was confirmed, whereas anemia in patients, who have SA syndrome, affects the occurrence of frequent supraventricular and frequent ventricular extrasystoles.

CMV-associated carditis in a 5-month-old child

The article presents a case of cytomegalovirus-associated carditis in a 5-month-old child. Carditis proceeded in an arrhythmic form and was manifested by frequent ventricular extrasystoles. An increase in the activity of creatine-phosphokinase was noted in the blood. The isolation of cytomegalovirus DNA from the blood, as well as IgM and IgG to cytomegalovirus, made it possible to associate the development of carditis with IgG to cytomegalovirus. Carditis in a child proceeded without signs of heart failure. After diagnostic and therapeutic procedures, the child was discharged home. This case shows that one of the possible causes of carditis in children is cytomegalovirus, which necessitates testing for markers of active cytomegalovirus infection. In this age group, it is possible to register both congenital and acquired variants of infection with heart damage, having different treatment regimens and prognosis.

Clinical features of drug-induced long QT syndrome in a large prospective cohort

Abstract Introduction Drug-induced long QT syndrome (DI-LQTS) is a clinical entity with prevalence and arrhythmic risk not well defined. Purpose To determine the clinical characteristics of patients with DI-LQTS diagnosed in the setting of a tertiary hospital center. Methods Prospective observational study with consecutive inclusion of patients with the diagnosis of DI-LQTS as per standard criteria, in a tertiary hospital, between 2018 and 2022. Results Eighty-five patients were included (age 65±15 years, 59% male). The mean corrected QT interval (QTc) of the entire cohort was 545±56 ms. The drugs responsible for QTc prolongation were: psychotropic drugs 51%, antiarrhythmics 38%, anesthetics 29%, antibiotics 15%, antineoplastics 3%, other 2%. QTc prolongation was due to the combination of ≥2 responsible drugs in 46 (54%) patients, and to the use of a single drug in 39 (46%). Twenty-one patients (25%) presented ventricular arrhythmias at the time of drug-induced QT prolongation: 10 (12%) ventricular fibrillation, 7 (8%) sustained ventricular tachycardia, 3 (3%) non-sustained ventricular tachycardia, 1 (1%) frequent ventricular extrasystole. Patients with ventricular arrhythmias were older (73±12 vs 62±15 years, p<0.05) and exhibited longer QTc prolongation (600±59 vs 528±42 ms, p<0.05). Conclusion The DI-LQTS is a rare clinical entity but may be cause of clinically-relevant ventricular arrhythmias. Older age and greater prolongation of the QTc interval are associated with an increased risk of ventricular arrhythmic events. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Institute Carlos III, Spain

WHITE COAT EFFECT LEVEL CORRELATED WITH THE ECHOCARDIOGRAPHIC PARAMETERS AND COMPOSITE ENDPOINT DATA IN TREATED PATIENTS WITH ARTERIAL HYPERTENSION

Objective: The aim of our study was to determine relationship between echocardiography (Echo) left ventricular mass index (LVMI), composite endpoint data and white coat effect (WCE) level in treated patients with arterial hypertension (AH). Design and method: We nalysed database (treated AH patients (n = 125) with concomitant chronic diseases without exacerbation or in compensation stage). This study was prospective and included three visits every 3 months: 1 visit - screening, ambulatory blood pressure monitoring (ABPM) session, Echo; 2 - assessment of the patient’s status and the therapy effectiveness; 3- assessment of the patient’s status, ABPM session, Echo (the total number of ABPM was 239, Echo - 240). We assessed composite endpoint after 30.1 ± 7.6 months from the screening visit (the primary composite endpoint included death for any reason angina pectoris, transient ischemic attack, development of chronic heart failure, arterial revascularization, frequent ventricular extrasystoles, atrial fibrillation, secondary - deterioration of the cardiovascular diseases course and tertiary endpoint - deterioration of the arterial hypertension, concomitant diseases course). We used ANOVA for statistical analysis. Results: The baseline mean (M ± m) daytime systolic BP (SBP) was 125.1 ± 9.8 and diastolic (DBP) - 76.1 ± 7.0 mm Hg, age was 62.8 ± 9.0 years. We identified a positive correlation between tertiary composite endpoint data and WCE: for systolic WCE (SWCE) (F = 4.7, p < 0.031). We found correlations between WCE and Echo parameters: 1) SWCE level had with LVMI (r = 0.16, p < 0.017); 2) diastolic WCE (DWCE) had negative relationship with end-diastolic (EDD) and systolic (ESD) diameters (r = -0.181, p < 0.007 and r = -0.187, p < 0.005); with ejection fraction (EF) and posterior wall thicknesses (PWT) (r = -0.176, p < 0.008 and r = -0.142, p < 0.033). In addition, we have identified that age and duration of AH were associated with SWCE, height and body mass index (BMI) had negative correlations with DWCE (see table). Thus, SWCE level had positive correlation with tertiary composite endpoint results (F = 4.7, p < 0.031) and LVMI (r = 0.16, p < 0.017). DWCE level had negative relationships with Echo LV contractility indices (ESD, EDD, EF). Conclusions: Thus, only systolic WCE level had correlation with composite endpoint data and LVMI. DWCE level had negative associations with echocardiography LV contractility parameters.

641 Left ventricular non-compaction as a distinct cardiomyopathy or a phenotypic feature: a case report

Abstract A 71-year-old male with no cardiovascular risk factors and a history of two uninvestigated episodes of loss of consciousness one year before, presented in our department to undergo a treadmill exercise stress test in relation to inverted T waves in V5-V6 on his basal ECG and frequent ventricular extrasystoles (PVCs). The stress test was positive for inducible ischemia, with a significant depression of the ST-segment in the lateral lead. A transthoracic echocardiography revealed normal thicknesses and volumes of the left ventricle (LV) with a dyskinesia of the lateral wall and a mildly reduced ejection fraction (EF) up to 46%. Epicardial surface was unremarkable. Next, a coronary angiography showed no critical obstruction in the epicardial coronary arteries. In order to further investigate the frequent PVCs and the reduction of the LV systolic function, a cardiac magnetic resonance (CMR) with paramagnetic contrast agent was performed. The images outlined the presence of non-compaction in the distal lateral wall and apex with a late gadolinium enhancement (LGE) in the epicardial portion of the lateral wall (Figure 1). Moreover, the CMR showed an adipose infiltration of the interventricular septum and thickened right ventricular trabeculae, suggesting an overlap with arrhythmogenic left ventricular dysplasia. During the subsequent follow-up, the patient was implanted with an implantable cardiac defibrillator (ICD), after two reported episodes of loss of consciousness and an electrophysiology study (EPS) resulting in the induction of a symptomatic ventricular tachycardia. Non-compaction cardiomyopathy is a rare and still relatively novel nosological entity, which can sometimes be observed in the same patient with other forms of cardiomyopathy. In the context of an unexplained reduction of LVEF and frequent PVCs, the accuracy of CMR in describing cardiac morphology and myocardial layer remains an indispensable tool to detect otherwise underdiagnosed potentially fatal cardiomyopathies.

Post-COVID myocarditis diagnosed by endomyocardial biopsy and/or magnetic resonance imaging 2–9 months after acute COVID-19

Abstract Purpose To study clinical features of myocarditis and its possible mechanisms (including persistence of SARS-Cov-2 in the myocardium) in the long-term period after acute COVID-19. Methods Fifteen patients (8 male and 7 female, mean age 47.8±13.4, 24–65 years) diagnosed with postcovid myocarditis were included in the study. The diagnosis of COVID-19 was confirmed by positive PCR results in 40%, and seroconversion in all patients. The average time of admission after COVID-19 was 4 [3; 7] months, from 2 to 9 months. The diagnosis of myocarditis was confirmed by cardiac MRI in 10 patients and by right ventricular endomyocardial biopsy (EMB) in 6 patients. The PCR for cardiotropic viruses and PCR with immunohistochemical study for SARS-Cov2 detection were used. All patients had study for anti-heart antibodies (AHA), EchoCG, and Holter ECG. Coronary atherosclerosis was excluded in all patients over 40 years (7 coronary angiography, 4 cardiac CT). Results A clear association of the cardiac symptoms with a previous new coronavirus infection was noted in all patients. The symptoms started 1–5 months following COVID-19. MRI showed subepicardial and intramyocardial LGE, signs of hyperemia, increased T1 relaxation time, edema. AHA levels were increased 3–4-fold in 73%. Two variants of postcovid myocarditis were observed. 1. Arrhythmic variant (n=6) – newly developed frequent supraventricular or ventricular extrasystole, recurrent atrial fibrillation in the absence of systolic dysfunction. 2. Decompensated variant with biventricular heart failure (n=9): the mean LV EF was 34.1±7.8% (23 to 46%), LV EDD 5.8±0.7 cm, EDV 153.8±46.1 ml, pulmonary artery systolic pressure 40.7±11.2 mmHg. In one case, myocarditis was accompanied by IgG4- and ANCA-negative aortitis. SARS-Cov-2 RNA was detected in 4 of 5 myocardial biopsies (in one case the material in the study). The longest period of virus persistence after COVID-19 was 9 months. By using spike and nucleocapsid antibodies, coronavirus was detected in cardiomycytes and macrophages. Data of patients with morphologically proved myocarditis are presented in Table 1. Lymphocytic myocarditis was diagnosed and confirmed immunohistochemically (n=5); giant cell myocarditis with atrial standstill was detected in one more case (Fig. 1). Three patients had also signs of endocarditis, in two cases with parietal thrombosis. Conclusions COVID-19 can lead to the subacute and chronic myocarditis of varying severity. Post-COVID myocarditis manifests itself in two main clinical forms - isolated arrhythmias and systolic dysfunction with heart failure. Post-COVID myocarditis is characterized by prolonged persistence of coronavirus (up to 9 months in this study, in most patients with decompensated variant) in combination with high immune activity (high titers of AHA), which should be considered as the main mechanisms of its long-term course. Treatment approaches for such myocarditis require investigation. Funding Acknowledgement Type of funding sources: None. Table 1. Patients with EMB proved myocarditisFigure 1. The EMB in postcovide myocarditis

Trypanocidal therapy among children infected by Trypanosoma cruzi. Serological and electrocardiographic changes over a mean twenty-five-years follow-up period

This study compared the serological and electrocardiographic evolution among patients with chronic T. cruzi infection treated during childhood or left untreated. A retrospective cohort study was conducted during a mean follow-up period of 25 years in 82 patients: half of them underwent treatment (nifurtimox 8, benznidazole 33) before being 15 years old, whereas the other half remained untreated. During the follow-up, negative seroconversion occurred in 92.7% of the treated children, while all the untreated ones remained positive for conventional serology. At baseline, 2 patients from each group had electrocardiographic abnormalities. During the study period, 4/41 (9.75%) and 9/41 (21.95%) of treated and untreated patients displayed an altered electrocardiogram, respectively. In multivariate analyses, the probability of developing electrocardiographic abnormalities was significantly reduced among treated patients (OR = 0.18, 95% CI = 0.04-0.79; p = 0.023). Electrocardiographic abnormalities attributable to Chagas cardiomyopathy were seen in 3 patients from the untreated group (complete right bundle branch block + left anterior fascicular block, frequent ventricular extrasystole, and left anterior fascicular block). The remarkable seronegativization seen in Benznidazole and Nifurtimox recipients underlines the parasiticidal effect of both compounds. Such demonstration along with the fact that CCC-related alterations were only present in the untreated group, reinforces the view of trypanocidal treatment in chronically T. cruzi-infected children as decreasing the risk for cardiomyopathy development.

Porushennia sertsevo-sudynnoi diialnosti ta endotelialnoi funktsii u vahitnykh iz nedyferentsiiovanoiu spoluchnotkanynnoiu dysplaziieiu; yikh korektsiia zavdiaky vkliuchenniu do protokolnoi prohramy likuvannia karnitynarhininovoho kompleksu

Context. Undifferentiated connective tissue dysplasia (UCTD) has negative impact on myocardial contractility and endothelial microvascular dysfunction and their frequent combination with cardiac arrhythmias suggests an unfavorable course of pregnancy and childbirth due to the formation of uteroplacental dysfunction. Objective. To reduce the incidence of obstetric complications associated with cardiovascular disorders in women with UCTD by including carnitine-arginine complex in the treatment program. Materials and methods. 58 pregnant women with diagnosed signs of UCTD, including mitral valve prolaps (MVP) with and without frequent extrasystoles, and 14 pregnant women of control group were examined. Metabolic support with of 4.2 g of L-arginine and 2.0 g of L-carnitine in the form of a solution for intravenous infusion once a day for 5 days were used for prenatal care of pregnant women with UCTD and prevention of obstetric complications in the experimental group. Results. There are violations of morpho-functional parameters of the heart with the development of moderate systolic-diastolic myocardial dysfunction and endothelial microvascular dysfunction in the initial state of pregnant women with MVP and extrasystolic arrhythmia against the background of UCTD. They were significantly more often diagnosed with miscarriage, late preeclampsia, placental dysfunction, birth defects, birth trauma, postpartum hemorrhage, etc. Echostructural abnormalities of the heart acted as predictors of arrhythmias, the presence of which was associated with more pronounced disorders of intracardiac hemodynamics. The results of a comprehensive study of the clinical and functional status of pregnant women with phenotypic signs of UCTD, MVP and extrasystolic arrhythmia suggest that in most cases they occur with moderate heart remodeling and significant endothelial dysfunction of the microvascular circulation, that was accompanied by significant deterioration of the obstetric situation. The use of standard medication by pregnant women did not significantly restore the incidence of arrhythmias, inotropic capacity of the myocardium and endothelial function of microvessels. Supraventricular and ventricular arrhythmias remained resistant to standard treatment, which justified the use of additional antiarrhythmic drugs. At the same time, there was a significant reduction in the incidence of arrhythmias in the group of patients with MVP and frequent ventricular or mixed extrasystoles – by 90.6 and 77.8 % respectively under the influence of complex drug treatment with the inclusion of L-arginine and L-carnitine. In the group of pregnant women with supraventricular arrhythmias, the antiarrhythmic effect was observed in only 37.5 % of patients, which justified the additional use of nebivolol hydrochloride at a dose of 2.5 mg/day. At the same time, such a comprehensive treatment in pregnant women with MVP and arrhythmia on the background of UCTD contributed to the restoration of the studied indicators of endothelial function of microvessels. Conclusions. In pregnant women with MVP and extrasystolic arrhythmia against the background of UCTD in the initial state there are violations of morpho-functional parameters of the heart with the development of moderate systolic-diastolic myocardial dysfunction and endothelial microvascular dysfunction, which are triggers of complicated pregnancy and childbirth. The inclusion of L-arginine and L-carnitine led to a significant improvement in the parameters of central cardiohemodynamics and restoration of endothelial function of microvessels and accompanied by a significant reduction of the incidence of extrasystolic arrhythmia and pregnancy complications.

Ventricular arrhythmias in a patient with obstructive sleep apnea syndrome and its effective non-pharmaceutical treatment

Patients with obstructive sleep apnea syndrome (OSAS) are characterized by various cardiac arrhythmias during sleep. However, while the association between OSAS and atrial fibrillation is considered proven, the presence of a pathophysiological link between sleep apnea and ventricular arrhythmias remains a matter of debate.We present a case of a 51-year old man with arterial hypertension and type 2 diabetes who was referred for sleep assessment after being diagnosed with predominantly nocturnal cardiac arrhythmias. Overnight cardiorespiratory monitoring showed that the patient had a severe OSAS with an apnea-hypopnea index of 57 per hour and a minimal SpO2 during sleep of 73%. On the channel of electrocardiogram (ECG) frequent single monomorphic ventricular extrasystoles, eventually of the bigeminal type, and one short paroxysm of a wide-complex regular rhythm of 60 beats per minute (accelerated idioventricular rhythm) associated with prolonged apnea were identified. Continuous airway positive pressure (CPAP) therapy was started which was able to control for breathing disorders during sleep. At the follow-up 24-hours Holter ECG monitoring, the numbers of ventricular extrasystoles during sleep decreased 2-fold, without any idioventricular rhythm episodes.The clinical case clearly illustrates that in some patients with OSAS, first of all, in those with severe OSAS and comorbid cardiovascular disorders, breathing disorders during sleep can trigger ventricular arrhythmias. In such patients, CPAP therapy could both improves their quality of life and provide an indirect antiarrhythmic effect.

THE PSYCHOLOGICAL COMPONENT OF THE QUALITY OF LIFE WAS RELATED TO COMPOSITE ENDPOINT IN TREATED PATIENTS WITH ARTERIAL HYPERTENSION

Objective: The aim of our study was to determine association between composite endpoint and quality of life (QL) scale scores in treated patients with arterial hypertension (AH). Design and method: We analyzed database of treated AH patients (n = 125) with concomitant chronic diseases without exacerbation. We assessed relationships between the initial ambulatory blood pressure monitoring (ABPM) data, socio-demographic indicators, QL scale scores, Asthma Control Questionnaire (ACQ) indices and composite endpoint (death for any reason, angina pectoris, transient ischemic attack, development of chronic heart failure, arterial revascularization, frequent ventricular extrasystoles, atrial fibrillation) after 30.1 ± 7.6 months from the inclusion visit. QL questionnaires (J.Siegrist et al.), ACQ (45 patients had asthma) was completed initially, after 6 months and after 12 months, the ABPM session was performed initially and after 12 months, antihypertensive therapy was corrected at all visits. We analyzed the following QL scale scores: 0 scale: mood at the doctor's visit, I scale: physical well-being; II scale: physical performance; III scale: positive psychological well-being; IV scale: negative psychological well-being; V scale: psychological performance; VI scale: social well-being; VII scale: social performance. We used ANOVA for statistical analysis. Results: The baseline mean daytime systolic BP (SBP) was 125.1 ± 10.5; diastolic (DBP) - 76.1 ± 7.3 mm Hg. We found negative correlations between composite endpoint and: III scale scores (positive psychological well-being) (F = -5.3, p < 0.05); 0 scale (mood at the doctor's visit) (F = -5.6, p < 0.05). We identified a positive correlation between endpoint data and V scale scores (psychological performance) (F = 12.2, p < 0.001). The composite endpoint was not correlated with sex, age, BMI, smoking, ambulatory and clinical blood pressure, the number of drugs in concomitant therapy, pulmonary forced vital capacity. At the end of the study, we registered 21 cases included in the composite endpoint: death (2), transient ischemic attack (1), arterial revascularization (4), frequent ventricular extrasystole (3), atrial fibrillation (8), angina pectoris (3). Conclusions: Thus, psychological QL component such as good mood at the doctor's visit (scale 0), positive psychological well-being (scale III) had negative relationship with composite endpoint, at the same time the psychological performance (scale V) had positive correlation with composite endpoint results.

Electrical myocardial instability as a problem of modern therapeutic practice – the realities of prognosis (a literature review)

The aim of the study – to analyze the latest research to predict development of myocardial electrical instability on the basis of literature data.Materials and methods. An analysis of the literature sources which cover prediction methods of electrical myocardial instability development.Results. The analysis of the literature shows that electrical myocardial instability, which is based on the heart’s response to various pathogenic factors, leads to significant changes in the electrophysiological properties of the heart muscle, is clinically manifested in heart rhythm and conductivity disturbances and prognostically characterized by different risk of developing fatal cardiac events.Conclusions. Non-invasive methods for assessing electrical myocardial instability include: echocardiography, Holter monitoring of the electrocardiogram, identification of depolarization change indicators – the phenomenon of QRS fragmentation, late ventricular potentials, repolarization change indicators – microvolt T-wave alternation, QT interval dispersion, autonomic nervous system parameters – heart rate variability and turbulence. With a view to determining the arrhythmogenic substrate, cardiac magnetic resonance imaging can be performed. Markers of fibrosis make it possible to control the assessment of individual risk for electrical myocardial instability. Prediction and prevention of electrical myocardial instability in patients with hypertension without / and in combination with ischemic heart disease, based on a study of the relationship between the presence of frequent ventricular extrasystole, such as electrical myocardial instability, and plasma fibrosis biomarkers (aldosterone, galectin-3 and transforming growth factor-β1) have not been clarified in the studies.

The clinical and electrophysiological characteristics of nonsustained repetitive monomorphic ventricular tachycardia from the left His-Purkinje system.

Repetitive monomorphic ventricular tachycardia (RMVT) arising from the left His-Purkinje system can occasionally be encountered during clinical practice. We describe eight cases as a unique entity in this study to characterize the clinical and electrophysiological features of the patients. Eight patients with frequent palpitation (five men with median age of 28 years) were included in the study from January 2003 to July 2018. Twelve-lead ECG (Electrocardiogram), Holter, and echocardiographic tests were performed after medical history interrogations and physical examinations. Antiarrhythmic drug therapy was essential to all patients, and catheter ablation was attempted if the patients could not tolerate or were not responsive to drug therapy. No patients had a history of syncope and a family history of sudden cardiac death. ECGrecording was characterized by frequent ventricular extrasystoles, ventricular couplets, and salvos of nonsustained VT competitive with sinus rhythm. The QRS morphology of ectopic beats was in the right bundle branch block pattern with severe left axis deviation. The width of the QRS complex from ECG was 135ms (120-140) during ventricular tachycardia. Verapamil had no effect on all VT individuals. Enlargement of the left ventricle was found in two patients. Four out of six cases were successful with catheter ablation treatment. RMVT arising from the left His-Purkinje system is a special arrhythmic and nonverapamil-sensitive entity. The electrophysiological mechanism of this treatment appears to be focal firing, which is amendable to catheter ablation in symptomatic and high-burden patients.