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Saint-Petersburg State University
As a manuscript
Maksim Sergeyevich Kamenskikh
THE EFFECT OF MYOCARDIAL REVASCULARIZATION IN THE
PROGNOSIS OF PATIENTS WITH ALTERED CORONARY BLOOD FLOW
DETECTED BY TRANSTHORACIC ULTRASOUND
3.1.15. Cardiovascular surgery
The thesis for the degree of candidate of medical sciences
Translation from Russian
Academic Supervisor: Doctor of Medical Sciences
Dmitry Viktorovich Shmatov
Saint-Petersburg – 2022
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CONTENTS
INTRODUCTION………………………………………………...………
…
.....118
Chapter 1. Literature review………………………………………………..…...126
1.1. Statistics and drug treatment of coronary artery disease…………………...126
1.2. Percutaneous and surgical treatment of coronary artery disease…………...128
1.3. Invasive diagnostic methods for the arteriostenosis detection…………………..134
1.4 Non-invasive methods for detecting coronary artery lesions…
…………………
..136
1.5 Ultrasound examination of coronary bed function………............................ 138
Chapter 2. Materials and methods…………………………….…………………144
2.1 Clinical characteristics of patients………………………………….…… …144
2.2 Research methodology and methods………………………………………..144
Chapter 3. New method of patient selection for coronary angiography and surgical
treatment of coronary artery disease……………………..……………………...151
3.1. Introduction....................................................................................................151
3.2. Purpose of the research..................................................................................152
3.3. Materials and methods………………………………….…………..............152
3.4. Results.....................................................................................................…..154
3.5 Discussion......................................................................................................162
Chapter 4. Comparing the data of the coronary angiography and non-invasive
measurement of heart artery blood flow velocities……………………………..165
4.1 Introduction…...………………...…….….....................................................165
4.2. Purpose of the research…...………………...…….…..................................165
4.3. Materials and methods………………………………….………….............165
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4.4. Results……………………..……………………………………...…......….167
4.4.1 Correlation analysis……………………………………...…...........……....167
4.4.2 Determining limit value, ROC analysis……………...….........…………....168
4.5. Discussion………...………………………………………………….…......173
Chapter 5. Prognosis of patients with altered blood flow according to ultrasound
scanning data. The role of myocardial revascularization in changing the prognosis
in patients with found impaired coronary artery function according to the
transthoracic scanning parameters.……………………………………………...175
5.1. Introduction....................................................................................................175
5.2 Purpose of the research…………...………………………......................…..175
5.3. Materials and methods…………………………….….…………………… .175
5.4. Results……………………..……………………………………....….....….179
5.4.1.Clinical characteristics.………………………………… ..……………….179
5.4.2. Echocardiographic data of the groups.……………………………............179
5.4.3. Stress echocardiographic data.…………………………… .............…… .180
5.4.4. Results of coronary angiography. ………………………….......................181
5.4.5. Clinical outcomes of patients during the year.……………………………181
5.4.5.1. Overall mortality analysis....................................………………………181
5.4.5.2. Analysis of the incidence of acute coronary events ……………………186
5.4.5.3. Frequency analysis of cumulative point of deaths and acute coronary
events………………….............………………………………………………...190
5.4.5.4. Analysis of the incidence of adverse outcomes......................................195
5.4.5.5. The role of revascularization in changing the prognosis of patients with
high blood flow velocities in the left coronary artery.…………… ………........201
5.5 Discussion …………………………………………....……...………………204
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Limitations……………………………………………………………….....…....207
Conclusions……………………………………………......…………..………...209
Practical guidelines…………………………………………..……..…………...210
Abbreviations……………………………………… ………………....………...211
References… … … ………………………………………………...…………...212
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INTRODUCTION
Relevance of the Research Topic
Over the past several decades, myocardial revascularization surgery has taken a
confident leading position in the choice of a method for treating coronary artery
disease (CAD). Surgical myocardial revascularization methods and modern drug
treatment provide a proven positive prognosis with timely medical care. However,
even with the current level of medicine development, morbidity and mortality from
cardiovascular diseases remains high in Russia and most developed countries [3,
93, 96]. Surgical myocardial revascularization significantly affects the prognosis in
patients with stenosis of the LMCA, with proximal stenosis of the left anterior
descending artery (LAD), two- or three-vessel lesions of the coronary arteries with
stenosis of more than 50% and preserved function of the left ventricle, as well as in
patients with a large zone of myocardial ischemia according to the functional tests
or a low value of invasively determined fractional reserve of the coronary artery. In
this case, the indications for revascularization in most cases are determined by the
results of invasive diagnostic methods, and the functional stress test is applied
according to special indications. In turn, functional tests are made according to
modern guidelines [4], only in symptomatic patients. For many patients with the
clinical pattern of coronary artery disease, functional stress tests remain
unavailable due to a number of factors, e.g. the patients with atherosclerosis of the
arteries of the lower extremities and joint diseases cannot exercise. It should be
noted that up to 50% of patients do not have specific symptoms of coronary artery
disease before myocardial infarction or death [33, 5], and therefore they do not
undergo stress tests, nor further invasive diagnostics, which would reveal coronary
circulation issues. Echocardiography is a widespread method of ultrasound
diagnostics, a large number of people undergo, regardless of the indications for
stress tests or coronary angiography. This method may be supplemented by
ultrasound examination of the coronary arteries for the possible identification of
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119
patients with altered blood flow. However, knowledge of ultrasound diagnostics of
coronary lesions is insufficient. There is no data on the incidence of altered
coronary blood flow in the population, it is not known whether there is a need for
coronary angiography in patients with altered blood flow, and the prognosis in this
category of people is unclear, as well as whether they require revascularization.
Currently, modern cardiac surgery still requires timely diagnosis of coronary artery
disease, including in patients with an inapparent clinical pattern in the absence of
specific symptoms. Specialists need a non-invasive, fast, accurate, inexpensive,
safe method without radiation exposure and provocative ischemic tests to
determine the state of the coronary bed, applicable in routine practice in most
patients and quantifying the degree of change in coronary blood flow at the
outpatient stage; a method that identifies a high-risk group of patients in whom
myocardial revascularization would reduce this risk.
Status of the Research Topic
For the last decade, modern highly sensitive ultrasound devices made it
possible to visualize the main, major coronary vessels throughout their entire
length, to assess the structure of their walls and perform a Doppler study to assess
the blood flow velocity. An important criterion in ultrasound examination of
coronary arteries is the coronary blood flow velocity in different vessel portions.
The relationship between changes in the velocity parameters of large heart arteries
during an stress test with exercise and coronary angiography have been proven [26,
138]. These papers discuss the dependence of changes in velocities of blood flow
in the coronary arteries, that is, the so-called coronary reserve, on the degree of the
vessel lumen stenosis according to coronary angiography, and impaired regional
contractility during stress echocardiography with exercises and pharmacological
agents. The authors also determine a high prognostic role of the coronary reserve
amount. Therefore, the diagnostic and prognostic value of echocardiographic stress
tests has been sufficiently studied.
120
Meanwhile, the researchers are now interested in the methods of studying the
properties of coronary blood flow at rest, during routine echocardiography, without
resorting to stress factors, which is the safest method for the patient [15, 72]. When
studying the velocity parameters of coronary blood flow using a Doppler study, the
researchers found out that these parameters may differ significantly from each
other in different portions of the artery. Subsequently, several papers were
published, proving a high correlation between the data of transthoracic ultrasound
examination of coronary arteries at rest with the data of invasive diagnostic
methods [32, 53, 65]. Most of the papers in this field were retrospective with a
small number of patients, and did not provide a complete picture of the
significance of this method for clinical work. Moreover, no work has been
published on the relationship between high blood flow velocities in the coronary
arteries and patient prognosis — subsequent acute coronary events and mortality.
The world literature still did not analyze the effect of myocardial
revascularization on adverse events in groups of patients with high coronary blood
flow rates visualized using transthoracic ultrasound at rest.
Purpose of the Research
Determining the role of myocardial revascularization in the prognosis of
patients with altered coronary blood flow detected by transthoracic ultrasound.
Research Objectives
1. Comparing the data of ultrasound parameters of coronary blood flow with the
results of stress echocardiography
2. Comparing the data of ultrasound parameters of coronary blood flow with the
data of selective coronary angiography.
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