Vladimir M. Shipulin

Background. The role of revascularization in patients with severe ischemic left ventricular (LV) dysfunction remains a matter of debate, particularly with regard to patient selection and prognostic stratification. Conventional assessment of myocardial viability does not always reliably predict clinical outcomes. The prognostic value of quantitative assessment of biventricular reserve during dobutamine stress echocardiography (DSE) remains insufficiently studied. Aim: To evaluate the prognostic value of conventional and additional DSE parameters for predicting 3-year all-cause mortality in patients with coronary artery disease (CAD) and severe LV systolic dysfunction referred for treatment strategy selection. Methods. This single-center retrospective observational study included 75 patients with ischemic LV systolic dysfunction and available 3-year vital status data: mean age 60,6 ± 7,1 years, 70 (93.3%) were men, LV end-systolic volume index 77,0 (69,6; 90,7) mL/m², and LV ejection fraction (LVEF) 30,1 ± 5,6%. All patients underwent DSE with assessment of conventional markers of myocardial viability and LV contractile reserve, including LVEF and regional wall motion abnormalities (RWMA), as well as global longitudinal strain (GLS), LV pump function, and right ventricular (RV) longitudinal systolic function assessed by tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity of the basal segment of the RV free wall (RV S′). Surgical revascularization was performed in 62 (82,7%) patients. The primary endpoint was all-cause mortality within 3 years. The prognostic value of the parameters was assessed using Cox regression and Kaplan–Meier analysis. Results. Three-year survival was 70,7%. Myocardial viability according to conventional criteria was identified in 51 (68,0%) patients; however, the presence of viable myocardium, type of stress response, increase in LVEF, and change in wall motion score index were not significantly associated with 3-year survival. Patients with adverse outcomes had lower stress-induced LVEF, LV pump function parameters (LVOT VTI), worse GLS, and more pronounced RV dysfunction at rest and during DSE. In univariable Cox models, significant associations with 3-year all-cause mortality were found for stress-induced LVEF, GLS, LVOT VTI, LV stroke index, TAPSE, and RV S′. In limited two-variable models adjusted for LV functional parameters, the maximal stress-induced RV S′ remained significantly associated with 3-year all-cause mortality. Kaplan–Meier analysis demonstrated significant separation of survival curves according to RV S′, TAPSE, and LVOT VTI. Conclusion. In patients with CAD and severe LV systolic dysfunction, conventional markers of myocardial viability and LV contractile reserve during DSE had limited prognostic value. A stronger association with 3-year all-cause mortality was observed for parameters of RV systolic function, particularly stress-induced RV S′, and LV pump function.

Background . Coronary artery disease (CAD) is characterized by abnormalities in the subpopulation composition of blood monocytes, which has specific features in ischemic cardiomyopathy (ICM), but its regulation by lineage-specific M-CSF has not been studied. Aim : To determine the nature of changes in monocyte numbers and their subpopulation composition in vitro in the presence of M-CSF in patients with CAD, both with and without ICM. Material and Methods . 22 patients with CAD (11 with ICM and 11 without ICM) and 10 healthy donors were examined. Their monocytes were cultured for 6 days with and without the addition of 50 ng/ml M-CSF. In both samples, flow cytometry was used to assess the proportion of classical CD14 ⁺⁺ CD16 ^– , intermediate CD14 ⁺⁺ CD16 ⁺ , non-classical CD14 ⁺ CD16 ⁺⁺ , and transitional CD14 ⁺ CD16 ^– forms relative to the total number of monocytes (CD14 ^++/+ cells). Results . In patients with coronary artery disease (CAD), regardless of ICM, the proportion of intermediate forms (and, in ICM, the total number of CD14 ^++/+ cells) in native monocyte culture is reduced relative to healthy individuals. M-CSF inhibits the decline of intermediate monocytes in in vitro cell culture in patients with CAD, both with and without cardiomyopathy. In ICM, this is accompanied by an increase (to normal) in the proportion of non-classical cells and the total number of monocytes in the culture. Conclusion . M-CSF in CAD normalizes the subpopulation composition and number of monocytes in vitro , which is impaired to a greater extent in patients with ICM, in whom non-classical and intermediate forms exhibit increased sensitivity to it.

Aim . To identify the role of impaired production of hypoxia-inducible factors (HIF) 1 and 2 in determining the balance of angiogenesis mediators, pro- and antiinflammatory cytokines in peripheral and coronary sinus blood in patients with coronary artery disease (CAD), with and without ischemic cardiomyopathy (ICM). Material and methods . The study included 30 patients with coronary artery disease (CAD) and non-cardiomyopathy, 22 patients with CAD without cardiomyopathy, and 20 healthy donors. Patients with non-cardiomyopathy had a lower left ventricular ejection fraction (LVEF) compared to CAD patients without cardiomyopathy (30,00 [22,00; 36,00]% and 59,50 [50,25; 67,00]%, pResults . In the peripheral blood of patients with CAD, regardless of ICM, the concentration of TNF-α, IL-6, VEGF-A, PDGF was normal, while the SCF level showed a tendency to increase (p=0,054), and TGF-β1 — to decrease (p=0,059); excess IL-10 and HIF-2α was determined only in patients with ICM (respectively, 2,80 [2,00; 3,30] pg/ml versus 1,78 [0,50; 2,40] pg/ml, p=0,018; 40,0% vs 0% of positive cases, p=0,047), excess HIF-1α — only in CAD patients without cardiomyopathy (6,00 [5,00; 6,20] ng/ml and 4,60 [3,28; 5,11] ng/ml, p=0,049). In the coronary flow relative to the peripheral flow in CAD patients without ICM, the concentration of TNF-α, IL-6, PDGF was higher (1,09 [0,68; 2,47] pg/ml, p=0,004; 5,85 [3,12; 7,15] pg/ml, p=0,011; 7,60 [3,70; 9,94] pg/ml, p=0,036), which was not determined in patients with ICM, who had a higher content of TGF-β1 (4,42 [3,38; 5,69] pg/ml, p=0,022). Regardless of ICM type, the VEGF-A content in sinus blood exceeded the systemic level (7,80 [3,25; 9,75] pg/ml, p=0,041), while the concentration of HIF-1α, IL-10, and SCF corresponded to them. Conclusion . Insufficient cardiac angiogenesis in ICM is largely associated with the anergy of the myocardial proinflammatory response with atherogenesis, rather than with reduced response to hypoxia. This, on the contrary, is more significant at the systemic level in ICM pathogenesis and is characterized by the predominance of HIF-2 over HIF-1.

Background: Assessment of left ventricular (LV) contractile function along with blood supply has recently become an increasingly common “extension” in the analysis of perfusion scintigraphy and single-photon emission computed tomography data, isolated or combined with myocardial X-ray computed tomography. It enables to reveal additional, more sensitive markers of various pathologies, one of which is mechanical dyssynchrony. However, in case of largeperfusion defects, this approach may provide unreliable information. Objective: The study aimed at assessing the impact of extensive perfusion defects on the determination of mechanical dyssynchrony indices using ECG-synchronized perfusion single-photon emission computed tomography of myocardium. Methods: Sixty-five patients with ischemic cardiomyopathy were included in the study. All patients were examined using ECG-synchronized myocardial perfusion scintigraphy and radionuclide tomoventriculography, as well as cardiac magnetic resonance imaging. All examinations were carried out in the resting state. Patients were assigned to two groups according to ECG-synchronized myocardial perfusionscintigraphy data. Some formed a group with big perfusion defect relative to thearea of the LV in a state of functional rest (BDP; summed rest score ≥ 20%), while the others entered the group with minor defect of perfusion (MDP; summed rest score < 20%). The following parameters of LV contractile function were assessed using radionuclide modalities: ejection fraction (%), end-systolic (ml) and enddiastolic(ml) volumes, as well as parameters of mechanical dyssynchrony (phasehistogram standard deviation (deg) and phase histogram bandwidth (deg)).Magnetic resonance imaging as a reference method was used to assess ejection fraction, end-diastolic and end-systolic volumes of LV. The primary endpoint was summed rest score ≥ 20 %. Results: The MDP group comprised 21 patients (summed rest score 11.7 (5.8;16.1) %) and the BDP group amounted to 44 patients (summed rest score 30.8 (25; 41.1) %). In the MDP group, no differences in the estimated parameters between modalities were found. In the BDP group the parameters obtained by the ECGsynchronized myocardial perfusion scintigraphy differed significantly from those obtained by both radionuclide tomoventriculography and magnetic resonance imaging; whereas, no significant differences in the measured parameters were foundbetween radionuclide tomoventriculography and magnetic resonance imaging. The mechanical dyssynchrony indices in the BDP group were significantly higheraccording to the data of ECG-synchronized myocardial perfusion scintigraphy compared to radionuclide tomoventriculography. According to Bland – Altman analysis, allparameters did not show significant differences in the MDP group. Along with that, in the BDP group, volumes and mechanical dyssynchrony were significantly overestimated according toECG-synchronized myocardial perfusion scintigraphy data (mean differences end-diastolic volume 52.5 ml, end-systolic volume 35.9 ml, phase histogram standard deviation 7.9, phasehistogram bandwidth 67.2), while ejection fraction was underestimated (–3.4 %). Conclusion: In patients with large (≥ 20 % of the LV myocardium area) perfusion defects, monitoring indices by the ECG-synchronized myocardial perfusion scintigraphy may lead to overestimation of LV mechanical dyssynchrony indices.

Aim. To evaluate the effect of vascular endothelial growth factor A (VEGF-A) on the subpopulation composition of monocytes in the blood mononuclear cell culture of patients with coronary heart disease (CHD), with and without ischemic cardiomyopathy (ICMP).Materials and methods. A single-center, experimental in vitro study was conducted. The study included 22 patients with CHD: 11 with ICMP, 11 without ICMP, and 10 healthy donors. Blood mononuclei were isolated from venous blood by immunomagnetic separation for CD14 and CD34 antigens, then incubated with and without the addition of VEGF-A 50 ng/mL (control and stimulated samples). After 6 days, the total monocyte content, the proportion of classical CD14⁺⁺CD16^–, intermediate CD14⁺⁺CD16⁺, non-classical CD14⁺CD16⁺⁺, and transitional CD14⁺CD16^– monocytes were assessed using flow cytofluorimetry.Results. In groups of patients with CHD and in those groups where the patients were considered relatively healthy, a decrease in the content of CD14⁺⁺CD16⁺ in the control and stimulated samples was shown. Only in the CHD group with ICMP relative to the control sample, after VEGF-A stimulation, a statistically significant increase in all CD14+ was found: 10.63% (6.80; 17.64) vs. 15.28% (8.75; 27.99), p < 0.01, and their subpopulations: CD14⁺⁺CD16−: 6.08% (1.76; 8.84) vs. 8.57% (3.51; 16.8), p < 0.05, CD14⁺⁺CD16+: 3.64% (2.03; 8.59) vs. 6.26% (3.87; 10.3), p < 0.05. In the same group, a tendency towards an increase in CD14⁺CD16⁺⁺ was noted after stimulation: 0.19% (0.18; 1.11) vs. 0.61% (0.37; 1.58), p = 0.062. No differences in the content of all monocytes and their subpopulations after VEGF-A stimulation were found in the CHD without ICMP group nor in the healthy group. The content of CD14⁺CD16^– in all groups in the control and stimulated samples did not differ.Conclusion. CHD is characterized by a deficiency of all CD14⁺ cells and intermediate monocytes due to their transdifferentiation. VEGF-A affects the subpopulation composition of monocytes in CHD only in the presence of ICMP by increasing the content of all CD14⁺ cells, and in their intermediate and classical forms without exceeding the indicators in healthy donors.

Background. A severe form of coronary heart disease (CHD) is ischemic cardiomyopathy (ICMP), the pathogenesis of which has not been fully studied. Disturbances in the mobilization of endothelial progenitor cells (EPC) due to an imbalance of angiogenesis mediators may exacerbate ischemia in ICMP. The aim — to establish the peculiarities of changes in the balance of early and late EPС and subpopulations of VEGFR2+ cells in the blood and bone marrow in relation to the content of angiogenesis mediators and the number of desquamated endothelial cells (DEK) in the blood of patients with CHD, suffering and not suffering from ICMP. Methods. A single-stage, clinical, controlled (case-control) study was conducted from March 2019 to June 2022. 52 patients with CHD who had a history of myocardial infarction were examined: 30 people suffering from ICMP and 22 people not suffering from ICMP, as well as 15 healthy donors. The content of VEGFR2+, VEGFR2+CD34+CD14+ (early EPC), VEGFR2+CD34+CD14– (late EPC), VEGFR2+CD34–CD14+, VEGFR2+CD34–CD14– cells in patients with CHD in the blood (before surgery) and bone marrow (sampling was performed at the beginning of coronary bypass) and in healthy individuals in the blood, as well as (in both groups) the content of CD45–CD146+ DEC in the blood was determined by flow cytometry. The concentration of SDF-1, VEGF-A, MCP-1, GM-CSF, G-CSF in blood plasma was measured by multiplex immunofluorescence analysis. Results. The development of CHD without cardiomyopathy was accompanied by an increase in the content of VEGFR2+CD34+CD14+ and VEGFR2+ cells (0.74 [0.46; 1.23]% and 10.00 [8.20; 11.60]%, respectively, versus 0.19 [0.13; 0.32]%, p 0.001 and 5.40 [4.30; 6.50]%, p = 0.005) and concentrations of SDF-1, MCP-1, GM-CSF (respectively 60.00 [50.00; 81.00] pg/ml; 223.0 [180.0; 297.0] pg/ml; 2.10 [1.45; 3.40] pg/ml versus 30.00 [5.00; 45.00] pg/ml, p = 0.041; 175.1 [140.0; 204.0] pg/ml, p = 0.046; 0.96 [0.46; 1.41] pg/ml, p = 0.038) in the blood relative to the norm. No such changes were observed in patients with ICMP. Regardless of the presence of ICMP, the content of VEGFR2+CD34+CD14–, VEGFR2+CD34–CD14+, VEGFR2+CD34–CD14– cells, VEGF-A, G-CSF in the blood of patients with CHD varied within physiological values, and the number of DEC exceeded the norm (7.26 [5.43; 17.94]×105/l, p = 0.039). The number of VEGFR2+ cells and their immunophenotypes in the bone marrow of patients with ICMP did not differ from the parameters in patients with CHD without cardiomyopathy. Prolonged bleeding from the venopuncture area was registered in one CHD patient without cardiomyopathy. Conclusion. The development of ICMP is associated with the absence of a compensatory response to atherogenesis in the form of increased mobilization of early EPC from the bone marrow due to the absence of a reaction associated with hyperproduction of SDF-1, MCP-1, GM-CSF, which is characteristic of CHD without cardiomyopathy. The content of EPС, VEGFR2+CD34–CD14+ and VEGFR2+CD34–CD14– cells, VEGF-A and G-CSF in the blood in СHD corresponds to physiological values, regardless of the presence of ICMP. The generation of EPC in the bone marrow in ICMP is not impaired.

Aim. To evaluate the nature of changes in the expression of markers of endothelial progenitor cells (VEGFR2, CD34, CD14) and endothelial cells (CD146) in association with the expression of the leukocyte common antigen CD45 in the culture of blood mononuclear cells in the presence of M-CSF in patients with coronary heart disease (CHD) and healthy donors.Materials and methods. The study included 12 patients with CHD with class III–V angina pectoris and 10 healthy donors, from whom 30 ml of venous blood was taken on an empty stomach in the morning and stabilized with heparin. Blood mononuclear cells were isolated by Ficoll density gradient centrifugation (1.077 g / cm³) and subject to immunomagnetic separation using CD14-MicroBeads and CD34-MicroBead Kit (Miltenyi Biotec B.V. & Co. KG, Germany). The resulting CD14⁺ and CD34⁺ culture of mononuclear cells was incubated for 6 days in a complete nutrient medium with and without M-CSF 50 ng / ml (Cloud-Clone Corp., USA) with complete replacement of the medium and repeated application of M-CSF on day 3. After 6 days, the proportions of CD45⁺, CD14⁺, CD34⁺, VEGFR2⁺, and CD146⁺ cells in the culture were assessed by flow cytometry using CD14-FITC, CD34-PE, VEGFR2-Alexa Fluor 647; CD45-FITC and CD146-PerCP antibodies (BD Biosciences, USA).Results. It was shown that in healthy donors, the proportion of CD146⁺ cells in the co-culture of blood mononuclear cells with M-CSF exceeded their number in the sample without it, with comparable expression rates of CD45, CD14, and VEGFR2 markers between the control and stimulated cultures. In CHD patients, the number of CD146+ and VEGFR2⁺ cells did not change when M-CSF was added to the mononuclear cell culture; however, the proportion of CD14⁺ cells increased and the proportion of CD45⁺ cells decreased compared to the control sample. The number of CD34⁺ cells was comparable both between control and stimulated samples, and between the groups of examined individuals. At the same time, in patients with CHD, an increased proportion of VEGFR2⁺ cells was found in the control and stimulated samples compared to healthy individuals, while an increased proportion of CD14⁺ cells was detected only in the stimulated culture.Conclusion. The development of CHD disrupts the response of blood mononuclear cells to the effect of M-CSF, increasing the number of CD14⁺ and reducing the proportion of CD45⁺ cells in the culture in the absence of stimulating effects on the expression of endothelial cell marker CD146. At the same time, M-CSF does not affect the expression of CD34 and VEGFR2 in endothelial progenitor cells both in patients with CHD and in healthy individuals.

Background. In the pathogenesis of ischemic cardiomyopathy (ICMP), angiopoiesis remains unexplored.The aim. To describe the vasculature of the heart and the imbalance of angiogenesis mediators in the coronary circulation in association with the number of endothelial progenitor cells (EPC) and desquamated endothelial cells (DEC) in the blood of patients with coronary heart disease (CHD), suffering and not suffering from ICMP.Methods. Fifty-two patients with CHD (30 patients with ICMP, 22 patients without ICMP), 15 healthy donors were examined. The content of EPC (CD14⁺CD34⁺VEGFR2⁺) in the blood from the cubital vein and DEC (CD45^–CD146⁺) in the blood from the coronary sinus and the cubital vein was determined by flow cytometry. The concentrations of VEGF-A (vascular endothelial growth factor A), PDGF (platelet-derived growth factor), and SDF-1 (stromal cell-derived factor 1) in blood plasma were recorded using immunofluorescence assay; the angiopoietin-2, MMP-9 (matrix metallopeptidase 9) were recorded using enzyme immunoassay. In myocardial biopsies the specific area of vessels and the expression of αSMA (smooth muscle alpha-actin) were determined by morphometric and immunohistochemical methods.Results. In the peripheral blood of patients with CHD, regardless of the presence of ICMP, the DEC content exceeded the physiological level, and the VEGF-A, PDGF, angiopoietin-2, and MMP-9 corresponded to the norm. In CHD patients without cardiomyopathy, there was an excess of SDF-1 and EPC in the blood from the cubital vein, and in ICMP, their physiological significance was noted. In the coronary blood flow in patients with CHD without cardiomyopathy, an increase in the concentration of PDGF was found, which was not determined in patients with ICMP, who had an increased content of DEC, angiopoietin-2 and MMP-9. The specific area of the vessels in the patients of the two groups was comparable; the expression of αSMA in ICMP was 6.2 times lower than in patients with CHD without cardiomyopathy.Conclusion. The development of ICMP is accompanied by impaired maturation of vessels in the myocardium, associated with the absence of a compensatory reaction of activation of cellular and humoral factors of angiogenesis.

Highlights Dysregulation of angiogenesis may be the pathogenetic factor of ischemic cardiomyopathy (ICMP). Aim. To determine the content of growth factors and desquamated endothelial cells (DEC) in the blood from the coronary sinus and ulnar vein in association with the number of progenitor endothelial cells (PEC) in the blood from the ulnar vein in patients with coronary heart disease (CHD), suffering and not suffering from ICMP.Methods. The study included 30 patients with ICMР and 22 patients with CHD, and 18 healthy donors. The content of DEC (CD45^–CD146⁺) was determined in blood from the cubital vein (peripheral) and coronary sinus, and the content of DEC (CD14⁺CD34⁺VEGFR2⁺) was determined in peripheral blood by flow cytometry (antibodies “BD Biosciences”, USA). The concentrations of VEGF-A, VEGF-B, PDGF, SDF-1, SCF, FGF-1, TGF-β1 in blood plasma from both locations were evaluated by multiplex analysis (set “Cloud-Clone Corp.”, USA).Results. The content of DEC in peripheral blood was elevated in patients with CHD of both groups, and in patients with ICMP in sinus blood was higher than in peripheral. At the same time, in patients with CHD without cardiomyopathy, an excess of PEC and SDF-1 in the blood from the ulnar vein was established in combination with an increase in the concentration of PDGF and a decrease in the content of VEGF-B in the blood from the coronary sinus relative to the parameters of systemic blood flow. In patients with ICMP, these changes were not detected, but there was an increase in the concentration of TGF-β1 in sinus blood compared with peripheral blood. Regardless of the presence of ICMP, the concentration of SCF, FGF-1, VEGF-A in the blood from the ulnar vein corresponded to the norm and that in sinus blood; the content of VEGF-A in the coronary bloodstream exceeded its systemic level.Conclusion. In patients with ICMP, desquamation of the coronary vascular endothelium is enhanced against the background of violations of its repair processes due to insufficient (relative to CHD without cardiomyopathy) mobilization of PEC from the bone marrow due to the absence of an excess of SDF-1 in the blood and their insufficient homing into the myocardium due to weak PDGF production in the heart.

(1) Objective: The objective of this study was to assess the prognostic value of stress-gated blood pool SPECT (GBPS) estimates in patients with ischemic cardiomyopathy (ICM) in the early postoperative period. (2) Methods: A total of 57 patients (age 59.7 ± 6.6, 47 men) with ICM and LV ejection fraction (30 [27.5; 35]%) were enrolled in the study. Before surgical treatment, all patients underwent GBPS (rest–stress, dobutamine doses of 5/10/15 µg/kg/min). Stress-induced changes in left ventricular (LV) ejection fraction, peak ejection rate, volumes, and mechanical dyssynchrony (phase histogram standard deviation, phase entropy (PE), and phase histogram bandwidth) were estimated. Two-dimensional transthoracic echocardiography was performed baseline. Serum levels of NT-proBNP were analyzed with enzyme-linked immunoassay. (3) Results: After surgical treatment, patients were divided into two groups, one, with death, the need for an intra-aortic balloon pump (IABP) or/and inotropic support with a stay in the intensive care unit for more than two days and two, without complications in the early postoperative period (EPOP). Complicated EPOP (CEPOP) was observed in 17 (30%) patients (death—2, IABP—4, extra inotropic support in intensive care unit—11), and 40 patients had no complications (NCEPOP). GBPS showed differences in LV EDV (mL) (321 [268; 358] vs. 268 [242; 313], p = 0.02), LV ESV (mL) (242 [201; 282] vs. 196 [170; 230], p = 0.005), and stress-induced changes in PE (1 (−2; 3) vs. −2 (−4; 0), p = 0.02). Aortic cross-clamp time and stress-induced changes in PE between rest and dobutamine dose of 10 µg/kg/min were the only independent predictors of CEPOP. An increase in LV entropy ≥ 1 on the dobutamine dose of 10µg/kg/min in comparison to rest investigation showed AUC = 0.853 (sensitivity = 62%, specificity = 90%, PPV = 71%; NPV = 85%; p < 0.0001). Conclusion: Stress-induced changes in PE obtained during low-dose dobutamine GBPS are associated with a complicated course of the early postoperative period after surgical treatment for ICM.