**4. Conclusion**

130 Front Lines of Thoracic Surgery

not found in 10.8 % of ICMP patients, in 24.3 % – they were detected in titre 20, in 43.3 % –

Maximal detection rate of antibodies to nuclear structures in titre 80 in the control group was 11.8%, in 88.2% of the patients did not have these antibodies. The highest titre in ICMP patients where nuclear antibodies were found was equal to 80 (2.7%); in 5.4% of the cases antibodies to nuclear structures were detected in titre 40, in 32.4% - in titre 20, in 59.5%

In a year after the surgical treatment all the patients included into the study were examined (n=53, 100%). In accordance with the aforementioned algorithm for the evaluation of late postoperative period 40 patients were assigned into group I (with positive dynamics of the late postoperative period), 13 patients – into group II (with negative dynamics of the late postoperative period). The levels of pro-ANP, NT-proBNP and pro-ММР-1, MMP-3, MMP-9, TIMP-1 in blood plasma and serum In the ICMP patients with different dynamics of the

Nonnormal distribution law U p Q25 Me Q75 Q25 Me Q75

(nmol/l) 0.917 0.03 57 0.73 3.69 6.34 8.59 3.31 5.30 7.78

(ng/ml) 0.861 0.002 25 0.03\* 5.16 5.70 7.05 6.25 7.11 8.49

(ng/ml) 0.838 0.001 46 0.32 426.0 455.8 502.6 447.4 480.8 512.4 Normal distribution law t р Mean Std. Dev. Mean Std. Dev.

(ng/ml) 0.954 0.26\* –2.255 0.03\* 64.51 24.23 90.64 27.97

(ng/ml) 0.948 0.19\* –0.651 0.52 6.10 3.72 7.25 4.28

Table 8. The content of natriuretic peptides and matrix meatlloproteinases in blood plasma and serum in ICMP patients with different dynamics of the late postoperative treatment

We managed to follow the late postoperative period of 32 (86.5%) out from 37 patients whose blood was tested for antimyocardial antibodies. Postoperative LV remodeling took place in only 5 patients which does not allow to reliably associate the activity of

Thus, evaluation of the content of MMP-3 and MMP-9 in blood serum at the preoperative stage let us "foresee" the outcome of possible surgical treatment since their content is significantly higher in the group of patients with postoperative heart remodeling. We made

inflammatory response in myocardium with postoperative heart function.

0.729 <0.01 59 0.82 12.30 38.45 58.42 19.48 39.93 90.37

Group I Group II

t- TEST n=40 n=13

Significance of differences between the groups

Mann–Whitney

in titre 40, in 16.2 % – in titre 80, in 5.4 % – in titre 160.

autoantibodies of this specificity were absent.

late postoperative period are shown in Table 8.

Normality of distribution law

Shapiro– Wilk <sup>р</sup>

*Note*: \* – statistically significant data.

Value

pro-ANP

NTproBNP (fmol/l)

MMP-3

TIMP-1

MMP-9

MMP-1

Our clinical observations demonstrate progress of chronic HF in the late postoperative period and inefficiency of SVR in ICMP patients in 35% of the cases. These patients should be refused from the standard procedure of surgical restoration of normal left ventricular geometry in favor of alternative methods of surgical treatment – isolated bypass grafting for the patients with symptomatic CAD, cardiac resynchronization therapy for patients with QRS >120 msec and left bundle branch block, primary heart transplantation and implant of the devices preventing ventricular dilatation. Attempts to find clinical, instrumental or other markers of chronic HF progression have been made many times but the results are very modest. The age older than 55 years and high values of LV ESVI in preoperative period have been considered as risk factors of such interventions.

In our opinion the reason of unfavorable outcomes of surgical treatment lies in peculiarities of myocardial functional morphology of an each and every patient and depends on irreversibility of the far gone pathological changes in cardiac muscular tissue. Assessment of an initial morphofunctional condition of myocardium (at the moment of surgical treatment)

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based on pre- and/or intraoperative LV biopsies taken for the detection of irreversible pathological changes in myocardium by a number of qualitative and quantitative histomorphometrical values taking into account the condition of tissue trophy to the full extent, should contribute into prevention of repeated heart remodeling and progression of chronic HF in the late postoperative period.

Cellular-stromal relationships on the background of chronic ischemia of myocardium precondition destructive processes of a heart muscular tissue remodeling which is reflected also in peripheral blood of ICMP patients: the content of MMPs and MMP-3 and MMP-9 in particular, which becomes molecular prognostic markers of the late postoperative period.

Basing on the obtained data we offer the following algorithm of surgical treatment of patients with ICMP: for the candidates for a complex surgical treatment older than 55 years old with preoperative LV ESVI >80 ml/m2 it would be reasonable to widen indications for endomyocadial biopsy at the preoperative stage or to perform intraoperative biopsy of LV myocardium in order to identify prognostic criteria of the postoperative progressive heart remodeling and take blood samples for the detection of blood markers of HF progression. If the combination of unfavorable prognostic criteria takes place: the presence of diffuse inflammatory infiltration of myocardial stroma in combination with pronounced fibrosis, low TI (<0.010) and high values of KI (>1.5) and PcDZ (>1000 mcm) of LV myocardium as well as high concentrations of MMP-3 (>7.7 ng/ml) and MMP-9 (>102.4 ng/ml) in blood serum, the patient should be refused from a standard procedure of surgical reconstruction of normal left ventricular geometry in favor of alternative methods of surgical treatment (in the case of taking preoperative biopsy of myocardium) or surgeons should refuse from SVR in favor of a surgical procedure with less risk (in case of taking intraoperative biopsy of myocardium).
