[Postoperative sternomediastinitis: morphology of lesion, treatment strategy]. / Posleoperatsionnyi sternomediastinit: morfologiya porazheniya, taktika lecheniya.

OBJECTIVE: To analyze bone tissue damage at different stages of disease (El Oakley classification), treatment options for each clinical situation and results after each approach. MATERIAL AND METHODS: There were 45 patients with wound complications after cardiac surgery between October 2022 and September 2023. Thirty-eight (84.4%) patients underwent CABG, 7 (15.6%) patients - heart valve or aortic surgery. Mean age of patients was 68.1±10.3 years. There were 35 men (77.8%) and 10 women (22.2%). The first type was found in 11 (24.5%) patients, type 2-3 - 19 (42.2%), type 4 - 4 (8.8%), type 5 - 11 (24.5%) patients. RESULTS: Systemic inflammatory response syndrome was observed in 7 (36.8%) persons of the 1st group, 14 (73.7%) ones of the 2nd group, 4 (100%) patients of the 3rd group and 2 (18.2%) patients of the 4th group. C-reactive protein and procalcitonin increased in all patients with the highest values in groups 2 and 3. Redo soft tissue inflammation occurred in all groups after treatment. Mean incidence was 25%. Two (10.5%) patients died in the 2nd group and 1 (25%) patient in the 3rd group. CONCLUSION: The modern classification of sternomediastinitis does not fully characterize severity of disease in a particular patient. Simultaneous debridement with wound closure demonstrates acceptable mortality (within 10%). The highest mortality rate was observed in patients with diffuse lesions of the sternum. Less aggressive treatment approaches are possible for stable anterior chest wall.

[A new paradigm for the treatment of sternomediastinitis]. / Novaya paradigma lecheniya sternomediastinita.

OBJECTIVE: To analyze the results of simultaneous surgical treatment of sternomediastinitis compared to stage-by-stage approach. MATERIAL AND METHODS: The study included 27 patients between October 2022 and March 2023. All patients underwent heart surgery through median sternotomy. There were 11 (40.7%) women and 16 (59.3%) men. Mean age of patients was 68.4±9.8 years. All patients were divided into 2 groups: 12 patients underwent partial necrectomy and vacuum wound therapy (or long-term dressings) before surgery (group 1), 15 patients underwent surgery without prior conservative treatment (group 2). RESULTS: The most common causative agent of infection was staphylococcus (48.1%). In all patients, we found histological signs of osteomyelitis. Preoperative clinical status was similar in both groups. There were differences in the following indicators: C-reactive protein upon admission - 74.9±18.6 versus 94.8±23.8 mg/l, procalcitonin - 0.13 [0.02; 1.43] versus 0.21 [0.02; 0.94] ng/ml. Postoperative outcomes were similar in both groups. Mortality was 8.3% (n=1) and 13.3% (n=2), respectively. CONCLUSION: Simultaneous combined surgical treatment (sequestrectomy + muscle flap grafting) demonstrates optimal results in the treatment of sternomediastinitis.

[Pathogenetic treatment of postoperative sternomediastinitis]. / Patogeneticheski obosnovannyi sposob lecheniya posleoperatsionnogo sternomediastinita.

Sternotomy is the most common surgical approach for cardiac surgery. Incidence of postoperative sternal diastasis and wound suppuration ranges from 0.11 to 10%. We present a variant of one-stage surgical treatment of patients with these postoperative complications. Surgical tactics and features of postoperative period are described in detail. Pathogenetic approach to the treatment is substantiated. This approach can be used in patients with aseptic diastasis of the sternum and sternomediastinitis.

[Preventive surgery after vascular reconstruction for chronic lower limb ischemia]. / Preventivnye khirurgicheskie vmeshatel'stva posle sosudistykh rekonstruktsii po povodu khronicheskoi ishemii nizhnikh konechnostei.

OBJECTIVE: To analyze the results of redo reconstructions of lower limb arteries in patients with obliterating atherosclerosis, immediate and long-term results in patients who underwent reconstructive interventions with occlusion of previous reconstruction and preventive interventions. MATERIAL AND METHODS: The study included 43 patients. The main group (group 1) consisted of 18 patients who underwent preventive vascular reconstructions. The control group enrolled 25 patients who underwent redo interventions for occlusion of previous reconstructions. The control group was divided into 2 parts; 15 patients had chronic limb ischemia (group 2), 10 patients had acute limb ischemia (group 3). Mean age of patients was 56.8±8.2 years; there were 37 (86%) men and 6 (14%) women. Multifocal vascular atherosclerosis was noted in 41 (95.3%) patients, carotid artery lesion - 29 (70.7%), coronary artery disease - 34 (79%). Patients with type II diabetes mellitus were excluded. RESULTS: We chose each surgical intervention considering preoperative diagnostic data. Open, endovascular and hybrid interventions were performed. There were no deaths and limb amputations in the 1st group. Two (13.3%) amputations were registered in the 2nd group, 3 (30%) amputations and 1 (10%) death were registered in the 3rd group. The follow-up period was 24 months. An 18-month freedom from amputations was 71.5%, 78% and 38%, respectively (p<0.05 compared to the 1st and 2nd groups). CONCLUSION: Preventive surgical interventions prevent ischemia and amputation, as well as improves the results of redo surgery.

[Is thoracoscopic heart suturing possible for stab wounds?] / Vozmozhno li torakoskopicheskoe ushivanie rany serdtsa pri koloto-rezanom ranenii?

The authors report two clinical cases with similar stab wounds of the heart. The first patient underwent open wound closure, the second one - thoracoscopic suturing of the wound. The authors concluded that conversion may be unnecessary after diagnosis of heart injury if severe bleeding is absent.

[Treatment of recurrent traumatic sternomediastinitis after cardiac surgery]. / Lechenie retsidivnogo travmaticheskogo sternomediastenita posle kardiokhirurgicheskikh operatsii.

OBJECTIVE: To assess the possibilities of omentoplasty for prevention of complications after redo sternum osteosynthesis for traumatic rupture. MATERIAL AND METHODS: The study included 53 patients with recurrent sternal diastasis. Greater omentum was additionally implanted in 19 (35.8%) cases to improve healing and reduce the risk of infectious complications. In 34 patients, redo osteosynthesis was carried out using a metal wire and deployment of irrigation-aspiration system. In 19 patients, omentoplasty was additionally used to close the wound. RESULTS: Omentoplasty was characterized by less duration of lavage (7.4±1.5 vs. 4.2±3.3 days, p<0.0001) and no cases of arrosive bleeding (p=0.04). CONCLUSION: Omentoplasty reduces duration of treatment and risk of arrosive bleeding.

[Hybrid interventions for acute thrombosis after reconstructive operations on lower-limb arteries]. / Gibridnye operatsii pri ostrykh trombozakh posle rekonstruktivnykh operatsii na arteriiakh.

BACKGROUND: A steadily growing number of primary lower extremity arterial reconstructions is inevitably followed by the need to perform repeat interventions. Shunt reocclusion may become a cause of return of ischaemia to the initial level, may significantly increase the degree of limb-threatening chronic ischaemia, as well as lead to the development of an acute condition requiring urgent corrective measures to be taken. A reoperation currently continues to remain the standard of treatment. Despite advances in modern resuscitation, the postoperative mortality rate in such patients reaches 20%. AIM: This study was aimed at assessing feasibility of hybrid technologies in acute thrombosis after reconstructive operations on lower-limb arteries. PATIENTS AND METHODS: We retrospectively analysed the results of treatment of 66 consecutive patients urgently admitted to the City Clinical Hospital named after S.S. Yudin from 2015 to 2020 with acute lower limb ischaemia caused by acute occlusion of the zone of primary vascular reconstructions previously performed at other medical facilities. Depending on the method of surgical treatment, the patients were divided into two groups. The Study group included 20 patients subjected to open surgical interventions followed by angiographic control and using one or other type of X-ray-endovascular treatment. Endovascular interventions were performed for more than 70% stenoses in the major arteries and zone of the previously performed operation. The Comparison group comprised 46 patients treated without endovascular technologies. They were subjected to thrombectomy from the vascular construction with/without reconstructive-restorative operations. RESULTS: Seventeen (85%) of the 20 Study group patients were operated on in a stagewise manner, with the first stage consisting of an open intervention - thrombectomy and reconstruction followed by angiographic control and roentgenendovascular treatment. The remaining three (15%) patients underwent simultaneous interventions. In the postoperative period, limb amputations were performed in ten (22%) Comparison group patients and in one (5%) Study group patient (p=0.049). There were three (7%) lethal outcomes in the Comparison group, with none in the Study group. CONCLUSION: A combination of open and endovascular interventions in patients with shunt occlusion after vascular reconstructions makes it possible to reveal the cause of shunt occlusion, as well as to remove multilevel lesions, minimizing surgical wound and contributing to reducing the amputation rate.

[Negative pressure wound therapy for deep sternal wound infections: microbiological characteristics and antibiotic resistance]. / Vliyanie vakuum-assistirovannoi povyazki na lechenie glubokoi infektsii grudiny: bakteriologicheskii analiz i antibiotikorezistentnost'.

OBJECTIVE: To evaluate bacterial flora in patients with deep sternal wound infection and the effect of negative pressure wound therapy on eradication of the pathogen. MATERIAL AND METHODS: There were 102 patients with deep wound infection after cardiac surgery. Mean age was 66.9±9.9 years. Diabetes mellitus was detected in 21 (20.5%) cases, chronic obstructive pulmonary disease - in 15 (14.7%). Wound debridement via daily dressings was performed in 64 patients; vacuum-assisted dressings were applied in 38 patients. Bacteriological analysis of discharge was carried out every week.Results. Mixed infection was observed in 38 (37.3%) patients. S.aureus was the most common pathogen (n=51, 50%), Gram negative bacteria were found in 36 (35.3%) patients. Negative pressure wound therapy ensured eradication of S.aureus within 3 weeks while dressings were associated with only 40% decrease of the incidence of positive analyses (p<0.05). Effectiveness of the method was not obtained for Gram negative bacteria. CONCLUSION: Negative pressure wound therapy accelerates eradication of Gram positive pathogens but does not affect eradication of Gram negative microbes.

[Staged approach for hybrid thoracoabdominal aortic replacement]. / Étapnyi metod gibridnogo protezirovaniia torakoabdominal'noi aorty.

AIM: To generalize our experience of step-by-step hybrid thoracoabdominal aortic replacement. MATERIAL AND METHODS: Twenty-three patients were enrolled who underwent staged hybrid treatment of thoracoabdominal aortic aneurysm. There were 5 (21.7%) women and 18 (78.3%) men aged 61.4±8.3 years (37-74 years). The first stage was proximal debranching, the second - distal (abdominal) procedure and the third - stenting of the thoracoabdominal aorta. RESULTS: There were no any complications after proximal debranching and aortic stenting. Abdominal debranching was followed by lethal outcome in 3 (13.0%) patients and early postoperative occlusion of the prosthesis brunch in 3 out of 87 cases. CONCLUSION: Staged approach for hybrid surgical treatment is optimal solution, especially in high risk patients. In our opinion no necessity for cardiopulmonary bypass is the main advantage of this technique.

[Long-term results of surgical treatment of patients with aortic valve disease and functional mitral insufficiency].

AIM: To analyze long-term surgical results in patients with aortic valve disease and concomitant mitral regurgitation (MR) depending on volume of valve surgery. MATERIAL AND METHODS: It was studied 5-year results in 71 patients with aortic valve disease and different degree of mitral regurgitation. Patients were divided into 3 groups. Control group included 40 patients after aortic valve replacement (AVR) and no mitral insufficiency. The 2nd group consisted of 16 patients after AVR and concomitant mitral regurgitation degree 2-3. The 3rd group - 15 patients after aortic and mitral valve replacement. Mortality in long-term postoperative period, quality of life, incidence of complications and echocardiography data were analyzed. RESULTS: There was no significant improvement of mitral regurgitation after AVR. It was showed that persistent MR decreases remote survival and quality of life as well as deteriorates echocardiography data. Herewith these data in the 3rd group did not differ from the control group. CONCLUSION: Double-valve replacement may be advisable in patients with aortic valve disease and concomitant moderate MR because persistent MR deteriorates long-term RESULTS: However prolonged time of cardiopulmonary bypass, aortic cross-clamping, greater blood loss require comprehensive approach to advanced cardiac surgery.

[Cardiopulmonary bypass duration as predictor of immediate results after cardiac surgery].

It was analyzed the results of treatment of 152 patients who underwent heart valve surgery. Depending on cardiopulmonary bypass (CPB) duration patients were divided into 4 groups: the 1st--up to 90 min, the 2nd--90-120 min, the 3rd--120-180 min, the 4th--more than 180 min. Severity of initial comorbidities was comparable in all groups. It was revealed that CPB duration effects on intraoperative blood loss, incidence of acute renal failure, encephalopathy, use of inotropic and angiotonic support (p<0.05). Accession of CPB duration was associated with increased number of postoperative complications in all groups (p<0.05). "Critical periods" of CPB for every type of postoperative complications are defined.

[The effect of prosthesis-patient mismatchon early myocardial remodeling after aortic valve replacement].

The reductionofan effective orifice area is associated with the development of the phenomenon of prosthesis-patient mismatch (PPM). The purpose of this study was to evaluate the impact of PPM on the immediate results of surgical treatment in patients with aortic valve stenosis. The study included 50 patients who underwent aortic valve replacement. All patients were divided into 2 groups: with PPM (27 patients) and without it (23 patients). Immediate postoperative results were not statistically different. Analysis of echocardiographic data showed worse results in patients with PPM. It was marked reduction of LV EDV on 23.43 ± 8.93 ml in the group without PPM and on 16.5 ± 1.76 ml in patients with PPM (p<0.05). Also it was noted a greater decrease of pulmonary artery pressure (16.56 ± 12.94 mm Hg) compared with the group with PPM (8.44 ± 7.38 mm Hg), p<0.05. The presence of PPM in patients after aortic valve replacement leads to a slower reverse remodeling of the myocardium.

[Reverse myocardial remodeling in patients with aortic valve disease and mitral insufficiency in early postoperative period].

Surgical treatment of patients with aortic valve disease and concomitant mitral insufficiency remains debatable. We analyzed early postoperative results of surgical treatment of 80 patients depending on type of surgery. All patients were divided into three groups: the 1st - aortic valve replacement in patients without mitral valve dysfunction (control group) (n=44); the 2nd - isolated aortic valve replacement in patients with concomitant mitral regurgitation degree 2-3 (n=18), the 3rd - simultaneous aortic and mitral valve replacement (n=18). Combined valve replacement was associated with more intraoperative blood loss (852.78±442.08 ml) compared with aortic valve replacement (658.7±374.09 ml), p<0.05. In patients with mitral regurgitation greater hematocrit decrease was observed (22.13±3.6% in group 2 and 21.4±4.48 in group 3) in comparison with control group (24.17±3.72% in group 1), p<0.05. Incidence of postoperative complications did not differ in all groups. Mortality rate was 6.8% in group 1 and 11.1% in group 3, there were no deaths in group 2. Both valves correction provided faster myocardial remodeling. Left ventricular end-diastolic volume decreased on 50 ml in group 3, on 33.67 ml in group 2 and on 50.73 ml in group 1 (p<0.05). Pulmonary pressure decreased on 20 mm Hg in group 3, on 13 mm Hg - in group 2 and on 12.57 mm Hg - in group 1, p<0.05. In groups 1 and 3 pulmonary pressure became normal after operation, in group 2 signs of pulmonary hypertension were observed (pressure - 35.3 mm Hg). Analysis of the results showed that simultaneous mitral and aortic valves replacement initiates normalization of intracardiac hemodynamics in early postoperative period.

[Expansion of indications for total replacement of thoracoabdominal aorta].

Experience of surgical treatment of 111 patients with thoracoabdominal aorta aneurysm are presented in the article. All patients were operated in terms 2007 to December 2011 in the department of aortic surgery of acad. B.V. Petrovskogo RSCS of RAMS. All patients were divided into 3 groups. Thoracoabdominal aorta prosthetics from isthmus to bifurcation was performed in 10 patients of the first group. It was done descending thoracic aorta prosthetics in the second group (72 patients). The third group (29 patients) had suprarenal aorta prosthetics. The groups were comparable with respect to initial severity of underlying and concomitant diseases. Hemorrhage was 6242±3040, 2666±1590 and 2962±1547 ml respectively. Liver and renal failure developed in 10, 7 and 24% of cases respectively (p<0.05). Respiratory failure developed in 40, 33 and 27.6% of cases. Mortality was 10, 7 and 13.8% respectively. It was concluded about comparable treatment outcomes regardless of the amount of reconstruction. It is necessary to develop the techniques improving surgical treatment results and decreasing postoperative complications frequency.

[Risk factors and causes of hospital mortality after Bentall-deBono's surgery].

It was done an evaluation of surgical treatment results of 71 patients with aortic arch aneurysm and aortic insufficiency, who were operated routinely. According to data of correlation and multiple regression analysis, chronic obstructive pulmonary disease and kidney disease before operation are significant factors predisposing to death in postoperative period. The authors consider that normalization of lungs and kidneys function before operation improves surgical treatment results in patients of this group.

[Revascularization of the brain in the acute stage of ischemic stroke]. / Revaskuliarizatsiia golovnogo mozga v ostrom periode ishemicheskogo insul'ta.

A literature review on the early surgical revascularization using carotid endarterectomy in the acute stage of ischemic stroke is presented. Special attention is drawn to criteria of patient selection and time of surgery. A history of the problem is given.

[Mega aorta: Borst operation or Kouchoukos operation?].

It was done 163 operations on aortic arch in terms 2000 to December 2011. All patients were operated in the department of aortic surgery of acad. B.V. Petrovskogo RSCS of RAMS. 36 operations were performed by using of Borst's technique and 9 operations - by using of Kouchoukos technique in case of extended aneurysms of thoracic aorta. All patients did not differ in the severity of primary state, concomitant diseases and age. Duration of cardiopulmonary bypass and internal organs ischemia were 189±55/190±47 and 55±8/77±20 min respectively. Complication frequency was 27% and 22% in case of cardiovascular failure. Respiratory failure was 16.7% and 33%. Liver and renal failure was observed in 27% and 11% of cases. Encephalopathy was detected 33% and 22% of cases. Mortality was 22% and 11% of cases. It was concluded that Kouchoukos technique is alternative and safe method in thoracic aorta aneurysm treatment.

[The version of the Bentall-DeBono operation].

The Bentall-DeBono operation was proposed in 1968. It is the «gold standard" of the aneurysm treatment of the ascending aorta and aortic insufficiency nevertheless this technique is fraught with a number of possible postoperative complications. We have proposed an improved method: two short (10 mm) jaws and «skirt"« formed from the distal portion of the prosthesis were sewed to valved conduit. 19 operations were done by the proposed method in all. The control group included 73 patients who had operation according to the standard technique. Duration of extracorporeal circulation, myocardial ischemia, blood loss were the following: 145.4±54.4 and 117.4±40.9 min; 106.4±30.2 and 77.5±22.5 min; 473±355 and 1853±940 ml respectively. The mortality rate was 5.2% and 10.9% respectively. Our experience shows the technical simplicity of the procedure and satisfactory postoperative results.

[Does the volume of the intervention on the aortic arch influences the results of surgical treatment?].

The issue centers on the critical analysis of the results of the aortic arch surgery, performed using the two basic methods: hemiarch and total arch replacement. 130 patients were included in the study. All were operated on in conditions of moderate hypothermia and antegrade brain perfusion. The study demonstrates that the volume of the intervention does not influence the results. The main success criteria is the adequacy of the brain and internal organs perfusion.