Mitral valve replacement and implantation of an extracardial mesh frame in patients with severe heart failure: results of a clinical study and a description of a clinical case 18 years after surgery.

Aim    Dilated cardiomyopathy (DCMP) is a major cause for severe heart failure. Development of a combination (drug and surgery) treatment of this disease is relevant. This prospective observational study was aimed at evaluating short- and long-term results of extracardiac mesh implantation in DCMP patients with heart failure resistant to the optimum drug therapy.Material and methods    The extracardiac mesh ACOR-1 was implanted in 15 patients with DCMP. All meshes were produced individually for each patient and made of Gelweave (great Britain) vascular graft strips. The mesh size corresponded to the heart diastolic size, which was measured after achieving a maximum possible clinical improvement for the patient. Long-term results were followed for up to 4 years. Mean age of patients was 43.1±10.8 years (from 28 to 62 years). One patient was followed up for 18 years. Data of that patient were presented as a clinical case report.Results    From October, 2003 through October, 2007, 15 DCMP patients received mesh implants. Cases of in-hospital death were absent. In 3 mos. after the surgery, left ventricular volumes decreased (end-diastolic volume decreased from 251.7±80.7 to 229.0±61.3 ml; end-systolic volume decreased from 182.3±73.6 to 167.7±46.2 ml), and the left ventricular pump function improved (ejection fraction increased from 25.2±6.0 to 27.1±5.1 %; cardiac index increased from 2.0±0.5 to 2.4±0.7 ml /min /m2). The functional state of patients improved by one NYHA class, from 3.7±0.3 to 2.8±0.6. In some cases, the left ventricular size and the systolic function completely normalized. There were no episodes of circulatory decompensation in the long term after surgery. Actuarial survival for the observation period was 100%.Conclusion    Implantation of extracardiac mesh prevented progression of heart dilatation and, in combination with drug therapy, it may represent an effective method for treatment of DCMP.

[Nutritional support in surgically treated patients with dilated cardiomyopathy].

The efficiency of nutritional support was studied in patients operated on for dilated cardiomyopathy (DCM). In 36 patients with DCM and signs of circulatory decompensation, preoperative nutritional support with a MD mil Clinipit mixture was carried out in addition to medical treatment. The trophological, laboratory, and functional parameters of the operated patients were assessed on admission to hospital, 14 days after treatment and in the late postoperative period (up to 3 years). Preoperative medical treatment and nutritional support in all the patients during 14 days could achieve circulatory compensation, lean weight gain, improved pool of visceral proteins (prealbumin and albumin), decreased C-reactive protein levels, and increased exercise tolerance. The developed complex protocol provided effective preparation for surgery, rapid activation and recovery of patients with DCM in the postoperative period. In the operated patients with DCM, the three-year actuarial survival rate was 85.6 +/- 7.4% while it was not greater than 12% in the patients receiving medical treatment only. Analysis of long-term results indicated the higher functional activity and improved quality of life in the operated patients.

[Changes in hemodynamics and volemic status during intraoperative blood exfusion in patients with chronic heart failure].

Forty-five patients with dilated cardiomyopathy, NYHA Functional Classes III-IV chronic heart failure with left ventricular ejection fraction 26.98+/-7%, who had undergone surgical left ventricular remodeling using an extracardiac conduit in combination with mitral or tricuspid valve correction and blood exfusion, were examined. Central hemodynamic monitoring was performed, by using a Swan-Ganz catheter in all the patients at surgery. In 11 patients, transpulmonary thermodilution in combination with pulmonary artery catheterization with a Swan-Ganz catheter (PICCO-Plus + VOLEF, Pulsion, Germany) was used in 11 patients to monitor central hemodynamics. Right atrial blood autoexfusion was carried out at a volume of 6-10 ml/kg prior to extracorporeal circulation. At blood sampling, blood pressure (BP), heart rate (HR), central venous pressure (CVP), and pulmonary pressure were in the normal range. There were no significant changes in HR, BP, and CVP after blood exfusion. A significant lowering was noted in systolic and diastolic pulmonary pressure by 20-25%. Under the influence of blood exfusion, there was a reduction in cardiac pump function, which appeared as decreases in stroke index by 24% (p < 0.05) and cardiac index by 18% (p < 0.05). The parameters reflecting left and right ventricular myocardial contractility (functional state index, global ejection fraction, and dPmax) underwent no negative changes. According to the changes in systolic and diastolic BP and total peripheral vascular resistance index, left ventricular postload did not change either. At the same time, global end-diastolic volume index was reduced by 22% (p < 0.05), right cardiac and right ventricular end-diastolic volumes were decreased by 20% (p < 0.05) and 23% (p < 0.05), respectively; the left ventricular end-diastolic volume index tended to be lower. These data suggested that diminished cardiac pump function was caused by a predominant reduction in global preload, as evidenced by volumetric monitoring. At the same time the changes in CVP, BP, and HR did not reflect the altered volemic status. To prevent destabilization of the circulatory system, blood should be sampled just before extracorporeal circulation after aortic cannulation.

[Anesthesiological provision of surgical correction of dilated cardiomyopathy in patients with chronic heart failure].

When dilated cardiomyopathy (DCM) is surgically corrected, intraoperative intracardiac hemodynamic changes and additional ischemia of the disabling myocardium make special demands for anesthesia, prevention of cardiovascular insufficiency, and maintenance of circulatory oxygen-transporting function (COTF). For the development and evaluation of an anesthetic support protocol for patients with DCM, clinical parameters, hemodynamics and oxygen transport was comprehensively analyzed in 50 DCM patients aged 16-68 years in the intraoperative period of surgical correction of myocardial pathology. All the patients underwent implantation of an extracardiac mesh framework in combination, if required, with correction of mitral insufficiency under extracorporeal circulation (EC), drug-induced cold cardioplegia. Analysis of comprehensive clinical studies made it possible to provide scientific evidence and to successfully use the anesthetic support protocol for correcting operations of chronic heart failure in patients with DCM, the basic principles of the support being an effective preoperative preparation of a patient to attenuate the signs of congestive heart failure; preventive intraaortic balloon contrapulsation before surgery; overall monitoring of hemodynamics and oxygen transport; balanced use of anesthetic agents in the doses that exert no cardiosuppressive effect; preload optimization and postload reduction; the minimum use of catecholamines; prevention of arrhythmias; and a reduction in the duration of myocardial ischemia.

[Analysis of the performance of the clamping pads of jet injectors]. / Analiz raboty prizhimnykh ploshchadok bezygol'nykh in'ektorov

Nine shapes of clamping pads for injector syringes were tried out in the course of mass immunoprophylaxis (34 thousand injections). The reliable locking of injectors was judged about by the frequency and intensity of complications. Optimal shapes of clamping pads were determined, the ones suitable to be used for mass immunoprophylaxis that ensure, alongside a regular performance of high-quality subcutaneous injections, a firm fixation of the injector in the skin at the time of vaccination.

[Features of topographic anatomy of internal thoracic and right gastro-omental arteries as applied to coronary shunting]. / Osobennosti topograficheskoi anatomii vnutrennei grudnoi i pravoi zheludochno-sal'nikovoi arterii primenitel'no k operatsiiam koronarnogo shuntirovaniia.

The aim of the study was to specify topographoanatomic features of internal thoracic artery (ITA) and right gastroepiploic artery (RGEA) for optimization of surgical and endoscopic methods of their mobilization. The study was carried out on 50 cadavers (27 men, 23 women) aged from 29 to 82 years (mean age 59 years). The following topographic parameters of the conduits were evaluated: disposition of the artery ostium; presence and disposition of parietal branches; presence and disposition of visceral branches; type of a terminal part of the artery; interdisposition with surrounding anatomic structures. It was found that topographic anatomy of ITA and RGEA permits one to use effectively mini-invasive and endoscopic methods of their mobilization and therefore, to reduce rate of complications and to optimize methods of ITA and RGEA effective use.

[Heart transplantation conducted at the All-Union Research Center of Surgery (the first clinical experience)]. / Transplantatsiia serdtsa v VNTsKh (pervyi klinicheskii opyt).

The authors analyse experience in the first eight operations for orthotopic transplantation of the heart. Six patients were discharged from the clinic with good immediate results. Comparison of their own data with summarized results gained in other countries allowed the authors to define some specific problems which are of practical interest for clinics embarking on the clinical realization of the problem of heart transplantation.

Transplantation of allogenic cells in the therapy of patients with dilated cardiomyopathy.

We carried out a pilot study on intracoronary transplantation of prenatal allogenic skeletal myoblasts and multipotent bone marrow stromal cells to patients with dilated cardiomyopathy. Intracoronary transplantation of allogenic cells is a feasible and safe procedure: there were no life-threatening rhythm and conduction disturbances, symptoms of hemodynamic instability, and thromboembolic complications. Positive clinical effect of cell transplantation persisted for 6 months and consisted in decreased content of brain natriuretic peptide and improved tolerance to physical exercises. We observed no reliable dynamics of the major echocardiographic parameters and their correlations with patient's status.

[Ampicillin concentration in the blood when administered by jet injection and needle-syringe methods]. / Kontsentratsiia amptisillina v krovi pri bezygol'nom struinom i igol'no-shpritsevom sposobakh vvedeniia.

The studies were carried out on 50 persons. Ampicillin was administered with the help of a jet injector B1-2 and needle syringe in doses of 250 or 500 and 500 mg respectively. When the drug was administered by infusion, its maximum blood levels were achieved earlier than after needle-syringe administration of the drug and were higher (22.83+/-4.10 and 6.3+/-0.09 gamma/ml respectively). Even when ampicillin was administered with the help of the injector in a dose of 250 mg its blood levels were much higher than those after needle-syringe administration in a dose of 500 mg. After jet infusion the prolongation of the drug retention time in the blood at therapeutical levels was observed as compared to the needle-syringe administration.