Early surgical myocardial revascularization as an effective method of treating patients with acute coronary syndrome. / Ranniaia khirurgicheskaia revaskuliarizatsiia miokarda kak éffektivnyi metod lecheniia patsientov s ostrym koronarnym sindromom.

BACKGROUND: One of the main methods of treating patients with acute coronary syndrome (ACS) is percutaneous coronary intervention (PCI), however in patients with multivascular, abnormal, or technically complicated coronary lesions, early surgical myocardial revascularization is more promising. Despite modern development of surgical and interventional techniques, the application of one strategy for all patients with acute coronary syndrome is problematic and should be based on the heart team's decision and patient data. AIM: The study was aimed at assessing the results of early surgical myocardial revascularization in patients with acute coronary syndrome. PATIENTS AND METHODS: Retrospectively with continuous sampling the study included 342 patients who underwent surgical treatment of acute coronary syndrome at the Federal Centre of High Medical Technologies from January 1st, 2014 to December 31st, 2018. Myocardial revascularization using two internal thoracic arteries was performed in 220 (64.3%) cases. The mean age of the patients was 64.2±10.8 years. Prevailing in the study were men - 69.3%. The average number of affected vessels amounted to 3.1±0.9. Fifty-six (16.4%) patients had cardiogenic shock at the time of operation, with 9 (2.6%) patients diagnosed as having severe mitral insufficiency and 5 (1.5%) with interventricular septal defect. All patients were on antiplatelet therapy. RESULTS: In-hospital mortality was 5.2% (18 patients). The mean time of operation amounted to 205.3±58.9 min, with that of artificial circulation to 57.9±13.2 min. Such complication as postoperative haemorrhage was observed in 20 cases (5.8%). The average volume of drainage losses amounted to 507.3±66.7 ml. The average length of stay in the ICU was 3.8±1.4 days, with that of hospital stay being 16.6±2.1 days. Twenty-seven (7.9%) patients after removal of drainages were diagnosed as having exudative pericarditis which resolved on the background of medicamentous therapy. CONCLUSION: Early surgical myocardial revascularization in patients with acute coronary syndrome may be performed safely and effectively, and should be considered individually in each patient by the heart team.

[Minimally invasive operations for varicose disease of lower extremities].

The authors discuss specific using minimally invasive surgical technique of ablation of the saphenous vein trunks by a modified Oesch PIN stripper method proposed by the authors. An experience with surgical treatment of 245 patients with varicose veins using the same modified technique is analyzed. Postoperative complications and medium-term results are evaluated.

[Changes of intracardiac hemodynamics in plasty of the mitral valve with a synthetic band, early period of observation].

Valve saving interventions have a number of advantages over prostheses of the heart valves. An analysis of early results of annuloplasty of the mitral valve fibrous ring with a synthetic band in mitral failute (MF) did not detect any considerable difference in the indices of postoperative MF both in the main and in the control groups (p = 0.257). At the postoperative period lower mean index of residual MF was noted in the group with mixomatous lesion of the valve as compared with the control group (p = 0.004).

[Modern diagnostic technologies in determination of the strategy of treatment of patients with obliterating atherosclerosis of the lower artery vessels].

The authors analyzed results of surgical treatment of 332 patients in whom 410 reconstructive operations were performed on the lower extremity arteries. During 12 months after operation on the aorto-femoral segment with high peripheral vascular resistance reocclusions were noted in 61% of the cases, with normal resistance--in 11.8%, after operation on the femoro-popliteal segment--in 77.1% and 28.3% respectively. According to the findings of computed tomography and magnetic resonance imaging, densitometry the indices were established allowing prognosis of high peripheral resistance in the lower extremity arteries at the preoperative stage. Such indices are considered to be indications to femoro-profundoplasty on the aortofemoral segments or arterio-venous fistula on the femoro-popliteal segment. Such effectively fulfilled interventions could reduce the frequency of reocclusions to 3.1% on the aorto-femoral segment and to 11.8% on the femoro-popliteal segment.

[Surgical treatment of small aneurysms of the ascending aorta by the method of plasty and bandage].

On the basis of cardio-vascular department of the Saint Petersburg Medical academy of postdiploma education the authors made an analysis of surgical treatment of 23 patients with small (45-55 mm) aneurysms of the ascending portion of the aorta. Mean age of the patients by the time of operation was 55 years (from 35 to 75 years). The causes of the disease were as follows: poststenotic dilatation of the aorta--in 15 patients, atherosclerosis--in 5 patients, degenerative media pathology--in 3 patients. Critical aortal stenosis was revealed in 15 patients, 12 of them had insufficiency of the aortal valve. All the patients were subjected to longitudinal plasty of the aneurysm and banding with a vascular prosthesis, under conditions of mild hypothermic chemical cardioplegia. Good results were followed up for 5-10 years.

Coronary endarterectomy during off-pump coronary artery bypass surgery.

Coronary endarterectomy (CEA) is often combined with coronary artery bypass grafting (CABG), which is performed on cardiopulmonary bypass (CPB). Recent advances in off-pump surgical technique and cardioanesthesiology, along with the increasing number of patients with high risk of CPB complications made it possible and desirable to execute CEA on a beating heart. Russian scientific literature lacks reports on these interventions. The study was aimed at evaluation of off-pump CEA feasibility and early outcomes. From 59 patients with ischemic heart disease (IHD), who underwent combined CABG and CEA, off-pump technique was used for 16 (27.1%) patients, including 12 men and 4 women, mean age 55.3 +/- 6.4. All of them had long-lasting history of IHD; 2 patients had angina CCS class II, 12--class III and 2 patents--class IV. Total number of anastomoses was 51 for 16 patients or 3.18 per patient. Open endarterectomy was used in 7 (9%) CEAs, semi-closed--in 9 (11.5%) CEAs. The technique of atherosclerotic plaque extraction, coronary artery reconstruction and bypass was similar in both groups. Complete revascularization was achieved for all patients. At discharge clinical improvement was evident in patients with functional classes 0-1. Diffuse involvement of coronary arteries is not considered to be contraindication for CABG. Simultaneous CEA with off-pump technique helps to achieve complete myocardial revascularization and good early outcomes, comparable with the results of conventional CPB-assisted procedures.

[Venectomy under local tumescent anaesthesia].

The authors have analysed the findings of the examination and outcomes of surgical management of 142 patients with lower limb varicosity (a total of 160 lower extremities). Of theses, there were 52 (36.6%) men, and 90 (63.4%) women. The patients' age varied from 18 to 74 years old (mean age 44+/-11.1 years). The average duration of the disease amounted to 8.3+/-5.2 years. The distribution according to the CEAP clinical classes was as follows: C2 - 90 patients (63.4 %), C3 - 43 (30.3 %), C4 - 6 (4.2 %), C5 - 3 (2.1 %). The proportion of the patients with large varicose veins (more than 1 cm in diameter) amounted to 31.25%. Lesions of the bed of the great saphenous vein (GSV) were observed on 139 lower limbs (86.8%), of the small saphenous vein (SSV) - on 19 lower limbs (11.9%), and of both the GSV and SSV - on two lower extremities (1.3%). In all the cases, the operation was performed under local tumescent anaesthesia in outpatient conditions. The anaesthetic mixture was based on 0.2 - 0.5% ropivacain. The subjective score of the anaesthesia quality averaged 9.6 points. Immediate postoperative complications were observed in 1.4% of the patients (lymphorrhoea and wound process). Side effects of anaesthesia in the form of a vegetovascular reaction, transient cutaneous paresthesia, and a skin reaction were noted in 8.4% of the patients. Local postoperative haematomas were observed in 9.1% of cases. A total of 83.8% of the patients did not use tabletted analgetics in the postoperative period. The subjective assessment of the surgical intervention performed and postoperative outcomes achieved was excellent to good in 98.6% of the patients.

[Coronary artery of the heart reconstructions after endarterectomy].

Coronary endarterectomy is necessary in up to 37% of patients undergoing coronary artery bypass grafting surgery. Bypass grafting of "inoperable arteries" allows complete revascularization, improves prognosis and quality of life of patients with diffusely diseased coronary arteries. The article considers reconstructive techniques for coronary arteries after endarterectomy.

[Revascularization of the anterior wall of the heart using the radial artery].

An experience with the application of the radial artery for revascularization of the heart anterior wall is described as compared with the internal thoracic artery. Using the radial artery for shunting the anterior interventricular artery is followed by good immediate and long-term results.

[Revascularization of the myocardium with the radial artery]. / Revaskuliarizatsiia miokarda s pomoshch'iu luchevoi arterii.

The experience with using the radial artery (RA) includes 561 patients. RA was used in 203 minimally invasive operations on the working heart and in 358 traditional operations with extracorporeal circulation. Early postoperative ultrasonic and angiographic examinations have shown high immediate patency of RA. The loading tests have revealed the absence of syndrome of hypoperfusion and good tolerance to physical exercise of the patients. Long-term results up to 8 years were followed-up in 231 patients. The average period of observations of 4.3 years showed the survival in 97.9% of cases, acute myocardial infarction was endured by 6.3% of the patients, recurrent stenocardia took place in 8.3%. The investigation of RA have shown good immediate and long-term results of the clinical application of it, that allows this conduit to be recommended for a wider use in coronary surgery.

[Surgical treatment of incompetence of the mitral valve of ischemic genesis]. / Khirurgicheskoe lechenie nedostqatochnosti mitroal'nogo klapana ishemicheskogo geneza.

The authors made an analysis of results of the surgical treatment of 107 patients. It was shown that differentiated approach to correction of incompetence of the mitral valve and complete revascularization of the myocardium allow to get good immediate and long-term results.