[Myocardial revascularization in chronic coronary artery disease. State of art].

The review addresses debatable issues of myocardial revascularization in chronic forms of ischemic heart disease, shows major differences between percutaneous coronary intervention and coronary artery bypass grafting in terms of long-term prognosis, and the dependence of the results on the clinical profile of the disease. The review of current publications demonstrates advantages of open surgery in long-term survival and prevention of adverse outcomes in target groups of patients.

[Surgical treatment of lung injuries and diseases in patients with blunt chest trauma]. / Khirurgicheskoe lechenie povrezhdenii i boleznei legkikh u patsientov s zakrytoi travmoi grudi.

OBJECTIVE: To establish the indications for optimal open lung surgery in patients with severe blunt chest injury. MATERIAL AND METHODS: Hematomas, lung wounds and purulent pulmonary complications were studied in four groups of victims. Causes of injuries included road accidents (n=426), falling and beating (n=387), catatrauma (n=217), squeezing the body with a massive weight (n=46). Majority of victims (n=731, 67.9%) were transferred to the hospital within 1-5 hours after injury; 345 (32.1%) patients were transferred from other hospitals to treat combined injuries of head, chest, abdomen and complications within 1-49 days after injury. RESULTS: Lung surgery was applied in 48 patients. Typical resections and pneumonectomies made up 77.1%. Indications for surgery included lung wounds complicated by pulmonary hemorrhage grade IIa and severe hemothorax, intrapulmonary hematoma ≥6 cm with high risk of bleeding and suppuration, gangrene, gangrenous and purulent abscesses of aspiration genesis, lung cancer first diagnosed in victims. Postoperative mortality was 14.6%. Twelve victims with unrecognized deep lung wounds and pulmonary root rupture were not operated. Thus, 5.6% of victims with severe blunt chest trauma need for open lung surgery.

[Infectious complications after endoprosthetic repair of the thoracic aorta]. / Infektsionnye oslozhnenii pri éndoprotezirovanii grudnoi aorty.

Presented herein is a review of publications of foreign authors on the problem of infectious complications after endoprosthetic repair of the thoracic aorta. The problem discussed is of current importance, however in the Russian literature it is covered insufficiently. The article contains the data on frequency, terms and possible causes of the development of complications, also discussing the problems of diagnosis. The authors demonstrate extreme danger of infection of an aortic stent graft, difficulty of early diagnosis and mostly unsatisfactory therapeutic outcomes. Also noted are possible ways of prevention of complications and aimed at improving the results of this extremely severe patient cohort.

[Haemangioma of the left atrium]. / Gemangioma levogo predserdiia.

Presented herein is a clinical case report concerning successful surgical management of a rare variety of a primary tumour of the heart, i. e., a capillary haemangioma of the left atrium, simulating by the contours and localization a myxoma. The final diagnosis was verified only by histological examination. The authors describe difficulties of diagnosis of the disease involved, underlying the necessity of plastic correction for restoration of the normal anatomical configuration of the heart. This is followed by a review of the literature, reflecting a possible course of the disease, problems of diagnosis, and therapeutic policy.

[Endovascular closure of iatrogenic arteriovenous anastomosis of the iliac artery and vein].

The presented herein clinical case report concerns successful endovascular closure of a iatrogenic lesion of the iliac artery and inferior vena cava with formation of a pathological arteriovenous anastomosis manifesting itself by venous thromboembolic syndrome and severe right-ventricular insufficiency.

[The key role of calcium in the mechanism of deprivational potentiation of population responses in hippocampal CA1 neurons].

We investigated a role of calcium in the mechanisms of deprivational potentiation (DeP) of the popspikes amplitude of CA1 neurons that was induced in consequence of long (60 min) interruption of rare test stimulation (0.05 Hz) of Schaffer collaterals in rat hippocampal slices. There are two phases of deprivational potentiation that have presumably different genesis: short-term initial "peak" (about 12 min) and long-term "plateau" (more than 1 h). The presence of the membrane permeable Ca2+ chelator (BAPTA-AM) in the solution, or decrease of [Ca2+](out), or depletion of intracellular Ca2+ stores (in the presence of thapsigargin/cyclopiazonic acid) led to reduction of the short-term and to suppression of the long-term phases of DeP. Thus the key role of calcium in the DeP induction mechanisms and participation of two main sources (the extracellular environment and the intracellular Ca2+ stores) was demonstrated.

[Somatic genome variations in vascular tissues and peripheral blood leukocytes in patients with atherosclerosis].

The first data on the existence of multiple genomic rearrangements, such as copy number variation (CNV) and copy neutral loss of heterozygosity, in vascular tissues and peripheral blood leukocytes from patients with atherosclerosis, are presented. Compared to internal mammary arteries and peripheral blood leukocytes, right coronary arteries in the atherosclerotic plaque area presented with a higher CNV length and number of genes located in their vicinity. In each of the patients, 6-16% of CNVs were common to the three types of tissues examined. Therefore, most of the copy number variations in the tissues affected by atherosclerosis (from 68 to 91% in each of the patients) were of somatic origin. The gains in 3p21.31 (CACNA2D2), 7q32.1 (FLNC), 19p13.3 (C19orf29, PIP5K1C), and 21q22.3 (COL6A1) were detected in vascular tissues but not in peripheral blood leukocytes. Moreover, the gain in 7p15.2 (SKAP2), detected in the patients with atherosclerosis, did not overlap with any CNV regions currently reported in The Database of Genomic Variants. The loss of heterozygosity in 12 out of 13 chromosomal regions was copy neutral and covered tumor suppressor genes (SFRP1, CEBPD, RB1CC1, DIRAS3, TUSC3, and ZDHHC2).

[Transcutaneous coronary intervention accompanied by biventricular circulatory support and combined with extracorporeal membranous oxygenation].

In a multiple-vessel lesion of the coronary bed, pronounced accompanying pathology, low ejection fraction of the left ventricle, obesity, previously performed operation of coronary aortic bypass grafting may be causes of refusal from revascularization by means of coronary bypass grafting. A transcutaneous coronary intervention (TCI) in this patient cohort is also associated with the risk of an unfavourable outcome in case of a technically complicated procedure and a large volume of the myocardium supplied with blood by the target arteries. Haemodynamic support of such high-risk TCI by means of intra-aortic balloon contrapulsation or a left-ventricle assist device is associated with a series of shortcomings which are removed by means of a biventricular bypass used in a combination with extracorporeal membranous oxygenation. This article deals with a case report of successful stenting of the unprotected trunk of the left coronary artery and the right coronary artery in the conditions of a mechanical biventricular bypass.

[Effect of the terms of complete revascularization on the outcomes of treatment of patients with st segment elevation myocardial infarction and multivessel coronary artery disease].

The study was aimed at evaluating the results of treating a total of 227 patients presenting with ST segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), who underwent primary percutaneous interventions (PCI). The patients were subdivided into three groups: Group One consisted of the patients having endured multivessel stenting (MVS) within the framework of a primary PCI (n=40); Group Two comprised patients having endured stagewise revascularization (SWR) carried out within 60 days after the index event (mean 29.9±19.6 days) (n=39), and Group Three was composed of patients with stagewise revascularization either performed or planned to be performed within the terms exceeding 60 days (mean value 183.4±90.7 days) (n=148). During 12 months significant differences were observed between Group One and Group Three patients, as well as between Group Two and Group Three patients by the frequency of the composite end point (death, myocardial infarction, secondary revascularization of the target vessel (TVR) (p<0.05) and separately by the TVR between Group Two and Three patients (p<0.05). Besides, there was a tendency towards significant differences between Group One and Group Three patients, as well as Group Two and Group Three patients by the development of recurrent MI (p<0.05). By the number of lethal outcomes no statistically significant differences between the groups were observed. Hence, in the cohort of patients with STEMI and MVD who were subjected to primary PCIs, performing of MVS or secondary revascularization within 60 days has advantages as compared with the time period > 60 days by the frequency of the composite end point, TVR and is associated with a tendency towards lower incidence rate of recurrent MI during 12 months of follow up. The strategy of MVS and the secondary SoR within 60 days demonstrated comparable results during 12 months. Performing complete revascularization within the framework of primary PCI or shortly after discharge from the hospital (29.9±19.6 days) is associated with greater availability of the second SoR as compared with that planned for the terms of 183.4±90.7 days.

[Left anterior descending bypass grafting from the anterolateral minitorakotomy].

Current efficient methods of open revascularization in patients with multivessel coronary artery lesions are associated with a certain amount of general and local complications depending on traumatic interventions, bypass, manipulation on the ascending aorta. Minimally Invasive Direct Coronary Artery Bypass Grafting (MIDCAB) allows to avoid certain perioperative risk factors and appears to be a promising myocardial revascularization model in isolated lesion of left anterior descending (LAD) and multivessel lesions, applying combines percutaneous intervention (PCI).

Effects of fullerene C60 nanocomposites on human platelet aggregation.

The effects of fullerene C(60) nanocomposites on human platelet aggregation induced by ADP, ristocetin, and collagen were studied. The nanocomposite containing fullerene C(60) in polyvinyl pyrrolidone solution did not change platelet aggregation, while fullerene C(60) in crown ether and Twin-80 solutions inhibited ADP-induced platelet aggregation by 20 and 30%, respectively.

[Multiple aortocoronary bypass without artificial circulation].

Results of 145 surgeries for direct myocardial revascularization without artificial circulation are presented. FC III and IV angina of effort was diagnosed in 80.6% and 13.5% of the patients respectively, acute coronary syndrome in 6.5%, past myocardial infarction in 63.8%. Mean left ventricular ejection fraction (EF) prior to surgery was 48.7 +/- 5.1%; it was below 40% in 28.8% of the patients. Three- and two-vessel coronary disease was documented in 54.7% and 35.3% of the patients respectively; 10% of them presented with the affected anterior interventricular branch, 14% with the stenotic trunk of the left coronary artery. Mean revascularization index increased from 22 to 76. The frequency of complete autoarterial revascularization amounted to 42.7%. Sequential and composite grafts were used in 93 and 257 cases respectively. No patient experienced perioperative myocardial infarction, acute disturbance of cerebral circulation, acute renal or cardiac insufficiency. Immediate postoperative hemorrhage requiring resternotomy developed in 0.9% of the patients, 1.2% with suppurative complications needed additional surgical treatment. It is concluded that myocardial revascularization on a beating heart is an efficacious and reliable method ensuring good results in the immediate and late postoperative period. Its success first and foremost depends on the previously gained experience that permits to operate patients with severe multi-vessel coronary artery disease and various concomitant disorders and thereby correct combined pathological conditions. The available data give reason to consider each patients in need of aortocoronary bypass as a candidate for myocardial revascularization on a beating heart regardless of the character and extent of coronary lesions and anatomical feature of the coronary bed.

[Functional rehabilitation of the myocardium after different kinds of direct revascularization of the myocardium in patients with occlusion lesion of the abdominal aorta and arteries of lower extremities].

The degree and terms of recovery of the functional state of the myocardium after direct revascularization of the myocardium under conditions of extracorporeal circulation and on the working heart were studied in 58 patients with occlusion lesion of the arteries of lower extremities. In 30 patients (1st group) coronary artery bypass grafting (CABG) was fulfilled under conditions of extracorporeal circulation, in 28 (2nd group) revascularization of the myocardium was fulfilled on the beating heart. In patients with occlusion lesion of the abdominal aorta and arteries of lower extremities and IHD of the III-IV functional class we followed the strategy of stage-by-stage interventions in the arterial basins. CABG is indicated at the first stage. The optimal method of direct revascularization of the myocardium was proved to be operation on the beating heart which had a number of advantages: lower risk of the development of postoperative complications, quicker restoration of the myocardium function and rehabilitation of the patients, shorter time for the 2nd stage of operation-revascularization of lower extremities.

[Tactics of surgical treatment of critical lower limbs ischemia and concomitant coronary heart disease class III-IV].

The possibility and use of prolonged epidural anesthesia in terms of preoperative care was studied in 78 patients. Patients with various stages of coronary arteries affection, central haemodynamics state and risk of reconstructive surgical treatment on lower limb arteries were marked out. Patient selection criteria for aortocoronary shunting or reconstructive operation on great lower limb vessels were worked out. It is proved, that prolonged epidural anesthesia allows not only to attain good analgesia but to minimize cardiac complications at reconstructive operations on abdominal aorta and its branches.

[Pickwick syndrome--problems for a surgeon and an anesthesiologist-resuscitator (clinical observation--121 days of intensive care of the patient with Pickwick syndrome)]. / Pikvikskii sindrome--problemy khirurga i anesteziologa-reanimatologa (klinicheskoe nabliudenie--121 sut intensivnoi terapii bol'nogo s Pikvikskim sindromom).

An analysis of a 121-day of intensive-care therapy of peritonitis and concomitant complications in a patient with Pickwick syndrome and somnolent apnea syndrome is reported. Right hemicolectomy was implemented in the patient for peritonitis, which developed on the 2nd day as a result of perforation of the blind gut at a place of tumor removed in a scheduled colonofibroscopy (CFS). The attempts of intubation of the trachea for as long as one hour failed due to the anatomic peculiarities. Tracheostomy was made. The switching-on of the patient, postoperatively, to spontaneous breathing was highly complicated because of Pickwick syndrome and the appearing dependence in the patient on the respirator. The alternating methods of respiratory support by using apparatus "Servo Ventilator 900" (Vo. Control + PEEP, SIMV, PS, regime CPAP) were a key technique of intensive care during 121 days. The postoperative cause was complicated on the 12th postoperative day by a massive gastrointestinal hemorrhage, by subsequent relaparotomy and a revision of anastomosis. The intensive-care therapy enabled, on the 80th day to transfer the patient, for 3 days, to a spontaneous independent breathing and to feed him, for 2 weeks, in the natural way. The subsequent postoperative cause was complicated by the development of massive decubituses in the lumbosacral area, and by the formation of intestinal fistula with leakages phlegmon in the anterior abdominal wall. The average cost of one day of the complex intensive-care therapy topped 5000 rubles. Because of an overweight (190 kg) the medical care rendered to the patient was complicated. The patient died on the 121 day due to intoxication, renal insufficiency and growing respiratory insufficiency. Finally, it is concluded that there is a necessity to make a motivated collective decision for carrying out any diagnostic invasive methods of examination in such category of patients; and in case of surgical interventions, the intubation of the trachea should be implemented with local spray anesthesia involving the use of fibrolaryngoscope.

[Ruptures of abdominal aortic aneurysms. The clinical course and classification]. / Razryvy anevrizmy briushnoi aorty. Osobennosti klinicheskogo techeniia i klassifikatsiia.

Surgical treatment of abdominal aortic aneurysm (AAA) ruptures is a matter of great concern in current vascular surgery. The results of surgical treatment of patients presenting with such severe disease could have been improved due to the early and correct diagnosis. The present work is concerned with a study into the characteristic features and causes of the atypical clinical manifestations and the course of AAA ruptures as well as with the development of the classification accessible for practical uses. Later on it would allow to refine the treatment policy for an extremely severe patient group and to define a permissible algorithm of examination in the postoperative time and would favour the early diagnosis of disease. The study is based on an analysis of the clinical course of AAA rupture in 53 patients operated on at the Department of Vascular Surgery. MONIKI. The clinical manifestations were typical in 46 (86.8%) patients. The progressing course of AAA rupture was observed in 21 (39.6%) patients; the disease ran a wave-like course in 17 (32.1%) patients. Stabilization of the condition was marked in 15 (28.3%) cases. In 39 (73.6%) cases, AAA rupture affected the retro-peritoneal space, the free abdominal cavity was affected in 8 (15.1%), the duodenum in 2 (3.8%), the sigmoid intestine in 2 (3.8%), and the inferior vena cava in 2 (3.8%) of cases. The rupture of the posterior wall of the aortic aneurysm was identified in 29 (54.7%), of the lateral wall in 12 (22.6%), and of the anterior wall in 8 (15.1%) patients. Four (7.5%) patients demonstrated aneurysmal rupture of the iliac artery. The clinical manifestations of AAA rupture were marked by polymorphism whereas its course was often masked by other diseases making it difficult to establish the early and correct diagnosis. The difficulties in the diagnosis of AAA ruptures gave rise to a lot of diagnostic errors and late hospitalization to specialized unita.

[Differential diagnosis of lobar (regional, segmental) extent pulmonary tuberculosis]. / Differentsial'naia diagnostika tuberkuleza legkikh dolevoi (zonal'noi, segmentarhoi) protiazhennosti.

Two hundred and fifteen patients with pulmonary involvement of lobar (regional, segmental) extent were examined. The examination procedure included clinical and laboratory tests, X-ray tomographic study, and computed tomography, bronchoscopy with biopsy, cyto- and histological studies. The nosological diagnosis was established in 96.5% of cases. Differential diagnosis was found to be difficult in 3.5% of cases.

[Means for decreasing emboligenic complications and ischemic damage to the kidneys in the surgical treatment of abdominal aortic aneurysms]. / Puti snizheniia émbologennykh oslozhnenii i ishemicheskikh povrezhdenii pochek pri khirurgicheskom lechenii anevrizm briushnoi aorty.

The authors analyze their experience gained in prevention of embologenic complications and ischemic injuries to kidneys based on surgical treatment of 25 patients with abdominal aorta aneurysm. Original preventive methods are suggested. In ascending supra-aneurysmatic aortic thrombosis (in 4 patients) a left-side thoracophrenolumbotomic approach and open thrombectomy from the aorta were used and, if necessary, from visceral branches and renal arteries as well. If aortic clamping above renal arteries was needed (in 6 cases) and its time surpassed the permissible duration of thermal ischemia of the kidneys the authors resorted to autoarterial perfusion of the kidneys through an aortorenal shunt with which cannulation of the thoraco-abdominal segment of the aorta was made. No embologenic complications or postischemic renal insufficiency occurred after surgery, this indicating the efficacy of the suggested measures.