[Aorto-esophago-bronchial and aorto-pulmonary fistulas in a patient with aortic aneurysm]. / Aortopishchevodno-bronkhial'nyi i aortolegochnyi svishchi u bol'nogo s anevrizmoi aorty.

Aorto-esophageal and aorto-bronchial fistulas are rare and life-threatening diseases if emergency treatment is absent. The most of publications devoted to this problem are case reports describing successful treatment of patients with aorto-esophageal and aorto-bronchial fistulas by using of endovascular or open transthoracic surgery. However, we did not find reports of several aortic fistulas in a patient after previous aortic stenting. It is presented case report of patient with aorto-esophago-bronchial and aorto-pulmonary fistulas in postoperative period after thoracic endovascular aortic repair (TEVAR).

[Cardiopulmonary bypass and circulatory support in Petrovsky Russian Research Center for Surgery]. / Ispol'zovanie iskusstvennogo i vspomogatel'nogo krovoobrashcheniia v Rossiiskom nauchnom tsentre khirurgii im. akad. B.V. Petrovskogo.

Since initial application of cardiopulmonary bypass (1960) and circulatory support (1977) unique methods of extracorporeal circulation have been developed at Petrovsky Russian Research Center for Surgery. Some of them were introduced for the first time in the country (USSR and then in the Russian Federation). It was possible due to creative team of Boris Vasilyevich Petrovsky, whose potential was aimed at expanding the indications for surgical treatment of cardiac, aortic, liver, lung and kidney diseases under artificial circulation and then circulatory support.

[Cardiopulmonary bypass in thoracic surgery]. / Iskusstvennoe krovoobrashchenie v torakal'noi khirurgii.

AIM: To analyze advisability of cardiopulmonary bypass in thoracic surgery. MATERIAL AND METHODS: We estimated early and long-term results of CPB-assisted thoracic interventions in 31 patients with malignant and benign thoracic diseases and invasion into vital mediastinal structures or with concomitant cardiovascular pathology. RESULTS: Acceptable rates of mortality and morbidity confirm safety of CPB in thoracic surgery while satisfactory long-term outcomes are arguments in favor of this direction of thoracic oncology.

[ASSESSMENT OF LIVER FUNCTION WITH TRANSESOPHAGEAL ECHOCARDIOGRAPHY HEART SURGERY WITH CARDIOPULMONARY BYPASS].

AIM OF THE STUDY: evaluation of arterial and venous liver circulation during cardiopulmonary bypass (CPB) using the method of transesophageal echocardiography (TEE). MATERIALS AND METHODS: 62 patients undergoing reconstructive cardiac surgery with CPB were analyzed. During all the stages of treatment we performed monitoring of mean arterial pressure, heart rate and central venous pressure. TEE was performed using specialized Philips iE-33 3-D matrix multifrequency probe X7-2t in transgastral position. Ultrasonic and dopplerographic measuring of blood flow in hepatic artery and veins was performed before sternotomy, in 30 minutes after starting CPB and after stopping CPB during sternal closure. The speed of bloodflow in hepatic artery, hepatic veins, biochemical blood analysis was evaluated, i.e. lactate level, AST ALT ratio before the intervention, during CPD and in early postoperative period RESULTS: Correlation between blood flow in liver vessels and dynamics of biochemical analysis. It is considered to that this change during procedures with CPB may be linked with liver insufficiency during first hours of evaluation. In other words reduced blood flow in liver vessels may be one of the liver insufficiency early symptoms and is one of factors that require correction during operative and early postoperative period. So dynamic follow-up of hepatic circulation may be used as a method of early diagnostics of functional organ disorders.

[GAS MICROEMBOLISM DURING EXTRACORPOREAL CIRCULATION].

INTRODUCTION: Over the past 20 years, there are many studies, where great attention is paid to the gas and material embolism as the cause of cognitive impairment in patients undergoing surgery with cardiopulmonary bypass. PURPOSE: To identify the filter capacity of 4 extracorporeal circuits for removing gaseous microemboli in various interventions on the heart and aorta. MATERIAL AND METHODS: Work carried out on 60 patients operated on acquired heart and aorta under cardiopulmonary bypass. We used 4 different extracorporeal circuits, divided into groups of 15 patients. Quality and quantity of gaseous microemboli recorded in real time on the device BCC-200 GAMPT (Germany). RESULTS: According to two indicators: Vol. Red (reduction in the volume of gas microemboli) and Fl (filter index) the best results were obtained after statistical processing systems Medtronic and Terumo, followed by Maquet system and Eurosets. CONCLUSION: BCC-200 device allows identifying the sources of gaseous microemboIi. The perfusionist, having on-line information time about the number of microemboli coming in heart-lung machine can increase patient safety, using the capabilities of a particular extracorporeal circuit and minimize the amount of emboli from entering the patient's arterial line.

[ANAESTHETIC MANAGEMENT OF RECONSTRUCTIVE SURGERY ON THE AORTIC ARCH: THE NUANCES OF ORGAN PROTECTION].

UNLABELLED: Aortic arch reconstruction is one of the most difficult surgical procedures. Therefore the aims of our study were: to choose appropriate flow rate for antegrade cerebral perfusion and assess its adequacy in relation to cerebral metabolic demands; to evaluate safety of temperature settings during the surgery; to assess the effectiveness of chosen protocol for brain and visceral organ protection during aortic arch reconstruction surgery. Our study included 67 patients. Patients of the first group (n = 33) underwent aortic arch reconstruction with antegrade cerebral perfusion and hypothermic circulatory arrest (target core temperature 26 °C). The second group (n = 34) underwent ascending aorta repair using cardiopulmonary bypass with modest hypothermia (target core temperature 32 °C). Cerebral and tissue oxygenation monitoring was performed in all patients. In the first group transcranial Doppler monitoring and jugular venous bulb catheterization were performed. Target core temperature during rewarming was 36 °C. In the first group air-warming device in addition to fluid warming was used. In all patients cognitive function was assessed before and after surgery. The multimodal monitoring allowed to dynamically adjust flow rate of antegrade cerebral perfusion. As a result cerebral SO2 and linear velocity were maintained in acceptable range, while flow rate varied significantly from 5.8 to 16.5 ml/ kg/min (average rate 13.4 ± 3.69 ml/kg/min). CONCLUSION: Combined use of cerebral oximetry and transcranial Doppler monitoring allows assessing how oxygen delivery meets metabolic demands of the brain during antegrade cerebral perfusion. This method allows to maintain the proper flow rate of antegrade cerebral perfusion and to choose an appropriate modification of perfusion (unilateral vs bilateral). Multichannel monitoring of core temperature and combined use of air- and fluid warming techniques are required for effective temperature management.

[Role of academic B.V. Petrovskii in the development of extracorporeal circulation]. / Rol' akademika B.V. Petrovskogo v razvitii problemy iskusstvennogo krovoobrashcheniia.

The paper shows the role of Academician B.V. Petrovsky and his scientific school in the development of extracorporeal circulation, as well as his ties with S.S. Bryukhonenko (1890-1960), the founder of extracorporeal circulation in Russia. Heart-lung apparatuses were designed with the participation of collaborators of the Surgery Research Center (SRC), Russian Academy of Medical Sciences. A short account is given of the principal aspects of extracorporeal circulation, which have been studied at the SRC, such as protective blood flow distribution, centralization of circulation, the optimal perfusion rate, criteria for adequate extracorporeal circulation, control of blood coagulation and acid-base state, blood concentration, extracorporeal circulation with autooxygenation, hyperbaric perfusion, normothermal perfusion with continuous warm blood cardioplegia).

[Hypothermal perfusion: protection or damage?]. / Gipotermicheskaia perfuziia -- zashchita ili povrezhdenie?

Ninety six patients were examined during operations on the open heart and great vessels: 25 perfusions were performed at a temperature of 30-32 degrees C; 41 perfusions at 26-29 degrees C; 10 at 23-26 degrees C; 20 at 12-14 degrees C. It was found that with superficial hypothermia and moderate PaO2, blood myoglobin (MG) release was minimal and the count and activity of platelets were optimal. The degree of myoglobinemia increased as PaO2 rose. As the body's temperature lowered, the blood concentrations of MG, its differences smoothed in the subgroups with different PaO2 values. Critical myoglobinemia (over 30 times higher than the baseline values) was noted in a group with superdeep cooling to a temperature of 14 degrees C. By taking into account the fact that the myocardium contains large quantities of MG, loss of this heme-containing protein involves myocardial blood supply disorders and hence decreased myocardial contractility. A considerable platelet loss entails higher postoperative hemorrhagic diathesis and requires efforts in correcting coagulopathies.

[Orthotopic liver transplantation: surgery research center's experience]. / Opyt ortotopicheskoí transplantatsii pecheni v Nauchnom Tsentre Khirurgii RAMN.

From 1990 to 1996, 178 patients with severe diffuse and advanced focal liver diseases with grave prognosis were observed for indications to orthotopic liver transplantation (OLT). According to the revealed indications and contraindications, 95 patients were enrolled for the procedure. Eighteen patients underwent 19 OLTs, including 1 urgent retransplantation and 3 living related graftings. Surgical techniques were conventional; with these, intraoperative mortality and biliary complications could be avoided. Long-term survival (6 to 68 months) was achieved in 8 recipients, including in those after liver retransplantation. Double or triple suppressive regimens were used. These included corticosteroids, cyclosporin A, azathioprine, antithymocytic globulin. The life quality of recipients promoted restoration of their working capacities. Two recipients gave birth to healthy babies.

[Transplantation of the right hepatic lobe from an alive relative donor]. / Transplantatsiia pravoi doli pecheni ot zhivogo rodstvennogo donora.

The use of relative donors in the transplantation of the liver has shown a good performance as an alternative line in its orthotopical grafting. Shortage of donor organs actively stimulates the development of relative transplantation. The main problem of relative hepatic transplantation is the limited capacity of obtaining a required mass of a hepatic graft for obese recipients. To settle this problem, the Russian Surgery Research Center, Russian Academy of Medical Sciences, has developed an original safe procedure for obtaining the right lobe of the liver from an alive relative donor and for implanting it in a recipient. In November 1997 to October 2001, transplantation of the right hepatic lobe from an alive relative donor was made in 23 recipients (10 males and 13 females aged 9 to 55 (mean 22.3 +/- 3.1) years. Their body weight was 24 to 80 (mean 51.4 +/- 3.0) kg. Indications for surgery were as follows: hepatic cirrhosis (HC) at the end stage of the Wilson-Konovalov disease (n = 10), primary sclerotic cholangitis (n = 4), HC of viral etiology (n = 3), Bailer's disease (n = 2), primary biliary HC (n = 2), HC in the presence of alpha 1-antitrypsin deficiency (n = 1), and secondary biliary HC (n = 1). The donors of the right lobe of the liver were recipients' mothers in 9 cases, their fathers in 6 cases, sisters in 2 cases, sons in 1 cases, their daughter, brother, aunt, cousin in 1 case each. The donors' age ranged from 19 to 49 (mean 37.9 +/- 1.4) years. The donors underwent right hemihepatectomy, complications were absent in them. There were early mortality among the recipients. Two patients died in the late postoperative period. The remaining 21 recipients were survivors and followed up for 1 to 48 (mean 14.9 +/- 2.9) months. Their life quality was good. The use of the right lobe of the liver from an alive relative donor is the optimum alternative to transplantation of the cadaverous liver and partially compensates the shortage of donor organs for children, adolescents, and adults.

[Orthotopic liver transplantation]. / Ortotopicheskaia transplantatsiia pecheni.

Orthotopic liver transplantation is the only method of choice for many severe liver diseases with poor prognosis. The development of liver transplantation programmes is based on medical science achievements and high technology in surgery, anesthesiology and perfusiology. The experience of the Surgery Research Center, Russian Academy of Medical Sciences, made it possible to obtain positive results of liver transplantation and posttransplantation management. This in turn provided longer survival for 80% of recipients. At the same time the mortality of potential recipients was 60.4%, which is due to the greater shortage of donor organs and which is the main problem in the development of organ grafting in Russia. The fact that there is a high proportion of children who are recipients for the donor's liver requires that liver transplantation from living related donors should be developed.

[Venoarterial perfusion without oxygenation as a means of mechanical aid to the heart in acute failure]. / Venoarterial'naia perfuziia bez oksigenatsii kak sposob mekhanicheskoi pomoshchi serdtsu pri ego ostroi nedostatochnosti.

The efficacy of veno-arterial perfusion without oxygenation was established in experiments on dogs with a model of acute cardiac insufficiency. The overall index of circulation and the percentage of the heart participation in it is an important criterion of the effectiveness of shunting of the left ventricle. This criterion made it possible to determine the therapeutic role of veno-arterial perfusion without oxygenation in aiding the diseased ventricle even when the size of the shunt did not exceed 1/3 of the initial cardiac ejection.

[Surgical treatment of giant aneurysms of ascending parts and arch of the aorta in condition of deep hypothermia and circulatory arrest with artificial assisted circulation]. / Khirurgicheskoe lechenie gigantskikh anevrizm voskhodiashchego otdela i dugi aorty v usloviiakh glubokoi gipotermii i ostanovki krovoobrashcheniia s perifericheskim podkliucheniem apparata iskusstvennogo krovoobrashcheniia.

Sternotomy in giant (10 cm and more in diameter) aneurysms is highly dangerous due to possibility of injury of aneurysmatic wall with fatal bleeding. That is why sternotomy in condition of artificial circulation (AC) and cooling of patients to 29-30 degrees C are preferred. Two cases of successful surgical treatment of critical patients with giant aneurysms of ascending parts and arch of the aorta in condition of femoro-femoral AC, hypothermia (20 degrees C) and circulatory arrest are presented. One of the patients had a giant false posttraumatic aneurysm of an ascending part of the thoracic aorta with fistula between aneurysm and pulmonary artery. Suturing of defects of ascending aorta and pulmonary artery wall, aneurysmorrhaphia of pulmonary artery were performed. The other patient with acute disruption of a giant dissected aortal aneurysm and hemomediastinum underwent prosthesis of ascending part and arch of the aorta.

[Orthotopic liver transplantation (first clinical experience)]. / Ortotopicheskaia transplantatsiia pecheni (pervyi klinicheskii opyt).

The article deals with the results of work conducted according to the orthotopic liver transplantation (OLT) program from January 1990 to January 1992. To select the patients for OLT, 54 persons (24 males and 30 females aged from 12 to 55 years) with diffuse (34) and focal (20) diseases of the liver were examined. OLT was indicated for 19 patients who were registered in the waiting list. In the period of waiting for the donor organs, 5 persons died, 3 refused to undergo OLT, and 4 remain on the waiting list. Eight OLT (including one retransplantation) were conducted on 7 patients. The indications for OLT in these patients were: unresectable hepatocellular carcinoma (4), cirrhosis of the liver of viral etiology (1), fulgurant form of hepatitis B (1), transplant rejection crisis which could not be arrested (1). Immunosuppression was conducted by the two- and three-component programs with the use of corticosteroids, cyclosporine A, and azathioprine. Eight crises of transplant rejection were encountered, successful retransplantation of the liver was accomplished for one of two crises which could not be arrested. The survival of the operated on recipients ranged from 3 days to 15 months. Various complications (mainly hemorrhagic and infectious) were encountered in the posttransplantation period. At the time that the article is written, 3 patients are living for 15, 9, and 4 months (after retransplantation of the liver in the last case), their condition is satisfactory. The death of the other recipients was caused by candidosepsis (on the 40th day), polyorganic insufficiency (on the 10th and 3rd days), sepsis (on the 12th day). The results of the liver transplantation program correspond to those of transplantation centers in other countries in the period of OLT mastering.

[Perfusion management in liver transplantation]. / Perfuziologicheskoe obespechenie transplantatsii pecheni.

Veno-venous bypass (VVB) with a Biopump centrifugal pump (Biomedicus, USA) was used in 36 patients with liver diseases during orthotopic transplantation of the liver. Volume rate of perfusion (VR), systolic, diastolic, and mean arterial pressure (AP), and central venous pressure (CVP) were monitored. VR during liver-free period was 850-1350 (1064.2 +/- 87.5) ml/min in femoral-axillary bypass and 1700-3500 (2630.5 +/- 112.3) ml/min in femoral-porto-axillary bypass. A trend to a decrease of the mean AP to 65 mm Hg was observed at the end of liver-free period (p < 0.05), while CVP decreased to 2 mm Hg (p < 0.05); there was a trend to a moderate tachycardia. No significant shifts in acid-base balance, oxygen balance, and blood electrolytes were observed during the liver-free period. Maximum blood loss occurred during the liver-free period and reperfusion of the transplant. Blood loss was evaluated by the amount of washed autoerythrocytes obtained after processing of collected blood in the Cell-Saver device. VVB had a favorable impact on the course of orthotopic transplantation of the liver, maintaining stable hemodynamic and biochemical parameters and preventing ischemia of the abdominal organs. Preservation of autoerythrocytes by the Cell-Saver device minimized the need in donor erythrocytes, thus ruling out the complications associated with homologous blood transfusion.

[Changes in the content of microelements--copper, zinc and iron--in the blood of patients following cardiopulmonary bypass]. / Izmenenie soderzhaniia mikroélementov--medi, tsinka i zheleza--v krovi bolnykh, operirovannykh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

Changes in the blood content of trace elements (E)--copper, zinc and iron--have been studied in 10 patients with ischemic heart disease subjected to cardiopulmonary bypass surgery. It has been shown that blood TE concentrations decreased considerably during surgery. Variability in blood TE levels could be accounted for by hemodilution caused by the administration of colloids and crystalloids that contained no TE under study. These solutions were used initially for filling assisted circulation device. However, it is noteworthy that the degree of hemodilution was not the only reason for the changes in blood TE content, as despite hematocrit normalization it was only blood iron content that returned to preperfusion level. It has been demonstrated that copper and zinc blood concentrations were considerably lower in patients developing heart failure in the early postperfusion period than in those with an uncomplicated postoperative period. It has been shown that the nature and degree of changes in copper, zinc and iron levels in the coronary sinus blood during heart surgery can be assessed by changes in their arterial blood content.

[The left atrial-femoral bypass in operations on the descending aorta]. / Levopredserdno-bedrennyi obkhod pri operatsiiakh na niskhodiashchei aorte.

Fifteen patients were operated on for aortic aneurysms and were fitted with prostheses of the thoracoabdominal portion of the aorta in March 1997-February 1999. The operations were performed under conditions of a left atrial-femoral bypass with a centrifuge pump with a working heart. The patients were divided into 2 groups. In group 1 (10 pts), standard extracorporeal shunting and Cell-Saver were used, in group 2 (5 pts) the extracorporeal contour included an original system for rapid collection and return of autoblood. A left-atrial bypass prevented ischemia of the organs of the abdominal cavity and lower part of the body. Incorporation of a system for rapid collection and return of autoblood into the extracorporeal contour maintained stable hemodynamics, decreased heparin dose, preserved autoblood, and decreased the amount of transfused donor blood and its components.

[First experience in normo-thermal artificial circulation with constant warm blood cardioplegia]. / Pervyi opyt normotermicheskogo iskusstvennogo krovoobrashcheniia s postoiannoi teplovoi krovianoi kardioplegiei.

Normo-thermal artificial circulation (NAC) with constant thermal blood cardioplegia (CTBC) was carried out for the first time in Russia in 12 coronary patients subjected to surgical revascularization of the myocardium. Artificial circulation device with the vesical type oxygenator was used for NAC. For CTBC, systems for delivery of the cardioplegic solution and blood from the oxygenator in 1:4 ratio were used. Freme type cardioplegic solutions made by the authors were used. NAC duration was 53 to 139 min, the mean value being 103.4 min. The aorta was clamped for 38 to 96 min, the mean value 70.1 min. Asystole developed soon after CTBC began. After CTBC was discontinued, heart work recovered without cardiotonics.

[Comparative assessment of temperature of the myocardium during its protection by 2 methods in aortocoronary bypass]. / Sravnitel'naia otsenka temperatury miokarda pri ispol'zovanii dvukh metodov ego zashchity pri operatsiiakh aortokoronarnogo shuntirovaniia.

Eighty-eight patients operated on for coronary heart disease were examined. Continuous irrigation of pericardial cavity with circulating cold solution in combination with antegrade cardioplegia was used in 53 patients, antegrade cardioplegia with external cooling of the heart by icy mass in the rest 35. Intensive external cooling provided a stable temperature of the myocardium during clamping of the aorta.

[Causes of myoglobinemia in surgery with artificial circulation]. / Prichiny mioglobinemii pri operatsiiakh s iskusstvennym krovoobrashcheniem.

Release of myoglobin (Mg) into the plasma and increase of its concentration during perfusion are a result of muscle cell injury during artificial circulation. High values of oxygen tension and hypothermia during cardiosurgery are sources of active oxygen forms damaging the biomembranes. We investigated release of Mg into the blood and relationship of this parameter with oxygen tension and depth of cooling. 95 patients were tested during open-heart surgery and operations on the main vessels: 25 perfusions at 30-32 degrees C, 41 at 26-29 degrees C, and 20 at 12-14 degrees C. The patients were divided into subgroups depending on arterial blood oxygen pressure. Myoglobin release into the blood was minimum under mild hypothermia and moderate PaO2. The degree of myoglobinemia increased with elevation in PaO2. As body temperature decreased, the concentration of Mg increased and differences between the groups with different PaO2 leveled. Critical myoglobinemia (30-fold vs. the initial value) was observed in the group with the deepest hypothermia (14 degrees C). Since the myocardium contains high amounts of Mg, it is clear that loss of this heme-containing protein impairs the feeding of the myocardium and, hence, decreases its contractility.