Morphologic changes of red blood cells during hemorrhagic shock replicate changes of aging.

Blood loss leads to the reduction in vitality of red blood cells (RBCs). However, the changes in morphology at different stages of hemorrhagic shock have not been studied. Thus, the aim of this study was to identify and quantitate the sequence of morphological changes in RBCs during hemorrhage. This study was performed on 15 adult inbred dogs. Blood samples were taken before hemorrhage, when the mean arterial pressure reached 40 mm Hg (initial stage of shock), and at a mean arterial pressure level of 20 mm Hg (decompensated stage of shock). The volume of blood removed averaged 33.6+/-8.9 and 55.1+/-6.9 mL/kg, respectively. Evaluation of RBC morphology was performed by computerized light microscopic morphometry and scanning electron microscopy. At the early stage of hemorrhage the number of "young-appearing" RBCs with large visible surface areas (41-50 microm2) increased from 17.7%+/-3.1% to 26.6%+/-3.5% (P < 0.05). Concomitantly, the number of "old-appearing" RBCs with small visible surface area (20-30 microm2) significantly decreased from 5.3%+/-2.7% to 2.7%+/-2.3% (P < 0.01). At the stage of decompensated blood loss, the opposite phenomenon was observed. The number of "old-appearing" RBCs increased to 8.2%+/-1.1% (P < 0.01), whereas the number of "young-appearing" RBCs decreased to 12.3%+/-4.2% (P< 0.01). The changes in visible surface area of RBCs was accompanied by significant alterations in their shape. The percentage of abnormal shaped RBCs increased from 8.9%+/-1.1% before the hemorrhage to 36.4%+/-5.8% at the stage of decompensated hemorragic shock (P < 0.01). Thus, during the late decompensated stage of hemorrhagic shock, RBCs assume shape and surface area changes that are similar to those seen in aging. These changes in RBC size and shape may be due to the effects of shock-induced oxidative stress.

Comparative assessment of hepatic Glisson's capsule and bovine pericardium in heart valve bioprostheses.

BACKGROUND AND AIM OF THE STUDY: The optimal material for heart valve bioprostheses remains disputable. This investigation was initiated to compare the properties of hepatic Glisson's capsule, clinical experience of which in cardiovascular surgery is minimal, with those of bovine pericardium. METHODS: Hepatic Glisson's capsule was harvested from bull calves and used to create composite pulmonary arterial monocusp grafts and bioprostheses. Comparison of the strength and elastic properties of Glisson's capsule and bovine pericardium, as well as the hydrodynamic characteristics of valves made from these materials, was performed. Late results of operations using these materials were estimated echocardiographically. RESULTS: Although Glisson's capsule tissue is thinner than the bovine pericardium, its elasticity modulus is greater. However, the hydrodynamic characteristics of heart valves made from either tissue are similar. Moreover, valves made from Glisson's capsule have a lower systolic pressure gradient on the prosthesis and a higher effective orifice area. Composite pulmonary arterial xenopericardial grafts with a monocusp of Glisson's capsule were used in 30 patients during tetralogy of Fallot repair. Glisson's capsule was also used for tricuspid valve reconstruction and as a bioprosthesis in six patients with Ebstein's anomaly. At 1-2 years after surgery, the Glisson's capsule tissue remained thin and flexible, with no calcification. CONCLUSIONS: Although the hydrodynamic properties of hepatic Glisson's capsule and the bovine pericardium are similar, the capsule tissue is thinner and has a greater elasticity modulos. Thus, Glisson's capsule may be used for bioprosthesis construction both independently and in combination with bovine pericardium.

Immediate results of the 'Bioglis' valve use in the surgical treatment of Ebstein's anomaly.

BACKGROUND AND AIM OF THE STUDY: The optimum material for heart valves bioprostheses remains in dispute. We have created a biological valve made from hepatic Glisson's capsule and named 'Bioglis'. Experimental studies have shown the major characteristics of the 'Bioglis' valve to be equivalent to, and in some cases superior to, those of traditional valves made from xenopericardial tissue. We present the first experience of the 'Bioglis' valve use in surgical treatment of Ebstein's anomaly. METHODS: Twelve consecutive patients (age range: 7-48 years) with Ebstein's anomaly who underwent surgery between 1997 and 1999 were reviewed. A 'Bioglis' valve was implanted in all cases; two patients underwent repeat surgery because of incompetence of a previously implanted xenopericardial valve. The 'Bioglis' valve was formed, using a flexible frame, from the hepatic Glisson's capsule of bull calves. Short-term results at between two and 10 weeks after surgery were analyzed. Valvular function of the implanted 'Bioglis' valve was monitored by echocardiography. RESULTS: The implanted 'Bioglis' valve diameter ranged from 31 to 33 mm. There were no in-hospital deaths or complications. Echocardiography showed good function of the bioprostheses. Consequent peak and mean pressure gradients across the biological valve ranged from 3 to 7 mmHg and from 1.2 to 2.3 mmHg, respectively. Valve insufficiency occurred in one patient, but was minimal. CONCLUSION: Preliminary results with the 'Bioglis' support our recommendation of this new biological valve for clinical use.

Comparative assessment of Fontan operation in modifications of atriopulmonary and total cavopulmonary anastomoses.

OBJECTIVES: The optimal technique of the Fontan operation remains disputable. This investigation was aimed at the comparison of atriopulmonary and total cavopulmonary anastomoses. METHODS: The results of 81 operations of total cavopulmonary and 69 operations of atriopulmonary anastomosis, performed from 1983 to 1995 were analysed. A control study was carried out 1-10 (3.7 + 0.2) years after the operation in 80 patients (36 after total cavopulmonary and 44 after atriopulmonary anastomoses). 70 patients were studied several times. Cardiac catheterization was done in 70 patients. In 78 patients central hemodynamical indices were studied during exercise. RESULTS: Preoperative hemodynamical indices were not reliably different in the two groups. Early mortality after total cavopulmonary anastomosis was 15%, after atriopulmonary anastomosis 23%. The highest mortality was seen when the criteria of Choussat et al. (Choussat et al. Pediatric Cardiology. Edinburgh: 1977:559-566) were surpassed. In the early postoperative period after total cavopulmonary anastomosis circulatory insufficiency was less marked, transsudation from pleural cavities was reliably lower (15.3 + 1.2 versus 25.5 + 1.8 ml/kg/day, P < 0.01). Arrhythmias were more common after total cavopulmonary anastomosis (18.5 versus 12%). Late mortality after total cavopulmonary anastomosis was 6%, after atriopulmonary anastomosis 12%. 82% of patients after atriopulmonary anastomosis and 81% after total cavopulmonary anastomosis were in NYHA classes 1 and 2.7% of patients after total cavopulmonary anastomosis and 11% after atriopulmonary anastomosis were reoperated. Physical tolerance rose stepwise in both groups and by the third post-operative year reached 75% of normal level. At this time we saw the most optimal hemodynamical indices during exercise. However, the best hemodynamics during exercise were seen after atriopulmonary anastomosis. CONCLUSIONS: Total cavopulmonary anastomosis is accompanied by lower mortality rate and a more favourable course of early postoperative period. However, the best long-term functional results are obtained after atriopulmonary anastomosis.

[Correction of tricuspid valve atresia using direct right atrium to right ventricle and right atrium to pulmonary artery anastomoses]. / Korrektsiia atrezii trekhstvorchatogo klapana s pomoshch'iu priamykh anastomozov pravogo predserdiia s pravym zheludochkom i pravogo predserdiia s legochnoi arteriei.

Some aspects of the surgical control of tricuspid valve atresia by means of establishing direct communication between the right atrium and the right ventricle or the right atrium and the pulmonary artery are discussed. Six operations have been performed: atrioventricular anastomoses in 3 cases and atrio-pulmonary anastomoses in the other 3, with the pulmonary trunk being joined to the right atrium sparing the pulmonary-arterial valves in one of the latter cases. One patient with a complex of congenital valvular defects died postoperatively from acute heart failure, which may have developed as a result of the newly-established anastomosis being compressed by the breast bone. In the rest, surgical results were quite satisfactory.

[Angiocardiographic diagnosis of atresia of the right atrioventricular orifice and associated congenital heart defects]. / Angiokardiograficheskaia diagnostika atrezii pravogo atrioventrikuliarnogo otverstiia i soputstvuiushchikh vrozhdennykh porokov serdtsa.

Ninety patients with atresia of the right atrioventricular orifice were examined. Their ages ranged from 3.5 to 24 years (9.9 +/- 0.5 years on the average). Stenosis of the pulmonary artery was found in 86 patients and was absent in 4 patients. Various intraarterial anastomoses had been established previously in 46 patients with stenosis of the pulmonary artery. All the patients were subjected to angiocardiographic examination including angiocardiography from the right and left parts of the heart and from the great vessels. Several anatomical variants of atresia of the right atrioventricular orifice and concomitant anomalies were studied. The following program of roentgeno-surgical examination in this complex congenital heart disease was elaborated. 1. Catheterization of the right and left parts of the heart and the great vessels. 2. Angiocardiography: right atriography; left ventriculography in anteroposterior, lateral, and, if indicated, axial views; aortography; pulmonary arteriography and, when indicated, right ventriculography.

[Bidirectional cava-pulmonary anastomosis in complex congenital heart defects]. / Dvunapravlennyi kavapul'monal'nyi anastomoz pri slozhnykh vrozhdennykh porokakh serdtsa.

An operation for bidirectional cava-pulmonary anastomosis was performed in 11 patients. Anatomical correction could not be made due to the multiple pattern and complexity of the malformation. None of them was, however, an ideal candidate for hemodynamic correction either. The authors took into account not only anatomical and hemodynamic contraindications for Fontana's operation, but the latter was not performed when the patient's status was grave (severe hypoxemia). The operation was made under extracorporeal circulation and hypothermia. In addition to bidirectional cava-pulmonary anastomosis, dilation of the intraatrial junction, pulmonary artery plasty, etc. were conducted in some cases. Bilateral bidirectional cava-pulmonary anastomosis was performed when an accessory vena cava superior was present. Nine patients benefited from the operation. There was a significant health improvement and a substantial increase in arterial blood oxygen saturation. Four patients underwent a repeated examination one year after surgery. The anastomosis was found to function well.

[Total cavo-pulmonary anastomosis in the surgery of complicated congenital heart defects]. / Polnyi kavopul'monal'nyi anastomoz v khirurgii slozhnykh vrozhdennykh porokov serdtsa.

The authors discuss experience in 8 operations for total cavo-pulmonary anastomoses in patients with various complicated congenital heart anomalies in which radical or anatomical correction could not be undertaken. The operation for total cavo-pulmonary anastomosis is an alternative of Fonten's method since many authors claim that the last-named has some shortcomings. Total cavo-pulmonary anastomosis was established in 4 stages under conditions of extracorporeal circulation. End to side cavo-pulmonary anastomosis was formed in the first stage; the proximal end of the divided superior vena cava was joined to the pulmonary artery in the second stage; the communication between the heart and pulmonary artery was closed in the third stage, and, finally, a tunnel was formed between the inferior and superior venae cavae by means of a xenopericardial flap in the fourth stage. Six patients tolerated the operation successfully. The immediate postoperative period was more favourable than after Fonten's operation. However, to come to a deeper general conclusion and compare the two methods clinical material must be accumulated and the long-term results of the operations studied.

[Assessment of patients' condition by noninvasive methods of examination in the follow-up after Fontan's operation in atresia of the right atrioventricular ostium]. / Otsenka sostoianiia bol'nykh s pomoshch'iu neinvazivnykh metodov issledovaniia v otdalennye sroki posle operatsii Fontena pri atrezii pravogo atrioventrikuliarnogo otverstiia.

The article discusses the results of using noninvasive methods to study the condition of patients (20) in late-term periods after Fonten's operation in atresia of the right atrioventricular orifice. All patients were subjected to physical examination, electro-, phono- and echocardiography, radiological examination, radioisotope scintigraphy, and left ventriculography. Most patients change to functional class I in the late-term periods after the operation. Though the patients have a sense of well being, the left-ventricular pumping and contractile functions remain disturbed. A tendency towards gradual improvement of these parameters is noted, however. The right atrium is enlarged and its myocardium hypertrophied. Its overexertion increases significantly in physical loading. The blood flow in the lungs becomes normal gradually. The results of various noninvasive methods correlate with one another and with the results of angiocardiography. This allows in some cases to avoid intracardiac examination which presents a certain risk, especially in the first one-two years after Fonten's operation when the mechanisms of cardiac activity compensation are still weak.