[Analysis of indocyanine green plasma disappearance rate in clinical practice]. / Vybor metodiki opredeleniya skorosti plazmennoi eliminatsii indotsianina zelenogo v klinicheskoi praktike.

OBJECTIVE: To justify the optimal method for determining indocyanine green plasma disappearance rate (PDRICG). MATERIAL AND METHODS: We analyzed PDRICG in intensive care units. Indocyanine green was administered intravenously at a dose of 0.25 mg/kg. PDRICG was analyzed simultaneously by using of three methods: 1) PDD (PiCCO2 LiMON device), 2) SBS with analysis of plasma samples on precise spectrophotometer, 3) SBS with analysis of plasma samples on simple experimental photometer. RESULTS: PDD method was used for 346 PDRICG tests in 256 patients. Of these, 14.3% of measurements were erroneous. Paired tests using PDD and SBS methods were performed in 299 cases. SBS method resulted erroneous data in 0.6% of cases. Certain correlation (r=0.79, p<0.001) was found between the reference method (SBS with spectrophotometry) and the PDD method. Bland-Altman plot for these two methods showed that proportional bias of mean difference was caused by extremely high PDRICG of the PDD method (for example, more than 30%/min). Comparison of two SBS variants (spectrophotometer and experimental photometer) revealed good correlation (r=0.91, p<0.001). CONCLUSION: SBS method for measuring PDRICG ensures accurate results under mechanical interferences in patients with impaired capillary blood flow. This eliminates the need for redo measurement. Duplication of the PDD and SBS methods is recommended when repeating the test is not possible (organ donors).

ANESTHETIC MANAGEMENT AND INTENSIVE CARE DURING PERIOPERATIVE PERIOD OF ABDOMINAL DELIVERY IN PREGNANT WOMEN WITH PULMONARY ARTERIAL HYPERTENSION.

Background The presence ofpulmonary arterial hypertension (PAH) in pregnant women increases mortality up to 12- 30% and up to 50% when PAH is associated with Eisenmenger syndrome. Due to low prevalence of PAH in pregnancy many aspects ofperioperative management are still unclear. THE AIM: To summarize our approaches to the anesthesia and intensive care in pregnant women with PAH. MATERIALS AND METHODS: 21 pregnant women with PAH (systolic pulmonary artery pressure (SPAP) higher than 60 mm Hg)-who underwent delivery by Caesarean section in 2010 - 2015 were included in the one-centre retrospective study. Data are presented as median (25th, 75th percentile). RESULTS: The median age was 27 (23; 29) years. Among the patients, there were 4 (19%) cases of idiopathic PAH and in 17 (81%) women PAH was associated with congenital heart disease (CHD); 12 (57%) patients'demonstrated Eisenmenger syndrome. Baseline SPAP was 90 (82; 103) mm Hg. SpO2 90 (85,95)%. All women taken PAH-specific therapy (sildenafil) before delivery. Caesarean section (CS) were performed at 32 (28; 34) weeks. In 20 cases CS was perfofined under epidural anesthesia and in one case under general anesthesia due thrombocytopenia. Inhaled nitric oxide (NO) was administered intraoperative to all women in a dose of 40-60 ppm. Postoperative period was uncomplicated in five women (23?8%). Decompensation with PAP rise, acute right ventricular failure and hypoxemia developed in 16 (76,2%) cases 30 (24, 40) h after abdominal delivery. These patients required combined PAH-specific therapy (NO, sldenafil, iloprost) and inotropic agents, additionallyrespiratory support was used in four patients. The median ICU stay was 13 (9; 22) days. 3 patients died (14?2%); mortality in Eisenmenger syndrome cases was 25% (3/12). 18 healthy babies.

[SPECIFICS OF INHALED ILOPROST PHARMACODYNAMICS IN PATIENTS WITH SEVERE LEFT VENTRICULAR SYSTOLIC DYSFUNCTION].

PURPOSE: To determine the specifics of inhaled iloprost effect on pulmonary and systemic hemodynamics in patients with pulmonary hypertension (PH) associated with left ventricular systolic dysfunction. MATERIALS AND METHODS: 47 vasore- activity tests (VRT) with 20 micrograms inhaled iloprost (Ventavis, Bayer) were performed in 39 candidates on heart transplantation. All patients had heart failure III-IV NYHA and PH with pulmonary vascular resistance (PVR) more than 2.5 Wood units. Hemodynamic parameters were evaluated at baseline and 15 minutes after inhalation of iloprost. RESULTS: Iloprost significant decreased PAPmean: from 36.8 ± 8.5 mm Hg to 29.9 ± 9.4 mm Hg (p < 0.001). There was a significant decrease in PVR:from 4.5 1.6 Wood units to 3 ± 1 Wood units (p < 0.001). PVR dropped more than 20% in 34 cases (72.3%). Iloprost inhalation caused significant changes in systemic hemodynamic. There were decrease in sys- temic vascular resistance (SVR)from 1820 ± 527 dynes·sec·cm(-5) to 1423 ± 427 dynes·sec·cm(-5) (p < 0.001), increase in stroke volume index (SVI) from 26.1 ± 8.7 ml/m2 to 30.5 ± 9.5 ml/m2 (p < 0.001) and decrease in PCWP from 20.6 ± 5.9 mm Hg to 18.4 ± 6.6 mm Hg. (p = 0.016). We found significant negative correlation between systemic effects of iloprost and initial cardiac index (r = -0.63). CONCLUSIONS: Inhaled iloprost caused significant changes in systemic hemodynamic when was used in patients with severe LV systolic dysfunction. Favorable changes in the left ventricle preload and after- load naturally increased its performance and decreased PCWP.

[PROTEIN KINASE C EXPRESSION FOLLOWING REMOTE ISCHEMIC PRECONDITIONING IN CARDIAC SURGERY].

OBJECTIVE: To evaluate cardioprotective effects of remote ischemic preconditioning (RIPC) in cardiac surgery patients undergoing aortic valve replacement depending on the type of anesthesia and investigate the level of myocardial protein kinase C epsilon (PKC-ε) expression after RIPC. METHODS: In prospective randomized trial, forty eight patients aging from 50 to 75 years old (64 (56 ;69)) were included All patients were scheduled for aortic valve replacement using cardiopulmonary bypass (CPB). The patients were randomized into 4 groups: 1) RIPC applied during propofol anesthesia (RIPC prop, n = 12), 2) RIPC applied during sevoflurane anesthesia (RIPC sev, n = 12), 3) propofol anesthesia without RIPC (CONTROL prop, n = 12), 4) sevoflurane anesthesia without RIPC (CONTROL sev, n = 12). There was no difference found between the groups as to the baseline patient's data. RIPC protocol consisted of 3 simultaneous ischemic episodes of both lower limbs (5 minutes) with 5-min reperfusion intervals. PKC-ε expression in right atrial myocardium was assessed using Western blotting. Troponin I (cTnI) was estimated before anesthesia induction, after 30 min, 6, 12, 24, 48 hours after CPB completion. Also we calculated area under curve of cTnI (cTnI AUC). According to nonparametric distribution, data were assessed by the Mann-Whitney U-test and Newman-Keuls methodfor multigroup comparison. p < 0.05 was considered signifcant. The data are presented as median (25th; 75th percentile). RESULTS: Cardioprotective effects of RIPC were observed only after sevoflurane anesthesia: cTnI AUC was 134,8 (122,3; 232.4) ng/ml/48 h in CONTROL sev group and only 74.3 (64.7; 85.0) ng/ml/48 h in RIPC sev group (p < 0.05). RIPC applied during propofol anesthesia was not associated with cTnIAUC decrease: 93.8 (74.1; 246.8) ng/ml/48 h in CONTROL prop group and 122.5 (74.1; 185.0) ng/ml/48 h in RIPC prop group (p = 0.37). RIPC applied during sevoflurane anesthesia significantly increased PKC-ε expression: 1221 (921; 1438) U in CONTROL sev group vs 1882 (1564; 2131) U in RIPC sev group 6 (p < 0.05). RIPC implication during propofol anesthesia was not associated with any significant difference in PKC-ε expression in comparison with control group: 620 (436; 782) U in CONTROL prop group versus 788 (574;1063) U in RIPC prop group. In control groups, PKC-ε expression was significantly higher in sevoflurane anesthesia in comparison with propofol anesthesia. CONCLUSION: RIPC was only effective when it was applied during sevofiurane anesthesia. This was confirmed by PKC-ε expression increase and lower value of cTnI. There were no evidence of preconditioning and cardioprotection when MPG was initiated during propofol anesthesia.

[Effects of remote ischemic preconditioning on perioperative period in elective aortic valve replacement].

PURPOSE OF THE STUDY: To evaluate the effects of remote ischemic preconditioning (RIPC) on the perioperative period in elective aortic valve replacement (AVR) along different anaesthesia techniques. MATERIALS AND METHODS: 48 patients aged 50 to 75 years (64 (56;69)) which were scheduled for AVR due to aortic valve stenosis were included into the prospective, randomized study. Four groups were formed after randomization: 1) RIPC applied during propofol anesthesia (RIPCprop, n = 12), 2) RIPC applied during sevoflurane anesthesia (RIPCsevo, n = 12), 3) propofol anesthesia without RIPC (CONTROLprop, n = 12), 4) sevoflurane anesthesia without RIPC (CONTROLsevo, n = 12). Groups were similar in baseline data of patients. RIPC protocol: three five-minutes episodes of simultaneous both lower limbs ischemia with five-minutes reperfusion intervals. Troponin I (cTrI), interleukin-6 (IL-6), Interleukin-8 (IL-8) and C-reactive protein (CRP) levels were assessed prior to induction of anesthesia, at 30 min, 6, 12, 24 and 48 hours after the cessation of CPB. Significant differences were assessed by the nonparametric Mann-Whitney and Fisher's exact tests. Data are presented as: median (25th percentile, 75th percentile). RESULTS: . Significant differences in cTnI were found between RIPCsevo and CONTROLsevo groups at 6, 12 and 24 hours: 1.68 (1.28, 2.09) ng/ml vs 3.66 (2.07, 4.49) ng/ml, respectively at 6 hours (p = 0.04); 1.89 (1.59, 2.36) ng/ml vs 3.66 (2.91, 5.64) ng/ml, respectively at 12 hours (p = 0.001); 1.68 (1.55; 2.23) ng/ml vs 3.32 (2.10; 5.46) ng/ml, respectively at 24 hours (p = 0.01). There were no differences found in cTnI between RIPCprop and CONTROLprop groups during the whole study. There were no significant differences found in the levels of IL-6 and CRP between RIPC and control groups during the whole study Unexpectedly significant excess concentrations of IL-8 at 24 h were found when RIPC applied during sevoflurane anesthesia: 12.3 (10.6, 14.4) pg/mL in RIPCsevo group vs 6.2 (4.8, 11.1) pg/ml in CONTROLsevo group (p = 0.02). There was no paroxysmal atrial fibrillation (AF) after RIPC, and 5 cases were registered in the control groups (p = 0.02). No other significant differences in the clinical course of the postoperative period were found. CONCLUSIONS: Cardioprotective effect of RIPC and its effect on systemic inflammatory response should be assessed in the selected anesthesia groups. RIPC on the background of sevoflurane anesthesia reduces myocardial injury during AVR. RIPC does not reduce the severity of the systemic inflammatory response after AVR. RIPC reduces the risk of AF after AVR.

[Hemodynamic effects of the alveolar recruitment maneuver in cardiosurgical patients with left ventricular systolic dysfunction].

PURPOSE: To evaluate hemodynamic effects of the ahveolar recruitment maneuver (ARM) in cardiosurgical patients with left ventricular systolic dysfunction. MATERIALS AND METHODS: We estimate hemnodynamics data obtained during intraoprative ARM in 16 cardiosuigical patients with left ventricular systolic dysfunction. ARMA were applied due to hypoxemnia with PaO2/FiO2 less than 250 nmm Hg. after CPB termination and heparin neutralization. Patients with signs of right heart failure were excluded from the study ARM were carried out after sternum closing. ARM method: Pinsp was increased stepwise until achievement of the alveoli opening point. PEEP was used 5 cm H2O greater than the lower inflection point in "pressure - vohlume" loop. The average alveoli opening pressure was 44.7 ± 2.5 cm H2O and the average PEEP was 12.8 ± 1.7 cm H2O. Hemodynamic parameters were eva luated before ARM and at the point of alveoli opening. Pulmnonary artery pressure and cardiac output were evaluated by Swan-Gant- catheter and thermodilution method Left ventricle contractility, preload and end-systolic (LVESWS) and end-diastolic (LVEDWS) wall stress were studied using TEE. t -test for dependent variables was used for statistical analysis. Data are presented as M ± δ. RESULTS: During ARM stroke volumne index decreased from 36.5 ± 4.2 to 33.5 ± 3.9 ml/m2 (p <0.05). Left ventricle contractility was not changed (there were no reduction in the left ventricle fraction area change (FAC)). Descent of left ventricular preload was the main cause of cardiac output decrease: end-diastolic area of the left ventricle decreased friom 22.6 ± 4.3 to 19.5 ± 4.1 cm2 (p <0.05). Preload renduction was accompanied by paradoxical increase in PCWP associated with an increase in intirathoracic pressure: friom 10.8 ± 4.6 to 13.8 ± 4 mm Hg (P <0.001). There was decrease in intramural left ventricular afterload during ARM: LVESWS decreased from 50.6 ± 11.5 to 39.5 ± 10.6 cm * kdyn-2 (p <0.01), which also contributed to the decline of oxygen demand in systole. ARM did not lead to deterioration of left ventricular systolic dysfunction and increased doses of inotropic agents. PaO2/FiO2 increased from 238.3 ± 11.7 to 301.7 ±22.3 mm Hg (p<0.05). CONCLUSION: Reduction of left ventricular preload is the main cause of cardiac output decrease during ARM. Positive hemodynamic effects of ARM are afterload reduction and left ventricle oxygen demand reduction. Our study showed the possibility ofARM applying in cardioswrgical patients with moderate left ventricular systolic dysfunction.

[The first experience with heart transplantation in the Federal Center of the Heart, Blood and Endocrinology named after V. A. Almazov].

At the present time heart transplantation is considered to be the operation of choice in treatment of patients with terminal stage of chronic heart failure. Results of the first 5 heart transplantations made in the Federal Center of the heart, blood and endocrinology named after V. A. Almazov are assessed. There were no perioperational lethality and complications at the hospital stage. An analysis of the long-term results has shown effectiveness of heart transplantations in treatment of severe heart pathology.

[Surgical treatment of aneurysms of the abdominal aorta in patients with generalized atherosclerosis]. / Khirurgicheskoe lechenie anevrizm briushnoi aorty u bol'nykh s generalizovannym aterosklerozom.

The authors made operations on 131 patients with aneurysms of the abdominal aorta (AAA). Most severe patients were operated on using a modified resection or "exclusion" of the AAA and aorto-iliac bifurcation prosthesis with reverse formation of anastomoses. It was found that the proposed method increases safety of the operative treatment of AAA and is preferable for patients with a severe coexisting pathology.

[The first experience with using a preparation of lung surfactant for prevention and treatment of the acute lung injury syndrome after operations on the heart and aorta]. / Pervyi opyt primeneniia preparata legochnogo surfaktanta dlia profilaktiki i lecheniia sindroma ostrogo povrezhdeniia legkikh posle operatsii na serdtse i aorte.

The authors made an analysis of their experience with using the preparation in 29 patients (22 for treatment and 7 for prophylactics) with acute injury of the lungs. When used for treatment, it gave good results in 16 patients. The prophylactic application of the preparation allowed to avoid acute respiratory insufficiency.

[Transprosthetic aortotomy in reconstruction of the brachiocephalic zone arteries for multiple injury of the opening]. / Transproteznaia aortotomiia v rekonstruktsii arterii brakhiotsefal'noi zony pri ikh mnozhestvennom ust'evom porazhenii.

An experience with transprosthetic aortotomy in 8 patients is analyzed. There were no lethal outcomes. The technique of the operation is described.

[Natural surfactant preparation in complex therapy of acute respiratory distress syndrome in adults following open-heart surgeries]. / Rezul'taty primeneniia preparata prirodnogo surfaktanta v kompleksnoi terapii respiratornogo distress-sindroma vzroslykh posle operatsii na otkrytom serdtse.

The clinical course and outcomes of cases of acute respiratory distress syndrome (ARDS) as evolved after open-heart surgeries under the conditions of traditional treatment and under the conditions of using the exogenous surfactant drug were comparatively analyzed. A reliably improved oxygenation was registered in the 1st group patients (18 subjects), who received surfactant, yet 24 hours later; while the identical improvement was noted in the 2nd group patients (19 subjects) only in 98 hours. The possibility of respiratory support with FiO2 below 45% was ensured in 15 (83.3%) patients of group 1 and in 10 (52.6%) patients of group 2. Thirteen (72.2%) patients in the 1st group and 9 (47.4%) patients in the 2nd group were transferred to independent breathing. The lethality rate in ARDS with the surfactant therapy made up 33.3%, it was 52.6% in traditional treatment.

[Critical state medicine. Surfactant therapy of adult respiratory distress syndrome (results of multicenter studies)]. / Meditsina kriticheskikh sostoianii. Surfaktant-terapiia respiratornogo distress-sindroma vzroslykh (rezul'taty mnogotsentrovykh ispytanii).

The paper provides evidence for the pathogenetic approach to treating acute lung lesion (ALL) and adult respiratory distress syndrome (ARDS). An algorithm of the use of Russian lung surfactant preparations: CT-HL and CT-BL has been developed. In involves earlier (the first days following the onset of respiratory failure) use of surfactant, its combined bolus intratracheal or intrabronchial administration in doses of 200-400 mg/m2, followed by continuous (5-day) aerosol inhalation in doses of 20-30 mg/h for children and 30-75 mg/h for adults until pronounced clinical and X-ray effects are shown. Fifty three patients were found to develop ALL and ARDS in the presence of severe pneumonia, postperfusion lung disorders, reperfusion syndrome, pulmonary embolism, long-term artificial ventilation, combined car accident injury and gunshot wounds of the chest, heroine intoxication, septic shock, sepsis, postoperative sequels in cancer patients, and after hepatic transplantation or massive aspiration of gastric contents. Fifty patients were overcome their critical status, 44 survived. The duration of artificial ventilation (AV) ranged from 1 to 6 days. Earlier use of the drugs made it possible to transfer patients to safe AV regimens and to eliminate ALL and ARDS rapidly and to significantly reduce mortality due to critical states.

[Diagnosis and treatment of early bleedings after open-heart surgery]. / Diagnostika i lechenie rannikh krovotechenii posle operatsii na otkrytom soerdtse.

On the basis of practical experience of the clinic for Cardiovascular Surgery and up-to-date literature data the causes of early bleedings after open-heart surgery are summarized. The main clinical, roentgenological and laboratory features of the bleeding and the methods for the assessment of their origin are demonstrated. The authors consider pathophysiologic causes of hemocoagulation disturbances after surgery with artificial circulation. Characteristics of clinical and laboratory tests for coagulation and hemostasis disturbances and the algorhythms for their interpretation are described. Both nonspecific and pathogenetic methods for management of coagulopathy bleedings in early postoperative period have been described and discussed.

[Continuous inhalation administration of surfactant-BL for control of adult respiratory distress syndrome after reconstruction of the abdominal aorta]. / Dlitel'noe ingaliatsionnoe vvedenie surfaktanta-BL dlia kupirovaniia respiratornogo distress-sindroma vzroslykh razvivshegosia posle rekonstruktivnogo vmeshatel'stva na briushnoiaorte.

A 62-year-old patient with Leriche's syndrome and critical ischemia of the low extremities has undergone the surgery of aortofemoral grafting. A patient has developed the severe ARDS on the second day of reperfusion (bilateral diffuse infiltrates, PO2/FiO2 < 100, lung injury score was 3). Different ways of administration of bovine surfactant (SURFACTANT BL, Russia) were used during the treatment. Total application time was 84 hours, total dose was 4000 mg (50 mg/kg). Considerable improvement of lung function occurred after start of the continuous inhalation of surfactant with a constant rate of 63 mg/h. Two hours after this step PO2/FiO2 reached 400 mm Hg and remained stable 12 hours more, up to the end of surfactant administration. The patient was soon successfully extubated and discharged on the 25th day after surgery. It is supposed that in spite of a small total dose of bovine surfactant the success was achieved due to an early start of the surfactant replacement, continuous inhalation and its definite rate.