[Complications After Transcatheter Aortic Valve Implantation].

PURPOSE: to assess rate of complications after transcatheter aortic valve implantation (TAVI). MATERIAL AND RESULTS: Our study included 99 patients who underwent TAVI. Frequent complications were: bleeding not requiring surgical hemostasis (17.2%), hemopericardium (6%), novel cardiac rhythm disturbances requiring permanent pacemaker implantation (15.1%), delirium in early postoperative period (10.7%), acute kidney injury (8.0%), stroke (7%), ventricular fibrillation (5.1%), myocardial infarction (2%). There were no significant differences in rate and type of complications between transapical and transfemoral TAVI. Comparison of general and local anesthesia showed that rate of ventricular fibrillation was significantly higher among patients subjected to transfemoral TAVI under local anesthesia (p less or equal 0.012).

[DEXMEDETOMIDINE SEDATION DURING TRANSCATHETER AORTIC VALVE IMPLANTATION.]

THE AIM: to determine the efficacy and safety of dexmedetomidinefor sedation and analgesia during transcatheter aortic valve implantation (TA VI) withfemoral access. MATERIALS AND METHODS: the study included 34 high-risk surgical patients with "critical aortic stenosis". All patients underwent TAVI with femoral access. TAVI performed under local anaesthesia: in 18 cases - with midazolam-ketamine sedetion, in 16 cases - with dexmedetomidine sedation. The depth of sedation was evaluated by Richmond agitation-sedation scale (RASS) and Ramsay scale. Assessment includes frequency of complications arising during perioperative period. RESULTS: in dexmedetomidine group compared with a group of midazolam/ketamine was observed significantly greater median of sedation level with RASS and Ramsay scales (- 3.5 and -1.0, p=0,000004, 5.0 and 3.0, respectively, p=0,000001). There was a signficant decrease in rapid pacing episodes in dexmedetomidine group (p = 0.0005). In the structure of complications prevailed delirium, stroke, ventricularfibrillation. There were no significant differences in the incidence and nature of complications in the groups studied. Under midazolam/ ketamine trend toward increased incidence of delirium compared with a group of dexmedetomidine (6.16 % and 6.25 %, respectively, p =0.604). There was no significant difference in the duration of operation and anesthesia in the study groups (p=0.889, p=0.103). There were no significant differences in length of hospital-stay and in the length of ICU-stay in groups studied (p =0.243, p=0.899). CONCLUSIONS: Sedation with dexmedetomidine during TA VI with femoral access demonstrates its safety and effectiveness. Dexmedetomidine provides deep level of sedation with RASS and Ramsay scales without depression of respiratory function. There is a good tolerability of operation and good conditions for long-term use of transesophageal ECHO. In the context of ECHO monitoring further reduces the need for multiple rapid pacing (p = 0.0005), which may reduce frequency of delirium in elderly patients.

[Monitoring of haemodynamics and function of the aortic prosthesis during transcatheter aortic valve replacement].

PURPOSE: To find an advisability of use of invasive monitoring of intracardiac haemodynamics during transfemoral transcatheter aortic valve replacement. PATIENTS AND METHODS: The study included 12 patients underwent transfemoral transcatheter aortic valve replacement (TTAVR). All patients were monitored according to Harvard standard. Additionally, we performed a catheterization of the right heart chambers, transesophageal or transthoracic echocardiography. Pressure in the left ventricle and aorta was measured directly after implantation ofthe aortic prosthesis. RESULTS: Cardiac output was increased authentically in comparison with baseline in all patients. There was cardiac index increasing, however the increasing was not reliable (p ≤ 0.07). In 9 cases, baseline pulmonary artery pressure (PAP) was not changed during surgery. In 3 patients, PAP and pulmonary artery wedge pressure (PAOP) before surgery were increased. In 2 of this 3 patients, PAP and PAOP were significantly decreased after surgery. In 1 case, the pressure in the pulmonary circulation stayed increased. Ejection fraction (EF) of the left ventricle was increased after surgeries in 2 patients from 30 to 40% and from 20 to 25%. The values of stroke volume and stroke index were similar in all patients before and after surgeries. Valvular regurgitation after successful implantation of the aortic prosthesis was found in 11 patients (91.6%). We calculated dia- stolic gradient of left ventricle and the aorta and aortic regurgitation index and compared this parameters with data of echocardiography. The index of aortic regurgitation was 36.5 (35; 46), and diastolic pressure gradient in the aorta and ventricle was 48.0 (40.5; 65.5) mmHg. Calculated systolic pressure gradient in the left ventricle and aorta was 5.5 (3.0; 11.5) mmHg., this data proved that there was no stenosis of aortic prosthesis. CONCLUSION: Invasive monitoring of intracardiac haemodynamics during transfemoral transcatheter aortic valve replace-ment allows to diagnose quality of prosthesis implantation accurately and provides data about valvular regurgitation. Invasive monitoring helps to provide haemodynamic stability in patients with critical aortic stenosis during anaesthesia.

Experience in early rehabilitation of patients after coronary artery bypass graft surgery.

UNLABELLED: A strategy of rapid in-hospital postoperative rehabilitation is currently a priority trend in managing the patients after coronary artery bypass graft (CABG) surgery. OBJECTIVE: To investigate the baseline characteristics and peculiarities of perioperative treatment of patients with a short period ofin-hospital rehabilitation. MATERIALS AND METHODS: We studied a total of 690 patients who had endured CABG operations according to the conventional technique performed over the period from January 2007 to August 2008. The procedures of preoperative preparation, surgical intervention and postoperative management both at the stage of the intensive care unit (ICU) and at the Cardiosurgical Department in all the patients were carried out in accordance with the accepted protocol. RESULTS: The Study Group (Group 1) comprised a total of eighty-three 39-to-79-year-old (average age 55.7 +/- 7.9 years) patients whose postoperative hospital stay amounted to 8.1 +/- 1.3 days. Of these, there were 76 men and 7 women. The Comparison Group (Group 2) was composed of one hundred 39-to-76-year-old (mean age 56.2 +/- 8.3 years) patients, with 89 men and 11 women enrolled. The duration of the postoperative hospital stay in the Comparison Group amounted to 12 +/- 1.4 days (p < 0.05). All the operated patients according to the findings of coronary angiography (CAG) had had haemodynamically significant atherosclerotic lesions of three and more coronary arteries. The patients in both Groups were comparable by the main clinical characteristics. There were no patients with recently sustained myocardial infarction, unstable angina, or left-ventricular aneurysms in either of the groups studied. CONCLUSIONS: Employing the protocol we devised makes it possible to reduce the postoperative hospital stay to 7 days in electively operated patients presenting with a stable course of coronary artery disease (CAD), without pronounced co-existing pathology, with a satisfactory left-ventricular systolic function, with preoperatively compensated diabetes mellitus (DM) and adequately controlled arterial hypertension (AH).

[Surgical treatment of cancer patients with significant cardiovascular disease]. / Khirurgicheskoe lechenie onkologicheskikh bol'nykh s vyrazhennoi serdechno-sosudistoi patologiei.

Twenty patients were operated on for cancer of the lung, stomach, trachea, esophagus, kidney, urinary bladder, rectum, and sigmoid, and tuberculoma of the lung in the presence of significant cardiovascular disease. It has been shown that surgical treatment of cancer patients with significant cardiovascular diseases makes it possible to expand a contingent of radically operated patients who are otherwise doomed to palliative or symptomatic therapy.

[Effects of metabolic substrates and mannitol on efficiency of cardioplegic protection in isolated rat heart]. / Vliianie metabolicheskikh substratov i mannita na éffektivnost' kardioplegicheskoi zashchity izolirovannogo serdtsa krysy.

The aim of this work was to study rationality of addition of aspartic acid, phosphocreatine, mannitol and tris(bydroxymethyl) aminomethane (trisamine) to a sanguineous cardioplegic solution. Isolated perfused rat hearts were subjected to 40-min normothermic total ischemia and 30-min reperfusion. Cardioplegic solutions were infused for 5 min prior to ischemia. A modified Ringer solution with 25 mM KCI was used as control. Osmolarity and pH of cardioplegic solutions were 340+/-5 mOms and 7.6+/-0.1 at 22 degreesC, respectively. Efficiency of myocardial protection was evaluated by recovery of contractile and pump function during reperfusion. The optimal solution contained aspartic acid (21.5 mM), mannitol (20.0 mM) and trisamine (5 mM). By the end of reperfusion the heart protected by this solution showed almost complete recovery of coronary flow (98+/-3% of the initial value vs. 77+/-3% in the control), and 2.6-fold higher recovery of stroke volume compared to the control. As a result, recovery of external cardiac work index, calculated as cardiac output-mean perfusion pressure, was 64+/-1% of the initial value vs. 24+/-5% in the control. Increase in buffer capacity of this cardioplegic solution by trisamine (up to 20.0 mM) as well as addition of phosphocreatine (10.0 mM) did not result in further augmentation of cardiac function recovery. The results suggest promising perspectives for development of medicinal form of this solution.

[Prolonged pulmonary artery pressure monitoring in patients with pulmonary hypertension]. / Dlitel'noe monitorirovanie davleniia v legochnoi arterii u bol'nykh s legochnoi gipertenziei.

Pulmonary artery pressure (PAP) was monitored for 24-48 hours in 10 and 8 patients with primary and secondary pulmonary hypertension, respectively. The data obtained were compared with results of prolonged PAP monitoring in 2 healthy volunteers. Variability of mean PAP was 7.43-/+3.1, 5.78-/+1.64, and 3.4-/+0.63 mm Hg, coefficient of variability - 10.39-/+3.68, 13.04-/+6.01 and 22.73-/+8.03% in patients with primary and secondary pulmonary hypertension and healthy subjects, respectively. After surgery in patients with secondary pulmonary hypertension coefficient of variability rose from 13.04-/+6.01 to 16.7-/+12.8%, while variability decreased from 5.78-/+1.64 to 4.3-/+1.65 mm Hg. Level of spontaneous fluctuations of PAP was the highest in healthy subjects (71.4%) and the lowest - in patients with primary pulmonary hypertension (34.9%). Thus PAP variability is a widespread phenomenon which should be taken into consideration during right heart catheterization and acute pharmacological tests.

Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery.

The purpose of this study was to work out an adequate operative technique for patients with malignant tumors who also need open heart surgery or procedures on major blood vessels. We had 8 such patients. In 6 of them, a tumor (3 cases hypernephroid cancer and 3 cases retroperitoneal sarcoma) had grown through the inferior vena cava (IVC) up to the right atrium. Two patients had lung cancer together with severe coronary artery disease. All of these patients were operated on using a heart-lung machine (HLM) and cell saver (CS). In 6 patients the intravascular portion of the tumor was extracted as much as possible through a right atrium approach (in 3 cases a nephrectomy was performed). Two patients had a one-stage coronary artery bypass graft (CABG) and a lobectomy. All of the patients had uneventful postoperative periods and were alive when checked on 1 year after the procedures. During cytological investigation after each operation, tumor cells were found only on the internal surface of the HLM arterial filters with 20 microns holes. We suggest that special cardiovascular devices such as the HLM and CS might be used in borderline situations in oncology without increasing the risk of hematogenous tumor dissemination.

Intraoperative transesophageal echocardiography for detection of myocardial ischemia.

Preoperative myocardial ischemia seems to be a predictor of poor outcome when detected by electrocardiography, pulmonary capillary wedge/pressure measurement and echocardiography. It could be demonstrated, that regional wall motion abnormalities appear earlier and are more sensitive signs of myocardial ischemia than the ECG. Using intraoperative epicardial and transesophageal echocardiography, high quality 2-d echocardiographic images of the heart can be recorded. For monitoring of left ventricular function and wall motion the transesophageal approach is most often used. By the transesophageal approach the left ventricle can be scanned in the long axis and by the transgastric approach in cross sections. They correspond to the apical four-chamber and left parasternal cross sectional imaging of the heart. Using the transgastric approach in the papillary short axis view all segments representing the three coronary arteries can be imaged. Recording in this position have been found to be highly reproducible. Only localized ischemia of the apex of the ventricle may be missed. Methologically the rotation and translocation of the heart remain a problem using the cross section images of the heart. But the left ventricular papillary muscles and the septal-right ventricular boarders can be used as land marks. Wall motion is scored in five grades. In addition to the semiquantitative analysis also a quantitative calculation using computers is possible. Using the midd papillary short axis view in nearly 120 intraoperative transesophageal echocardiograms since 1989 analysis of the systolic wall thickening was possible in 73% of the patients. According to the literature review 87% of the patients undergoing coronary bypass surgery or non-cardiac surgery have signs of preoperative ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Current trends in the development of coronary surgery]. / Sovremennye tendentsii razvitiia koronarnoi khirurgii.

The authors conducted a comparative study of various methods of coronary shunting by means of microsurgical techniques in 240 patients who were operated on for ischemic heart disease. Total myocardial revascularization, including arteries measuring less than 1.5 mm in diameter and vessels in the zones of cardiosclerosis, was found to be more effective than the techniques of shunting of only the affected major branches. The advantages of a mammary-coronary shunt over anauto- logous venous shunt in reconstruction of coronary arteries under unfavourable hemodynamic conditions are demonstrated. It is also shown that multiple bi-mammary-coronary shunting of the branches of the left coronary artery is a promising method.

[Transplantation of the heart-lung complex (the first clinical experience)]. / Transplantatsiia kompleksa serdtse-legkie(pervyi klinicheskii opyt).

The article deals with experience in the first transplantation of a heart-lung complex in the USSR. The recipient was a 34-year-old male with dilation cardiomyopathy. It was decided to perform the transplantation because the terminal stage of cardiac failure and secondary pulmonary hypertension developed (cardiac index 1.3 l/m, pressure in pulmonary artery 80/50 mm Hg, resistance of pulmonary vessels 10.4 units after Wood). The heart and lung were transplanted from a 19-year-old male who died from a craniocerebral injury. Cyclosporine, metipred , imuran, dopamine in small doses, cardiotonics, and antibiotics were given in the postoperative period; the patient was kept on artificial respiration for 48 hours. For up to 10 days the patient's condition was relatively stable and his consciousness was clear. Bilateral pneumonia developed, however, from which he died on the 12th postoperative day. The article discusses organizational problems and some questions of immunosuppressive therapy, immunological monitoring, and the management of patients after transplantation of a heart-lung complex.

[Effect of nitrous oxide on myocardial activity and blood supply in patients with ischemic heart disease]. / Vliianie zakisi azota na rabotu i krovosnabzhenie miokarda u bol'nykh ischemicheskoi bolezn'iu serdtsa.

The effect of N2O at a concentration of 66 vol.% on hemodynamic parameters and myocardial oxygen supply has been studied in 46 patients with ischemic heart disease, functional class III-IV. A marked disbalance between heart work and myocardial O2 consumption manifested in a drop of blood pressure, stroke index, left ventricular stroke index, coronary perfusion pressure with retention of baseline global coronary flow, which may be indicative of the onset of "steal syndrome" in ischemic zones. Therefore, it is recommended not to use N2O in patients with severe coronary pathology.

[Potentials of transesophageal echocardiography in cardiology and cardiac surgery]. / Vozmozhnosti chrespishchevodnoi ékhokardiografii v kardiologii i kardiokhirurgii.

The paper is concerned with some potentialities of transesophageal echocardiography (TE echoCG) in diagnostic and cardiosurgical practice. Four examples are provided (interatrial septal defect, a new growth in the right atrial cavity, vegetation on the cusps of the aortal valve, left atrial thrombus), illustrating that the use of TE echoCG was of help in the establishment of a correct diagnosis. The method is described as holding promise for observation over heart activity in cardiosurgery. In addition, the authors mark difficulties encountered during interpretation of the data obtained.

[Transesophageal echocardiography in the diagnosis of perioperative ischemia and myocardial infarct]. / Chrespishchevodnaia ékhokardiografiia v diagnostike perioperatsionnoi ishemii i infarkta miokarda.

In 50 patients undergoing direct revascularization of the myocardium, an attempt was made to carry out transesophageal echocardiography. In 5 of them, visualization of the myocardium appeared unsatisfactory, 2 patients were excluded from the investigation in view of the fact that they were operated on in the acute phase of myocardial infarction. Among 43 patients who were entered into the investigation, the areas of abnormal local contractility of the myocardium (AILC) occurred during surgery in 14 (33%). In 3 patients, the newly occurring disorders of local contractility of the myocardium persisted till the end of the operation. In the remaining cases, the presence of the AILC was temporary. The sensitivity of the newly occurring stable AILC in the diagnosis of perioperative myocardial infarction and acute coronary death amounted to 75%, specificity was 100%.