COVID-19 management in heart transplanted recipients: registry of Almazov National Medical Research Centre.

Aim      This study presents the experience of managing patients with COVID-19 after cardiac transplantation (CT).Material and methods  Infectious complications (IC) following CT are a leading cause for morbidity and mortality. A prolonged incubation period, atypical IC symptoms, and originally altered results of laboratory and instrumental diagnosis are characteristic of recipients due to immunosuppression. In 2020, the coronavirus infection (COVID-19) rapidly spread worldwide, and timely diagnosis and searching for effective treatments for this disease became a major challenge. From January 2010 through July 2020, 148 patients received orthotopic heart transplants at the V.A. Almazov National Medical Research Center; 34 of these patients died by the present time and were excluded from this analysis. 114 patients were included into the retrospective evaluation of results. These patients had been a part of the group followed up at the Center for more than a month.Results From March through July 2020, 12 (10.5 %) of 114 CT recipients were infected with the virus SARS-CoV-2. In 75 % (n=9) of the sick patients, the COVID-19 infection developed after more than one year after CT. From the first day of clinical symptoms, mycophenolic acid/everolimus were temporarily suspended. The outpatient treatment was started on the first day and included an antiviral therapy (oseltamivir), mucolytics (bromhexine), vitamin C, and anticoagulants. If the disease onset was associated with pyretic fever the empiric antibacterial levofloxacin treatment was administered due to a high risk of mixed infection. Hospitalized patients with moderately severe COVID-19 (n=3) were treated with oxygen inhalation through nasal cannula and prone position with a positive effect.Conclusion      Remote counseling of patients after CT and consistency of the outpatient treatment with recommendations of managing transplant physicians provided timely diagnosis of IC, early administration of treatment, and the absence of COVID-19 complications. Reducing the regimen of immunosuppressive therapy (antiproliferative agents) for up to 14 days facilitated infection control and was not associated with acute rejection crisis and/or impairment of the transplant function.

[Arterial hypertension after heart transplantation].

Aim To evaluate incidence of arterial hypertension (AH) in the posttransplantation period and to identify risk factors for this complication.Materials and methods From January, 2010 through December, 2017, 96 heart transplantations (HT) (70 men and 26 women aged 46.5±13.9 years) were performed. During the first month following HT, 8 recipients died and were excluded from the analysis. The retrospective evaluation of results included 88 patients followed up for more than one year.Results For the entire post-HT period (maximum 92 months), AH was observed in 75 of 88 (85%) recipients. Post-HT AH was correlated with male gender (r=0.24; p=0.031), history of smoking before HT (r=0.45; p<0.001), history of ischemic heart disease (IHD) (r=0.28; p=0.01), older age (r=0.35; p=0.001), higher body weight index (r=0.37; p=0.0005), creatinine level (r=0.37; p=0.001), and low-density lipoprotein cholesterol level (r=0.27; p=0.04). Interrelations with other AH risk factors were not found. Most patients developed AH within the first two years after HT. During the first year, AH was diagnosed in 60% (53 of 88) of patients (relapse, 85% (n=29); newly diagnosed, 45% (n=24), p=0.0003). At two years, AH was detected in 79% (46 of 58) of patients (relapse, 53% (n=18); newly diagnosed, 53% (n=28), p=0.9). All recipients received an adequate antihypertensive therapy. 40-63% of patients required a single-drug therapy at different points of follow-up; from 29 to 45% of patients required a two-drug therapy, and 5-15% of patients required three or more drugs. During all 5 years of treatment, most patients used angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (70-87%) and slow calcium channel blockers (SCCB) (48-53%). The presence of AH following HT was associated with development of all cardiovascular events (CVE; r=0.31; p=0.012) whereas persistent AH, which required a combination antihypertensive treatment, was associated with a high mortality (r=0.61; p=0.015).Conclusion AH is a frequent complication of HT (85%), which is newly diagnosed in most patients during the first two years. AH incidence was higher for male recipients with a history of IHD, hypertension, and smoking. Approximately half of patients required only a single-drug antihypertensive therapy. After HT, the most frequently prescribed drugs included ACE inhibitors or ARBs and SCCBs (70-87% and 48-53%, respectively, depending on the time elapsed after HT). Persistent AH requiring a treatment with two or more antihypertensive drugs was associated with development of all CVEs and a higher long-term mortality.

[Experience of general surgical procedures in patients after heart transplantation].

PURPOSE: To study the frequency of general surgical diseases development snd their features in patients after heart transplantation (HTx). METHODS: From January 2010 to December 2018 it was performed 112 HTx (mean age - 46.7±14.0 years old; 82 - male, 30 - female). During 30 days after HTx 9 patients died. After discharge all recipients (n=98) were included in dispensary observation list. We retrospectively analyzed patients (n=35) who underwent general surgery manipulations in more than 30 days after HTx. All surgical interventions have been done under the reduction of immunosuppression therapy. RESULTS: During 9 years of post-heart transplant follow-up 45 surgical interventions were performed, 7% (n=3) of them due to infectious complications, 31% (n=14) - oncology and others (62%, n=28). Most of manipulations were planned (39 from 45, 87%), the following general surgery interven- tions prevailed: laparoscopic cholecystectomy (n=13) and those to remove inguinal and umbilical hernia (n=12). During the 1st year the frequency of diseases required surgical treatment was 26% (n=11), infectious causes took place in 5 patients, non-infectious - in 6. Subsequently the incidence of infectious complications decreased that could be associated with the minimization of immunosuppressive therapy. Oncology was more frequent long-term after HTx - more than 3 years: among them the development of colon polyps prevailed and all recipients underwent polypectomy. There was no impact of age, gender, causes of chronic heart failure, obesity, immunosuppressive regimen (including the induction) on the frequency of general surgery diseases development (p>0.05). CONCLUSION: Based on our experience, we proposed an algorithm of examination, the features of surgical tactics and preparation for it in heart transplanted recipients are described. The important role of post-heart transplant follow-up in the timely detection of diseases requiring general surgical care is given.

[TREATMENT OF NON-SMALL CELL CARCINOMA OF LUNG IN SENILE PATIENTS].

A comparative analysis of surgical treatment of non-small cell carcinoma of lung was made in 64 patients of senile age and more young patients. It was stated, that preference should be given to the partial lung resections (lob- and segmentectomies). The authors recommended to avoid pneumoectomy and typical resection of the lung as non-radical operations accompanied by high rate of local recurrences. The comorbidity background of patients should be thoroughly investigated before planning of surgery. If necessary, a surgical treatment of accompanied vascular pathology should be fulfilled as the first stage before oncology surgery.

[Surgical treatment of multiple isolated intrapulmonary metastases].

An analysis of treatment results was made in 226 patients with multiple isolated intrapulmonary metastases of solid tumors. It appears that surgical removal of metastases was possible in patients with satisfactory functional resources and accurate evaluation in order to validate the indications for surgery. The operation shouldn't result in considerable reduction of quality of life and didn't prevent using other methods of treatment such as medicamental and radiation therapy. The indications to surgical intervention have to be set as individual in consideration of the number of metastases and potential of the patient to undergo the surgery.

[The assessment of surgical treatment of patients with malignant pleural effusion].

An analysis of results of 498 patients with malignant pleural effusion was made. All patients were divided into three groups depending on methods of treatment: in the first group of patients the puncture of pleural cavity and the evacuation of liquid were made against the background of complex treatment; in the second group of patients the thoracocentesis and suspension induction were performed; in the third group the video thoracoscopy was carried out. In an assessment of each method of treatment, the researchers came to the conclusion that in case when the patient had the sufficient functional capabilities, the doctors should give preference to the thoracoscopy operations and in case of severe somatic status the doctors should give preference to the drainage of pleural cavity with release from exudates and with subsequent introduction of talc as the most effective sclerosing agent.

[First experience of application of assist circulation device using biventricular type "excor"].

The frequency of use of assist blood device as the "bridge" to the heart transplantation increased in last years. An assessment of results of first 7 implantations of assist circulation device using biventricular type "Excor" was made. The implantations were performed in Federal Almazov centre of the heart, blood and endocrinology. An observation period after implantation was since 11 till 301 days. The heart transplantation of 4 patients was carried out in different terms after implantation. One of the patients passed away on the fifth day due to the pulmonary embolism. Another patient died on the eleventh day after the implantation because of multiple organ failure against the background of severe chronic cardiac failure. The waiting list of heart transplantation includes 2 patients.

[An experience with cardiac transplantation with a single stage reduction of the left atrium cavity and correction of valvular disease].

The immediate and long-term results of cardiac transplantation with a reduction of the left atrium and correction of valvular diseases were performed on 4 patients with atriomegalia and associated valvular disease of the heart. There were no cases of hospital lethality. Within 7 days after operation the patients had a tendency to reducing the mean value of the left atrium. Within 38 months the tendency to normalization of the sizes, volumes and ejection fraction of the left atrium persisted. Cardiac autotransplantation is an effective method of a single stage reduction of the left atrium and correction of valvular diseases.

[Surgical treatment of chronic thrombo-embolic pulmonary hypertension with floating thrombi in the right heart ventricle].

A 31 years old male patient was admitted to a resuscitation unit with severe dyspnea (MMRC 4 grade). The patient had the dyspnea for 3 months.The diagnosis of chronic thrombo-embolic pulmonary hypertension with floating thrombi in the right heart ventricle was established. On the sixth day of admission after IVC filter insertion, the patient underwent thromboectomy with pulmonary endarterectomy. For an access to segmentary pulmonary arteries during operation SVC and the aorta had been cross-clamped. The duration of deep hypothermic (20 degrees C) circulatory arrest was 54 minutes. The patient was discharged in satisfactory condition on the 17th day. At the check-up at 3 months the dyspnea was absent and heart hemodynamic parameters had been normalized.

[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.

[Role of biological tumor markers CEA, Cyfra-21, NSE, TU M2-PK in diagnosis and treatment of lung cancer].

The authors investigated the dependence of increasing serum oncomarkers CEA, Cyfra-21, NSE, TU M2-PK on survival in 739 patients with nonsmall cell lung cancer. The tests for the determination of the content of CEA, Cyfra-21, NSE in blood serum have low sensitivity and are of little use for the diagnosis of lung cancer. The tests because of their simplicity and low cost can be used for the detection of groups of patients with preliminarily diagnosed nonsmall cell lung cancer needing additional methods of examination for more exact staging of the disease and exclusion of remote metastases and more active using adjuvant method of treatment. The use of tumor pyruvate kinase can be perspective for clinical oncopulmonology. However, due to its low specificity, further experiences are required for using this oncomarker in the group of patients with nonsmall cell lung cancer.

[Specific medical strategy for spontaneous pneumothorax in patients with chronic obstructive pulmonary disease].

Results of examination and treatment of 62 patients with spontaneous pneumothorax which appeared against the background of chronic obstructive pulmonary disease during the period from 1998 to 2009 were analyzed retrospectively. Emergent drainage of the pleural cavity was made to all the patients at admission to hospital. Surgical intervention was fulfilled in 28 (45%) patients. Complications at the postoperative period were noted in 54% of the patients. An assessment of occurrence of complications did not reveal their regular increasing along with the degree of bronchial obstruction. Differential approach and selection of high risk patients is considered to be necessary.

[Use of determination of the serum carcinoembryonic antigen in oncopulmonology].

The test for the determination of the serum carcinoembryonic antigen was found to possess low specificity and to be of little use for the diagnosis of lung cancer. The test can be used for the detection of patients with diagnosed non-small-cell cancer of the lung for more exact staging of the disease and exclusion of distant metastases as well as for more active using adjuvant methods of treatment and for the dynamic observation of the course of the disease.

[The first successful bilateral lung transplantation in Russia].

Lung transplantation is one of the most difficult fields of contemporary transplantology. The operation was performed on a 53-year-old female who had been suffering from terminal stage COPD. The period of cold ischemia for the right and left lung was 1 hour 30 minutes and 2 hours 25 minutes respectively. The total operation time was 4 hours and 40 minutes. There were no surgical complications. There were no signs of transplant rejection 6 weeks after the operation. The considerable decrease in dispnea and increase in quality of life were registered during the follow-up. FEV1 was increased by 80% and 6 minute walk test distance was increased by 200 meters.

[The surgical lung volume reduction in patients with diffuse emphysema]. / Khirurgicheskaia reduktsiia ob"ema legkikh pri diffuznoi émfizeme.

Twelve patients with severe chronic pulmonary obstructive disease complicated by a strong respiratory failure underwent lung volume reduction operations. An examination of the baseline functional parameters showed a significant outflow obstruction and lung hyperinflation. All the patients selected for the operation had a heterogeneous pattern of emphysema. Air leak from the lung suture was the main problem in the postoperative period. Long-term results were studied in 9 patients. A significant reduction of the respiratory failure and improvement of quality of life of the patients were noted. Significantly increased vital capacity, forced expiratory volume for 1 second, decreased residual volume and bronchial resistance were demonstrated.

[Nervous and mental disorders in patients with chronic alcoholic pancreatitis]. / Nervno-psikhicheskie rasstroistva u bol'nykh khronicheskim pankreatitom alkogol'noi étiologii.

Presented are the results of comprehensive CNS examinations in 53 alcoholics with chronic pancreatitis. Related psychopathological and neurological syndromes are specified. Hepatopancreatoduodenal and CNS abnormalities were found directly correlated. The addition of pancreatitis to alcoholism leads to development of encephalomyelopolyradiculoneurotic syndrome.

[Neuropsychiatric disorders and bodily reactivity in thermal lesions]. / Nervno-psikhicheskie rasstroistva i reaktivnost' organizma pri termicheskikh porazheniiakh.

The urgent questions of neuropsychic disorders related to thermal lesions are discussed on the basis of an analysis of the literature data and the results of the authors' long-term studies. It is shown that all these disturbances are formed in patients with deep burns affecting over 15% of the body's surface in the presence of marked disturbances of all links of the systemic anti-infection defence, the latter being conducive to the generalization of the infectious process. Thus, these pronounced disorders of the immunologic mechanisms of homeostasis are responsible for the background against which those severely burned develop the organic neuropsychopathological syndrome, burn-associated encephalopathy, which persists for a long time after the trauma.