[Surgical treatment of postinfarctial ruptures of interventricular septum].

21 patients were operated on the reason of postinfarctial ruptures of interventricular septum within 1989-2009 years. The mean age was 61.3 ± 7.8 years. The preoperative diagnostic means were echocardiography and magnetic resonance imaging. All patients were in critical condition, demonstrated postinfarctial left ventriculum remodeling and significant decrease of its functional reserves. Myocardial revascularization together with septal reconstruction, mitral valve and ventricular cavity reconstruction were performed. The analysis of the results proves that the active-expectant treatment tactics leads to the significant decrease of perioperative lethality. The optimal volume of surgical treatment is a liquidation of the interventricular defect together with geomentrical reconstruction of the ventricular cavity, wich is indepentant from the stage of infarction.

[Anesthetic maintenance during myocardial revascularization in patients over 70 years of age].

The authors performed a comparative retrospective analysis of preoperative and intraoperative periods in 50 patients aged 70-83 years with coronary heart disease (CHD). A control group comprised the similar patients aged 40-59 years. The geriatric patients showed a higher incidence of arterial hypertension, respiratory and central nervous system diseases, cardiac arrhythmias, and anemia as an outcome. In CHD patients aged 70-80 years, balanced general anesthesia based on lower-dose midazolam and fentanyl, on subnarcotic-dose ketamine during the metered use of isoflurane and adequate infusion therapy provided reasonable hemodynamic stability during the induction of anesthesia and the preperfiusion period without administering cardiotonic agents. Intraoperatively, there was a more pronounced reduction in pulmonary oxygenizing function, body temperature and more needs for cardiotonic and diuretic therapy and erythrocyte mass after the basic stage of surgery.

[Target-oriented infusion therapy in patients during myocardial revascularization].

The paper analyzes goal-oriented infusion therapy used during myocardial revascularization on the working heart. Forty-seven patients with coronary heart disease were examined. Group 1 (control) (n = 20) received standard infusion therapy (a combination of colloids and crystalloids (1:1) at a rate of 6-7 ml/kg/h, by being oriented to indices, such as heart rate, blood pressure, central venous pressure, and diuresis rate. In group 2, an anesthetist was oriented to central hemodynamic parameters during infusion therapy. In addition, the patients of this group underwent the 45 degrees passive leg raising test. In this group, a volume load was done at the beginning of an operation until the maximum possible SV resulted from increased preload (global end-diastolic volume index). The goal of infusion therapy throughout the operation was to maintain these values of the latter index. Goal-oriented infusion therapy, the purpose of which was to determine and maintain the individual optimal values of preload, was found to minimize hemodynamic disorders at surgery and to reduce the frequency of use of cardiotonic agents and the duration of artificial ventilation.

[Optimization of the volemic status of cardiosurgical patients before initial anesthesia].

Twenty-six patients with coronary heart disease who had undergone aortocoronary bypass surgery were examined. In all the patients, central hemodynamic parameters were monitored by transpulmonary thermodilution. The patients were divided into 2 groups. In Group 1 (n = 14), routine initial anesthesia was made without a preliminary volumetric loading test. In Group 2 (n = 12), a controlled volumetric loading test was carried out before induction; a decision on whether it might be made was taken on the basis of the results of a loading test for passive leg raise. The patients from both groups were hypovolemic at baseline, as suggested by the low values of central venous pressure (CVP) and global end-diastolic volume index (GEDVI). By the initiation of initial anesthesia, in Group 2 the mean blood pressure (BPmean), CVP, stroke index (SI), and GEDVI were significantly higher and total peripheral vascular resistance index (TPVRS) was significantly lower than in Group I (p < 0.05), as achieved via preliminary loading tests. After the maximum hypnotic effect being achieved in Group 1, there were reductions in BPmean, SI, GEDVI, dPmax, and TPVRS (p < 0.05). In Group 1, 50% of the patients were observed to have hypotension episodes requiring the patient to be placed in Trendelenburg's position and to be given colloids as jets, and 3 patients received bolus vasopressors. After achieving the maximum hypnotic effect, BPmean, SI, GEDVI, and dPmax also decreased in Group 2 patients (p < 0.05). However, due to preliminary loading tests, these variables remained to be in the normal ranges and were significantly higher than in Group 1 (p < 0.05). IOPSS objectively reflects the preload status at all stages of initial anesthesia and the leg raising test enables prediction of a cardiovascular response to a volumetric load. When infusion therapy is performed, it is advisable to take into account a relationship between altered preload (GEDVI) and cardiac performance (SI). This volumetric loading testing tactics before induction promotes GEDVI to be maintained in the normal ranges throughout the initial anesthesia and minimizes hemodynamic disorders at this stage.

[Effect of intravenous hypnotics on autonomic response in patients with ischemic heart disease]. / Vliianie vnutrivennykh gipnotikov na vegetativnyi otvet u bol'nykh IBS.

The purpose of the case study was to investigate the effect from the bolus dosing of midazolam and ketamine on the autonomic hemostasis in patients with ischemic heart disease (IHD) with the prevalence of the activity of sympathetic or parasympathetic parts in the autonomic nervous system. The IHD patients (n = 75) were examined, after scheduled preoperative therapy, active orthostatic tests and tests of cardiac rate variability (CRV to determinine a type of autonomic response. After orthostatic-test results were analyzed, patients with sympathicotonic (n = 15) and vagotonic (n = 15) types of vegetative response were selected. After midazolam at 0.08-0.12 mg/kg and ketamine at 0.5-1.3 mg/kg were administered, CRV was analyzed in the operating theater.

[Use of H2-receptor blocker famotidine (quamatel) in anesthesiology for cardiopulmonary bypass surgery]. / Primenenie blokatora H2-retseptorov gistamina famotidina (kvamatela) v skheme anesteziologicheskogo obespecehniia kardiokhirurgicheskikh vmeshatel'stv s iskusstvennym krovoobrashcheniem.

The efficiency of perioperative therapy with quamatel (histamine H2-receptor blocker) for preventing gastrointestinal complications in cardiosurgical patients was evaluated. Quamatel was used in 68 cardiosurgical patients subjected to aortocoronary bypass surgery for coronary disease. Perioperative pH profile of the gastric contents was evaluated by a Gastroscan-5 acidogastrometer (Russia). The volume of gastric juice secretion was evaluated after induction anaesthesia, at the end of operation, and 6-8 h after the intervention. Quamatel was highly effective and well tolerated by cardiosurgical patients with concomitant gastrointestinal diseases during preparation to surgery. Use of quamatel for premedication, particularly in patients with gastrointestinal diseases, stabilized pH and decreased the gastric juice hypersecretion during the entire intraoperative and early postoperative period, thus preventing gastrointestinal complications. High therapeutic efficiency of quamatel and its good tolerance recommend it for cardiosurgical patients and to surgical patients of other profiles for prevention of gastrointestinal complications.

[Implementation of modern principles of blood saving methods at cardiac surgery under extracorporeal circulation]. / Realizatsiia sovremennykh printsipov beskrovnoi khirurgii pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

The introduction of principles of bloodless surgery into different areas of practical medicine is favoured by not only risks from donor blood transfusion, but also by the results of the researches dealing with the body's adaptation to acute anemia, with the determination of its allowable limits, and with much experience with bloodless operations used in Jehovah's Witnesses. The present study was undertaken to make a scientific-and-practical assessment of actual own blood funds and their introduction in order to decrease or refuse to use donor blood at cardiac surgery under extracorporeal circulation (EC). A retrospective analysis of hemotransfusion policy in 1993-2001 was conducted in over 2000 patients operated on under EC for coronary heart disease, acquired and congenital cardiac diseases at the Open Cardiac Surgery Department, Russian Surgery Research Center, Russian Academy of Medical Sciences. Own blood saving methods, such as intraoperative autohemotransfusion as two modalities, washed autoerythrocytic reinfusion, autoplasma reinfusion, as well as the use of different pharmaceuticals effective in reducing hemorrhage after EC were evaluated. The introduction of the above own blood saving methods may decrease the use of donor erythrocytes and freshly frozen plasma by 2.6 and 1.8 times, respectively, may completely refuse transfusing thromboplasma, assure adequate hemostasis, reduce the incidence of adverse reactions associated with donor blood transfusion in cardiac surgical patients. A complex use of the developed saving donor blood methods and pharmaceuticals aimed at improving hemostasis allowed donor blood transfusion to be completely refused in more than 70% of patients at aortocoronary bypass surgery under EC.

[Modern nondepolarizing myorelaxants in cardiac surgery]. / Sovremennye nedepoliarizuiushchie miorelaksanty v kardiokhirurgii.

The electromyographic and hemodynamic profile and side effects of the new nondepolarizing myorelaxants Mivacurium chloride (Mivacron), Cisathracurium besilate (Nimbex), Rocuronium bromide (Esmerone) were studied in 117 adult patients. All the test myorelaxants as bolus or infusion in a dose of 3.ED95 were found to be effective in creating adequate conditions for tracheal intubation and neuromuscular block (NMB) maintenance during operations on the coronary arteries and cardiac vales under extracorporeal circulation. In terms of the onset rate of NMB, Esmerone is the drug of choice for tracheal intubation. Esmerone and Nimbex in a dose of 3.ED95 did not produce a noticeable hemodynamic effect. The former was found to have a slight vagolytic effect. When rapidly injected as bolus, Mivacron caused a significant decrease in blood pressure and heart rate by 10-12%. Based on a comprehensive study, the authors have scientifically substantiated principles in the choice of nondepolarizing myorelaxants in cardiac surgical patients in relation to the baseline hemodynamic values, the stage of an operation, and the duration of artificial pulmonary ventilation.

[Anesthesia during liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

Different methods and components of anesthesia during operations in donors and recipients were studied by using the experience in maintaining anesthesia during 39 relative and 7 cadaveric hepatic transplantations. The experience in using epidural anesthesia and total intravenous anesthesia at the donor stage of hepatic lobar transplantation was comparatively analyzed. Combined epidural anesthesia (CEA) may be used during long-term and traumatic operations dealing with hepatic lobectomy in a relative donor since it is noted for low hepatotoxicity and no drastic hemodynamic exposures. CEA can substantially reduce pharmacological loading with opioids or myorelaxants, which is particularly important in taking the lobe of the liver. This reduces the recovery period of adequate own respiration, activates a patient more rapidly, substantially reduces the risk for postoperative iatrogenic complications. Balanced general anesthesia whose major component is inhalational anesthesia with isoflurane is the method of choice in performing an operation in the recipient. The use of isoflurane in the minimal-flow mode is cost-effective and safe. When anesthesia is performed in the recipient, it is necessary to take in account drastic hemodynamic pattern changes at the liverless stage during vein-venous bypass surgery, including the liver into systemic circulation, and the likelihood of development of significant reperfusion and concomitant metabolic and coagulative disorders.

[The anesthesiological support of liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

The choice of anesthesia for a high risk operation, orthotopic transplantation of the liver (OTL), is discussed. The authors propose a protocol of anesthesia for OTL. For induction anesthesia, intravenous drugs should be preferred; the liver-free stage of the operation is carried out under anesthesia with a closed isoflurane contour, and the initial metabolic disorders of patients are corrected. When the bloodflow is let in the transplanted organ, intravenous drugs (ketamine, phentanyl, and benzodiazepines) should be administered in order to reduce the vasodilating effect of isoflurane and vasopressors for preventing relative hypovolemia. At the final stage of anesthesia, isoflurane is used. Before transporting the patient into intensive care ward, phentanyl in a dose of 1.5-3 micrograms/kg was injected, because of rapid elimination of isoflurane and awakening of the patient. This protocol maintained the hemodynamics and the major metabolic parameters at the optimal level.

[Fiber optics oximetry of blood in the upper bulb of the internal jugular vein in heart surgery]. / Fibroopticheskaia oksigemometriia krovi verkhnei lukovitsy vnutrennei iaremnoi veny pri kardiokhirurgicheskikh operatsiiakh.

The authors assess the potentialities of a new method; fiber optic oxyhemometry of the blood flowing from the brain (at the level of the upper bulb of the internal jugular vein) during heart surgery. They demonstrate a sufficiently high accuracy of the method. Using it during cardiosurgical operations under artificial circulation, they found it highly informative and sensitive to even suddenly emerging and short-term changes in the ratio of oxygen delivery/consumption by the brain.