Right Ventricular Function in Surgical Treatment of Left Heart.

Aim    The aim of this study was to evaluate right ventricular (RV) function during left chamber surgery.Material and methods    This was a single-site prospective cohort study. The study included 197 patients with valvular pathology of heart left chambers. Mean age of patients was 58 [47; 65] years. Precordial echocardiography was performed preoperatively and within one week after surgery.Results    Decreased parameters of the right ventricular (RV) longitudinal function and global contractile function were observed postoperatively in the majority of patients. More noticeable decreases were observed in parameters of the longitudinal function (p<0.001). Analysis of the changes in RV contractility depending on the underlying pathology revealed the greatest changes in the contractile function in the mitral insufficiency group. In the mitral stenosis group, the greatest difference was observed in the tricuspid annular systolic excursion (TAPSE) (p=0.027). In the groups with aortic defects, all parameters of RV contractile function, except for the fractional area change (FAC), showed statistically significant decreases after correction of the underlying defect (p<0.05).Conclusions    Surgical intervention for left heart valvulopathy can result in a decrease in RV function unrelated with systolic deficit of the left ventricle. Modern technologies allow multi-vector assessment of the RV contractile function. To assess the RV function, it is advisable to use a combination of parameters that reflect both global and longitudinal function.

[Surgical treatment of patients with stomach cancer and severe concomitant cardio-vascular pathology].

51 patients with gastric cancer and severe concomitant ischemic heart disease (90.2%), valvular heart disease (5.9%), critical stenosis of the internal carotid artery (2%) or abdominal aortic aneurism (2%) were operated on during 1995-2011yy. Of them men were 41, women - 10; mean age was 65.1 years (51-82). The first stage of gastric cancer was diagnosed in 18 (35.3%) of patients, second, third and fourth in 12 (23.5%), 17 (33.3%) and 4 (7.8%), respectively. Radical tumor resection was achieved in 37 (72.5%), palliative operations were performed in 13 (25.5%) patients. 17.6% of patients were operated on stomach and vessels simultaneously. 82.4% received the stepwise treatment. Intra- and postoperative complications were registered in 47.1% (24 of 51 patients); of whom 5.9% (3 patients) ended lethally. Simultaneous operations showed the 55.6% complications and zero lethality rate, whereas stepwise treatment resulted in 45.2% complications and 7.1% lethality.

[Surgical therapeutic decision-making in elderly patients with heart valvular defects combined with lesions of coronary and brachiocephalic arteries].

Due to considerable incidence of combined cardiac and vascular pathology in elderly and aged patients with heart valve defects, of special importance is the problem regarding surgical therapeutic decision-making. The present article is aimed at considering the problems concerning possibility and feasibility of stagewise or simultaneous surgical correction in patients diagnosed as having cardiac valve defect and haemodynamically significant lesions of coronary and/or brachiocephalic arteries based on generalizing the results of international studies.

[Cardiomyocyte structural rearrangement in patients with dilated cardiomyopathy and valvular heart disease].

Light and electron microscopies were used to analyze cardiomyocyte structural changes in the dilated left ventricle in patients with dilated cardiomyopathy and valvular heart diseases. The patients were found to have cardiomyocyte hypertrophy and ultrastructural rearrangement with a tissue-specific reduction. There was hypertrophic cardiomyocyte lengthening that continued after these cells stopped growing thicker, as well as occurred due to the loss of myofibrils, which increased during the cell rearrangement, and directly correlated with the lower ejection fraction and higher end-systolic volume of the left ventricle.

[Expert assessment of operations' complexity and its interrelationship with lethal outcomes and duration of treatment].

The aim of the work was to carry out expert assessment of complexity of operations and to study interrelationship of the average score of complexity of the interventions with lethal outcome and duration of treatment in the Intensive Care Unit (exemplified by comparison with the outcomes of operations on cardiac valves performed in 2009 in the setting of artificial circulation in adult patients). Complexity was assessed by a total of 13 cardiovascular surgeons specialized in operations aimed at correcting valve defects (4 of them were from the A. N. Bakulev Scientific Centre for Cardiovascular Surgery), with none of the participants being aware of the therapeutic outcomes of each type of the operation performed. An average expert-defined score was assigned for each of the 33 names of the operations. The Kendall coefficient of concordance for all operations amounted to 0.29 (p<0.001); consensus in the complexity-score (from 69 to 85%) was achieved for 48.5% of the operations thus considered. The values of the mean scores of complexity of operations, defined by the specialists form the SCCS (2.02±0.54) were significantly lower (Wilcoxon's test; p<0.001) as compared with the average score assigned by specialists from other facilities (2.28±0.43). The duration of the stay at the ICU of the patients subdivided into groups depending on the expert score was found to differ significantly (p=0.007). The area under the ROC curve using the EuroSCORE (0.59) is suggestive of its lower accuracy in assessing the lethal outcome as compared to the expert score (0.68). The obtained findings strongly suggest advisability of using expert score of operations' complexity for solving complicated non-formalized tasks on allied problems of cardiovascular surgery and organization of public health care (accrediting of medical facilities, formation of the government order, and planning of the budget of medical facilities).

[Cryopreserved allo-grafts in aortic valve surgery].

Bakulev Scientific Center for Cardiovascular Surgery resumed research into cryopreservation and creation of valve bank in 1990. This technology allowed preparation of valve allo-grafts with preserved cell reproductive capacity for clinical use. A new technology, allowing reduction of calcinosis in the graft's aortic wall, was developed and experimentally tested in 2003. 61 aortic valve replacements with cryopreserved allo-grafts were performed between 1992 and 2003. The three techniques of implantation included: subcoronary (38), intraaortic cylinder (8) and "free-standing root" (15). 44 patients developed active infective or prosthetic endocarditis. Hospital mortality rate was 11.5%, 12-year survival rate--90%. Dysfunctions and reoperations were significantly rarer in cases of inclusion cylinder and free standing root. The authors conclude that cryopreserved allo-grafts allow good quality of life without use of anticoagulants and low rate of reinfection. The use of subcoronary technique for implantation must be limited and method of choice should be free-standing root, especially in cases of destructive infective or prosthetic endocarditis. Cellular engineering probably will elongate the stability of long-term results.

[Left ventricle dilatational lesion. Problems of nosology, diagnostics, and treatment].

The article deals with the problem concerning the use of the term "specific cardiomyopathy", adopted by WHO in 1995, in cases of advanced left ventricle lesion in patients with valvular heart defects. The group of patients with dilated left ventricle cavity, related to acquired heart diseases, is rather heterogeneous and large in number, and includes about 50% of the patients who underwent an operation. In the authors' opinion, it is reasonable to divide them into the following main subgroups: patients with quickly regressing symptomatic left ventricle dilatation, resulting from volume overload; patients with valvular cardiomyopathy (the terminal stage of heart defect); patients with left ventricle dilatational lesion, typical of the intermediate stage with characteristic pathological remodeling and the disturbance of its segmental contractility. The authors consider such a division to be useful for further study of patients with left ventricle dilatation due to valvular heart defects.

[Current views on acquired valvular heart disease and the results of treatment]. / Sovremennyi vzgliad na sroki operativnogo lecheniia priobretennykh porokov serdtsa i ego rezul'taty.

The article deals with the problems of diagnosis of acquired valvular defects (AVD) and indication to surgical treatment of AVD in accordance with international recommendations and modern knowledge of this issue. The following AVD diagnosis methods are described: heart auscultation, echocardiography, tests with regulated load, angiographic and radionuclide methods. Among pathological conditions, more attention is placed on stenoses, aortic, mitral and tricuspid valve insufficiency, IHD. Of importance is interpretation of the data obtained at diagnostic tests in terms of indications to cardiosurgical interventions, optimization of the terms and outcomes of the surgery. Statistics are provided on natural survival of patients and efficacy of surgical treatment.

Primary rhabdomyosarcoma of the right atrium.

Rhabdomyosarcoma is the rare malignant tumor of the heart. A case of a large malignant rhabdomyosarcoma in a 37 year old woman is presented. The tumor arose from the anterior wall of the right atrium and was treated by surgical resection with replacement of the tricuspid valve with bioprosthesis. The patient passed two courses of adjuvant chemotherapy. Six months later transthoracic echocardiography revealed absence of any tissue masses in right atrium, superior vena cava and normal function of the bioprosthesis.

[Migration of fibroblasts into heart valve leaflet tissue in vitro]. / Izuchenie migratsii fibroblastov v tkan' stvorok klapanov serdtsa in vitro.

Heart valve allografts are widely used for surgical treatment of the heart. In recent years a new field of research has emerged dealing with allograft modification by cells of recipient by means of tissue engineering. This method involves culturing fibroblasts and endothelial cells, using recipient tissue, followed by introduction of the fibroblasts into tissues of allograft and coating its surface by the endothelial cells. This modification is expected to ensure the structural maintenance of implanted tissues and to reduce its thrombogenecity. This procedure may promote the allograft adhering to the recipient tissues, thus prolonging the terms of the valve normal functioning after implantations. For this purpose, methods of luminescent microscopy are suggested using double staining of tissue with fluorescent dyes Hoechst 33,342 and ethidium bromide, or with fluorescein diacetate and ethidium bromide. Experimental results are presented indicative of fibroblast migration from the surface to the human heart valve leaflets.

[Prosthesis of the aortic valve by a loose allograft]. / Protezirovanie aortal'nogo klapana beskarkasnym allograftom.

A procedure has been developed to prepare live aortic allografts, which consists in taking a valve early after a donor's death, sterilizing it in antibiotics and freezing it to -190 degrees C in the presence of the cryoprotective agent dimethylsulfoxide. The preservation of valve tissue is evidenced by morphological studies. The first 3 operations for aortic valvular diseases were performed. In two cases, the indication for surgery was infectious endocarditis refractory to antibiotic therapy. Postimplantation complications were not seen. The competence of the allograft was confirmed by intraoperative transesophageal echocardiographical study. The patients examined 4 months postoperation developed no signs of aortic incompetence and infectious endocarditis. Thus, the creation of a bank of live valves allows this prosthesis to be implanted with appropriate indications, one of which is active infectious endocarditis of the aortic valve.

[Rupture of posterior wall of the left ventricle after mitral valve prosthesis]. / Razryv zadnei stenki levogo zheludochka posle protezirovaniia mitralnogo klapana.

Rupture of the posterior wall of the left ventricle is a comparatively rare complication occurring after prosthesis of the mitral valve, but resulting in high mortality. There is a great diverse of opinions regarding the causes of this complication. The likely causes are surgical injury and the used method for prosthesis. The authors studied 9 patients with rupture of the posterior wall of the left ventricle following mitral prosthesis. In all patients the prosthesis was carried out by the routine procedure by dissecting the two mitral cusps with subvalvular structures. Two (22%) patients survived after defect plasty. The above surgical policy is the most effective to control bleeding and achieve a favourable result of correction of this complication.

[Annuloplasty of the tricuspid valve with a controllable semi-ring under the control of transesophageal echocardiography]. / Annuloplastika trikuspidal'nogo klapana reguliruemym polukol'tsom pod kontrolem chrespishchevodnoi ékhokardiografii.

The paper analyzes the first clinical experience with a novel procedure of tricuspid annuloplasty with a controllable semiring under the control of transesophageal echocardiography in 6 patients with tricuspid dysfunction and those with mitral and tricuspid valvular diseases. The application of intraoperative transesophageal echocardiography makes it possible to control both the degree of mitral regurgitation and the severity of right atrioventricular stenosis. This echocardiography may serve a method for plastic correction of the tricuspid valve.