[Prevention and treatment of venous thromboembolic complications in orthopedic patients]. / Kompleksnaya profilaktika i lechenie venoznykh tromboembolicheskikh oslozhnenii u patsientov ortopedicheskogo profilya.

OBJECTIVE: To analyze the comprehensive program for prevention of thromboembolic complications in orthopedic patients. MATERIAL AND METHODS: We have analyzed thromboembolic complications in orthopedic patients after surgeries on large joints over the past 5 years (2018-2022). CONCLUSION: A comprehensive approach to prevention and treatment of thromboembolic complications including ultrasound, early surgical prevention of pulmonary embolism can significantly improve postoperative outcomes after joint replacement surgery. Vacuum aspiration retrograde thrombectomy is effective, feasible and safe for acute ilio-femoral venous thrombosis reducing hospital-stay (p=0.0124) and restoring vein patency. Widespread thromboembolic complications, especially for pulmonary embolism in 2022, are likely due to a new coronavirus infection and require careful screening of patients with risk factors with appropriate preventive antithrombotic therapy.

The use of an Inhaled Surfactant in Patients With Severe and Extremely Severe new Coronavirus Infection COVID-19 With Concomitant Cardiovascular Pathology.

Aim      To study the effectiveness of nebulized surfactant therapy as a part of a multimodality treatment of severe and extremely severe COVID-19 viral pneumonia with concomitant cardiovascular diseases (CVDs).Material and methods  This retrospective controlled study analyzed a multimodality treatment of 38 patients with severe and extremely severe COVID-19 viral pneumonia and concomitant CVDs who were administered nebulized surfactant for correction of acute respiratory distress syndrome (ARDS). The control group consisted of 105 patients with severe and extremely severe novel coronavirus infection with concomitant CVDs who were not administered surfactant as a part of the multimodality therapy.Results Administration of nebulized surfactant as a part of the multimodality treatment in patients with COVID-19 allowed alleviating the severity of respiratory insufficiency (р<0.001), which decreased the death rate of patients with severe and extremely severe COVID-19 and undoubtedly demonstrated the effectiveness of this medicine. The timely multimodality therapy, including nebulized surfactant, improves the course of the disease. Thus, the absence of a possibility for administering nebulized surfactant for more than 4 days was associated with fatal outcomes (р=0.045).Conclusion      Administration of nebulized surfactant as a part of the multimodality treatment of severe and extremely severe COVID-19 and concomitant CVDs increases the survival (р<0.001) and reduces the mortality by 46 %. The risk factors of an unfavorable outcome of this disease include an age older than 65 (р=0.020), a positive polymerase chain reaction test (р=0.037), a ferritin concentration at baseline >600 mg /ml (р<0.001), and a surfactant treatment duration < 4 days (р=0.045). Further study of the efficacy of nebulized surfactants as a part of the multimodality therapy is required and should include randomized clinical trials with a large number of patients and the development of distinct criteria for the treatment of ARDS.

Histological Justification for the Need of Radiofrequency Ablation of Pulmonary Arteries in Patients with High-Grade Secondary Pulmonary Hypertension.

The aim of the study was to perform a histological assessment of the effectiveness of radiofrequency exposure for circular denervation of the pulmonary artery in patients with secondary high pulmonary hypertension. Materials and Methods: The study was carried out on the autopsy material derived from non-operated patients. Three groups were formed. The experimental group included the material (207 histological samples) from the patients with chronic high pulmonary hypertension arising on the background of mitral heart disease. The samples of this group were exposed to circular radiofrequency ablation. In the comparison group, we used autopsy material (24 samples) obtained from the patients with high pulmonary hypertension. The control group included material (35 samples) from the patients without pulmonary hypertension who died from causes not associated with cardiovascular diseases. The samples of the comparison and control groups were not exposed to radiofrequency.Visual evaluation of the damage to the vascular wall was performed after hematoxylin and eosin staining, according to Van Gieson. Damage to the nerve plexuses was evaluated after their impregnation by silver salts. To assess the degree of damage to the vascular wall on the stained sections, a scoring method of semi-quantitative analysis of the observed pathological processes (fibrinoid necrosis, metachromasia, karyorrhexis, karyolysis, fibrinoid and mucoid swelling, lipid presence) was used. Silver salt impregnation allowed visualizing damage to the reticular fibers, trunks and endings of peripheral nerve fibers. Results: The mean optical density of the ablation group was statistically significantly lower than in the comparison and control groups (p<0.001). The mean specific area of tissue dissociation was higher in the "marginal zones" of the ablated sections, under pronounced mechanical compression in these areas. The difference in the mean areas of the argentophilic samples of the ablation and comparison and control groups was expressed in a lower percentage of argentophilic fibrous structures (p<0.05). At the same time, the highest concentration of argentophilic structures was observed in the comparison group, which points to a bigger content of nerve fiber structures in the patients with high pulmonary hypertension. Conclusion: The results of the histological study demonstrated the feasibility of radiofrequency ablation of the pulmonary arteries in patients with high-grade secondary pulmonary hypertension. Radiofrequency denervation leads to the destruction of the sympathetic ganglia in the adventitial layer of the pulmonary arteries, which are responsible for the spasm of the precapillary bed of the pulmonary circulation, which promotes vasodilation, an increase in the vascular bed, and, as a result, a reduction in pulmonary hypertension.

[Effectiveness of the Cox Maze-IV Procedure in Cardiac Surgery Patients With Atrial Fibrillation].

Aim Analyzing a 5-year experience of surgical treatment of cardiosurgical patients with atrial fibrillation (AF).Material and methods The study analyzed results of surgical treatment with extracorporeal circulation in 132 patients with AF who underwent the Maze-IV procedure using a radiofrequency ablator with transmurality feedback from 2013 through 2018.Results Two fatal outcomes were observed in the study group. These outcomes took place in the early postoperative period and were associated with progressive acute heart failure in patients with repeated surgery for mitral valve restenosis. 61.2% of the patients had no AF. Recurrent AF was observed during the first three years after surgery in association with withdrawal of the antiarrhythmic medication, which confirmed a need for long-term antiarrhythmic therapy. Analysis of risk factors for AF relapse identified significant predictors, including left ventricular dilatation larger than 5.5 cm at baseline and more than two-year duration of a history of arrhythmias.Conclusion The Maze-IV procedure proved an effective and safe method of surgical treatment in AF patients with acquired heart defects and ischemic heart disease, which allowed maintaining sinus rhythm in 61.2% of patients for 5 years. Preventive amiodarone saturation reduced the risk of AF relapse by 24.2 % (p=0.038) and incidence of postoperative arrhythmic complications by 34.9 % (p=0.008) in cardiosurgical patients.

[Circular Sympathetic Pulmonary Artery Denervation in Cardiac Surgery Patients With Mitral Valve Defect, Atrial Fibrillation and High Pulmonary Hypertension].

Objective Investigate the influence of the sympathetic denervation of the pulmonary trunk and the orifices of the pulmonary arteries on the degree of pulmonary hypertension (PH) and outcomes of the surgical treatment of atrial fibrillation (AF) in patients with mitral valve defects, complicated AF, and high PH.Material and methods We analyzed the surgical treatment of 140 patients with mitral valve defect, concomitant AF, and high PH - pulmonary artery systolic pressure (PASP) gradient more than 40 mm Hg. The group of interest included 51 patients (46 patients with severe mitral stenosis and five patients with grade 4 mitral valve regurgitation). All patients underwent mitral valve correction (47 valve replacement surgeries and 4 valve-sparing interventions), biatrial Maze IV procedure, and additionally, denervation of the pulmonary trunk and the orifices of the pulmonary arteries. The control group included 89 patients diagnosed with mitral valve defect, AF, and PH with PASP > 40 mm Hg. However, unlike in patients of interest, denervation of the pulmonary arteries was not performed.Results Circular radiofrequency denervation of the pulmonary trunk and the orifices of the pulmonary arteries using a clamp-destructor is an effective and safe method, significantly reduces secondary PH (p=0.018), promotes reverse remodeling of the heart chambers, left atrium in particular (p=0.01), and improves outcomes of the Maze IV procedure (p=0.022) by restoring sinus rhythm in patients with mitral valve defects, complicated AF, and high PH.Conclusion This technique must be studied further involving a more significant number of patients, analyzing long-term results, and using this technique in patients with non-valvular causes of secondary PH.

Large porous particles for respiratory drug delivery. Glycine-based formulations.

Large porous particles are becoming increasingly popular as carriers for pulmonary drug delivery with both local and systemic applications. These particles have high geometric diameters (5-30µm) but low bulk density (~0.1g/cm3 or less) such that the aerodynamic diameter remains low (1-5µm). In this study salbutamol and budesonide serve as model inhalable drugs with poor water solubility. A novel method is proposed for the production of dry powder inhaler formulations with enhanced aerosol performance (e.g. for salbutamol-glycine formulation the fine particle fraction (FPF≤4.7µm) value is 67.0±1.3%) from substances that are poorly soluble in water. To overcome the problems related to extremely poor aqueous solubility of the APIs, not individual solvents are used for spray freeze-drying of API solutions, but organic-water mixtures, which can form clathrate hydrates at low temperatures and release APIs or their complexes as fine powders, which form large porous particles after the clathrates are removed by sublimation. Zwitterionic glycine has been used as an additive to API directly in solutions prior to spray freeze-drying, in order to prevent aggregation of powders, to enhance their dispersibility and improve air-flow properties. The clathrate-forming spray freeze-drying process in the multi-component system was optimized using low-temperature powder X-ray diffraction and thermal analysis.