[The influence of continuous veno-venous haemodiafiltration start time on multiple organ dysfunction syndrome treatment results in cardiac surgery patients].

It was studied the influence of CVVHDF start time on MODS treatment results in 51 patients after cardiac surgery. It was found that early CVVHDFstart as apart of MODS treatment reduces the SIRS severity, normalizes cytokines balance, which leads to ALV duration decrease and significant reduction in renal replacement therapy (RRT) requirements and 28-day mortality rate.

[Use of levosimendan in cardiosurgical patients with chronic heart insufficiency].

The impact of administration of the calcium sensitizer levosimendan on hemodynamic parameters, dose of intraoperative and postoperative cardiotonic maintenance, length of intensive care unit stay, and hospital mortality was studied in cardiosurgical patients with dilated cardiomyopathy, second-fourth degree mitral valve insufficiency, or NYHA Class IV circulatory insufficiency. Levosimendan was administered to 25 patients 3-5 days prior to surgery. A control group of 22 patients did not receive levosimendan. The use of the agent caused statistically significant reductions in pulmonary artery pressure and pulmonary wedge pressure and increases in cardiac index and left ventricular ejection fraction. The levosimedan-treated patients needed smaller doses of sjmpathomimetics, less length of intensive care unit stay and showed lower mortality rates (p < O.05 for all indices).

[Impact of preoperative levosimendan therapy on the volemic status and vascular tone of patients with chronic heart failure during anesthesia].

The impact of preoperative levosimendan therapy on the volemic status and vascular tone was studied in patients with chronic heart failure (CHF) during anesthesia and the ways of correcting the occurring changes were defined. The study included 21 patients with CHF in the presence of dilated cardiomyopathy, who underwent mitral valve replacement and tricuspid valvoplasty. Group 1 patients (n = 11) were given levosimendan (Simdax) in a dose of 0.05-0.1 mg/kg x min 2 days prior to surgery; Group 2 (n = 10) was control. Central hemodynamics was monitored by the transpulmonary thermodilution technique (PiCCO-Plus, Pulsion Medical System). Intraoperative monitoring of microcirculation was made using a laser microcirculation analyzer. It has been established that the preoperative administration of levosimendan causes an increase in stroke index at critical surgical stages. With the use of levosimendan, peripheral microcirculation improves and nutritional blood flow increases. The preoperative use of levosimendan causes a reduction in the tone of resistance vessels during anesthesia, which can require vasopressor support in the postperfusion period; a levosimendan-induced decrease in preload requires infusion correction of relative hypovolemia.

[Surgical treatment of dilated cardiomyopathy].

The efficacy and safety of different variants of left ventricular geometrical reconstruction (LVGR) in patients with dilated cardiomyopathy (DKMP) were studied in 2-stage clinical trial during 4 years. Results of left ventricle plication, "Myosplint" surgery and implantation of extracardial net framework (ECNF) complemented with mitral insufficiency correction (in case of need) have been evaluated on the first stage of the study. Based on this study, the implantation of ECNF and correction of mitral insufficiency are recognized as the most effective and safe method of DKMP surgical treatment. Short- and long-term results of these surgical procedures have been studied on the second stage of the study. Overall 30 surgeries of LVGR have been performed (18 on stage 1 and 12 on stage 2 of the study). Hospital lethality on stage 1 was 27%, 4-year actuarial survival rate (taking into account hospital lethality)--54+/-12%. Original protocols of surgical, anesthetic and intensive care management led to decrease of hospital lethality to 8% and an increase of 2-year actuarial survival rate to 91.6+/-7.9% (that significantly higher than in the control group treated with therapeutic methods only).

[Intraaortic balloon counterpulsation in the treatment of perioperative cardiogenic shock-complicated myocardial infarction during aortocoronary bypass surgery].

The paper presents the results of use of intraaortic balloon counterpulsation (IABC) in complex therapy for cardiogemic shock in 31 patients with perioperative myocardial infarction (PMI) developed during aortocoronary bypass surgery under extracorporeal circulation (EC) and cold cardioplegia. The diagnosis of PMI was confirmed by the ECG data (the emergence of new Q waves) and by the high level of CPC-MB (more than 6%). IABC was performed, by using a Kontron M-7000 apparatus. The time elapsed from the onset of myocardial infarction to the start of IABC averaged 15.7 + 4.3 hours and the duration of the latter did 105 +/- 13 hours. IABC was initiated in 4 (12.9%) patients in the operating room before EC, in 20 (64.5%) during disconnection from EC, in 7 (22.6%) patients, who were unresponsive to pharmacological therapy, 6-26 hours after surgery. All the patients were divided into 2 groups: (1) 22 patients who had benefited from complex therapy using IABC; they were all successfully disconnected from the balloon pump; (2) 9 patients with refractory heart failure who had died during IABC. The latter has been shown to be one of the effective treatments of PMI and cardiogenic shock during aortocoronary bypass surgery, which achieves hemodynamic stabilization in 70.9% of cases. The results of complex therapy for cardiogenic shock depend on the site and extent of myocardial infarction. Lesions to the anterolateroposterior or anteroseptal area of the left ventricle belong to poor predictors. The outcomes of treatment are poor if there are significant hemodynamic disorders that require, besides cardiotonic agents, the administration of large doses of agents having a potent vasopressor effect (adrenaline and noradrenaline). Improvements in left ventricular pump function, cardiac output, and a significant reduction in the doses of sympathomimetics within the first 12 hours of IABC should be considered to be a good predictor. With the complex treatment of cardiogenic shock, by using counterpulsation after aortocoronary bypass surgery is 51.6%. The early initiation of IABC within 6 hours following the development of myocardial infarction allows mortality to be reduced.

[Continuous epidural infusion of ropivacaine hydrochloride (naropin) during postoperative analgesia in cardiosurgical patients]. / Postoiannaia épidural'naia infuziia ropivakaina gidrokhlorida (naropin) pri posleoperatsionnom obezbolivanii kardiokhirurgicheskikh bol'nykh.

An efficiency and safety of continuous infusion of naropin in the epidural analgesia of 38 patients after coronary artery bypass grafting were demonstrated. A variation of combined anesthesia, which was elaborated at the Russian Research Center of Surgery of the Russian Academy of Medical Sciences and which comprises (as a basic component of anesthetic management) a high thoracal epidural block (T2-T4) by continuous infusion of a 2% solution of naropin at a velocity of 5 +/- 2 ml/h. Anesthesia was supported by isoflurane (0.5 +/- 0.9%). The patients were extubated in the operated theater and taken to the resuscitation unit with continuous infusion of 0.2% naropin solution. All studied parameters were registered after discharge from the operating theater and 1, 3, 6, and 16-18 hours after surgery. The pain-syndrome intensity was measured at the verbal scale with 0 to 3 points. The mean duration of continuous naropin infusion was 16.7 +/- 0.5 h, mean dose--2.2 +/- 0.2 ml/h. Naropin was administered at a dose of 1-3 ml/h in 89.7% of cases and at a dose of 6 ml/h only in 2.9% of cases. The drug, when used in small doses, ensured a high anesthetic efficiency. A total lack of pain or a mild pain of 0.1 points was observed in 86.5% of patients at stage 5 of examinations and in 100% of patients at stage 3. Naropin infusion did not entail any impairment in ventilation or gaseous metabolism. A reliable decrease of arterial pressure (AP) and of central venous pressure (CVP), (p < 0.05) were registered beginning from stage 2. CVP decrease versus stage 1 was ensured in 38.% of patients by stage 4 and the number of patients with a decreased CVP (less than 60 mm H) went up, versus stage 1, by 3 times. APsyst of less than 90-80 mm Hg was registered in 15 (39.8%) of patients at different examination stages, which necessitated the use of noradrenalin at mean dose of 174 +/- 21 ng/kg.min. The infusion of naropin at dose of 1-6 ml/h did not entail any impairment in the central nervous system (hallucinations, convulsions, and headache).

[Reduced paired stimulation in patients in the early postoperative period after an open-heart surgery]. / Urezhaiushchaia parnaia stimuliatsiia u bol'nykh posle operatsii na otkrytom serdtse v rannem posleoperatsionnom periode.

The authors provide the technique of underdriving paired ventricular stimulation as a variant of treating drug-resistant tachycardias and a formula of calculating rhythm inhibition and the impulse delay. Basing on the stimulation pathophysiology and positive shifts in hemodynamics, the validity of this stimulation, its advantages and indications are inferred.

[Urine viscosity in the evaluation of homeostasis in heart surgery patients in the early postoperative period]. / Viazkost' mochi kak otsenka gomeostaza kardiokhirurgicheskikh bol'nykh v rannem posleoperatsionnom periode.

A total of 100 dynamic measurements of the urinary viscosity were carried out in 38 patients subjected to open-heart surgery. Biochemical parameters and levels of electrolytes were measured in the cystic urine. The viscosity of the urine was found to be unchanged from 10 to 300 sec-1. A significant increase of its level was observed only in acute renal failure and led to the development of multiorgan abnormalities. The results indicate that urine viscosity in the early postoperative period was due to pH values (r = 0.47, p < 0.05) and free hemoglobin level (r = -0.52, p < 0.01) in coronary patients and due to concentrations of sodium (r = -0.57, p < 0.01) and chloride ions (r = 0.38, p < 0.01), osmolarity (r = -0.53, p < 0.1), and protein levels (e = -0.37, p < 0.1) in patients with acquired heart diseases. These causal relations were conditioned by the postoperative directions of regular reactions of homeostasis, because in coronary disease it is virtually the same as before surgery. Contrariwise, renal perfusion has a great impact on homeostasis stabilization in new bloodflow state in patients subjected to open-heart surgery for acquired heart diseases. As molecular and cellular disorders anticipate the clinical symptoms, we came to a conclusion that increase of urine viscosity may be an early sign predicting the development of multiorgan abnormalities.