[COMPARISON OF LEVELS OF MYOCARDIAL INJURY MARKERS AND THE STATE OF THE OXYGEN BUDGET IN PATIENTS WITH MITRAL INSUFFICIENCY DURING SURGICAL CORRECTION, DEPENDING ON THE METHOD OF CARDIOPROTECTION].

The aim of our study was to compare the levels of myocardial damage markers and the state of the oxygen budget in patients with mitral valve insufficiency during its surgical correction, depending on the method of cardioprotection. We examined 85 patients with mitral valve insufficiency who underwent mitral valve replacement (MVR) surgery and anesthetic management according to the traditional method, the difference was only in the method of cardioprotection. In the I group (n=40) crystalloid cardioplegia (Bernsteinder's solution) was used, in the II group (n=45) - electrical fibrillation of the heart and intermittent clamping of the aorta. The level of markers of myocardial damage (MMD), indicators of the oxygen budget, and lactate were recorded in the patients. The method of cardioprotection of the heart did not affect the state of the myocardium, although such an indicator as the ratio of CPK MB/CPK was still lower in II group. In addition, in patients of this group, the state of the myocardium had a lesser effect on hemodynamic parameters. The oxygen budget was most influenced by the need for hemodilution, but indicators such as ΔSO2, ΔpO2, ΔCO2, EO2 and lactate levels indicate a more adequate supply of oxygen to tissues against the background of myocardial protection using electrical fibrillation of the heart and intermittent clamping of the aorta. Both methods of cardioprotection approximately equally affect the circulatory system, however, cardioprotection using electrical fibrillation of the heart and intermittent clamping of the aorta is more preferable.

The Case of Myocardial Infarction in a Fifteen-Year-Old Adolescent Caused by Toxic Substances.

The article reveals about the clinical accident of myocardial infarction in an adolescent after visiting a night club, where he had been drinking tequila. A "sniper" test was performed at home and showed synthetic marihuana in urine. The uniqueness of this case is the adolescent's difficult premorbid condition (severe diabetes mellitus type 1 and sub-compensated hypothyreosis) and the clinical course of the disease had caused difficulty in diagnosis which led to a belated hospitalization on the third day. Considering pain syndrome, infarction-like findings in ECG (ST elevation), high levels of cardiospecific enzymes (troponin elevated 70 times, aspartate aminotransferase-two times, creatine phosphokinase-4 times, lactate dehydrogenase and alkaline phosphatase-two times) and their slow tendency to normalize-a non-Q myocardial infarction diagnosis was performed. After complex treatment, the general condition of the patient improved; he was discharged from the clinic in satisfactory general condition and was given recommendations for further rehabilitation. Given the potential for premature death and long-term disability with the development of negative individual and social consequences, the correct diagnostic assessment in such cases becomes particularly relevant.

MULTIMODAL LOW-OPIOID ANESTHESIA - A NEW APPROACH TO THE ISSUE OF ADEQUATE INTRAOPERATIVE ANALGESIA.

The paper is devoted to the study of the effectiveness of multimodal low-opioid anesthesia during coronary bypass grafting (CABG) surgery under artificial blood circulation. The study included 36 patients aged 69,5±6.2 years, who were performed CABG. All patients were operated under general anesthesia. The average duration of anesthesia was 257,4±19,1 min. Induction included propofol (1,52±0.05 mg/kg), fentanyl (1-1.5 µg/kg), pipecuronium bromide (0.1 mg/kg). Maintenance of Maintaining anesthesia: Sevoflurane (1.5-2MAC). Аnesthesia: ketamine (0.5 mg/kg), lidocaine 1 mg/kg bolus, with the establishment of continuous infusion (1.5-2 mg/kg/h). The average dose of fentanyl, which was used for the entire period of anesthesiology support was 1,09±0.03 µg/kg/h (358,3±27,1 µg for the duration of surgery). As a result of the carried-out researches it was established, that multimodal low-opioid anesthesia, provides an adequate analgesic effect, and allows to refuse from intraoperative application of high doses of narcotic analgesics in the performance of highly traumatic operations, which is confirmed by the lack of hemodynamic and endocrine-metabolic shifts in its use.

[FEATURES OF CEREBRAL BLOOD FLOW DYNAMICS IN PATIENTS WITH ARTERIAL HYPERTENSION DURING CARDIAC SURGERY].

Cognitive dysfunctions (CD) is the most common postoperative neurological complication in cardiac surgery, which is detected in 30%-65% of patients within 1 month after myocardial revascularization and 20%-40% of the examined, during the next five postoperative months. This problem is especially relevant for patients with arterial hypertension (AH). Goal - to study of the correlation relationship between the mean arterial pressure (MAP) and the velocity of blood flow in the middle cerebral artery (MCA) in patients with AH during coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). The study included 128 patients with coronary artery disease, which was performed by the CABG with CPB. The average age - 62.1±4.8 years. All subjects were divided into 2 groups: 1-st group - 83 patients with AH (II-III degree); 2-nd group - 45 patients without AH. Patients were operated under sevoflurane-based endotracheal anesthesia. Registration of cerebral blood flow was carried out by the method of transcranial doplerography. For neuropsychological testing MMSE-test, FAB-test, clock drawing test and SAGE-test were used. Reduced blood flow in the MCA in patients of both groups was observed at the following stages: induction into anesthesia (by 46.7 ± 2.5% relative to the initial value, p=0.0139), the onset of hypothermia during CPB (64.2±3, 9% of the initial value, p=0.0024). There was no significant difference in the levels of the average blood flow velocity in the MCA during the non-pulsative and pulsative CPB modes (p=0.758). Correlation analysis of the assoсiation between MAP and average velocity of cerebral blood flow in MCA in patients with AH revealed a significant correlation weak strength (r=0.099, p=0.004). According to the results of the neuropsychological tests, on the 6-th day after the operation, in patients of 1-st group, there was a significant decrease in the results of the MMSE test (p=0.046) and the SAGE test (p 0.041) compared to the baseline values. Patients in 2-nd group had no significant difference in the results of all four tests. Determination of the level of MAP does not allow to fully and properly evaluate the cerebral blood flow. In view of this, we recommend intraoperative monitoring of cerebral blood flow to prevent the development of CD for all patients with AH.

[VIABILITY OF MYOCAROIUM AS RISK FACTOR FOR MORTALITY IN EARLY AND LATE PERIOD AFTER BYPASS SURGERY OF CORONARY ARTERIES IN PATIENTS WITH CORONARY HEART DISEASE AND SEVERE LEFT VENTRICULAR DYSFUNCTION].

In coronary heart disease and low ejection fraction of the left ventricle (LV) in patients after coronary artery bypass surgery tend mortality and complication rate higher than preserved LV systolic function. Significant preoperative predictors of early mortality and remote in these patients, and the incidence of complications in the early postoperative period were reveald.

[Expediency of application of miniinvasive access in prosthesis of aortal valve].

The literature data, concerning expediency of miniinvasive access in aortal valve prosthesis for its failures of various etiologies, are analyzed. Advantages and failures, occurring while its application, are discussed. Own clinical observation of successful conduction of operative intervention for aortal valve failure, using miniinvasive access, is adduced.

[Atherosclerosis of ascending aorta as a risk factor for neurological complications occurrence in surgical treatment of the ischemic heart disease].

Own experience of the ischemic heart disease (IHD) surgical treatment, combined with the ascending aorta (AA) atherosclerosis, was analyzed. Basing on results of surgical treatment for IHD there were noted mostly informative methods of diagnosis of the AA atherosclerotic affection severity and optimal approaches to surgical treatment of such patients.

[Experience of two-valve prosthesis in patients with combined aorto-mitral heart disease].

One of the main orientations of cardiosurgery is a surgical treatment of combined aortomitral valvular disease and often in combination with mitral valve insufficiency. The article presents the authors's surgical experience on treatment of patients with combined aortomitral valvular disease. Analysis of frequency and patern of complications during hospital stage of treatment and its remote results are given by authors in the article.

[Is there any alternative for the heart transplantation in patients with cardiac insufficiency of terminal stage?].

The heart transplantation constitutes the method of choice in the treatment of patients, suffering heart insufficiency, tolerant to medicinal therapy. Nevertheless, the donor's organs deficiency problem makes it necessary to search for methods of surgical treatment, which are alternative to transplantation and which would secure the patients life span prolongation as well as the quality of life improvement. New approach in surgical treatment of patients, suffering severe cardiac insufficiency have proposed Brazilian surgeon R. Batista. Experience of surgical treatment of 37 patients with dilatational cardiomyopathy and severe cardiac insufficiency (functional class III-IV, NYHA) is presented. In these patients surgical remodelling of left ventricle was done together with local myocardium plasty between papillary muscles base of mitral and tricuspid valves. Fair immediate and late results are noted.

[Efficacy of endovascular prophylaxis of pulmonary thromboembolism].

The improvement of the treatment results and efficacy of the endovascular prophylaxis methods in patients at risk for pulmonary thromboembolism (PTHE) occurrence constitute the aim of the investigation. The work is based on retrospective analysis of the treatment results of 114 patients, to whom cava filter (CF) was implanted for the PTHE accidents prophylaxis. During hospital period after the CF implantation the PTHE reattacks were revealed in 4 patients, the CF embolism and thrombosis--in 10, the ascending thrombosis--in 8, the CF dislocation and migration--in 8. Late results of the CF implantation were studied in 54 patients in terms from 1 to 10 years. In 3 of them the symptomless perforation of vena cava inferior (VCI) wall was diagnosed with nonsignificant CF diversion, distal migration of CF with adequate preservation of antiembolic function--in 1, the thrombosis had occurred in 5 patients. The CF implantation into VCI is an effective method of endovascular prophylaxis of fatal PTHE. The high efficacy of CF "Osot" was evidenced, witnessing the expediency of its clinical application.

[Morphological changes in the lungs and characteristics of thromboemboli in patients with thromboembolism of the pulmonary artery].

Basing on results of pathologoanatomical investigations, performed in 26 cases, the lungs changes in pulmonary thromboembolism were analyzed. It was shown, that an acute thromboembolism of a. pulmonalis main branches did not cause an acute necrosis of pulmonary alveolar tissue, but induces progressive diffuse changes of their microcircular bed, concomitant with pulmonary hypertension. In cases of chronical pulmonary thromboembolism the diffuse vascular sclerosis of the nonaffected lung and the alveolar tissue emphysema are formed, and in such cases the signs of pulmonary hypertension showing hypertrophy of the muscular vessels middle layer as well as their intima hyperplasia are revealed. This determines the expediency of earlier start of thrombolytic therapy conduction as well as surgical intervention in an acute pulmonary thromboembolism.

[Characteristics of hemodynamics and the oxygen balance during operation for massive pulmonary artery thromboembolism with artificial blood circulation].

The experience of artificial blood circulation application in 45 patients during surgical intervention performance for the pulmonary artery thromboembolism and vena cava inferior thrombosis was summarized. Peculiarities of the artificial blood circulation preparation and conduction were depicted and characteristic of the hemodynamics and oxygen metabolism indexes on various stages of operative treatment was presented. Analysis of results of treatment in patients after the operation was conducted. The efficacy of the operative treatment conduction was shown.

[Changes in the coagulational hemostasis system in venous thromboembolism].

The work is based on the results of examination of 51 patients, suffering various clinical variants of venous thromboembolism. There were adduced such indexes of the coagulational hemostasis systems, as the coagulation activation, anticoagulant and fibrinolytic. It was established, that disorders in the coagulational hemostasis system may be manifested by increase in activity of the coagulation activation system or by decrease in activity of anticoagulant or fibrinolytic system. The disorders in the coagulational hemostasis system causes the pulmonary thromboembolism occurrence.

[The tricuspid valve plasty in the surgical treatment of chronic pulmonary thromboembolism].

Chronic pulmonary thromboembolism causes persistent rising of pressure in the pulmonary artery system. Durable existing of hypertension promotes the right ventricle dilatation together with tricuspid valve insufficiency occurrence, dramatizing the disease clinical course and prognosis. There were considered the surgical methods of the tricuspid cardiac valve insufficiency correction. The performance of the tricuspid valve plasty according to De Vega and using supporting ring of Carpentiere was proposed, basing on experience of surgical treatment of chronic pulmonary thromboembolism and postthrombotic pulmonary hypertension.

[Surgical treatment of chronic post-thromboembolic pulmonary hypertension]. / Khirurhichne likuvannia khronichnoï posttromboembolichnoï lehenevoï hipertenziï.

Results of surgical treatment of 9 patients with postembolic chronic pulmonary hypertension, to whom thrombendarterectomy of the pulmonary artery branches was performed, using artificial blood circulation method, were studied up. Indications for conduction of operative treatment, including the heart--lungs complex transplantation, were made more precise. The ways of improvement of the surgical treatment results in patients, suffering this complication, were outlined.

[Cardiac valve prosthesis in patients with infective endocarditis and chronic renal insufficiency in terminal stage on a programmable hemodialysis]. / Protezirovanie klapanov serdtsa u bol'nykh infektsionnym éndokarditom i khronicheskoi pochechnoi nedostatochnost'iu v terminal'noi stadii, kotorym provodiat programmnyi gemodializ.

Mechanical cardiac valve implantation was performed in 3 patients with infective endocarditis, sepsis, chronical renal insufficiency of terminal stage, to whom the programmed dialysis was conducted. The operation was performed for vital indications. All the patients after the operation are alive, their treatment was continued, using programmed hemodialysis, effect of operation is good. The success of treatment of infective endocarditis in patients with chronical renal insufficiency of terminal stage depends on timely radical elimination of the infection foci in endocardium, the intracardial and systemic hemodynamics normalization, application of etiotropic antibacterial therapy, an adequate programmed hemodialysis.