Results of flowmetric assessment of composite Y-grafts and autovenous coronary artery bypass grafts. / Rezul'taty floumetricheskoi otsenki kombinirovannykh I-graftov i autovenoznykh aortokoronarnykh shuntov.

AIM: The purpose of the study was to perform intraoperative assessment of blood flow in coronary bypass grafts of the 'first' and 'third' order according to Calafiore A.M. with the help of the TTFM technique and to compare the obtained results. PATIENTS AND METHODS: This retrospective, single-centre study enrolled a total of 222 patients subjected to coronary artery bypass grafting (CABG) from January to November 2017. Depending on the type of bypass grafting of the posterior interventricular artery (PIVA), the patients were divided into 2 groups. Group One consisted of 108 patients undergoing bypass grafting of the PIVA with the help of combined Y-grafts from the right internal thoracic artery (RTIA). Group Two was composed of 114 patients subjected to autovenous coronary artery bypass grafting of the PIVA. Blood flow was assessed with the help of the VeriQ MediStim® flowmeter after termination of extracorporeal circulation (ECC), at systolic pressure of 100-110 mm Hg. The parameters of blood flow were assessed using the 1.5- and 2-mm probes. In a specially designed protocol we registered the type of the shunt, the bypassed artery, and values of flowmetry parameters. We also evaluated the pattern of the flowmetric curve according to Takemi Handa et al. RESULTS: The obtained findings revealed a statistically significant difference in the values of Qmean (p=0.001), with the PI values in the groups not statistically differing (p=0.14). Thus, in patients with similar parameters influencing the volumetric velocity of blood flow (the degree of proximal stenosis, diameter of the bypassed artery, mean systolic AP and HR) the value of Qmean was higher in the group with coronary artery bypass grafting (CABG), i. e., in the group of the 'first-order' conduits. Therefore, an autovein directly anastomosed to the aorta experiences grater haemodynamic overload, which completely confirms the theory of Calafiore A.M. CONCLUSION: First-order conduits (CABG) appear to experience greater wall strain because of greater haemodynamic overload as compared with third-order conduits (Y-grafts). A composite Y-graft may be an alternative technique of bypass grafting of the basin of the right coronary artery (RCA). A composite Y-graft has greater resistance to wall shear stress than an autovein anastomosed to the aorta.

Minimally invasive Ozaki technique. / Operatsiia Ozaki iz mini-dostupa.

Implantation of a mechanical or biological graft remains the gold standard in treatment of patients with aortic valve pathology. However, the necessity of taking anticoagulants, the problem of graft durability, the risk for thromboembolic and haemorrhagic complications, prosthetic infective endocarditis impel surgeons to search for and develop new technologies. One of such new techniques is prosthetic repair of the aortic valve using autologous pericardium according to the S. Ozaki operation. This procedure makes it possible to form an aortic valve with excellent haemodynamic characteristics and low frequency of re-do operations in both the early and remote periods. Current trends are towards exponential growth of minimally invasive cardiosurgical interventions. Upper partial sternotomy is one of the most commonly used techniques in surgery of the aortic valve. The results of previous studies demonstrated that a minimally invasive approach apart from a good cosmetic effect has a series of advantages over full sternotomy by the in-hospital and remote outcomes. On the other hand, a minimally invasive access is associated with limited surgical exposure and tight operative field and is therefore technically more complicated than the operation via full sternotomy. In our retrospective study we compared the clinical outcomes of the minimally invasive Ozaki technique (Ozaki Mini Group, n=30) and full sternotomy (Ozaki Full Group, n=112). Because of differences between the groups by the clinical and demographic parameters in order to ensure maximum comparability we conducted computer-assisted propensity score matching, resulting in formation of 2 groups consisting of 30 patients each. The primary outcome measures of the study were 30-day all-cause mortality and postoperative major adverse cardiac events (myocardial infarction, stroke). As additional categorical outcomes we examined new-onset atrial fibrillation and renal failure, resternotomy, prolonged (>24 h) assisted artificial pulmonary ventilation, mediastinitis/sternal instability. Secondary outcome measures were as follows: the duration of the operation, duration of myocardial ischaemia and artificial circulation, blood loss, requirement for transfusion of donor blood components.

Immediate results of bypass grafting of the territory of the right coronary artery using the 'Penza Coronary Technology'. / Neposredstvennye rezul'taty shuntirovaniia basseina pravoi koronarnoi arterii s ispol'zovaniem metodiki 'Penza Coronary Technology'.

Coronary artery bypass grafting (CABG) is known to be an effective method of treatment for multivessel obstructive coronary disease with low rates of reintervention and excellent long-term survival and freedom from angina. Graft patency lies at the heart of its procedural success and durability, which in its turn largely depends on the appropriate choice of the conduit, as well as the target coronary artery (CA). It should be mentioned that patency of one and the same conduit used for bypass grafting of the territory of either the left or right coronary artery (LCA and RCA, respectively) may differ, which is probably determined by differences in physiology, size, territory of runoff, and local flow characteristics between different coronary targets. Previous reports have supported the use of bilateral internal thoracic arteries to revascularize the left coronary circulation. If this becomes standardized practice, the optimal conduit for the right coronary system remains to be established. Proposed in the present article is a variant of bypass grafting of the RCA territory using a composite I-graft formed from the proximal portion of the right internal thoracic artery (ITA) in situ and the great saphenous vein (GSV) harvested by the 'no-touch' technique. This technique is part of a CABG schematic algorithm worked out in our Clinic and called the 'Penza Coronary Technology'.

Indications for ascending aorta-bifemoral bypass grafting in patients with IHD and occlusion of the infrarenal aorta. / Pokazaniia dlia astsendo-bifemoral'nogo shuntirovaniia u patsientov s IBS i okkliuziei infrarenal'noi aorty.

The problem concerning surgical decision-making in patients with significant atherosclerotic lesions of arteries of more than one basin will, probably, be important for cardiovascular surgeons for more than one decade. Even the centres possessing experience in several thousand cases of successful treatment of multifocal atherosclerosis have from time to time been facing non-trivial clinical situations requiring a non-standard decision the recommendations for which could hardly be found in the guidelines available, if at all. This article describes the technique and immediate results of an operation making it possible to simultaneously carry out revascularization of the myocardium and lower limbs in patients diagnosed as having a critical coronary lesion and Leriche syndrome with no intervention on the abdominal portion of the aorta. Also given is a detailed description of the technique of performing ascending aorta-bilateral femoral arteries bypass combined with coronary artery bypass grafting. Also presented herein are the data from publications having described this operation previously. Our article for the first time demonstrates the findings of intraoperative flowmetry, proving the leading role of the internal thoracic arteries for collateral blood supply of lower limbs in occlusion of the terminal portion of the aorta. This test lays a pathophysiological foundation for the necessity of a simultaneous intervention on the vessels of two basins.

[Flowmetric and angiographic predictors of occlusion of coronary bypass grafts]. / Floumetricheskie i angiograficheskie prediktory okkliuzii koronarnykh shuntov.

OBJECTIVE: The study was aimed at assessing remote (up to 42 months) results of coronary artery bypass grafting (CABG) and revealing flowmetric and angiographic predictors of coronary bypass graft occlusion. PATIENTS AND METHODS: Our retrospective single-centre study included a total of 141 patients undergoing coronary artery bypass grafting (CABG). All patients were subjected to assessment of coronary bypass grafts by means of transit-time flowmetry (TTFM), as well as angiographic control of coronary bypass grafts in the remote period. The duration of follow up amounted to 42 months. We performed flowmetric assessment of blood flow by the following parameters: mean volumetric blood flow velocity (Qmean), peripheral resistance (PR), as well as studied angiographic parameters such as: the degree of proximal stenosis of the bypassed coronary artery (CA), the diameter of the bypassed CA. Competence of bypass grafts after carried out coronaroshuntography (CSG) was determined according to the classification of Fitzgibbon. RESULTS: We performed flowmetric and angiographic assessment of 235 autoarterial and 117 autovenous bypass grafts. During the follow-up period of up to 42 months we revealed 33 (14%) occluded arterial conduits and 30 (25.6%) venous ones. The Kaplan-Meier analysis demonstrated that the probability of the lack of occlusions of venous grafts amounted to 74.4±5.8%, with that of arterial grafts equalling 86±3.3%, i. e. during the follow-up period of up to 42 months, the probability of occlusion of venous grafts was reliably higher than that of arterial ones (Log Rank=0.006). The Cox regression analysis made it possible to reveal that occlusion of grafts was influenced by an increase in the peripheral resistance index (p=0.033, HR=1.374), a decrease of volumetric blood flow velocity in the graft (Qmean) (p=0.005; HR=0.981), and by the type of the graft (venous) (p=0.001; HR=2.587). CONCLUSIONS: 1) arterial grafts appeared to yield better results of myocardial revascularisation within the terms up to 42 months as compared with venous coronary artery bypass grafting; 2) using a vein increases the risk for the development of graft occlusion 2.5-fold each month after the operation; 3) an increase in the peripheral resistance index (PR) by 1 unit elevates the risk of occlusion of the coronary graft 1.3-fold with each month after the operation; 4) a decrease in the volumetric blood flow velocity (Q) by 1 ml leads to an increase in the risk of graft occlusion by 2% with each month after the operation.

[Risk factors for the development of life-threatening ventricular arrhythmias following surgical reconstruction of the left ventricle]. / Faktory riska vozniknoveniia zhizneugrozhaiushchikh zheludochkovykh aritmii posle khirurgicheskoi rekonstruktsii levogo zheludochka.

Death in patients with postinfarction aneurysms of the left ventricle (LV) is mainly caused by life-threatening ventricular arrhythmias - ventricular tachycardias (VTs) and ventricular fibrillations (VFs). Surgical reconstruction of the LV may potentially lead to disruption of the re-entry mechanism, lying at the basis of ventricular tachyarrhythmias. A series of authors demonstrated high efficacy of such procedures as endocardectomy and radiofrequency ablation of the borderline zone of the LV. But high incidence of relapses, difficulty detecting the localization of VT and performing radiofrequency ablation (RFA), as well as high incidence of spontaneous and induced VTs in patients with postinfarction aneurysms of the LV have preserved dissatisfaction with the currently existing techniques. The findings of several large studies have shown that placing an implantable cardioverter-defibrillator (ICD) makes it possible to prevent sudden cardiac death and improve the survival rate in patients with ischaemic cardiomyopathy. However, those studies did not include patients with less than 2-3 months having elapsed after the open operation. In order to determine optimal terms of implantation of ICDs and to reveal independent predictors of an ICD's triggering after surgical reconstruction of the LV we carried out a retrospective study of the outcomes of operative treatment of 84 patients divided into two groups: Group One comprised 63 patients found to have neither VFs nor VTs registered according to the findings of follow-up and Group Two included 21 patients with an ICD's triggering registered. We assessed the medium-term survival, the time and frequency of ICDs' triggering, as well as risk factors for onset of VF and VT.

[Myocardial protection during left-ventricular reconstruction in patients with an ejection fraction below 30]. / Zashchita miokarda pri rekonstruktsii levogo zheludochka u bol'nykh s fraktsiei vybrosa menee 30.

Surgical reconstruction of the left ventricle is an effective method of treatment for ischaemic cardiomyopathy. One of the conditions of successful intervention is correctly choosing a method of intraoperative myocardial protection. Currently, two techniques of myocardial protection are used: cardioplegic cardiac arrest and continuous myocardial perfusion on the beating heart. A series of experimental studies demonstrated that myocardial oxygen requirements in ischaemic cardiomyopathy during permanent perfusion are three times higher than during cardioplegic cardiac arrest. However, the technique of continuous myocardial perfusion in conditions of the beating heart makes it possible to prevent ischaemia of the most sensitive subendocardial layers of the myocardium. In order to determine optimal strategy of myocardial protection during surgical reconstruction of the left ventricle we retrospectively assessed therapeutic outcomes in a total of 136 patients presenting with ischaemic cardiomyopathy, an ejection fraction below 30%, and an end-systolic volume index of more than 100 ml/m2. The patients were divided into two groups: group 1 (n=44) subjected to reconstruction of the left ventricle performed on the beating heart and group 2 (n=92) undergoing surgery in conditions of cardioplegic cardiac arrest. We examined early and medium-term clinical and echocardiographic results (30-day mortality, postoperative complications, medium-term survival, and probability of the development of major adverse cardiac and cerebrovascular events (MACCE)). It was determined that short- and medium-term clinical and echocardiographic results of surgical reconstruction of the left ventricle in patients with an ejection fraction less than 30% do not depend on the method of myocardial protection (continuous myocardial perfusion in conditions of the beating heart or crystalloid cardioplegia).

[Autotransplantation of the internal carotid artery in patients with high localization of an atherosclerotic plaque]. / Autotransplantatsiia vnutrennei sonnoi arterii u patsientov s vysokim rasprostraneniem ateroskleroticheskoi bliashki.

Acute and chronic cerebral circulatory impairment is a very commonly encountered type of neurological diseases, annually affecting more than six million people worldwide. The absolute majority of all cases are associated with atherosclerosis of cerebral arteries. Surgical intervention in a stenotic lesion of the internal carotid artery (ICA) is a method of preventive treatment with confirmed efficacy. Eversion carotid endarterectomy (ECEA) is currently the most commonly used 'open' operation for this cohort of patients. It is connected with relative technical simplicity of the operative procedure, no foreign material in the wound, low risk of haemodynamic disorders in the zone of reconstruction owing to no considerable alteration in the ICA diameter, as well as favourable remote results. A disadvantage of ECEA is lack of visual control above the distal portion of the ICA and, as a consequence, limited application of the technique in cases of a highly located atherosclerotic plaque (by more than 2 cm above the bifurcation). Specialists of the Federal Centre of Cardiovascular Surgery in the city of Penza worked out a modification of the operative technique making it possible to widen the indications for using ECEA. Its essence consists in total resection of the stenosed portion of the ICA, performing eversion endarterectomy outside the wound, followed by reimplantation thereof with the help of two 'end-to-end' anastomoses, as during prosthetic repair. This technique was called autotransplantation of the ICA. Advantages of this technique are considered to include precision of removing the plaque and intimal ruptured fragments, which is easier and more convenient to achieve outside the wound; reliable fixation of the intima and non-stenosing residuals of the plaque by a distal anastomosis, as well as a possibility of using this technique in cases of high location of the plaque. The purpose of this study was to compare the immediate results_outcomes of ECEA and autotransplantation of the ICA in two groups comprising 108 and 72 patients, respectively. The measures assessed included the mean time of ICA cross-clamping during surgery, frequency of the development of perioperative strokes, haemorrhage, lesions of craniocerebral nerves, wound complications.

[Prevention of wound infection in cardiac surgery: how much is topical use of antibiotics justified?].

The authors studied efficacy of preventing wound infection of a sternotomic wound with and without conventional use of topical antibiotics, also determining predictors of the development of infectious complications after cardiosurgical interventions. Our retrospective study included a total of 1,593 patients subdivided into two groups. In Group One patients (n=951) sternal infection was prevented according to the P. Vogt technique; Group two patients (n=642) were also subjected to the same methodology, but with the exception of topical use of antibiotics. By the frequency of re-sternotomies performed, cases of superficial and deep wound infection, as well as by the average duration of operation, hospital and ICU stay there were no statistically significant differences between the groups (p<0.05). The average cost of antibacterial agents as calculated per one patient in Group One turned out substantially higher than in Group Two (amounting to 8.1±3.9 and 3.3±1.4 thousand roubles, respectively, p<0.001). Analysing possible predictors of the risk for the development of wound infection showed that the body mass index, duration of the operation, and performing re-sternotomy exerted a statistically significant influence on probability of infections complications. It was determined that using the methodology of preventing sternal infection with topical application of antibiotics led to predominance of Gram-negative flora in the wound discharge (p=0.02). Exclusion of topical use of antibiotics does not lead to an increase in the incidence rate of wound complications (p=0.78) and normalizes the ratio of Gram-negative and Gram-positive strains.

[Aorta-associated complications after prosthetic repair of the aortic valve].

The authors analyzed dependence between the presence of preoperative predictors of aorta-associated complications and risk for the development of these complications in the remote period after prosthetic repair of the aortic valve. The study included a total of 231 patients subjected to aortic valve prosthetic repair with no additional intervention on the root and ascending portion of the aorta. The follow up duration varied from 12 to 62 months. As predictors of the development of aorta-associated complications we examined such factors as the bicuspid structure of the aortic valve, dilatation of the aortic ascending portion relative to the upper border of the individually calculated norm, disordered configuration of the complex "aortic root - ascending portion of the aorta", resistant arterial hypertension, diabetes mellitus. Depending on the number of predictors for the development of aorta-associated complications the patients were subdivided into 2 groups: Group One consisting of 105 patients with two and more predictors of the development of aorta-associated complications, and Group Two comprising 126 patients with not more than one predictor of the development of aorta-associated complications. It was determined that in the first group of patients the total number of aorta-associated complications in the remote period after prosthetic repair of the aortic valve amounted to 25.7% (27 of 105 patients). The total number of aorta-associated complications in the second group amounted to 1.6% (2 of 126 patients). All detected aorta-associated complications were divided into "critical" and "noncritical". The critical complications were those the detection of which required performing a second operation in the patient: formation of an ascending aortic aneurysm and type A aortic dissection. To the "noncritical" aorta-associated complications belonged dilatation of the ascending portion of the aorta progressing at a rate of 2 mm/year. Resulting from the performed study it was determined that each specific of the examined predictors exerted no influence on the risk for the development of aorta-associated complications in the remote period after prosthetic repair of the aortic valve (p>0.05). Any combination of two and more predictors in one patient considerably increased the risk for the development of complications (p<0.001). A conclusion was made that revealing two and more predictors of the development of aorta-associated complications in one patient it is appropriate to perform a simultaneous operation of prosthetic repair of the aortic valve and the ascending aortic portion.

[Comparative analysis of the results of using the method of elimination of sternal infection and standard methodology of cardiosurgical operations].

Postoperative mediastinitis belongs to one of the severest complications of cardiosurgical operations. There have been suggested many methods of pre- and intraoperative prevention of sternal infection. Summarizing the obtained experience, in 2006 specialists of the EurAsia Heart Foundation under the leadership of Professor P. Vogt (Im Park Clinic, Zurich, Switzerland) elaborated and suggested a methodology of eliminating sternal infection, which according to the author s opinion made it possible to decrease the frequency of the development of sternal infection from 5.6 to 0%. This methodology was implemented at the Federal Centre of Cardiovascular Surgery (city of Penza) in July 2012, thus leading to a decrease in the rate of wound complications from 4.05 to 0.3%.

[Risk factors and causes of hospital mortality after Bentall-deBono's surgery].

It was done an evaluation of surgical treatment results of 71 patients with aortic arch aneurysm and aortic insufficiency, who were operated routinely. According to data of correlation and multiple regression analysis, chronic obstructive pulmonary disease and kidney disease before operation are significant factors predisposing to death in postoperative period. The authors consider that normalization of lungs and kidneys function before operation improves surgical treatment results in patients of this group.

[Ultrasonic doppler flowmetry in intraoperative diagnosis of coronary bypass grafts incompetence].

According to the findings of many authors, occlusion of bypass grafts may develop as early as during surgery in 4-12% of patients. At discharge from hospital this index may reach 5-20%, increasing to 30% within the first year. Incompetence of bypass grafts is in many cases a consequence of errors in surgical technique and may therefore be decreased by means of improving the control over quality of coronary bypass grafting. Using the method of ultrasound Doppler flowmetry in the conditions of artificial circulation and clamped artery, we assessed a total of 64 composite bypass grafts. Blood flow was assessed by such parameters as the pulsatility index (PI), mean volumetric blood flow velocity (Qmean), and percentage of diastolic volumetric filling (DF). The obtained results were statistically processed. The mean values of blood flow parameters were obtained, followed by determining dependence between peripheral resistance (PI) prior to removal of the clamp from the aorta and peripheral resistance (PI) measured after termination of extracorporeal circulation.

[The version of the Bentall-DeBono operation].

The Bentall-DeBono operation was proposed in 1968. It is the «gold standard" of the aneurysm treatment of the ascending aorta and aortic insufficiency nevertheless this technique is fraught with a number of possible postoperative complications. We have proposed an improved method: two short (10 mm) jaws and «skirt"« formed from the distal portion of the prosthesis were sewed to valved conduit. 19 operations were done by the proposed method in all. The control group included 73 patients who had operation according to the standard technique. Duration of extracorporeal circulation, myocardial ischemia, blood loss were the following: 145.4±54.4 and 117.4±40.9 min; 106.4±30.2 and 77.5±22.5 min; 473±355 and 1853±940 ml respectively. The mortality rate was 5.2% and 10.9% respectively. Our experience shows the technical simplicity of the procedure and satisfactory postoperative results.

[Comparative study of the results of using stagewise open interventions and single-step hybrid operations in patients with coronary artery disease accompanied by lesions of carotid arteries].

The authors describe herein the technique of a hybrid single-stage intervention performed in patients presenting with coronary artery disease (CAD) combined with carotid artery atherosclerosis, as well as comparing the outcomes of using similar operations with the results of stagewise open interventions within a 30-day postoperative period. High risk for the development of severe and not uncommonly fatal complications both in the carotid basin and coronary bed determines difficulty of therapeutic decision-making regarding this patient cohort. This problem has been the subject of study and discussion in both Russian and foreign literature for more than two decades. However, none of the currently existing techniques has yet been accepted as an optimal one. The hybrid approach is a relatively novel technique, with the number of publications describing its application being only sporadic. The present article demonstrates significantly better immediate results of using the hybrid technique, thus suggesting that it may well be considered as an alternative to the classical approaches, requiring however further studies.

[Intraoperative assessment of composite bypass grafts by means of ultrasonic Doppler flowmetry].

The use of the both internal thoracic arteries while forming a composite bypass graft has been suggested as a method making it possible to carry out total myocardial revascularization. However, controversial still remain the problem of the distribution of blood in these bypass grafts, as well as that concerning T-grafts' capability of providing the sufficient blood inflow to the basin of the coronary arteries being bypassed. The method of ultrasonic Doppler flowmetry was used to perform the intraoperative assessment of 59 composite bypass grafts along such parameters as the pulsatility index (PI), mean volume blood flow velocity (Qmean), and percentage of diastolic volumetric filling (DF). The obtained findings were statistically processed making it possible to obtain the average parameters of blood flow for the composite bypass grafts and their branches. A dependence was established between blood flow distribution in the composite conduit and the degree of the lesion of the artery being bypassed.

[Single-stage correction of aortic coarctation combined with an aneurysm of the ascending portion of the aorta and/or intracardiac pathology in adults].

OBJECTIVE: the work was aimed at substantiating and studying the outcomes of single-stage correction of aortic coarctation combined with an aneurysm of the ascending portion of the aorta and/or intracardiac pathology in adult patients. MATERIAL AND METHODS: From August 2009 to September 2012, a total of nine patients were operated on for aortic coarctation combined with an aneurysm of the ascending portion of the aorta and/or intracardiac pathology. The patient s average age amounted to 35.6±15 years. The risk median according to the Euroscore scale equalled 9.35 % (7 points). Aortic coarctation was corrected by means of ascending-to-descending bypass grafting of the aorta, simultaneously accompanied by prosthetic repair of the ascending portion of the aorta and/or correction of cardiac pathology from the median sternotomy approach. RESULTS: The mean duration of artificial circulation amounted to 178.7±25.5 min, with that of myocardial ischaemia equalling 133.7±29.4 min. The average volume of blood loss was 616.6±325 min. The postoperative follow-up period ranged from two months to three years. No lethal outcomes were observed. The clinical manifestation of hypertension regressed in all patients. There were no cases of either dislocation of the ascending-descending bypass graft or compression of the surrounding formations thereby. CONCLUSION: The presented technique of single-stage surgical correction of aortic coarctation combined with an aneurysm of the ascending aorta and/or intracardiac pathology in adult patients makes it possible to perform all technical manipulations during a single-step surgical intervention from one approach, i. e. sternotomy. Placing the aorto-aortic graft behind the inferior vena cava toward the front of the right pulmonary veins makes it possible to minimize the risks associated with an extra-anatomical position of the prosthesis.