[Vasculopathy of the grafted heart: the synergism of proinflammatory and proatherogenous factors and viral infection].

The authors analyze the pathogenetic significance of hyperhomocysteinemia, antiphospholipid syndrome, the hyperexpression of cell adhesion molecules, inflammation, and oxidative disorders for, as well as the role of viral infections in the development of coronary artery disease of the grafted heart. The paper shows that viral infections in recipients lead to the development of proinflammatory, proatherogenous, and prothrombogenous status, expressing themselves in an increase in the corresponding laboratory markers in recipients' blood plasma, and points out the role of viral infection in the pathogenesis of coronary artery disease of the transplanted heart. Control and treatment of viral infections, as well as pharmacocorrection of proinflammatory, proatherogenous, and prothrombogenous status would made it possible to influence the development of coronary artery disease of the grafted heart.

[The peculiarities of bone exchange disorder and its regulation in men after long terms following orthotopic heart transplantation and cadaveric kidney transplantation].

The study found bone exchange disorder manifested by accelerated bone resorption, retarded bone formation, and the loss of the bone mineral density (BMD) of the axial and peripheral skeleton in 19 men (39 observations) 66 +/- 44 months following orthotopic heart transplantation (OTHT) and in 92 men 45 +/- 28 months after cadaveric kidney transplantation. An accelerated bone resorption, more pronounced in cadaveric kidney (CK) recipients, is associated with hyperparathyroidism (HPT) and renal dysfunction, while bone formation retardation is associated with a decrease in insulin-like growth factor-1 level. An increase in osteoprotegerin level is of compensatory character. The prominence of HPT depends on the degree of renal dysfunction; in CK recipients it also depends on the degree of the reduction in the levels of biologically active testosterone and estradiol. Reduction in BMD of the peripheral skeleton after OTHT are associated with the degree of renal dysfunction and a decrease in free testosterone index; after CK transplantation it is associated with HPT, the cumulative dose of glucocorticoids, reduction in the levels of biologically active testosterone and estradiol, as well as sex-hormone binding globulin (SHBG); reduction in spine BMD is only associated with SHBG.

[Indicators of bicycle ergometry after heart transplantation]. / Pokazateli veloérgometrii u bol'nykh posle transplantatsii serdtsa.

Exercise tolerance in postcardiac transplantation patients versus healthy controls was studied at different intervals after the surgery using bicycle ergometry. Being low after the transplantation, exercise tolerance in the patients increased throughout the rehabilitation period but still did not reach the values characteristic for healthy subjects. Initial heart rate in the above patients was higher, while chronotropic and inotropic reserves of the transplanted heart appeared lower than in the controls. The data obtained help objectively assess the condition of the patients with transplanted heart.

[The dynamics of the heart contraction rate and arterial pressure during physical loading after a heart transplant]. / Dinamika chastoty serdechnykh sokrashchenii i arterial'nogo davleniia pri fizicheskoi nagruzke posle transplantatsii serdtsa.

Compared to healthy controls, patients with transplanted heart have higher baseline heart rate (HR), delayed initial HR reaction, slower changes of HR both during exercise and after it, diminished chronotropic and inotropic reserves. The data obtained contribute to better understanding of physiology of transplanted denervated heart and objective assessment of patients after heart transplantation.

[Anesthesiological management in transplantation of the heart after temporary mechanical substitution of its function]. / Anesteziologicheskoe obespechenie transplantatsii serdtsa posle vremennogo mekhanicheskogo zameshcheniia ego funktsii.

The first experience of anesthesiological management of three two-step orthotopic heart transplantations is reviewed. As the first step of surgical treatment one recipient was implanted an artificial heart "POISK-IOM" (Russia), in 2 other patients left ventricular bypass was achieved using a "Biopump" ("Biomedics", USA). Anesthesia techniques, methods of infusion-transfusion therapy, and other components of intraoperative management are described. Hemodynamics, donor heart function recovery, and other homeostasis parameters have been analysed. It has been noted that high doses of fentanyl in combination with ketamine and diazepam ensured satisfactory course of general anesthesia. There were no cases of intraoperative lethality. A more complex aspect of anesthesiological management was correction of various homeostasis disturbances which progressed during surgery in patients with left ventricular bypass. In two cases the intraoperative period was characterized by the onset of multiorgan failure (heart, respiratory, renal failure, metabolic disorders, coagulopathy), which played a negative part for the postoperative period of heart transplantations. It is concluded that prediction of possible complications during temporary mechanical replacement of the cardiac function and timely determination of contraindications for the second step of two-step heart transplantations are the most important trends of investigations for anesthesiologists, intensive care specialists, and transplantologists.

[The hemodynamics of the lesser circulation before and after heart transplantation in patients with dilated cardiomyopathy]. / Gemodunamika malogo kruga krovoobrashcheniia do i posle transplantatsii serdtsa u bol'nykh s dilatatsionnoi kardiomiopatiei.

Studies of the lesser circulation hemodynamics in 150 patients with dilatation cardiomyopathy and in 15 after heart transplantation revealed secondary postcapillary pulmonary hypertension of more than 60 mm Hg in cases with dilatation cardiomyopathy with systolic pressure in the pulmonary artery (SPPA) in 30% of patients, transpulmonary gradient (TPG) of more than 15 mm Hg and pulmonary vascular resistance (PVR) or more than 4 Wood's U in 15.3% of patients. Two stages of pulmonary hypertension in dilatation cardiomyopathy should be singled out: I with SPPA of 60 mm Hg, TPG of 15 mm Hg, and PVR of less than 4 Wood's U, and II with SPPA of more than 60 mm Hg, TPG of more than 15 mm Hg, and PVR of more than 4 Wood's U. Orthotopic transplantation of the heart is indicated for patients with Stage I pulmonary hypertension. For patients with Stage II condition prolonged inotropic and vasodilator therapy is necessary, and if it fails, heterotopic transplantation of the heart or transplantation of the heart and lungs should be resorted to. The basic characteristics of the lesser circulation reflecting the reversibility of pulmonary circulation disorders are SPPA, TPG, and PVR. Failure of prolonged inotropic vasodilator therapy may be indicative of irreversible injury to pulmonary vessels. Lesser circulation hemodynamics usually normalizes a month after heart transplantation. If TPG is less than 15 mm Hg and PVR less than 2 Wood's U, the incidence of reversible posttransplantation right-ventricular insufficiency depends on SPPA pretransplantation level. Mortality because of right-ventricular insufficiency was 8.33%. One-year survival after heart transplantation is related to preoperative TPG and PVR values.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic diagnosis of acute rejection of transplanted heart]. / Ekhokardiograficheskaia diagnostika ostrogo ottorzheniia peresazhennogo serdtsa.

Comparing echocardiographic parameters with endomyocardial biopsy findings in 6 patients with acute crises of mild, moderate, and severe graft rejections and in 2 patients with persistent acute rejection crisis has shown that there are decreases in end-diastolic size and left ventricular end-diastolic ejection fraction volume, an increase in left ventricular myocardial mass, and thickening of the left ventricular posterior wall and ventricular septum, as evidenced by ultrasonic study. Such changes are detected in moderate and severe acute crises of graft rejection. Normalization of ultrasonic parameters of the grafted heart occurs 2-3 weeks after abolition of rejection crisis. A positive dynamics of echocardiographic parameters in persistent acute rejection crises suggests a good prognosis. Echocardiographic monitoring data obtained in the outpatient setting may serve an indication for unplanned endomyocardial biopsy.

[Morphohistochemical characteristics of heart myocardiocytes under profound donor hypothermia]. / Morfogistokhimicheskaia kharakteristika miokardiotsitov serdtsa pri glubokoi gipotermii donora.

Hearts of 52 pups were studied histochemically and electron-microscopically at various stages of total-body hypothermia. The dependence of the myocardiocyte metabolic alterations on the factors acting in the myocardium during different stages of hypothermia and during subsequent warming is shown. The vitality of the cooled heart is largely determined by retaining not only of its function, but by its anatomo-physiological links with the organism. The method of the profound hypothermia of the donor organism is, according to the authors, one of the ways to sustain the donor heart vitality before transplantation.

[Immunopathologic study of the myocardium in dilated cardiomyopathy]. / Immunopatologicheskoe issledovanie miokarda pri diliatatsionnoi kardiomiopatii.

Myocardial tissues of patients with dilated cardiomyopathy were studied by immunofluorescence. While immunoglobulin A fixation was observed in myocardial capillary wall and cardiomyocyte sarcolemma in the majority of patients (11 of 12), immunoglobulin G and C3 complement component were a rare finding. In the vessel wall of heart allografts immunoglobulin A fixation occurred 3-6 days after transplantation. As a result of the intensive immunosuppressive therapy which was used after the operation immunoglobulin A disappeared from heart allografts within 4-5 weeks. Immunoglobulin A fixation in the heart of patients with dilated cardiomyopathy is attributed to the anti-tissue or antivirus antibodies and probably is involved in the development of this disease.

[Surgical tactics in patients with ischemic heart disease, extensive cicatricial myocardial lesions and circulatory insufficiency]. / Khirurgicheskaia taktika u bol'nykh ishemicheskoi bolezn'iu serdtsa s obshirnymi rubtsovymi porazheniiami miokarda i nedostatochnost'iu krovoobrashcheniia.

The article discusses the results of surgical treatment of patients suffering from ischemic heart disease with extensive cicatricial affections of the myocardium and circulatory insufficiency. Thirteen patients of group I were treated by various reconstructive operations (resection of an aneurysm, formation of an aortocoronary shunt, septoplasty), 10 patients of group 2 underwent orthotopic heart transplantation. Perioperative and long-term (up to 3 years) mortality rates were, respectively, 7.6 and 8% in group I and, respectively, 30% and zero in group 2. The unfavorable prognosis of survival and medicamentous therapy in such patients, the lack of donors, and the acceptable results of reconstructive operations are evidence that they should be undertaken whenever possible. The main criteria of the selection of patients for a reconstructive operation are the values of regional contractility of the left ventricle, the severity of the dystrophic processes in the preserved segments, and the condition of the coronary arteries.

[Arrhythmia in patients after heart transplantation]. / Narusheniia ritma u bol'nykh posle transplantatsii serdtsa.

Holter monitoring was performed in 15 patients surviving over 3 months after homotopic cardiac transplantation. The frequency and types of arrhythmias occurring in the grafted innervated heart were studied according to its postoperative period duration. The follow-up lasted 3 to 29 months. Supraventricular arrhythmias were detected in 80%, whereas ventricular ones were found in 86.7%. Ventricular arrhythmias accompanied chronic graft rejection in 2 patients. It was ascertained that Holter monitoring was of greater diagnostic value than routine ECG recording. Innervation is not essential in the occurrence of cardiac arrhythmias.

[Infectious complications following heart transplantation]. / Infektsionnye oslozhneniia posle transplantatsii serdtsa.

The work analyses infectious complications after 35 orthotopic transplantations of the heart. The infectious complications are divided into 2 groups. Group 1 consisted of 6 patients with local complications. Group 2 was made up of 8 patients who died from bacterial infectious complications (mediastinitis 3, sepsis 2), from miliary tuberculosis of the lungs 1, cytomegaloviral infection 1, and systemic candidiasis 1.

[Chronic rejection of a transplanted heart]. / Khronicheskoe ottorzhenie peresazhennogo serdtsa.

Three cases of chronic rejection occurring 7.5, 10, and 24 months after transplantation of the heart are analysed. The clinical features of chronic rejection in the late-term periods after transplantation of the heart are discussed. The problems of clinical diagnosis of chronic rejection, the role of endomyocardial biopsy and disorders of lipid metabolism are dealt with. Tactics of saving the patient are recommended. The authors substantiate the necessity for heart retransplantation and, in the absence of a donor's heart, for two-stage transplantation of the heart through an artificial heart or a biventricular approach by means of artificial heart ventricles.

[Clinical use of artificial heart ventricles]. / Klinicheskoe primenenie iskusstvennykh zheludochkov serdtsa.

The article discusses the results of applying for the first time Soviet-made "Modul" and "Yasen" artificial ventricles of the heart (AVH) in a left ventricular bypass regimen in patients with refractory cardiac insufficiency. Improvement of AVH design and rational tactics of attendant drug therapy allowed the period of the safe application of the AVH in the organism to be increased to more than 8 days.

[The first clinical experience with heart transplantation]. / Pervyi klinicheskii opyt transplantatsii serdtsa.

The article analyses the first clinical experience in orthotopic allotransplantation of the heart at the Scientific Research Institute of Transplantology and Artificial Organs, USSR Ministry of Health, in the period from October, 1986 to July, 1989 (26 transplantations of the heart and one two-stage transplantation of the heart with the use of "Poisk-10M" artificial heart for 3.5 days in the first stage). Eleven patients are alive. Follow-up periods: maximum over 2.5 years, minimum 3 months. Sixteen patients died in different periods (up to 12 months). Three-component therapy (cyclosporine A, methylprednisolone, azathioprine) was applied for immunosuppression. The authors analyse the problems of the selection of potential recipients (indications and contraindications) and donor, the optimum surgical techniques, complications of immunosuppressive therapy, and infectious complications. The first clinical experience in two-stage transplantation of the heart is analysed. The first experience in transplantation of the heart in patients allows the conclusion that the use of this method for the management of the terminal stage of congestive cardiac insufficiency is a reality.

[Heart transplantation. The current problems of patient selection, examination and treatment]. / Transplantatsiia serdtsa. Aktual'nye voprosy otbora, obsledovaniia i lecheniia bol'nykh.

An analysis was made of the work carried out by the Department of Coronary Surgery and Heart Transplantation as regards heart transplantations during 1988. As many as 119 patients, hypothetical heart recipients, received medical advice. The Department refused hospitalization to 42 patients because of the nonconformity to the indications and contraindications to heart transplantation. 77 patients were admitted to the Department. During examinations and treatment, 53 persons were discharged from hospital. 8 patients died before donor's hearts were received. Donor's hearts were transplanted to 10 patients. 3 persons died from severe infectious complications on days 12, 15 and 43 after the operation. Following the operation 7 patients have been surviving from 4 to 17 months. The patients' status remains satisfactory. The functional parameters of the donor's heart are within normal. Taking into consideration the lack of the treatment methods for patients with terminal heart lesions, it is necessary that the number of operations be increased. A great importance in this case is attached to the joint efforts of internists and cardiologists, aimed at the screening and examination of potential heart recipients.

[Extracorporeal methods of blood purification in cardiovascular diseases]. / Ekstrakorporal'nye metody ochishcheniia krovi pri serdechno-sosudistykh zabolevaniiakh.

Increasing sensitivity to drugs, elimination of endotoxicosis, recovery of normal homeostatic control after hemocarboperfusion help to break off the vicious circles associated with severe cardiovascular disorders, and improve the effect of subsequent medication. Hemocarboperfusion added to combined intensive care and resuscitation procedures was associated with a 82.9% success rate.