[LEVOSIMENDAN--THE FIRST 10 YEARS IN CLINICAL PRACTICE].

The article deals with a survey of the main pharmacological effects of levosimendane. Special attention is paid to cardiac and organ protective properties of the medication. The article reviews literature data on the efficacy of levosimendan in various fields of medicine and in the experiment and highlights the problem of heart failure and low cardiac output syndrome treatment in cardiology and cardiac surgery.

[Cases of successful treatment of heart failure after cardiac surgeries].

UNLABELLED: Low cardiac output syndrome (LCOS) is a leader in the structure of complications and mortality in patients after cardiac and vessels surgery. LCOS causes circulatory hypoxia. Opportunity to use of new inotropic drug draws attention of anaesthesiologists, and ICU physicians of cardio-surgical centers. Levosimendan (SIMDAX, Orion Farmina, Finland) is a only calcium sensitiser, pyridazinone-dinitrile derivative with additional action on adenosine triphosphate (ATP)-sensitive potassium channels. Most important effects are increasing of contractile ability of the heart and veins dilatation both to arteries. MATERIALS AND METHODS: Two patients with mitral heart disease were included in the study. The patients undergone mitral valve replacement (MVR) complicated with LCOS. The original condition of the first patient was critical. Purposes of the patient's hospitalization were haemodialysis and intensive care. Diuresis of the patient resumed after the haemodialysis. However heart failure increased and the patient received an urgent mitral valve replacement. Levosimendan infusion was started in order the low cardiac output. The second patient had a critical reduction of the left ventricular ejection fraction (LVEF) after MVR. Levosimendan infusion was repeated in 3 days. In both cases Levosimendan use had positive effect on LVEF, haemodynamics and the duration of artificial lung ventilation and stay in the ICU.

[The initial period in the formation of cardiac resuscitation service at the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences (1948-1973)].

The paper describes and analyzes the initial period in the formation of cardiac resuscitation service at the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, from the first heart operation performed in the USSR to the setting up of the resuscitation-anesthesiology department. On September 24, 1948, A. N. Bakulev was the first in the USSR to make an operation for congenital heart disease, the successful outcome of which predetermined anesthetic maintenance and antishock measures as well. On May 1959, the Institute of Thoracic Surgery, U.S.S.R. Academy of Medical Sciences, began performing heart operations under extracorporeal circulation. The number of postoperative complications has increased due to the higher severity of diseases and the complexity of open heart surgery. This has made the rehabilitative period require that vital function recovery specialists should participate more frequently (Smirenskaya Ye. M.), which ultimately give birth to a resuscitation department in January 1967 (Levant A. D.) and its transformation to a resuscitation-anesthesiology department on October 31, 1973 (Malyshev V. D.).

[Intensive care for newborns and babies of the first year of life with acute heart failure after cardiosurgical interventions].

After cardiosurgical interventions, the incidence of low cardiac output syndrome (LCOS) is 3-10% depending on age and surgery. The basis for management of patients with LCOS and high pulmonary hypertension is to maintain low total peripheral vascular resistance and to exclude volume overload. Due to the fact that the Russian Federation lacked phosphodiesterase (PDE) III inhibitors that are basic intensive care drugs in pediatric surgery in the West, levosimendan was used as an inodilator in the complex intensive care for postoperative LCOS in 75 infants aged 3 days to 2 years 10 months in October to December 2007. Before drug infusion, left ventricular ejection fraction (LVEF) varied from 17 to 29% (21 +/- 7%), left atrial pressure (LAP) was 25 +/- 2.82 (16-30 mm Hg). During levosimendan administration, the authors analyzed the following hemodynamic parameters: rate, blood pressure, central venous pressure (CVP), LAP, and LVEF by echocardiography, as well as the frequency of side effects and mortality rates. During levosimendan infusion after transient hypotension at the beginning of the drug administration, following 12 hours there was a significant increment in mean BP from 42 to 53 mm Hg (p < 0.05). Left ventricular (LV) preload changes as a significant reduction in LAP (from 25 to 17 mm Hg; p < 0.05) developed much earlier: 6 hours after initiation of levosimendan administration. During the drug administration, CVP values were unchanged. LVEF significantly rose from 21 to 27% following 12 hours of levosimendan therapy start. The major adverse reaction was a tendency towards systemic hypotension within the first hour of levosimedan infusion requiring bolus injection of 20% albumin in 11 cases and infusion of epinephrine (0.03-0.05 microg/kg/min) in 14 cases. Thus, levosimedan may be used as an inodilator in pediatric cardiosurgery as an alternative to PDE III inhibitors in LCOS after surgical correction for congenital heart disease (CHD), accompanied by LV hypoplasia, after surgical correction of CHD with baseline low LVEF, as well as a basic drug during extracorporeal circulation and after its cessation.

[Diagnosis and correction of thrombohemorrhagic complications in cardiosurgical patients in the early postoperative period].

The methods of the prevention, diagnosis, and correction of hemostatic disorders are discussed in cardiosurgical patients. Prevention of hemorrhages requires hemostatic history data collection that allows identification of patients with concomitant hemophilia and those, taking antithrombotic drugs. The benefits of an extended study of blood coagulation disorders are shown in neonates and babies of the first year of life due to the physiological features of the hemostatic system and the pattern of heart disease. Algorithms are proposed for the diagnosis and treatment of hemorrhagic diathesis in the early postoperative period; a complex of minor signs of surgical hemorrhage is formulated, which makes it possible to timely perform rethoracotomy and to reduce blood transfusion. Efficiency evaluation and exclusion criteria for the use of recombinant factor VIIa are given. The efficiency of using the Russian drug tranexam versus epsilon-aminocapronic acid and aprotinin in the perioperative period was evaluated. The blood coagulative system was monitored in the treatment of disseminated intravascular coagulation in multiple organ dysfunction and sepsis, which promoted the timely use of recombinant human activated protein C and human antithrombin III. A diagnostic and treatment algorithm for replacement therapy of congenital heart disease concurrent with hemophilia A is given.

[The use of assisted circulation in cardiosurgical clinic].

The first experience with the use of different artificial circulation systems for the treatment of critical cardiac insufficiency in A. N. Bakulev Research Centre of Cardiovascular Surgery is described. The authors analyse their efficiency, indications for use, possible causes of complications and fatal outcome.

[Intensive care for newborns and infants after anatomic correction of transposition of great vessels].

A retrospective study was made in 48 babies undergone an arterial switching operation at the Bakulev Research Center of Cardiovascular Surgery in January 2004 to September 2005. Their age at surgery was 5 days to 11 months; body weight, 3.9 +/- 1.1 kg (2.4-8.7 kg). According to the course of a postoperative period, the patients were divided into 2 groups: 1) 28 (58.3%) neonates with simple transposition of great vessels (TGV) and older babies (above 3 weeks of life) with simple TGV; 2) 20 (41.6%) patients with TGV + ventricular septal defect. The postoperative management of all the patients was based on the delayed bringing the sternum together in babies at risk for close mediastinum syndrome, on the reduction in left and right ventricular afterload with the mean blood pressure (BPmean) minimally sufficient to maintain adequate coronary blood flow and diuresis, by using inodilatators and nitric oxide (II) and by limiting the volume of administered fluid. The sternum was primarily brought together in 20 (41.6%) patients, in 13 (27.1%) on day 2. Sternal separation was required in 1 patient from Group 1 on postoperative day 2. The duration of artificial ventilation was 3.3 +/- 5.2 days (0.7-15 days); the length of stay in an intensive care unit was 4.8 +/- 8.2 days (1-20 days). There were 9 (18.7%) deaths. Left ventricular failure, high pulmonary hypertension, and coronary insufficiency were causes of death in 2 (4.8%), 1 (2.4%), and 2 (4.8%) patients, respectively. After arterial switching, the optimum management of patients with low cardiac output is to maintain low peripheral resistance and to restrict preload and to use FDE III inhibitors as the drugs of choice.

[The arsenal of extracorporeal circulation systems in pediatric cardiosurgery].

The paper presents the arsenal of extracorporeal circulation systems used in the surgical treatment congenital cardiac diseases. It provides some experience in using the extracorporeal circulation systems, indications for and contraindications for their use, and a working classification of extracorporeal circulatory techniques. Their methodological features, criteria for the adequate use of extracorcopreal techniques, and the results of their application are described.

[Acute respiratory distress syndrome in pediatric cardiosurgery].

The prognosis in acute respiratory distress syndrome (ARDS) is poor; its mortality is generally 40-60%. The mortality in patients with ARDS is more commonly associated with the sequels of sepsis and multiple organ dysfunction than with respiratory failure although the latest papers on protective ventilation suggest that death in these patients directly results from lung lesion in a number of cases. There have been encouraging data on the reduced mortality rates due to acute lung lesion/ARDS in the past decade. The development and introduction of new technologies of respiratory support, the emergence of new effective treatments for sepsis, and the improvement of general maintenance therapy in patients with ARDS may be a possible explanation for such changes for the best.

[Use of the exogenous surfactant curosurf in combined therapy for acute respiratory failure in children after cardiosurgical interventions].

This study was undertaken to evaluate the effectiveness and safety of use of an exogenous surfactant in combined therapy for acute respiratory failure in children after cardiac surgery. In 2003 to 2004, the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, used Curosurf in 58 infants undergone cardiac surgery. The infants' age ranged from 1 day to 27 months (4.6 +/- 0.75 months); the body weight was 1.1 to 14.8 kg (4.9 +/- 0.69 kg). According to the indications for replacement therapy with Curosurf, all the patients were divided into 4 groups: 1) 19 patients with acute pulmonary lesion syndrome; 2) 12 patients with bilateral pneumonia; 3) 22 infants with recurrent atelectases, and 4) 5 patients with paresis of the cupula of the diaphragm. Group 1 patients receiving the exogenous surfactant showed a significant increase in oxygenation and Cdyn, which allowed a significant reduction in the level of respiratory support. Group 2 patients were found to have similar changes, less pronounced as they were, in gas exchange and the mechanics of respiration. In most patients with recurrent atelectases, a steady-state smoothing-out of the latter could be achieved. In Group 4 patients, the exogenous surfactant did not affect the duration of artificial ventilation. Complications due to the administration of the exogenous surfactant (pneumothorax, short-term blood desaturation) were encountered rarely and readily arrested. As a whole, Curosurf is an effective component of combined intensive therapy for acute respiratory failure in pediatric cardiosurgery.

[Intensive therapy for multiple organ dysfunction in neonatal infants after cardiosurgical interventions].

This study was undertaken to evaluate the efficiency of complex intensive therapy for multiple organ dysfunction syndrome (MODS) after cardiosurgical interventions at the resuscitative and intensive care unit of the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences. In 2003-2004, MODS developed in 70 (37%) of the neonatal infants operated on the heart and vessels. The babies' age ranged from 6 hours of life to 1 month (8.3 +/- 2.1 days of life, their body weight was from 1.7 to 4.1 kg (3.0 +/- 0.49 kg). All the patients were found to have significant renal and respiratory failures. There were more than 4 (4.1 +/- 0.5) failing vital viscera. The use of phosphodiesterase (III) inhibitors in therapy for acute left ventricular insufficiency significantly improved the performance of the left heart whereas nitric oxide inhalation significantly lowered pulmonary pressure in babies with acute right ventricular insufficiency and improved oxygenation in patients with MODS. The efficiency of nitric oxide inhalation in MODS significantly increased when it was used in combination with endotracheal administration of a surfactant and high-frequency oscillatory ventilation. Peritoneal dialysis effectively replaced renal function when acute renal failure (ARF) developed. Nevertheless, the development of ARF in the pattern of MODS is a marker of high mortality (89% in ARF versus 46% in MODS without ARF).

[Experience with rotation of basic antibiotics in intensive care unit of cardiosurgical hospital]. / Opyt rotatsii bazovykh antibiotikov v otfelenii reanimatsii i intensivnoi terapii kardiokhirurgicheskogo statsionara.

Clinical and microbiological efficacies of antibiotic rotation in the intensive care unit of the Hospital were evaluated. The results of the local microbiological monitoring of the profile of the acquired resistance of gramnegative nosocomial pathogens (n = 151) isolated from adult patients with artificial ventilation of the lungs for more than 3 days after the open heart operations (n = 150) were analysed. Three 6-month cycles of cephalosporins rotation in the following order were performed: cefoperazone--ceftazidime--cefepime. The procedure provided a significant decrease in the frequency of infectious complications (7.2 vs. 4.5%, p=0.015). The rotation did not require any increase of the use of reserve antibiotics such as vancomycin and carbapenems. The use of the drugs active against Pseudomonas aeruginosa promoted its eradication in the structure of the nosocomial pathogens in the intensive care unit.

[The effect of long-term UV radiation exposure on the skin autonomous microflora and on body nonspecific resistance]. / Vliianie dlitel'nogo vozdeistviia UF-izlucheniia na automikrofloru kozhi i nespetsificheskuiu rezistentnost' organizma.

Hairless mice of strain HRS were exposed to vertical UV-B-irradiation (280-320 nm) at daily doses of 1 or 2 kJ/m2 (biologically effective doses 200 and 400 J/m2) five days a week for 13 and 6 weeks. As the length of exposure increased, the abundance of automicroflora of the dorsal skin first decreased, then exceeded the control value, was normalized, and remained at the normal level until the end of the experiment. The rates of effect appearance and disappearance, just as its amplitude, increased with the daily doses. No changes were found in resistance to staphylococcal alpha-toxin after its post-irradiation intraperitoneal injection.

[Anatomic correction of transposition of the great arteries in infants:experience of the first 10 operations]. / Anatomicheskaia korrektsiia transpozitsii magistral'nykh arterii u grudnykh detei: opyt pervykh 10 operatsii.

In the period March 1992 to January 1993, ten patients with transposition of great arteries (TGV) whose age ranged from 9 days to 8 months and body weight 3.2 to 7.2 kg were operated on using the arterial switch. A single-stage anatomic correction was made in 2 patients with patent arterial duct, 4 with ventricular septal defect (VSD), one with multiple VSD. Three patients with common TGA underwent correction in 2 stages: arterial switch followed prior constriction of the pulmonary artery switch followed prior constriction of the pulmonary artery and subclavian-pulmonary anastomosis. In all cases of single VSD, it was closed with a flap made from the Gore-Tex material. In the whole series of operations, 2 patients died: one being on the operating table due to anesthesiological errors, the other due to coronary blood flow disorder 3 hours after surgery. Six of the 8 discharged patients were followed 3-8 months after surgery. Two patients needed digitalis. No sign of myocardial ischemia was detected in antibody. All the patients were found to have normal left ventricular pump function. These surgeries are the first in our country and so our little experience may be of interest for national specialists.

[The effect of singly-administered super-erythematous doses of UV-radiation on the general body resistance of hairless mice]. / Vliianie odnokratnykh vozdeistvii superéritemnykh doz UF-izlucheniiana obshchuiu rezistentnost' organizma bezvolosykh myshei.

Male and female nude mice of the HRS strain were exposed to single UV-B-irradiation with biologically effective doses of 1.0 and 1.4 kJ/m2 at an intensity of 0.11 and 0.59 W/m2. The general resistance of animals was measured in terms of skin automicroflora and resistance to Staphylococcus aureus alpha-toxin injected intraperitoneally at LD50. The amount of microorganisms of the back and tail skin (shielded during exposure) did not differ from the control level 1 hour or 1, 3, 7, 14, and 21 days after irradiation. One day after exposure to UV-irradiation at a dose of 1.4 kJ/m2, toxin resistance declined. The lethality rate of mice was 33.6% and 17.9% at an intensity of UV-irradiation equal to 0.59 W/m2 and 0.11 W/m2, respectively. No effect was observed 3 days after UV-irradiation at a dose of 1.0 kJ/m2. It is concluded that single UV-irradiation with 7 MEDs can decrease body resistance, the decrease enhancing with intensity increase.