[Fifteen-year results of bilateral and unilateral internal mammary artery grafting]. / Pyatnadtsatiletnie rezul'taty revaskulyarizatsii miokarda s ispol'zovaniem dvukh i odnoi vnutrennei grudnoi arterii.

OBJECTIVE: To evaluate the clinical effectiveness of bilateral internal mammary artery grafting over long-term (15 years) postoperative period. MATERIAL AND METHODS: There were 276 patients divided into two groups: 135 patients (group A) underwent bilateral internal mammary artery grafting and 141 patients (group B) underwent unilateral internal mammary artery grafting together with venous bypass grafts. On-pump surgeries and cardioplegia, parallel CPB and on-pump procedures were performed in equal proportions. Mean age of patients was 57.3±7.6 years. Diabetes mellitus was detected in 21 (15.5%) and 24 (19.1%) patients, respectively (p>0.05). Mean LV ejection fraction was 55.4±9.9%, revascularization index - 3.1±0.8 and 3.0±0.7, respectively. In the 1st group, 43 patients underwent bilateral internal mammary artery grafting alone. Autovenous grafts were additionally used in other 84 patients. RESULTS: Ten-year survival exceeded 90% in both groups. Freedom from adverse cardiac events after 15 years was significantly higher in group A (77.3% vs. 59.3%, p=0.018). In group A, 16 patients died throughout this period due to cancer (50%), myocardial infarction (12.5%), stroke (18.8%) and complications of diabetes mellitus (6.3%). In group B, 22 patients died mainly from cardiac causes (myocardial infarction - 40.9%, cancer - 27.3%). CONCLUSION: Bilateral internal mammary artery grafting has obvious advantages over traditional coronary artery bypass grafting. If we take into account higher proportion of cardiac causes in structure of mortality in group B, we can talk about positive impact of bilateral internal mammary artery grafting not only on the quality of life, but also on life expectancy in long-term postoperative period.

[Early and long-term outcomes of bilateral inthernal thoracic artery grafting for coronary artery bypass surgery]. / Blizhaishie i otdalennye rezul'taty bimammarnogo koronarnogo shuntirovaniia.

OBJECTIVE: To evaluate safety of coronary artery bypass surgery using bilateral internal mammary artery and effectiveness of this procedure in long-term postoperative period. MATERIAL AND METHODS: The study involved 129 patients who underwent CABG for the period 2006-2007. There were 2 groups of patients depending on surgical strategy: group 1 (n=61) - double IMA harvesting, group 2 (n=68) - CABG using single IMA. Short-term results were compared using standard statistical methods. Long-term survival was compared using Kaplan-Meyer method. RESULTS: Revascularization index was 3.014±0.76 in the 1st group and 3.1±0.73 in the 2nd group (p>0.05). In-hospital mortality was 0% and 1.47%, respectively (p> 0.05). A 10-year survival was 95.1% and 91.2%, respectively (p>0.05). Freedom from cardiac events (mortality, myocardial infarction, recurrent angina pectoris) was significantly different (95% vs. 81%, p<0.05). CONCLUSION: Significantly lower rate of adverse cardiac events in long-term postoperative period in comparison with conventional CABG clearly demonstrates high quality of life after coronary artery bypass surgery using bilateral internal mammary artery for a long time. Therefore, this procedure is preferred in patients with coronary artery disease.

[Features of surgical treatment of advanced age patients with coronary artery disease]. / Osobennosti khirurgicheskogo lecheniia bol'nykh ishemicheskoi bolezn'iu serdtsa pozhilogo i starcheskogo vozrasta.

OBJECTIVE: To optimize surgical treatment of patients aged over 70 years with coronary artery disease. MATERIAL AND METHODS: There were 398 patients aged over 70 years with coronary artery disease for the period 2006-2017. All patients were divided into 3 groups: group 1 - on-pump coronary artery bypass grafting (CABG) with cardiac arrest; group 2 - on-pump beating heart CABG, group 3 - off-pump CABG. RESULTS: On-pump beating heart CABG in patients over 70 years old is followed by reduced incidence of perioperative complications including acute heart failure, acute respiratory failure, neurological complications, reduced length of ICU- and hospital-stay compared with on-pump CABG and cardiac arrest. However, off-pump CABG is optimal in advanced age patients because this approach reduces duration of surgery, intraoperative blood loss, incidence of acute heart failure, neurological complications and cardiac rhythm disturbances. Postoperative annual and 5-year survival rates were 98.1 and 84.2%, respectively. CONCLUSION: Off-pump CABG is preferable in advanced age patients. Surgical treatment of these patients is characterized by high clinical efficacy in long-term period after surgery.

[B.V. Petrovsky and development of home coronary surgery]. / B.V. Petrovskii i razvitie otechestvennoi koronarnoi khirurgii.

Academician B.V. Petrovsky had considerable impact on coronary surgery development in our country. Current Russian coronary surgery comparable with world standards is based on scientific and practical initiatives initiated and developed by B.V. Petrovsky and his students.

[Surgical treatment of postinfarctial ruptures of interventricular septum].

21 patients were operated on the reason of postinfarctial ruptures of interventricular septum within 1989-2009 years. The mean age was 61.3 ± 7.8 years. The preoperative diagnostic means were echocardiography and magnetic resonance imaging. All patients were in critical condition, demonstrated postinfarctial left ventriculum remodeling and significant decrease of its functional reserves. Myocardial revascularization together with septal reconstruction, mitral valve and ventricular cavity reconstruction were performed. The analysis of the results proves that the active-expectant treatment tactics leads to the significant decrease of perioperative lethality. The optimal volume of surgical treatment is a liquidation of the interventricular defect together with geomentrical reconstruction of the ventricular cavity, wich is indepentant from the stage of infarction.

[Personality disorders in postoperative period of coronary artery bypass graft surgery]. / Rasstroistva lichnosti v posleoperatsionnom periode aortokoronarnogo shuntirovaniia.

Personality disorders (PD) are recognized among key maladaptive factors in postoperative period of coronary artery bypass surgery (CABS). However studies on PD among CABS patients are predominantly under psychological approach and information on clinical features is very limited. A present investigation aimed at assessing clinical features and prognostic value of PD in late post operative period of CABS (from 1 to 3 years). Using psychiatric, cardiological and psychological methods, 48 patients (42 male, mean age 61.3 +/- 8.2 years) with diagnosis of PD and favorable cardiological status after CABS have been assessed. PD in post operative period is an important predictor of unfavorable social and occupational outcome of CABS. Three types of clinical course of PD were singled out: 1) hypohondric personality development; 2) "second life" personality development; 3) "denial of illness" reactions. Pronounced maladaptation was observed in type 1, most severe one--in type 2 and minimal maladaptation or its absence--in type 3. These types were differentiated by different repertoires of psychological defense mechanisms (PMD): type 1 was characterized by a limited number of them with a drift to mature mechanisms; PD of type 2 are featured by a narrow and rigid repertoire of defenses with predomination of immature mechanisms and in type 3 a maximum number of PMD with balanced involvement of mature and immature mechanisms was observed.

[Minimally invasive coronary grafting without using the artificial bypass blood circulation]. / Maloinvazivnoe koronarnoe shuntirovanie bez primeneniia iskusstvennogo krovoobrashcheniia.

An analysis, the shaping-up and perfection of the surgical treatment of ischemic heart disease (IHD) by using the method of small-invasion grafting of coronary arteries without applying the artificial bypass blood circulation is described. Indications and contraindications for the surgery of coronary grafting on the working heart and with minimal approach are discussed. Advantages of such surgeries boil down to a smaller trauma, a better cosmetic effect, milder pain, a quicker rehabilitation (with a shorter stay in hospital) and cost-efficiency.

[Currently available blood saving methods in a patient at cardiac surgery under extracorporeal circulation]. / Sovremennye metody sokhraneniia krovi bol'nogo pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

Different blood saving methods are analyzed in 2000 cardiac surgical patients undergoing coronary and vascular bypass surgery in 1993 to 2000. The basic blood saving methods are as follows: intraoperative autoreinfusion (normovolemic thermodilution), reinfusion of the patient's blood, preoperative autologous plasma donation in combination with aprotinine, aminocapronic acid, etc. An analysis revealed a decrease in homologous blood components intraoperatively. Red blood cell transfusion decreased from 100% in 1993 to 44% in 2000, fresh frozen plasma and platelet transfusions did from 98 to 39% and from 96 to 1%, respectively. Intraoperative homologous blood transfusion could be avoided in 70% of those undergone coronary bypass surgery.

[Anesthesiological aspects of early activation of patients after aortocoronary bypass surgery]. / Anesteziologicheskie aspekty rannei aktivizatsii bol'nykh posle operatsii aortokoronarnogo shuntirovaniia.

The specific features of the course of anesthesia and the time of extubation were studied in 142 patients suffering from coronary heart disease who had undergone myocardial revascularization. All the patients were divided into 3 groups in accordance with the type of anesthesia. Group 1 patients (n = 48) received routine anesthesia with ketamine, benzodiazepines, and large-dose fentanyl. Group 2 (n = 45) had combined anesthesia with inhalational and intravenous anesthetics having their better pharmacodynamics (such as isoflurane, diprivan, tracrium). In Group 3 (n = 49), the authors employed another developed modality of anesthesia using high thoracic (TII-TIV) epidural anesthesia as a basic component of anesthesiological maintenance. The two developed modalities of anesthesia almost halved the use of total dose opioids, which promoted patients' early postoperative recovery of consciousness and respiration. The time before extubation was 9.9 +/- 2.1, 4.5 +/- 1.1, and 1.5 +/- 1.2 hours in Groups 1, 2, and 3, respectively (p < 0.05). The developed anesthesia procedure using isoflurane, midazolam, propofol, and small-dose fentanyl ensures safe and early (up to 6-hour) extubation in 73% of the patients undergone aortocoronary bypass surgery. The developed anesthesiological protocol based on thoracic epidural anesthesia enables extubation to be carried out on the operating table within an hour in 75% of patients after aortocoronary bypass surgery. A comparative intraoperative analysis of hemodynamics, the incidence of myocardial ischemia, arrhythmias, glucose levels has indicated that the anesthesia techniques aimed at a patient's early activation are not inferior in the degree of protection to routine anesthesia using large doses of opioids, ketamine, and diazepam. When used in combination with thoracic epidural block, the methods are superior to the latter.

[Temperature regimen of extracorporeal circulation during aortocoronary bypass surgery]. / K voprosu o temperaturnom rezhime iskusstvennogo krovoobrashcheniia pri operatsiiakh aortokoronarnogo shuntirovaniia.

The purpose of the study is to comparatively evaluate the impact of normo- and hypothermic perfusion on acid-base balance (ABB), gas blood composition, metabolic parameters, and hemostasis. Fifty patients undergone multiple aortocoronary bypass under extracorporeal circulation (EC) were examined. Twenty four patients and 26 (Groups 1 and 2, respectively) had been operated on under normo- and hypothermia. The groups did not differ in age, body weight, the duration of an operation, the number of shunts, the time of EC, and myocardial ischemia. ABB, gas blood composition, the concentrations of hemoglobin, lactate, fibrinogen, prothrombin time, thrombin time, activated partial thromboplastin time, activated coagulation time, blood coagulation time as described by Leigh-White, the count of platelets, and ADP-induced platelet aggregation in the early postperfusion and postoperative periods, following 24 and 48 hours after surgery. There were no significant differences in the values of ABB, gas blood composition, blood lactate levels in patients from both groups. However, metabolic acidosis, elevated blood lactate concentrations were more frequently encountered in Group 2 patients, which suggests that hypothermia prduces a more aggressive effect on systemic homeostasis. Impact of normo- and hypothermia on the coagulative link of homeostasis was not revealed. Nevertheless, hypothermic EC halved the functional activity of platelets, which has a substantial effect on the size of postoperative blood loss.

[Chronic occlusions in patients with coronary heart disease: results of recanalization]. / Rezul'taty rekanalizatsii khronicheskikh okkliuzii u bol'nykh IBS.

The paper analyzes the results of endovascular treatment in 298 patients with chronic occlusions or subtotal stenoses of coronary arteries. The authors show that balloon coronary angioplasty for chronic coronary occlusions is an effective and relatively safe techniques of myocardial revascularization. Successful endovascularization has been achieved in 68.1% of patients with chronic coronary occlusions and in 97.5% of those with subtotal coronary stenoses. The results show a high incidence of restenosis and asymptomatic reocclusion.

[Autoarterial grafts for myocardial revascularization and their morphological assesment in coronary heart disease]. / Autoarterial'nye transplantaty dlia revaskularizatsii miokarda i ikh morfologicheskaia otsenka u bol'nykh ishemicheskoi bolezn'iu serdtsa.

A comparative analysis of arterial grafts used for myocardial revascularization has been done. The morphology of arteries, rate and degree of atherosclerotic process were evaluated. 55 thoracic internal arteries, 52 right gastro-epipiolcal arteries, 34 epigastrical inferior arteries have been tested in cadavers of people with signs of coronary heart disease. Arteria thoracica interna appeared to be a vessel with prevalence of elastic elements, while arteria gastro-epiplocia and arteria epigastrica inferior are predominantly muscle-type. Arteria thoracica interna and arteria epigastrica inferior appeared to be rarely affected with atherosclerosis in people under 60 years of age. Atherosclerotic lesions have been found more often in arteria gastro-epiploica without stenotic lesions. In people over 60 years of age the stenotic lesions in arteria thoracica interna and arteria epigastrica are found much more often than in arteria gastro-epiploica. Arteriography should be done in selecting the proper graft for myocardial revascularization.

[Effects of high doses of aprotinin on intra- and postoperative blood loss in surgery with artificial circulation]. / Vliianie bol'shikh doz aprotinina na intra- i postoperatsionnuiu krovopoteriu pri operatsiiakh s iskusstvennym krovoobrashcheniem.

A total of 100 patients subjected to multiple aortocoronary shunting under artificial circulation were examined. All of them were administered aprotinin or placebo in standard doses in a double blind test. The drug was infused over the entire course of the operation, total dose being 6 million KIU. The groups of patients did not differ by duration of artificial circulation and aorta clamping, or by the number of shunts used. The data permit a conclusion that prolonged intraoperative infusion of aprotinin in a dose of 6 million KIU resulted in a twofold reduction of the blood loss during and after the operation, thus permitting less frequent and lower in volume transfusions of donor blood during the operation and in the early postoperative period.

[Comparative assessment of temperature of the myocardium during its protection by 2 methods in aortocoronary bypass]. / Sravnitel'naia otsenka temperatury miokarda pri ispol'zovanii dvukh metodov ego zashchity pri operatsiiakh aortokoronarnogo shuntirovaniia.

Eighty-eight patients operated on for coronary heart disease were examined. Continuous irrigation of pericardial cavity with circulating cold solution in combination with antegrade cardioplegia was used in 53 patients, antegrade cardioplegia with external cooling of the heart by icy mass in the rest 35. Intensive external cooling provided a stable temperature of the myocardium during clamping of the aorta.

[First experience in normo-thermal artificial circulation with constant warm blood cardioplegia]. / Pervyi opyt normotermicheskogo iskusstvennogo krovoobrashcheniia s postoiannoi teplovoi krovianoi kardioplegiei.

Normo-thermal artificial circulation (NAC) with constant thermal blood cardioplegia (CTBC) was carried out for the first time in Russia in 12 coronary patients subjected to surgical revascularization of the myocardium. Artificial circulation device with the vesical type oxygenator was used for NAC. For CTBC, systems for delivery of the cardioplegic solution and blood from the oxygenator in 1:4 ratio were used. Freme type cardioplegic solutions made by the authors were used. NAC duration was 53 to 139 min, the mean value being 103.4 min. The aorta was clamped for 38 to 96 min, the mean value 70.1 min. Asystole developed soon after CTBC began. After CTBC was discontinued, heart work recovered without cardiotonics.

[Topographic-anatomical bases of the use of the inferior epigastric artery in creation of free graft for aortocoronary shunt]. / Topografoanatomicheskoe obosnovanie ispol'zovaniia nizhnei nadchrevnoi arterii v kachestve svobodnogo transplantata dlia aortokoronarnogo shuntirovaniia.

Ten experiments were conducted on nonfixed human cadavers of males and females 50 to 70 years of age. The inferior epigastric artery arises from the medial wall of the external iliac artery 1.0-1.5 cm proximal to the inguinal ligament. Its diameter at the site of its origin varies from 2.5 to 4.0 mm and is 3.25 +/- 0.13 mm on the average. At the level of the umbilical ring the average diameter of the artery is 1.47 +/- 0.03 mm. The total length of the arterial segment which can be used for transplantation varies from 11 to 16.5 cm, being 14.60 +/- 0.48 cm on the average. An approach through an inferomedian incision of the abdominal wall is preferable. The transplant is taken out together with the veins and the surrounding connective tissue. The length and diameter of the inferior epigastric artery are sufficient for using it as an aortocoronary shunt in revascularization of the myocardium in patients with ischemic heart disease.

The use of high doses of aprotinin to decrease blood loss in aortocoronary by-pass surgery.

There were examined 100 patients who had been operated in extracorporeal circulation for ischemic heart disease. In the 1st group (50 patients), each patient intraoperatively received 6,000,000 KIE of aprotinin; in the 2nd group (50 patients) placebo. Both groups were similar as for the age, duration of extracorporeal circulation, and myocardium anoxia. The total intraoperative blood loss was higher in 2nd group, 638 +/- 5 ml and 952.4 +/- 15.5 ml p < 0.05 correspondingly. The rate of cases without the intraoperative use of donor blood was 42% in group 1 and 18% in group 2. The postoperative blood loss was significantly lower with the use of aprotinin, 392 +/- 6.6 ml and 689.7 +/- 9.6 ml, p < 0.05 correspondingly; and in that the Hb concentration in the drainage blood was higher in group 2: 31.3 +/- 0.5 g and 73.1 +/- 2.2 g, p < 0.05. In group 1 22% of the patients received donor blood in the early postoperative period, and group 2 twice as many -56%. Thus prolonged intraoperative use of large aprotinin dosages in aortocoronary by-pass surgery is an effective means for stabilization of homeostasis, and it allows to reduce intra- and postoperative blood loss and diminishes the requirements in donor blood.

[Evaluation of adequate heparinization during artificial circulation in the framework of prolonged intraoperative administration of high doses of aprotinin]. / Otsenka adekvatnosti geparinizatsii pri iskusstvennom krovoobrashchenii na fone intraoperatsionnogo prolongirovannogo vvedeniia bol'shikh doz aprotinina.

The aim of this research was to evaluate the effect of high aprotinin doses on activated coagulation time (ACT) in patients with aortocoronary bypass. A total of 100 patients were examined. All of them were administered in a double blind test either aprotinin or placebo in standard doses. Our results permit a conclusion that adequate heparinization during aprotinin therapy can be achieved at ACT values more than 750 sec and protamine sulphate dose should be estimated from initially administered heparin dose. With ACT values exceeding twofold the usual ones there was no evidence of excessive heparinization leading to marked thrombocytopenia and bleeding.

[The protection of the myocardium with a circulating cold solution during aortocoronary bypass operations]. / Zashchita miokarda tsirkuliruiushchim kholodovym rastvorom pri operatsiiakh aortokoronarnogo shuntirovaniia.

Forty-three patients operated on under conditions of aortocoronary bypass were examined. In 29 of them continuous circulation of cold solution in pericardial cavity was combined with antegrade cardioplegia. In 14 routine technique of external myocardial cooling with snow and antegrade crystalloid cardioplegia was employed. Intensive external cooling of the heard helped not only maintain a lower myocardial temperature but permitted also a reduction of temperature gradients between various myocardial sites. This was conducive to a better preservation of energy reserve and contractility of the myocardium.

[Our initial experience of protecting the myocardium by irrigating the pericardial cavity with a circulating cold solution during operations with artificial circulation]. / Pervyi opyt zashchity miokarda putem orosheniia polosti perikarda tsirkuliruiushchim kholodovym rastvorom pri operatsiiakh s iskusstvennym krovoobrashcheniem.

In 21 patients with coronary heart disease, a procedure of protecting the myocardium was used during cardiac surgeries via irrigation of the pericardial cavity with circulating cold solution in combination with cardioplegia into the aortic root. The application of the procedure maintained stable myocardial temperature from 10.26 +/- 1.55 to 11.99 +/- 1.95 degrees C, excluding excessive overcooling and premature warming. The procedure awaits further studies in terms of biochemical changes and morphology of the myocardium at various stages of surgery.