[In-hospital outcomes of endarterectomy and coronary artery bypass grafting in multiple diffuse lesions of coronary arteries]. / Gospital'nye rezul'taty éndarteréktomii i koronarnogo shuntirovaniia pri mnozhestvennom diffuznom porazhenii koronarnykh arterii.

BACKGROUND: According to a series of studies, performing coronary endarterectomy in direct myocardial revascularization increases the risk of myocardial infarction and in-hospital mortality. There are no commonly accepted indications for carrying out endarterectomy, and in clinical practice this technique is used in severe diffuse lesions of coronary arteries. AIM: The study was aimed at assessing in-hospital clinical outcomes of coronary artery bypass grafting (CABG) with the use of endarterectomy in patients with severe multiple diffuse lesions of coronary arteries. PATIENTS AND METHODS: This was a single-centre retrospective study enrolling a total of 205 patients presenting with multiple diffuse lesions and subjected to CABG procedures. Of these, after excluding those with severe concomitant pathology (n=28), 177 were enrolled and divided into 2 groups: 76 patients during formation of a coronary anastomosis were subjected to forced endarterectomy from the native channel (Group 1, n=76) and the remaining patients to prolonged anastomosis and/or bypass grafting of distal branches of the diffusely damaged artery (Group 2, n=101). In-hospital outcomes were analysed in both groups. RESULTS: The demographic and clinical characteristics were comparable by all parameters except for age: Group 1 patients were older (66.3±8.4 vs 63.0±8.5, p<0.05). The groups were comparable by severity of coronary lesions by both the SYNTAX Score and diffuse lesion index. The incidence of perioperative myocardial infarction during coronary endarterectomy (Group 1) amounted to 9.2% (7/71) and in the group without endarterectomy (Group 2) to 0. There were no cases of in-hospital mortality in either group. CONCLUSION: In severe diffuse coronary lesions, endarterectomy combined with CABG makes it possible to perform adequate myocardial revascularization. Performing endarterectomy from coronary arteries is associated with an increased risk for the development of myocardial infarction, but its use is justified if it is impossible to create an anastomosis by means of other techniques.

[Capacities of multidetector spiral computed tomography in the planning and postoperative examination of patients undergoing coronary artery bypass surgery].

Multiple investigations show that multidetector spiral computed tomography (MSCT) bypass grafting becomes an alternative to invasive coronary angiography in detecting coronary graft stenoses and occlusions. The investigation retrospectively estimated the patency of aortocoronary and mammary coronary artery anastomoses by MSCT bypass grafting. Examinations were made in 85 (326 anastomoses) patients who had undergone aortocoronary and mammary coronary artery bypass surgery and had MSCT bypass grafting within 3 years after the surgery. In the first year following the surgery, 18 patients with graft stenotic changes, as evidenced by MSCT, underwent intervention coronary angiography, the sensitivity and specificity of which was 100%. The results of clinical and instrumental examinations were also compared with graft incompetence, as shown on MSCT that revealed that MSCT bypass grafting was the only noninvasive technique to evaluate early coronary graft closure both in the absence of clear signs of myocardial ischemia according to the data of exercise tests and in the presence of recurrent angina pectoris.

[Left main coronary artery stenosis and progression of coronary artery atherosclerosis after angioplasty and stenting in patients directed to coronary artery bypass surgery].

Recent investigations demonstrated appearance of left main coronary artery stenosis after PTCA. We performed a retrospective study of specific characteristics of development of coronary lesions after percutaneous coronary interventions (PCI) in patients subjected to coronary artery bypass grafting (CABG) because of angina recurrence after PCI. Data of 150 patients operated because of angina recurrence after PCI were analyzed. The recurrence of angina in 93% of cases was associated with development of significant stenoses in previously intact segments of coronary arteries, but not with restenosis or occlusion of the stented segment. The recurrence of symptoms occurred in 1 year after coronary stenting in 54% of patients. In 19 patients rapid development of a novel left main coronary artery stenosis was observed. Some characteristics of this group (the use of Back-up, XB, AL-catheters, repetitive PCI, manipulations in more than 2 coronary segments, stenting of bifurcations with 2 stents, use of kissing-balloons, small diameter of left coronary artery, and concomitant diabetes) significantly differed from those of the main group. In all patients CABG was successful.

Experience in early rehabilitation of patients after coronary artery bypass graft surgery.

UNLABELLED: A strategy of rapid in-hospital postoperative rehabilitation is currently a priority trend in managing the patients after coronary artery bypass graft (CABG) surgery. OBJECTIVE: To investigate the baseline characteristics and peculiarities of perioperative treatment of patients with a short period ofin-hospital rehabilitation. MATERIALS AND METHODS: We studied a total of 690 patients who had endured CABG operations according to the conventional technique performed over the period from January 2007 to August 2008. The procedures of preoperative preparation, surgical intervention and postoperative management both at the stage of the intensive care unit (ICU) and at the Cardiosurgical Department in all the patients were carried out in accordance with the accepted protocol. RESULTS: The Study Group (Group 1) comprised a total of eighty-three 39-to-79-year-old (average age 55.7 +/- 7.9 years) patients whose postoperative hospital stay amounted to 8.1 +/- 1.3 days. Of these, there were 76 men and 7 women. The Comparison Group (Group 2) was composed of one hundred 39-to-76-year-old (mean age 56.2 +/- 8.3 years) patients, with 89 men and 11 women enrolled. The duration of the postoperative hospital stay in the Comparison Group amounted to 12 +/- 1.4 days (p < 0.05). All the operated patients according to the findings of coronary angiography (CAG) had had haemodynamically significant atherosclerotic lesions of three and more coronary arteries. The patients in both Groups were comparable by the main clinical characteristics. There were no patients with recently sustained myocardial infarction, unstable angina, or left-ventricular aneurysms in either of the groups studied. CONCLUSIONS: Employing the protocol we devised makes it possible to reduce the postoperative hospital stay to 7 days in electively operated patients presenting with a stable course of coronary artery disease (CAD), without pronounced co-existing pathology, with a satisfactory left-ventricular systolic function, with preoperatively compensated diabetes mellitus (DM) and adequately controlled arterial hypertension (AH).

[Long-term follow-up use of "cypher" sirolimus-eluting stents in patients with coronary heart disease after coronary artery bypass grafting with occlusive lesions of the coronary artery].

UNLABELLED: The aim of this study is to assess the 1 and 2-year follow-up of treatment with Cypher drug- eluting stents (Cordis, Johnson & Johnson, USA) for chronic symptomatic coronary artery occlusions in CHD patients after coronary artery bypass graft. That was a retrospective study that included 51 patients who had been implanted Cypher stents. A control group comprised 65 symptomatic patients with coronary heart disease (CHD) after coronary artery bypass grafting with occlusive lesions of the coronary artery, who was carried out only conservative treatment (without PTCA). Patients received standard medicamentous treatment. The groups did not differ in clinical characteristics. 79 stenoses in the eluting stent groups were subject to revascularization. The immediate cure rate was 84.3%. During the follow-up, one patient (2.3%) died and 4 (9.3%) underwent coronary bypass surgery in the drug- eluting stent group; there were 3 (4.6%) deaths and 10 (15.4%) patients had coronary bypass surgery in the control group. After stenting we noted a reliable decrease of patients with anginal attacks, of the used nitrates, increase the average physical tolerance by stress- testing (p < 0.05) than by patients in control group. CONCLUSION: stenting chronic coronary artery occlusions in patients with coronary heart disease (CHD) after coronary artery bypass grafting with the use of Cypher drug- eluting stents (Cordis, Johnson & Johnson, USA) is an effective procedure from the viewpoint of long-term results, with low frequency of recurrent angina and repeated myocardial revascularization.

[Comparative analysis of efficacy of endovascular interventions in native vascular bed and grafts in patients with ischemic heart disease after coronary artery bypass surgery].

AIM: Investigation of efficacy of endovascular interventions in native vascular bed and grafts, elucidation of factors, affecting immediate and remote prognosis after endovascular treatment. MATERIAL AND METHODS Coronary stenting was carried out in 212 patients who had previously undergone coronary bypass surgery. Stents were implanted into native vessels and grafts in 116 (native vessels group) and 96 (grafts group) patients, respectively. Frequency of angina recurrence and development of complications were assessed during hospitalization and after 1 year. Coronary angiography was repeated after 1 year in 47 and 36 patients in native vessels and grafts groups, respectively. Multifactorial analysis of predictors of complications and angina recurrence was performed with the use of logistic regression. RESULTS AND CONCLUSION: In grafts group signs of distal embolism were observed in 9 patients (9.4%), shunt thrombosis occurred in 2 of these patients. Risk factors of embolism in grafts group were complicated lesions (type C) and length of stenosis >20 mm. There was 1 non-Q wave myocardial infarction after stenting of native vascular bed (0.8%). Angina recurrence was observed after 1 year in 9 (7.8%) and 26 (27.1%), myocardial infarction developed during 1 year in 2 (1.7%) and 3 (3.1%) patients of native vessels and grafts groups, respectively. Risk factors of recurrence of clinic of ischemic heart disease (IHD) after stenting of grafts were time interval between stenting and bypass surgery >5 years and the use of stents without drug coating. More frequent recurrence of clinic of IHD in patients of grafts group was a consequence of higher level of restenosis in stented segments and more frequent progression of atherosclerosis in previously unaffected segments.

[Potentialities of non-invasive diagnosis of coronary artery anomalies by electron-beam tomography and multislice computed tomography]. / Vozmozhnost' neinvazivnoi diagnostiki anomalii koronarnykh arterii s pomoshch'iu élektronno-luchevoi tomografii i multispiral'noi tomografii.

AIM: To assess diagnostic value of electron-beam computed tomography and multislice computed tomography (EBT and MSCT) for diagnosis of congenital anomalies of coronary arteries (CA). MATERIAL AND METHODS: Non-invasive coronary angiography with EBT and MSCT has been performed in 1162 patients. RESULTS: Different anomalies of coronary arteries have been found in 10 (0.9%) patients. Results of EBT and MSCT agreed with those of coronary angiography performed in 8 cases with CA anomalies. Though 720 of 1162 patients had coronary stenoses, no significant atherosclerotic lesions were found in anomalous CA. CONCLUSION: EBT and MSCT enable non-invasive screening and diagnosis of coronary arteries anomalies.

[Results of endovascular revascularization with the use of stents after coronary bypass surgery in patients with ischemic heart disease]. / Rezul'taty éndovaskuliarnoi revaskuliarizatsii s primeneniem stentov u bol'nykh ishemicheskoi bolezn'iu serdtsa, perenesshikh operatsiiu koronarnogo shuntirovaniia.

AIM: To compare results of stenting in patients with and without prior coronary artery bypass grafting (CABG). METHODS: In 21 patients after CABG stents were implanted both in venous grafts and native vessels (secondary revascularization) and in 25 patients without history of CABG native vessels were stented (primary revascularization). RESULTS: Primary revascularization: there was 1 periprocedural non Q wave myocardial infarction (4%), angina disappeared in 88% and recurred in 1 year in 24% of patients; one year restenosis rate - 18.2%. Secondary revascularization: 1 periprocedural non Q wave (4.8%) and 1 Q wave (4.8%) myocardial infarction. Angina disappeared after stenting in 90.5% and recurred in 1 year in 19% of patients; one year restenosis rate - 17.6%. CONCLUSION: Both primary and secondary revascularizations were highly effective. However secondary stenting was associated with more frequent acute complications.

[Role of electron-beam tomography in diagnosing patency of aortocoronary and mammary-coronary shunts (from data from a 3-year study)]. / Rol' élektronno-luchevoi tomografii v diagnostike prokodimosti aortokoronarnykh i mammarokoronarnykh shuntov (po dannym 3-letnego nabliudeniia).

AIM: To assess informative value of electron-beam tomography (EBT) and to compare dynamics of occlusive defects of autovenous and autoarterial shunts. MATERIAL AND METHODS: 36 patients with coronary heart disease entered the study. All the patients have undergone coronary artery bypass operation and/or mammarocoronary bypass operation (CABO and MCBO, respectively). For three years after the surgery the patients were annually examined with EBT-shuntography. The contrast agent was injected intravenously in a dose 135-140 ml with the injection rate 3.5-4.0 ml/s. In addition to EBT-shuntography, selective x-ray contrast shuntography was conducted one year after CABO. RESULTS: By a comparative analysis, EBT sensitivity and specificity in examination of autovenous shunts patency is 100%, in assessment of patency of mammary shunts is 93 and 100%, respectively. The 3-year retrospective analysis has revealed occlusions in 17.1% venous shunts and 2.7% arterial ones in the first year after CABO and MCBO, 5.2 and 2.8% in the second year, respectively, and in 1.8% venous shunts in the third year. CONCLUSION: EBT-shuntography is a highly informative non-invasive method of diagnosis of aortocoronary shunts patency.

[Changes of autologous coronary vessels and aortocoronary grafts in patients with ischemic heart disease after coronary artery bypass grafting]. / Izmeneniia nativnogo koronarnogo rusla i aortokoronarnykh shuntov u bol'nykh ishemicheskoi bolezn'iu serdtsa v raznye sroki posle operatsii koronarnogo shuntirovaniia.

AIM: 1) to assess effect of coronary lesion morphology on changes of grafts during first year after surgery; 2) to study the state of native coronary vascular bed during first year after surgery; 3) to elucidate special features of atherosclerosis in grafts and coronary arteries in remote period after surgery. MATERIAL AND METHODS: One hundred eighty seven patients with 3-vessel coronary artery disease subjected to aorto-coronary or mammary-coronary grafting. RESULTS AND CONCLUSION: Proportions of closed venous grafts were 24,2% among grafts to arteries with 50-75% stenoses, 13.1% among grafts to occluded arteries (p=0.023), and 20.1% among grafts to arteries with 75-99% stenoses. Among venous grafts to arteries with lumen diameter <1.5 mm 30.4% were occluded what was significantly more than among grafts to vessels with 1.5-2.5 mm (15.5%, p=0.003) and >2.5 mm (14.5%, p=0.004) diameter. Morphological risk factors of venous graft closure in immediate postoperative period were 50-75% stenosis and lumen diameter <1.5 mm. All mammary-coronary anastomoses were patent in 1 year, 99% of them remained patent 5 years after surgery. No relationship was found between patency of venous grafts after 5 years of follow-up and morphological characteristics (lumen diameter and percent stenosis) of bypassed arteries. During first year there was no significant differences between patients with patent and occluded grafts both in incidences of novel atherosclerotic lesions (10.4 and 10.3%, respectively, p=0.943) and proportion of closures of initially stenotic arteries (9.6 and 10.3%, respectively, p=0.085). After 5 years novel atherosclerotic lesions were found in 31.9 and 33.6% of patients with patent and occluded grafts, respectively (p=0.910). Complete occlusions of stenosed vessels proximal to anastomosis occurred more often among patients with patent than with occluded grafts (28.6 and 15.9%, respectively, p=0.047). Thus in remote postoperative period development of atherosclerosis in proximal segments of arteries with patent grafts was more 'aggressive' than in arteries with occluded grafts.

[Results of stenting and surgical treatment in patients with ischemic heart disease and multivessel coronary artery involvement]. / Rezul'taty koronarnogo stentirovaniia i khirurgicheskogo lecheniia bol'nykh ishemicheskoi bolezn'iu serdtsa s mnogososudistym porazheniem koronarnogo rusla.

Efficacy of surgical and endovascular (with the use of stents) methods of treatment was assessed in 56 patients with ischemic heart disease and double and triple vessel involvement. Coronary artery bypass grafting (CABG) was carried out in 31, implantation of stents - in 25 patients. Clinical factors used for assessment of efficacy of treatment were development of events (deaths, myocardial infarctions), presence of angina, changes of exercise capacity. In immediate postoperative period there were 2 myocardial infarctions (1 in each group, i.e. 4 and 3.2% after stenting and CABG, respectively) and no deaths. Absence of clinical effect (persistence of angina) more often occurred after stenting (12%) that after CABG (6.5%). Length of hospital stay was shorter after stenting (13-/+8 days) than after CABG (24-/+10 days). Increment of exercise tolerance was higher after stenting than after CABG (62-/+10 and 54-/+8 W, respectively). During 1 year of follow-up 1 myocardial infarction developed (after stenting). In a year after procedure angina recurred in 24 and 12.9% of patients subjected to stenting and CABG, respectively; increments of exercise tolerance were 53-/+8 and 49-/+7 W after stenting and CABG, respectively. These results are indicative of high efficacy of surgical and endovascular (with implantation of stents) treatment of multivessel coronary artery disease.

[Minimally invasive coronary artery bypass surgery]. / Minimal'no invazivnye operatsii koronarnogo shuntirovaniia.

From 19.06.97 to 06.01.2000 36 patients with coronary heart disease underwent direct myocardium revascularization surgery by minimally invasive method (through minithoracotomy, off-pump and on the beating heart), anastomosis between left internal mammaria artery and anterior descending artery (ADA). The majority of the patients (55.6%) had one-vessel damage of ADA coronary bed, in the patients with damage of two and more vessels full revascularization of coronary bed was achieved by two coronary arteries bypass at once or by combination of minimally invasive coronary bypass (MICB) with PTCA. MICB is performed in specially selected patients according to stuct indications. Technique of operation, early postoperative course, possibilities of combination of MICB with other methods of treatment is described. Potential of MICB is discussed.

Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery.

The purpose of this study was to work out an adequate operative technique for patients with malignant tumors who also need open heart surgery or procedures on major blood vessels. We had 8 such patients. In 6 of them, a tumor (3 cases hypernephroid cancer and 3 cases retroperitoneal sarcoma) had grown through the inferior vena cava (IVC) up to the right atrium. Two patients had lung cancer together with severe coronary artery disease. All of these patients were operated on using a heart-lung machine (HLM) and cell saver (CS). In 6 patients the intravascular portion of the tumor was extracted as much as possible through a right atrium approach (in 3 cases a nephrectomy was performed). Two patients had a one-stage coronary artery bypass graft (CABG) and a lobectomy. All of the patients had uneventful postoperative periods and were alive when checked on 1 year after the procedures. During cytological investigation after each operation, tumor cells were found only on the internal surface of the HLM arterial filters with 20 microns holes. We suggest that special cardiovascular devices such as the HLM and CS might be used in borderline situations in oncology without increasing the risk of hematogenous tumor dissemination.

[Occlusion of the trunk of the left coronary artery]. / Okkliuziia stvola levoi koronarnoi arterii.

Atherosclerosis-induced occlusion of the left coronary artery (LCA) is a rare findings registered angiographically. It is associated with a high risk of a fatal outcome. Eight cases of LCA occlusion are reported. A profound ST depression was shown by all ECG variants: bicycle exercise, Holter monitoring, 12-lead registration during angina attack. The conus branch gave collaterals to anterior descending artery in all the cases. Seven cases were treated surgically, one patient rejected operation and was alive at 3.5-year follow-up examination. Etiology and therapeutic policy in occlusion of the LCA are discussed.

[Prevention and treatment of infectious complications in myocardial revascularization]. / Profilaktika i lechenie infektsionnykh oslozhnenii pri revaskuliarizatsii miokarda.

The study was conducted in a group of 440 patients who underwent planned operations for ischemic heart disease. Three current methods of preventive antibiotic therapy were compared. The influence of various risk factors on the incidence of infectious complications was analysed. Experience with closed mediastinitis management was also analysed. The effect of a short-term (1-3 days) course of claforan in prevention of infectious complications is the same as that of a 5-7-day course of cefamezin or gentamicin. Postoperative mediastinitis developed in 11 (2.5%) patients. It was managed in all patients by closed irrigation and drainage of the retrosternal space. The average duration of mediastinal irrigation was 7.4 days. Convalescence was attained in all cases.