Vol 45, No 3 (2017)


Anesthetic preconditioning in cardiac surgery

Gerasimenko O.N., Grebenchikov O.A., Ovezov A.M., Prokoshev P.V., Likhvantsev V.V.


The problem of myocardial protection in cardiac surgery is a challenge due to an increased number of interventions and severity of their complications related to the patient's status, pathophysiology of the artificial circulation and the used techniques for replacement of vital functions. Oxidative stress and formation of active oxygen species, as a consequence of the above mentioned processes, may result in systemic injury, such as acute heart failure, central nervous system dysfunction and acute renal injury. Short ischemic episodes before prolonged hypoxia with subsequent reperfusion can decrease cardiomyocyte injury. This phenomenon has been referred to as ischemic preconditioning. A similar effect is caused by inhalation anesthetics. Experimental and clinical data on anesthetic preconditioning suggest that inhalation anesthesia with halogen-containing agents may be used as a method to protect the myocardium from damage by active oxygen species produced during the periods of oxidative stress in cardiac surgery. Studies analyzed in this review have shown benefits of inhalation anesthetics, compared to total intravenous anesthesia, such as effective cardiac protection and, what is most important, in potential reduction of mortality after coronary bypass grafting. The level of evidence for the effects of anesthetic preconditioning on long-term mortality in these studies was not high enough; therefore, a large multicenter randomized controlled trial is needed to confirm these results.

Almanac of Clinical Medicine. 2017;45(3):172-180
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Functioning of aortocoronary bypass grafts depending on the lesion and on the anatomical characteristics of coronary arteries

Rodionov A.L., Rafaeli Y.R., Babokin V.E.


Aortocoronary bypass grafting is a reliable and effective method of treatment for ischemic heart disease. Despite a well-defined spectrum of the used grafts, many tactic issues of aortocoronary bypass grafting remain unsolved. There is a lack of a unified classification of lesions in the native coronary vasculature; this prevents from establishing objective indications to direct myocardial revascularization and excludes any further improvement of surgical results. The strategy to bypass the maximal number of occluded coronary arteries irrespective on the patient’s age and the degree of coronary pathology could not be considered the most optimal in the absence of objective methods of post-operative diagnosis.

Almanac of Clinical Medicine. 2017;45(3):181-185
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The role of pulse oximetry in neonatal screening for critical and complex congenital heart defects

Tarayan M.V., Drozdova A.I., Efremov E.S., Shkarina N.V., Malyutina L.V.


Background: Timely diagnosis of complex and critical congenital heart defects in neonates can help to avoid fatal complications of their natural history and to establish correct treatment strategies. Therefore, easily available and inexpensive screening methods for their routine diagnostics are important.

Aim: To demonstrate the role of pulse oximetry in the diagnosis of complex and critical congenital heart defects.

Materials and methods: Forty six neonates aged from 1 to 27 days with congenital heart defects, diagnosed after birth, were included into the study. Their diagnoses were verified by expert echocardiography performed after positive pulse oximetry test or due to unexplainable oxygen dependency and/or clinical manifestation of severe heart failure. The pulse oximetry test was considered positive with SaO2 < 95% in any extremity and the difference between the right hand and foot of above 3%.

Results: The pulse oximetry test was positive in all neonates with transposition of the great arteries (n = 5), hypoplastic left heart syndrome (n = 6), total anomalous pulmonary venous collection (n = 2), common arterial trunk (n = 3), pulmonary artery atresia with ventricular septum defect (n = 1). The pulse oximetry test was non-informative in those with obstructive abnormalities of the left heart, such as aortic valve stenosis and aortic coarctation.

Conclusion: The pulse oximetry test can be used for routine screening for complex and critical congenital heart defects in neonates.

Almanac of Clinical Medicine. 2017;45(3):186-191
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Denervation of pulmonary trunk and pulmonary orifice in patients with surgically corrected mitral valve disease against high pulmonary hypertension

Trofimov N.A., Medvedev A.P., Dragunov A.G., Babokin V.E., Nikol'skiy A.V., Mizurova T.N., Gartfelder M.V., Orlova A.V.


Aim: To study efficacy and safety of denervation of the trunk and pulmonary arteries (PADN procedure) in patients with surgical correction of the mitral valve against a high degree of pulmonary hypertension compared to those of the isolated correction of mitral valve disease.

Materials and methods: Placement of a mechanical mitral valve prosthesis and radiofrequency ablation Maze IV with Atri Cure ablator was performed in 39 patients with a mitral valve disease and high pulmonary hypertension (> 40 mm Hg) and atrial fibrillation. From those, 8 patients (main group) had additional circular denervation of the ganglionic plexus of the pulmonary trunk and orifice (PADN) with a radiofrequency bipolar Atri Cure ablator under the control of transmurality.

Results: All patients who had underwent surgery showed positive changes of the echocardiographic parameters, such as a decrease in the heart cavities sizes, degree of pulmonary hypertension, and an improvement in the systolic function of the left ventricle. There were no deaths, as well as specific complications related to the PADN procedure. In the main group of patients (n = 8), pulmonary hypertension decreased from 56.3 ± 5.4 mm Hg to 23.4 ± 2.7 mm Hg at day 1, to 24.3 ± 3.1 mm Hg at day 7, and to 23.7 ± 3.8 mm Hg at 1 month after the PADN procedure. At day 1, the target levels of pulmonary hypertension were achieved in 87.5% (7/8) of patients in the main study group and in 25.8% (8/31) of patients in the control group (p = 0.001). At day 7, the corresponding values were 75% (6/8) and 32.3% (10/31), respectively. Better results in the main study group were observed throughout the whole follow-up period (up to 2 months).

Conclusion: The circular PADN procedure using a radio frequency bipolar ablator under the control of transmurality is an effective and safe method to correct a high-degree pulmonary hypertension. Further studies on the effectiveness of this procedure in larger patient numbers and assessment of long-term results are necessary.

Almanac of Clinical Medicine. 2017;45(3):192-199
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Myocardial revascularization in the beating heart without cardiopulmonary bypass in elderly patients with ischemic heart disease

Tkachev E.V., Kleshchev P.V., Vinogradov D.V., Khrenov Y.V., D'yakov S.V., Berezhnoy K.Y.


Rationale: Ageing of population results in an increase in number of aortocoronary bypass interventions in patients with ischemic heart disease aged 65 years and above. This patient group has an increased risk of complications related to systemic inflammatory response to surgical revascularization of the myocardium by on- pump coronary artery bypass (ONCAB). The off-pump coronary artery bypass (OPCAB) enables to avoid complications related to cardiopulmonary bypass; however, there is no consensus on this technique and no clinical guidelines have been developed.

Aim: To evaluate short-term results of surgical treatment of elderly patients with ischemic heart disease after OPCAB and after ONCAB.

Materials and methods: We performed a retrospective analysis of 61 patients aged above 60 years with multivessel coronary artery disease. The patients from group 1 (n = 31, mean age 72.2 ± 7.3 years) underwent OPCAB, whereas the patients from group 2 (n = 30, mean age 69.3 ± 7.7 years) underwent ONCAB and pharmaco-cold cardioplegia.

Results: In the patient group who had underwent OPCAB, there was a significant decrease in the duration of the surgery (4.15 ± 1.2 vs 4.53 ± 1.3 h, p < 0.05), reduction of the duration of mechanical ventilation (11.8 ± 2.3 vs 15.3 ± 1.4 h, p < 0.05), and the number of the transfused RBC doses (0.36 ± 0.9 vs 2.5 ± 1.1 U, p < 0.05). In the early postoperative period, there was a significant difference in the blood loss volume within the 1st day (280 ± 190 mL in group 1 and 359 ± 270 mL in group 2, p < 0.05). The group 1 patients showed a reduction in frequency of heart arrhythmia (4 (12.9%) vs 11 (36.5%) patients, p < 0.05), shorter duration of stay in the resuscitation unit (1.09 ± 0.3 vs 1.46 ± 0.8 days, p < 0.05) and in the department of cardiac surgery (5.06 ± 0.8 vs 7.3 ± 1.1 days, p < 0.05).

Conclusion: In the elderly patients, OPCAB could be the intervention of choice allowing for an improvement of short-term postoperative outcomes.

Almanac of Clinical Medicine. 2017;45(3):200-207
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The function of the left ventricular myocardial segments assessed by velocity vector imaging in patients with a myocardial infarction before and after coronary artery bypass

Petrova E.B.


Rationale: Velocity vector imaging is a non-invasive technique to analyze left ventricle (LV) fibers and determine the depth and area of an ischemic injury and the response to revascularization.

Aim: To assess LV functional parameters in patients with non Q-wave myocardial infarction and Q-wave myocardial infarction using velocity vector imaging before and in the early postoperative period after coronary bypass grafting.

Methods: We analyzed the strain (S) and strain rate (SR) of longitudinal, circular and radial fibers in 252 LV segments in 14 patients with non Q-wave myocardial infarction (group I) and in 252 segments in 14 patients with Q-wave myocardial infarction (group II) before and at day 12 after coronary bypass grafting.

Results: General analysis of the fibers from all LV segments, as well as a detailed analysis of each segment was performed by velocity vector imaging. The general analysis showed the following: the function of longitudinal fibers in group I was characterized by a low S parameter (-15.2 ± 7.4%) and normal SR (-1.04 ± 0.6 s-1); in group II – a low S (-12.7 ± 6.4%) and SR (-0.80 ± 0.4 s-1). The deformation characteristics of the circular fibers were reduced in both groups (group I: S -17.1 ± 8.9%, SR 1.23 ± 0.7 s-1; group II: S -14.02 ± 8.3%, SR -0.98 ± 0.6 s-1). The radial fibers had normal S values (group I: 29.1 ± 19.9%, group II: 25.9 ± 19.7%), high SR value in group I (1.73 ± 1.0 s-1) and normal SR in group II (1.35 ± 0.6 s-1). After coronary bypass surgery, the group II demonstrated an improvement in the SR of longitudinal (-0.91 ± 0.5 s-1, p = 0.001) and circumferential (-1.11 ± 0.5 s-1, p = 0.001) fibers, whereas the S of radial fibers deteriorated (21.7 ± 8.9%, p = 0.0004). In group I, radial fiber SR became normal (1.39 ± 0.6 s-1, p = 0.0004). A detailed analysis of the LV identified 10 groups of segments depending on the changes S and/or SR. Revascularization had an impact on all segments in patients of both groups. The segments with combined changes in S and SR improved its function. The segments with changes only in S or only in SR reduce their function, which is considered as a step to harmonic contraction.

Conclusion: General analysis of LV fibers shows the impact of myocardial infarction, and the detailed analysis helps to identify the impact of revascularization.

Almanac of Clinical Medicine. 2017;45(3):208-217
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Multidetector computed tomography in the assessment of neurologic complications after carotid endarterectomy

Vishnyakova Jr. M.V., Lar'kov R.N., Vishnyakova M.V.


Rationale: Carotid endarterectomy is a surgical procedure to prevent acute ischemic cerebrovascular accidents. Neurologic complications can occur after surgery. Multidetector computed tomography (MDCT) is used for their diagnosis in severely ill patients.

Aim: To evaluate the potential of MDCT in the diagnosis of neurologic complications after carotid endarterectomy.

Materials and methods: We analyzed the results of radiologic assessments in 15 patients with early postoperative neurologic complications which occurred after surgery for internal carotid artery occlusion (595 patients underwent surgery). In stable patients, brain magnetic resonance imaging (MRI) was performed (T1, T2, FLAIR, DWI modes) with non-contrast MR angiography. In critically ill patients, brain computed tomography, computed tomographic angiography and perfusion computed tomography were performed.

Results: Ischemic neurologic complications were found in 11 patients. One patient had no clinical manifestation of an ischemic stroke, and acute stage signs were found in his routine brain MDCT. In 9 patients with acute brain ischemia, MDCT (n = 6) and MRI (n = 3) results were specific for this diagnosis, with no diagnostic problems. There were problems with the diagnosis of the hyperacute ischemia in 1 patient. In this patient, the complication occurred against a background of abnormal carotid blood flow before surgery, therefore, differential diagnosis between the hyperperfusion syndrome on the intervention side and the hyperacute phase of ischemic insult on the opposite side was performed. Hyperperfusion syndrome and hemorrhagic strokes were observed in 4 patients.

Conclusion: The most difficult for diagnosis by MDCT is the hyperacute phase of brain ischemia. Further studies are necessary in the area of diagnosis of postoperative complications, with the search for potential specific diagnostic criteria.

Almanac of Clinical Medicine. 2017;45(3):218-224
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Neuroimmune and endocrine mechanisms of unfavorable geriatric status in patients with acute coronary syndrome

Sedova E.V., Paleev F.N., Prashchayeu K.I., Korshun E.I.


Background: Acute coronary syndrome (ACS) is the cause of above 70% of deaths in patients of older age. Frailty that develops in elderly patients provokes pro-inflammatory and neuroimmune inflammatory responses in the body that promote deterioration of the ACS course.

Aim: To study neuroimmunoendocrine alterations in elderly patients with ACS depending on the presence or absence of the frailty syndrome.

Materials and methods: The study was performed by retrospective, cross-sectional and prospective evaluation of the ACS patient registries within an international project GIRAFFE (Gerontological Research International Against Frailty: Fit Experience) in 2011–2015. We analyzed the results of measurement of serum tumor necrosis factor alfa (TNF-α) and the interleukin family (IL-1β, IL-4, IL-6, IL-10) in 633 patients with non-ST ACS (n = 270) and with ST-ACS (n = 363) at days 5, 12, and 26 from the beginning of the pain syndrome. From those, 265 patients were non-frail, 97 were pre-frail, and 271 patients had the frailty syndrome. The control group included 116 patients without significant somatic disease.

Results: In all study groups of patients with non-ST ACS, there was an increase in IL-4, IL-6 and IL-10 levels, compared to their reference ranges, at day 5 from the beginning of the pain syndrome. Subsequently, these parameters were changing with therapy, similarly in all groups: IL-4 level gradually decreased by the end of the follow-up, IL-10 level increased by day 12 from the beginning of the pain syndrome and decreased by day 26. The lowest IL-10 levels compared to the reference range (1.5 ± 0.2 pg/mL) were seen in the elderly frail patients: 2.9 ± 0.6 pg/mL at day 5 from the beginning of the pain syndrome, 7.2 ± 1.2 pg/mL at day 12, and 1.9 ± 0.3 pg/mL at day 26, compared to 8 ± 1.2, 15.5 ± 1.6 and 6.2 ± 1.1 pg/mL in the isolated ACS group, respectively (all p < 0.05). In the group with non-ST ACS, higher TNF-α and IL-1β levels, compared to the control, were registered only in the elderly frail patients. Under treatment, these parameters did not reached the reference ranges, being 187.7 ± 6.5 and 310.2 ± 29.5 pg/mL at day 5 from the beginning of the pain syndrome, 165 ± 6 and 299.5 ± 29.4 pg/mL at day 12 and 154 ± 5.9 and 265.9 ± 27.9 at day 26, respectively, compared to 68.7 ± 3 pg/mL (p < 0.05 for all comparisons to the control group). In the ST-ACS patients, TNF-α, IL-1β, IL-4, IL-6, and IL-10 levels exceeded the reference ranges in all groups studied for the whole study duration. In the patients with the elderly frailty syndrome the serum concentrations of TNF-α, IL-1β, IL-6 and IL-10 were higher than in the non-frail and pre-frail patients with ST-ACS. The IL-4 levels were not informative for the assessment of the contribution of the elderly frailty to the ST-ACS course.

Conclusion: The frailty syndrome of the elderly provokes the activation of the pro-inflammatory system that is confirmed by the consistent increase of serum pro-inflammatory mediators associated to the degree of the frailty syndrome in ACS patients.

Almanac of Clinical Medicine. 2017;45(3):225-233
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Reduction of the risk of thrombosis and restenosis with negatively charged electret covered stents

Fishman M., Knyazhansky M., Nemets A., Tsun A.


Rationale: Endovascular implantation may lead to mechanical injury of the vessel walls, their inflammation and subsequent formation of a thrombus in the stented portion of the vessel, as well as to endothelial growth and restenosis. Intimal injury changes the potential of the damaged area from negative to positive.

Aim: To demonstrate the efficacy of corrective negative charge on the stent surface after its endovascular implantation in the reduction of the risk of vessel thrombosis and restenosis.

Materials and methods: With a terminal element technique we created a model for distribution of electrostatic potentials in a healthy and in a partially injured vessel, as well as in a vessel with a negatively charged electret stent. Trials of experimental and serial stents in animals were performed with stent placement into the pig neck arteries with subsequent (at day 21) histological examination of the areas of stent placement. Morphological abnormalities and vessel wall reactions after endovascular carotid stent implantation, such as clot formation and endothelial reaction were assessed.

Results: Negatively charged electret cover of the stent produces corrective electrostatic field to prevent thrombus formation and vascular intima reaction with subsequent restenosis. The use of the stent with negatively charged electret cover ensures a significant reduction of the risk for positive potential inside the injured vessel, thereby dramatically reducing the risk of vessel thrombosis and restenosis. After placement of stents with negatively charged electret cover to animals, there was very mild proliferation of endothelial cells of the vessel wall neointima, compared to that after placement of the reference stents; no thrombus formation was observed. If the reference uncovered stents were placed, there was a dramatic narrowing of the arterial lumen due to proliferation of endothelial neointimal cells, as well as full thrombotic closure of the vessel.

Conclusion: The suggested technology allows for improvement of endovascular stent placement, for reduction of the risk of thrombosis and restenosis after endovascular interventions aimed at revascularization of arterial stenosis.

Almanac of Clinical Medicine. 2017;45(3):234-241
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Contrast induced nephropathy after transcatheter aortic valve implantation

Kranin D.L., Stets V.V., Pestovskaya O.R., Dunaev E.P., Nazarov D.A., Gaydukov A.V., Mashtanov G.V., Zamskiy K.S., Fedorov A.Y., Varochkin K.A., Kurnosov S.A.


Background: Aortic stenosis ranks the third in the structure of all cardiovascular diseases, conceding only to arterial hypertension and coronary heart disease. Transcatheter aortic valve implantation (TAVI) is a promising area of interventional endovascular surgery that enables to provide surgical care to a significant group of the patients with severe aortal stenosis.

Aim: To assess the efficacy of prevention of the contrast induced nephropathy (CIN) in patients who underwent TAVI under general anesthesia.

Materials and methods: We evaluated incidence of CIN in 19 patients who underwent surgery for aortic valve stenosis under general anesthesia with hemodilution and intravenous magnesium sulfate 1 g before administration of the contrast.

Results: Laboratory signs of nephropathy within the first 72 hours after the intervention were found in 8/19 (42.1%) of patients. In 4 (50%) of patients with CIN, its risk had been very high, in 3 (38%), high, and in 1 (12%), moderate. The results obtained are compatible with the contrast-induced acute kidney injury risk estimated from the Mehran-Barrett-Parfrey scale.

Conclusion: The used technique of hemodilution and magnesium-based prevention can be considered a safe method of CIN prophylaxis in TAVI patients.

Almanac of Clinical Medicine. 2017;45(3):242-246
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Late ventricular potentials in chronic heart failure patients with preserved ejection fraction

Dushina A.G., Libis R.A.


Rationale: More than half of patients with chronic heart failure have a preserved left ventricular ejection fraction. It has been found that sudden cardiac death is more frequent in this patient category. A reliable and easily available marker is needed that would predict the death outcome with a high probability. The use of the late ventricular potentials for this purpose could be reasonable.

Aim: To assess the prevalence of the late ventricular potential and their association with the structural and functional parameters of the myocardium in patients with early stages of chronic heart failure with preserved ejection fraction.

Materials and methods: We examined 77 patients with chronic heart failure (grade I to IIА, functional class I to III) with preserved ejection fraction (> 50%), aged 47 to 77 years (mean ± SD, 59.7 ± 7.8 years). Echocardiography (SonoScape 8000 and Vivid 3) at М-, В- and Doppler modes was performed in all patients. Ventricular ectopic activity and late ventricular potentials were registered during 24- hour ECG monitoring (Cardiotekhnika, INKART, St. Petersburg).

Results: Late ventricular potentials were found in 13% (10 of 77) of patients. The following correlations were found in patients with concentric hypertrophy (n = 53): between the duration of the filtered QRS (TotORSF) and the left ventricular end diastolic diameter (r = 0.27, p = 0.049), TotORSF and the interventricular septum thickness (r = 0.28, p = 0.04), TotORSF and the left ventricular myocardial mass (r = 0.35, p = 0.01), mean square magnitude of fluctuations within the last 40 ms of ORS (RMS40) and the left ventricular end diastolic diameter (r = -0.42, p < 0.01), RMS40 and the left ventricular end-systolic diameter (r = -0.37, p < 0.01). In the patients with eccentric hypertrophy (n = 14), the following correlations were found: between RMS40 and the left ventricular myocardial mass index (r = -0.77, p < 0.01), between duration of the low amplitude signal (< 40 μV) at the end of QRS (LAS40) and the left ventricular myocardial mass index (r = 0.76, p < 0.01), as well as between LAS40 and RMS40 with the end diastolic diameter of the left ventricle adjusted to the body surface area (r = 0.76, p < 0.01 and r = -0.83, p < 0.01, respectively). The patients with a pseudo normal type of diastolic dysfunction (n = 27) showed an association between their NT-proBNP levels and TotORSF (r = 0.56, p < 0.01).

Conclusion: The prevalence of late ventricular potentials among patients with early stage chronic heart failure and preserved left ventricular ejection fraction is not high. The parameters of electrophysiological myocardial instability in patients with concentric hypertrophy are mostly influenced by the size of heart chambers, whereas in those with the eccentric one, by the myocardial mass and volume parameters. The risk of sudden cardiac death is higher in patients with a pseudo normal type of diastolic dysfunction.

Almanac of Clinical Medicine. 2017;45(3):247-253
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Stenting of the right ventricular outflow tract after thrombosis of the modified Blalock-Taussig shunt in a 8 month old infant with tetralogy of Fallot and right pulmonary artery agenesis

Soynov I.A., Gorbatykh A.V., Nichay N.R., Omel'chenko A.Y., Leykekhman A.V., Kulyabin Y.Y., Voytov A.V., Gorbatykh Y.N.


Pulmonary artery agenesis combined with tetralogy of Fallot is the most rarely seen congenital heart disease. Children with this anomaly are an especially problematic category of patients undergoing staged surgical repair. The postoperative period quite often is complicated with shunt thrombosis while a redo open surgery is associated with a very high risk; therefore, endovascular repair is a preferred procedure. We describe a case of right ventricular outflow tract stenting in a 8 month old girl with tetralogy of Fallot and right pulmonary artery agenesis. The patient was admitted at 3 month after performing of a left-sided modified Blalock-Taussig shunt with severe signs of heart failure and desaturation caused by shunt thrombosis. Assessments performed at 2 months after stenting of the outflow tract demonstrated good oxygen saturation in arterial blood (80% and above) and improvement of heart failure symptoms to NYHA II class.

Almanac of Clinical Medicine. 2017;45(3):254-257
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Dissecting aortic aneurysm in a young woman

Iova O.Y., Morova N.A., Semenova L.N., Tsekhanovich V.N., Pavlov A.V.


We present a case of thoracic aortic dissection in a 33-year-old woman. The diagnosis was difficult, and the right diagnosis was made 4 months after the initial clinical manifestation. Aortic dissection was caused by necrosis of the media combined with longstanding arterial hypertension. Surgical intervention was performed timely and was effective.

Almanac of Clinical Medicine. 2017;45(3):258-261
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In memory of Raisa Stepanovna Tishenina



Almanac of Clinical Medicine. 2017;45(3):262-263
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