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A literature review is presented, reflecting the incidence, etiology, hemodynamics, localization, clinical manifestations, outcomes and treatment of infective endocarditis (IE) in patients with hypertrophic cardiomyopathy (HCM). Despite the relative rarity of IE in patients with HCM, the combination of these pathologies is characterized by mutual aggravation and poor prognosis. The addition of IE increases the risk of death in patients with obstructive HCM, deteriorating circulatory disorders, increasing the likelihood of uncontrolled sepsis and embolism. Conservative treatment of IE in patients with HCM does not differ from that without HCM. Interdisciplinary interaction is needed in the management of patients with IE against the background of HCM in determining the indications for cardiac surgery and choosing the optimal method. Antibacterial prophylaxis of IE before invasive medical manipulations in patients with HCM is not recommended by the current consensus documents, however, the decision for each patient should be made individually, with a mandatory assessment of the risk of IE, the severity of hemodynamic disorders and prognosis.

AIM OF STUDY Study of hospital results of emergency carotid endarterectomy (CEE) and carotid angioplasty with stenting (CAS) in the acute period of acute cerebrovascular accident (ACVA). MATERIAL AND METHODS From January 2008 to August 2020, the study included 615 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), operated on in the acute period of ischemic stroke (within 3 days from the onset of stroke). Depending on the type of revascularization implemented, all patients were divided into 2 groups: group 1 — CAS (n=312); 2nd group — CEE (n=357). Inclusion criteria were as follows: 1. Mild neurological disorders: NIHSS score 3–8; Modified Rankin Scale score 2 of less; Barthel Scale > 61; 2. Indications for CEE / CAS according to the current national recommendations; 3. Ischemic focus in the brain not more than 2.5 cm in diameter. Exclusion criteria: 1. Presence of con-traindications to CEE / CAS. Carotid angioplasty with stenting was performed according to the standard technique; in all cases, distal embolism protection systems were used. Carot-id endarterectomy was performed according to the classical and eversion techniques. When the retrograde pressure in the ICA was less than 60% of the systemic pressure, a temporary shunt (TS) was installed. In the postoperative period, all patients underwent multispiral computed tomography (MSCT) of the brain. In the absence of negative dynam-ics in the neurological status, MSCT was performed on the 7th day after the operation, if available, it was performed urgently. The checkpoints were the development of such unfa-vorable cardiovascular events as death, myocardial infarction (MI), stroke / transient is-chemic attack (TIA), “mute” stroke, “mute” hemorrhagic transformations, combined end-point (death + all strokes / TIA + MI). Strokes were mute if diagnosed according to MSCT, without symptoms. RESULTS In 69% of diabetic patients with anterior myocardial infarction and in 63% of patients with posterolateral MI 12 months after PCI, signs of LV inferiority were revealed in the form of an increase in the indices of end-diastolic and systolic volumes of the LV and low ejection fraction (≤45%). In patients without diabetes, these figures were 18% and 31%, respectively. High concentrations of NT-proBNP on the first day of myocardial infarction after PCI were of the greatest value in the diagnosis and prognosis of LV UR after 12 months. RESULTS When analyzing hospital complications, significant differences in the frequency of lethal outcome were not obtained (group 1: n=6 (1.92%); group 2: n=8 (2.24%); p=0.98; OR=0.85; 95% CI 0.29–2.49); MI (group 1: n=5 (1.6%); group 2: n=5 (1.4%); p=0.91; OR=1.14; 95% CI 0.32–3.99 ); ACVA (ischemic type) / TIA (group 1: n=5 (1.6%); group 2: n=6 (1.7%); p=0.82; OR=0.95; 95% CI 0.28–3.15), as well as “mute” ACVA (group 1: n=7 (2.2%); group 2: n=15 (4.2%); p=0.23; OR=0.52; 95% CI 0.21–1.3). However, the vast majority of hemorrhagic transformations (group 1: n=2 (0.64%); group 2: n=13 (3.6%); p=0.018; OR=0.17; 95% CI 0.03–0.76) and all “mute” hemorrhagic transformations (group 1: n=0; group 2: n=26 (7.3%); p=0.001; OR=0.02; 95% CI 0.001–0.33) were observed only in the CEE group, which was reflected in the maximum values of the combined end point: group 1: n=22 (7.05%); group 2: n=73 (20.4%); p

Background. The pandemic of severe acute respiratory syndrome COVID-19 drew the attention of researchers and practitioners worldwide to severe cardiovascular injury incurred by the new SARS-CoV-2 coronavirus. Objectives . A review and structuring of recent evidence on the pathophysiological mechanisms of SARS-CoV-2 impact on cardiovascular system and its major acute complications, assessment of indirect pandemic effects on treatment and diagnosis in practical cardiology. Methods . Literature sources were mined in the PubMed database with keywords “COVID-19” and “SARS-CoV-2” and the source type “Clinical Trial”, “Meta-Analysis”, “Review”, “Systematic Review”. The search depth was unrestricted, as the vast majority of publications appeared during the past year. Results . A screening of over 12,000 sources produced 329 most relevant articles available full-text, with 65 included in the review. A key factor of the SARS-CoV-2 penetration into human cell is protein S facilitating the virus—angiotensin-converting enzyme 2 binding and final fusion. Myocardial damage in COVID-19 can occur due to excessive inflammatory response, the disbalance of myocardial oxygen demand and supply, vasculitis, atherosclerotic plaque rupture, coronary spasm, hypoxic vascular damage and endothelial dysfunction, microthrombi formation. The most critical acute cardiovascular complications of COVID-19, apart from myocarditis, are cardiac arrhythmias, acute coronary syndromes, acute heart failure, thrombosis and embolism. The COVID-19 pandemic exerts an indirect negative influence on medical aid in patients with cardiovascular diseases and complications. Conclusion . Knowledge of the pathophysiological mechanisms of SARS-CoV-2 impact on cardiovascular system and major types of its acute complications allows targeted research into the scenarios of their prevention and treatment. A rational balance is expected between the infection control and treatment for critical noncommunicable, particularly, cardiovascular diseases.

Paradoxical thromboembolism due to the presence of an patent foramen ovale (PFO) is a rather rare phenomenon, especially when an embolism results in acute myocardial infarction (MI). The presented clinical case of the paradoxical embolism is interesting for several reasons: firstly, the patient's primary disease was deep vein thrombosis (DVT) and pulmonary artery thromboembolism (PATE); secondly, apparently, it was due to PATE and the subsequent overload of the right side of the heart that thelatent embolism became apparent; thirdly, the paradoxical embolism was apparently caused by the fragments of alarge thrombus stuck in PFO, fourthly, the current clinical situation was ambiguous with respect to medical decisions, primarily concerning antithrombotic therapy.

The objective : to study the hemostatic system of patients diagnosed with the novel new coronavirus infection and compare the data obtained with hemostatic system parameters in patients with advanced deep vein thrombosi s/p ulmonary embolism without COVI D -1 9. Subjects and methods. A singl e-c enter prospective study with retrospective control was conducted in Anesthesiological and Intensive Care Department No. 1 of Kuvatov State Medical University (Ufa) in April - May 2020, the objective of the study was to investigate the hemostatic system of patients with confirmed new coronavirus infection, patients diagnosed with venous thrombosis in 201 2-2 014, and a group of healthy volunteers. Results . Evaluation of the hemostasis system in patients with thrombosis and patients with COVI D -1 9 demonstrates the same type of changes: MA , Angle, G indices increase according to thromboelastography results, as well as D-d imer and fibrinogen levels increase, while antithrombin III activity decreases. Conclusion. Thus, TAG may be crucial for accurate identification of patients with advanced increased risk of thrombosis and thus possibly avoid unnecessary anticoagulation in patients at low risk of thrombosis.

Endothermal heat-induced thrombosis (EHIT) is a complication of endovenous thermal ablation in treatment of varicose veins. Existing classifications do not account for the length of thrombus extension floating in the deep venous system. While the risk of extension is minor, the consequences can be baleful.Aim. To report a rare clinical case of endothermal heat-induced thrombosis extension formed in spite of ongoing anticoagulant treatment in a patient with endovenous laser ablation.Results. A 39 years-old man with endovenous laser ablation of the right great saphenous vein had class 2 EHIT with 1.92 cm length on the next day after surgery. Rivaroxaban was prescribed at a dose of 15 mg 2 times a day. EHIT extension above the inguinal ligament occurred on the 15th day after surgery, despite oral anticoagulant treatment. Open thrombectomy with high ligation was ordered. Postoperative period without complications. Preoperative Caprini score was 6 (varicose veins, BMI> 25 kg/m2 , minor surgery, personal history of venous thromboembolism (VTE)).Conclusion. The reported clinical case illustrates that both the choice of treatment strategy and follow-up of patients with EHIT need to account for the combined risk of embolism with existing EHIT and potential thrombus extension with subsequent massive embolism.

Patent foramen ovale (PFO) is an important cause of embolic cryptogenic stroke (ECS) in young patients. The main mechanism in this case is paradoxical embolism (PE), the basis for which is a right-to-left (R-L) shunt. Objective: to comparatively characterize patients who have undergone ECS, with and without an R-L shunt, as evidenced by transcranial Doppler with the bubble test (TCD-BT). Patients and methods . In 40 patients with acute ECS, an R-L shunt was sought using TCD-BT, followed by transesophageal echocardiography (TEE). The left atrial volume index (LAVI) was additionally calculated. Brain damage was analyzed by probabilistic mapping of foci according to magnetic resonance imaging. Results and discussion. The mean age of the examined patients was 51.5 (39.5–60.0) years; of them there were 22 women and 18 men. An RL shunt was detected in 24 (60.0%) of patients with cryptogenic embolism that was mainly grades 2 and 3 (41.0 and 35.0%). TEE could visualize PFO (1.0 to 5.5 mm in size) in 16 (40%) patients and atrial septal aneurysm in 3 (7.5%). PFO was not found in 5 patients with positive results of TCD-BT, which may suggest that there is either a pulmonary shunt or a false-negative TEE. The patients with an R-L shunt versus those without an R-L-shunt showed lower LAVIs (23.9 and 26.5 mL/m2) (p=0.016). This fact may additionally confirm the causative role of PFO in the development of stroke, whereas higher LAVIs in the non R-L shunt subgroup should alert to the presence of atrial cardiopathy and initiate an appropriate diagnostic search for latent atrial fibrillation. According to the presence or absence of an R-L shunt, the groups did not significantly differ in gender, age, and clinical characteristics of the stroke. In patients with PFO, a lesion focus was most commonly localized in the middle cerebral artery bed (35.3%), cerebellum (23.5%), and posterior cerebral artery (17.6%). Five (29.0%) patients were ascertained to have several foci of acute stroke. There was a trend towards the larger size of cerebral infarction foci and their specific localization in the vertebrobasilar bed in PE, which determined the high (35.3%) incidence of ataxia with the onset of the disease. Conclusion. PE causes ECS in 60.0% of cases. The distinctive feature of patients with an R-L shunt is lower LAVIs and a trend towards the larger size of cerebral infarction foci and their specific localization in the vertebrobasilar bed.

The OBJECTIVE of the study was to assess the current trends in the surgery of acute upper limb ischemia (AULI). MATERIAL AND METHODS. We performed the comparative analysis of clinical data and treatment results of 261 patients with AULI urgently treated between 2008 and 2018 years (main group) and 162 patients with AULI treated between 1975 and 1985 years (control group). RESULTS. For the past 30 years, there were the growing rate of AULI. In 92.7 % of cases, the main cause of AULI was embolism. The main disease leading to embolism became atrial fibrillation in 80.8 % of cases. For the past decades, there was a significant improvement of treatment results in patients with AULI: complete extremity blood flow supply was achieved in 95 % in main group vs 90.5 % in control group (pCONCLUSION. AULI continued to remain the actuality in modern vascular surgery.

Aim. Neural progenitor cells (NPC) are used for the development of cell therapies of neurological diseases. Their stereotaxic transplantation in the middle cerebral artery occlusion (MCAO) model imitating ischemic stroke results in symptom aleviation. However, exploration of less invasive transplantation options is essential, because stereotaxic transplantation is a complex procedure and can be applied to humans only by vital indications in a specialized neurological ward. The aim of the present study was to evaluate the efficacy of cell therapy of the experimental ischemic stroke by the intra-arterial transplantation of NPC.Materials and methods. NPC for transplantation (IPSC-NPC) were derived by two-stage differentiation of cells of a stable line of human induced pluripotent stem cells. Stroke modeling in rats was carried out by transitory 90 min endovascular MCAO by a silicon-tipped filament. NPC were transplanted 24 hours after MCAO. Repetitive magnetic resonance tomography of experimental animals was made with the Bruker BioSpin ClinScan tomograph with 7 Tl magnetic field induction. Animal survival rate and neurological deficit (using mNSS standard stroke severity scale) were evaluated at the 1st (before IPSC-NPC transplantation), 7th and 14th day after transplantation. Histological studies were carried out following standard protocols.Results. Intra-arterial transplantation of 7 × 105 IPSC-NPC in 1 ml at a constant 100 l/min rate in case of secured blood flow through the internal carotid artery did not cause brain capillary embolism, additional cytotoxic brain tissue edemas or other complications, while inducing increase of animal survival rate and enhanced revert of the neurological deficit. IPSC-NPC accumulation in brain after intra-arterial infusion was demonstrated. Some cells interacted with the capillary endothelium and probably penetrated through the blood-brain barrier.Conclusion. Therapeutic efficacy of the systemic, intra-arterial administration of NPC in ischemic stroke has been experimentally proven. A method of secure intra-arterial infusion of cell material into the internal carotid artery middle in rats has been developed and tested.

Aim. To assess the potential of prevention cardiogenic embolism by resection of left atrium appendage (LAA) during open heart surgery in patients with atrial fibrillation (AFib). Materials and methods. Study design - cohort prospective. Study group consisted of 19 patients with AFib whom during open heart surgery for coronary and/or valvular disease additional radical resection of LAA was made. After removal of the appendage two-layer linear suture to left atrium was performed without leaving a stump. Control group consisted of 20 patients with AFib, in whom during open heart surgery LAA remained intact. Long-term results were studied using CROQ telephone questionnaire. Results. There was no hospital mortality in both groups. Long-term results in control group were followed up to 6 years, in study group up to 2 years. Radical resection of LAA in patients with AFib reduced the risk of thromboembolic events in long-term period. In control group there were 4 strokes (2 of them were fatal), but no strokes in study group (p < 0,05). Conclusion. Radical resection of LAA in patients with AFib during open heart surgery for coronary and/or valvular disease prevents cardiogenic arterial embolism. (For citation: Sotnikov AV, Melnikov MV, Marinin VA, et al. Prevention of embolism in patients with atrial fibrillation after resection of left atrium appendage during open heart surgery (pilot study). Herald of North-Western State Medical University named after I.I. Mechnikov. 2018;10(2):52-57. doi: 10.17816/mechnikov201810252-57).

The review article presents current data on the clinical and prognostic significance, as well as on the prevalence of comorbidities in patients with atrial fibrillation (AF). The prevalence of hypertension, diabetes and heart failure in patients with AF is discussed according to the Russian and foreign registry studies, randomized clinical trials. The problem of the effect of comorbidity on the risk of embolism and bleeding in AF is outlined. Potentialities of a novel oral anticoagulant edoxaban (based on the ENGAGE AF-TIMI 48 trial) for managing the risks of thromboembolic and bleeding events in AF and comorbidities. Sub-analyzes of the ENGAGE AF-TIMI 48 trial were discussed, which demonstrated efficacy comparable to warfarin in the embolism prevention and higher safety against bleeding, regardless of the comorbidity profile.

В данной статье демонстрируется случай необычной диагностики миксомы левого предсердия (ЛП) на фоне острого нарушения мозгового кровообращения, после чего пациентка была направлена в Национальный институт сердечно-сосудистой хирургии имени Н.М. Амосова НАМН Украины. По экстренным показаниям выполнена операция: удаление гроздевидной миксомы ЛП с множественными фрагментами, отрыв которых мог вызвать повторную эмболию сосудов большого круга кровообращения., У даній статті демонструється випадок незвичайної діагностики міксоми лівого передсердя (ЛП) на тлі гострого порушення мозкового кровообігу, після чого пацієнтка була направлена в Національний інститут серцево-судинної хірургії імені М.М. Амосова НАМН України. Виконана операція за екстреними показаннями: видалення гроноподібної міксоми ЛП з множинними фрагментами, відрив яких міг викликати повторну емболію судин великого кола кровообігу., This article demonstrates a case of unusual diagnosis of a left atrial myxoma on the background of acute cerebrovascular accident, after which the female patient was referred to the Amosov National Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. According to emergency indications, the following surgery was performed: removal of an aciniform left atrial myxoma with multiple fragments, the detachment of which could cause repeated embolism of the vessels of systemic circulation.

Background The advantages of thrombolytic therapy over anticoagulant therapy in the treatment of acute pulmonary embolism are uncertain. Aim of study To compare primary outcomes and incidence of complications in patients with PE of high and intermediate risk in the course of TLT or ACT and to assess efficacy and safety of TLT and ACT. Study Design Prospective non-randomized study. Intervention was administration of a thrombolytic, the control group consisted of patients who had an anticoagulant introduced. Characteristics of a sample 503 patients with a high and intermediate risk of early death at the age of 16 to 93 years (mean age 61±16, Ме 63 (51; 74) admitted to the resuscitation department in 2011–2016. Thrombolytics were administered to 222 patients, heparin — 281. Results The mortality rate was 10.8% (24/222) when treated with thrombolytic vs. 17.8% (50/281) with anticoagulant treatment; odds ratio was 0.56, 95% confidence interval 0.32; 0.97; p=0.031; P=0.60. The mortality rate in the subgroup with unstable hemodynamics was 30.2% (19/63) with thrombolytics vs. 47.1% (32/68) with anticoagulant treatment; OR 0.49 (0.22; 1.06); p=0.051; P=0.51. The mortality rate in the subgroup of intermediate risk was 3.2% (5/158) vs. 8.4% (18/214); OR 0.36 (0.11; 1.05); p=0.049; P=0.54. The use of thrombolytic was associated with a decrease in mortality: in the age group< 75 (mortality rate 5.5% (10/181) vs. 16.2% (33/204), OR 0.30 (0.14; 0.67); p=0.001, P=0.92); in the subgroup with acute cardiac arrhythmias (mortality rate 4.5% (1/122) vs. 44.0% (11/25); OR 0.061 (0.003; 0.557); p=0.002; P=0.91); in the subgroup with no hospital recurrence of embolism (mortality rate 1.6% (3/188) vs. 12.9% (32/248); OR 0.14 (0.03; 0.46), p< 0.001; P=1.0). With thrombolysis, infarction pneumonia developed less often: in 19.8% (44/222) vs. 28.8% (81/281); OR 0.61 (0.39; 0.95); p=0.022; P=0.64. There were no differences in the incidence of hemorrhagic complications in the treatment of thrombolytics in comparison with anticoagulant therapy: 7.7% (17/222) vs. 10.3% (29/281); OR 0.72 (0.37; 1.40); p=0.35; P=0.17. Severe hemorrhages (including intracranial): 2.7% (6/22) vs. 3.2% (9/281); OR 0.84 (0.26; 2.62); p=0.80; P=0.06. Minor hemorrhages: 5.0% (11/ 222) vs. 7.1% (20/281); OR 0.72 (0.31; 1.63); p=0.36; P=0.16. Intracranial hemorrhages: 0.90% (2/222) vs. 0.71% (2/281); OR 1.27 (0.13; 12.67); p=0.81; P=0.13). There was no difference in the re-occurrence of embolisms: 15.3% (34/222) and 11.7% (33/281); OR 1.36 (0.79; 2.35); p=0.29; P=0.22. Conclusion Thrombolytic therapy appeared to be more effective for survival compared to anticoagulant therapy with no differences in the incidence of complications.

OBJECTIVE. According to the analytical data, the acute non-occlusive mesenteric ischemia after infrarenal aortic aneurism repair occurs in 0.2–1 % of cases. This complication is difficult to diagnose and associated with unfavorable prognosis and high mortality. MATERIAL AND METHODS. The retrospective analysis included 112 case histories of patients with infrarenal aortic aneurism repair in the period from 2007 to 2017. RESULTS. During the early postoperative period, 2 patients (1.8 %) had an acute non-occlusive mesenteric ischemia with lethal outcome. In these cases, the complication developed with safety patency of main mesenteric arteries and was followed by developing early multiorgan failure and thrombocytopenia. The autopsy showed generalized atherosclerosis, infarctions of kidneys, spleen and liver, caused by cholesterol crystal embolism of microvascular bed, which was found after histological research. CONCLUSION. The clinical presentation of acute non-occlusive mesenteric ischemia after infrarenal aortic aneurism repair is low-specific. One of the etiological factors of this complication is cholesterol crystal embolism in microvascular bed of visceral arteries

Pulmonary embolism in pregnant women is fairly common complication, and it remains to be the one of major causes of maternal mortality in the number of countries. The need to compare risks of the mother and child makes the search for optimal treatment tactics very complicated in this specific case. The experience of the last decades provides evidences for choosing aggressive treatment tactics, accurate diagnostics and early surgical intervention. The authors of this article describe the clinical case of successful treatment of the young woman whose pregnancy course was complicated by pulmonary embolism at the 11th week of gestation. The article describes the results of laboratory and instrumental diagnostics and anasthesiological support technique within available scope of pharmacological and technical means. Also the article reviews the literature data on this problem. The conclusion contains recommendations for intra-operative management of such patients.

The review presents the results of experimental and clinical studies of the effect of early osteosynthesis in the femoral fracture on the development of systemic complications and the outcome of polytrauma with chest injuries. We explored the role of combination of thoracic injuries with a fracture of the femur, as well as its intramedullary osteosynthesis in the mechanisms of local and systemic inflammatory reaction formation, coagulopathy, fatty embolism and pulmonary embolism, respiratory failure. The concepts of “immediate total care” and “orthopedic damage control” are described with reference to fractures of the femur, combined with a chest trauma. The criteria for the relative safety of osteosynthesis of the femur in polytrauma with thoracic injuries are given.

The article presents a comparative analysis of the clinical course of pulmonary embolism and the effectiveness of thrombolytic therapy in patients with thrombophilia and in those without identified thrombolytic disorders. The impact of thrombophilia on the incidence of pulmonary embolism and phlebothrombosis was analyzed. The results obtained indicate the presence of thrombophilia in 25.7% of patients with pulmonary embolism. It was found out that thrombosis and embolism in the vena cava filter occurred more frequently in patients with thrombophilia rather than in those with pulmonary embolism of unknown etiology.

Bullet embolism is a rare and unpredictable complication of gunshot and mine‑explosive injuries. With only few cases described in the literature, bullet embolism may become a diagnostic challenge for emergency and military surgeons. Thus, bullet embolization is a rare phenomenon, the complications can be devastating.A clinical case of bullet embolism is described. 34‑years old man got combined abdominal‑skeletal mine‑explosive injuries with damage to hollow organs (duodenum and transverse colon), inferior vena cava and both low extremities. Internal bleeding was stopped by the inferior vena cava edge wound suturing. Wounds of duodenum and large intestine were sutured; gunshot fractures of both tibial bones were stabilized with external fixation devices. Computer tomography of the entire body showed the presence of embolus in the right middle lobe artery. Clinical manifestations of pulmonary embolism were not observed. The patients had several complications after surgery such as: multiple focal necrosis and perforations of transverse colon caused a fecal peritonitis; duodenum suture failure caused forming of a duodenal fistula; postoperative wound infection. These complications necessitated performing of multiple reoperations. Attempts of endovascular bullet extraction didn’t undertake because of severe concomitant injuries, its complications and asymptomatic clinical course of pulmonary artery projectile embolism. Open surgery removing of embolus was successfully performed in 80 days after injury. The patient was discharged from hospital in good condition in 168 days after gunshot wound. Patients with an explosive‑mine wound and gunshot wound with no exit should to be examined with whole‑body computer tomography for determining possible projectile migration with bloodstream. Patients with asymptomatic pulmonary artery embolism should to be managed non‑operatively in the early posttraumatic period. In case of symptomatic pulmonary artery bullet embolism is reasonable to consider of a possibility of an open thoracic surgery., Пулевая эмболия является редким и непредсказуемым осложнением огнестрельных и минно‑взрывных ранений. В связи с наличием единичных литературных сообщений пулевая эмболия может оказаться существенным диагностическим вызовом для неотложных и военных хирургов. Хотя пулевая эмболия является редкостным феноменом, ее последствия могут стать фатальными для раненного.Описан клинический случай пулевой эмболии. Мужчина 34 лет получил сочетанное абдоминально‑скелетное минно‑взрывное ранение с повреждением полостных органов (двенадцатиперстная и поперечная ободочная кишка), нижней полой вены и обеих нижних конечностей. Внутреннее кровотечение было остановлено путем ушивания краевого ранения нижней полой вены. Ранения двенадцатиперстной и ободочной кишки были ушиты, огнестрельные переломы костей обоих голеней стабилизированы с помощью аппаратов внешней фиксации. Компьютерная томография всего тела показала наличие эмбола в правой среднедолевой легочной артерии. Клинических проявлений легочного эмболизма не наблюдали. В послеоперационный период у пациента возник ряд осложнений: множественные фокальные некрозы и перфорации поперечной ободочной кишки с развитием калового перитонита, несостоятельность швов двенадцатиперстной кишки с формированием наружного функционирующего дуоденального свища, нагноение послеоперационных ран. Упомянутые осложнения требовали проведения многочисленных повторных оперативных вмешательств. Попыток эндоваскулярного удаления пули‑эмбола не проводили из‑за тяжелой сочетанной травмы, ее осложнений и бессимптомного течения пулевой эмболии легочной артерии. Открытое хирургическое удаление пули‑эмбола выполнено на 80‑й день после ранения. Пациент был выписан в удовлетворительном состоянии на 168‑й день после огнестрельного ранения.Пациентам с осколочными ранениями без выходного отверстия целесообразно провести компьютерную томографию всего тела для выявления возможной миграции осколков с током крови. У пациентов с бессимптомным течением пулевой эмболии легочной артерии следует придерживаться консервативной тактики в ранний посттравматический период. В случае наличия клинических симптомов пулевой эмболии легочной артерии необходимо рассмотреть возможность выполнения открытого торакального вмешательства., Кульова емболія є рідкісним та непередбачуваним ускладненням вогнепальних і мінно‑вибухових поранень. У зв’язку з наявністю поодиноких літературних повідомлень, кульова емболія може стати значним діагностичним викликом для невідкладних та військових хірургів. Хоча кульова емболія є рідкісним феноменом, її наслідки можуть бути фатальними для пораненого.Описано клінічний випадок кульової емболії. Чоловік 34 років отримав поєднане абдомінально‑скелетне мінно‑вибухове поранення з пошкодженням порожнистих органів (дванадцятипала і поперечна ободова кишка), нижньої порожнистої вени та обох нижніх кінцівок. Внутрішню кровотечу зупинено шляхом ушивання крайового поранення нижньої порожнистої вени. Поранення дванадцятипалої та ободової кишки ушиті, вогнепальні переломи кісток обох гомілок стабілізовані за допомогою апаратів зовнішньої фіксації. Комп’ютерна томографія всього тіла показала наявність емболу в правій середньочастковій легеневій артерії. Клінічних виявів легеневої емболії не спостерігали. В післяопераційний період у пацієнта виникла низка ускладнень: множинні фокальні некрози та перфорації поперечної ободової кишки з розвитком калового перитоніту, неспроможність швів дванадцятипалої кишки з формуванням зовнішньої дуоденальної нориці, яка функціонує, нагноєння післяопераційних ран. Зазначені ускладнення потребували проведення численних повторних оперативних втручань. Спроб ендоваскулярного видалення кулі‑емболу не проводили через тяжку поєднану травму, її ускладнення та безсимптомний перебіг кульової емболії легеневої артерії. Відкрите хірургічне видалення кулі‑емболу виконане на 80‑й день після поранення. Пацієнта виписано зі стаціонару в задовільному стані на 168‑й день після вогнепального поранення.Пацієнтам з уламковими пораненнями без вихідного отвору доцільно провести комп’ютерну томографію всього тіла для виявлення можливої міграції уламка з током крові. У пацієнтів із безсимптомним перебігом кульової емболії легеневої артерії слід дотримуватися консервативної тактики в ранній посттравматичний період. За наявності клінічних симптомів кульової емболії легеневої артерії необхідно розглянути можливість відкритого торакального втручання.

Aim. To evaluate the main possible reasons for arterial hypertension in patients with thrombotic occlusion of the large arteries of extremities in atherosclerotic disease. Material and methods. The course of arterial hypertension was analyzed in 129 cases of atherosclerotic aortic disease, complicated with acute thrombotic occlusion of the arteries of lower (112) and upper (17) extremities due to thrombosis (108) and embolism (21) of magistral vessels comparing to the data of 46 patients with chronic ischemia of lower extremities. Results. Arterial hypertension (AH) in anamnesis was marked in all patients of study groups and comparison group. systolic AH was diagnosed in 17,8% (23), and in comparsion group — 19,5% (9). Thrombectomy was followed by the decrease of mean BP in most of patients, with good effect of operation and return of adequate circulation in the extremity — in 82,2%, by mean 17,1% systolic and 21,4% — diastolic BP. In 31 patient the dynamics of systolic and diastolic BP after operation was not single-directed and did not raise for more than 5% over baseline, and in 7% cases there was increase of BP, by mean 19,4% systolic and 22,6% diastolic. GFR levels were lower than normal in more than 70% patients of AEI and more than 65% in comparison group. Conclusion. Thrombectomy and reconstruction interventions on occluded arteries, with successful restore of main circulation in the extremity, are followed by significant decrease of systemic systolic and diastolic arterial pressure in most patients.

Cardiac surgery is the only radical method of treatment of valvular defects (congenital or acquired): valve preservation procedures or prosthetics operations. 250 000 – 280 000 valve prostheses are implanted every year worldwide, while the number of prosthetic valves operation increases by an average of 5–7 % per year (biological prostheses – 8–11 %, mechanical prostheses – 3–5 %). Selection of biological or mechanical types of prosthesis, its location, the presence of associated risk factors for embolic events, such as atrial fibrillation, previous embolism, left ventricular dysfunction, hypercoagulable states determine patient management tactics. Particularly high risk of prosthetic thrombosis and thromboembolic complications can be seen in case of mechanical prosthesis implantation. Numerous prospective and retrospective clinical studies have proven high effectiveness of anticoagulants for reduction the risk of cardioembolic complications. The degree of anticoagulation (optimal international normalized ratio (INR)) is determined by risk factors for prosthetic thrombosis and thromboembolic complications in a patient, as well as thrombogenicity of the prosthesis by itself; INR may range from 2.5 to 4.0. International recommendations take into account the presence/absence of additional risk factors for thromboembolism, and based on warfarin administration with the achievement of target INR values combined with low-dose aspirin. Administration of novel direct oral anticoagulation remedies in patients with prosthetic heart valves has not been studied sufficiently up to date and is contraindicated. Thus, warfarin currently is a drug of choice for the prevention of thromboembolic complications in patients with prosthetic heart valves.

Background: High prevalence of stroke and constant mortality which is related to thromboembolic complications in one fourth of patients make it necessary to continue evaluation of clinically precise and technologically feasible methods of adequate control of coagulation and anticoagulation systems and predicting of venous thromboses and embolism. Aim: To improve diagnostics and treatment of patients with acute stroke of various types through assessment of haemostasis system and pathophysiological mechanisms of venous thromboembolism (VTE). Materials and methods: One hundred and forty five (145) patients with acute cerebral stroke (mean age, 69±13.2 years; 75 male and 70 female) were included into the study. All patients were admitted to the neuroresuscitation unit within 6 to 24 hours from manifestation; the diagnosis was verified by multiaxial computerized tomography. One hundred and four (104) (71.7%) of patients had ischemic stroke, 41 (28.3%) of patients had hemorrhagic stroke. At admittance, all patients had a certain level of consciousness derangement. All patients were monitored by means of computerized tomography, general and neurological assessment, functional assessment, chest X-ray, ultrasound examination of extremities and assessment of haemostasis (screening and direct thrombodynamics test). Results: In 95% of cases, VTE risk factors were found; VTE developed in 40 (27.6%) of patients. The most frequent complication was pulmonary embolism (90% of all VTE and 24.8% of 145 patients). In-hospital mortality was 44.1% (n=64) and correlated with VTE (r=0.384; р

Aim: To assess clinical and functional efficacy of implanted biological prosthesis “ASPIRE” (manufactured by Vascutek) for correction of mitral valve disease. Materials and methods: From October 2008 to December 2013, biological prostheses “ASPIRE” (Vascutek) were implanted to 34 patients with mitral valve disease (mean age 63.59 ± 4.96 years, 79.4% female). From these, 24 patients had mitral stenosis and 10 patients had mitral insufficiency. 73.5% of all patients had heart failure Strazhesko-Vasilenko IIA grade and 85.3% of patients had chronic heart failure NYHA III. Isolated mitral valve replacement was performed only in 8 (23.5%) of patients. In 22 (64.7%) of cases mitral valve replacement was combined with tricuspid valvuloplasty in various modifications. Duration of cardiopulmonary bypass and of aortic clamping was 88.09 ± 25.95 and 65.68 ± 25.51 minutes, respectively. Before and after surgery all patients underwent echocardiographic assessment and clinical assessment of their general status. Results: In-hospital mortality was 5.88% (n = 2) and was related to multiorgan failure in the early postoperative period. All 32 (94.12%) surviving patients improved with decrease or complete disappearance of heart failure. Postoperative complications were typical for cardiac surgery. There were no episodes of embolism, structural dysfunction, thrombosis of the prosthesis and endocarditis of the prosthesis in the early postoperative period. Pressure gradients across prosthetic valves were not high and corresponded to good clinical and hemodynamic results in the early postoperative period. Conclusion: Taking into account good immediate results of mitral valve replacement, as well as no need in lifelong anticoagulation in patients with multiple concomitant disorders, implantation of the biological prosthesis “ASPIRE” (Vascutek) could become a procedure of choice for correction of valve abnormalities in patients above 65 years. For more comprehensive assessment of the implanted prosthesis, it is necessary to further assess long-term results of valve replacement.

Analysis of the safety and efficacy of the currently marked oral anticoagulants in patients after large joints arthroplastyat outpatient step was presented for the first time in Russian clinical practice. Total number of 5025 patients after total knee and 5216 patients after total hip arthroplasty were examined. All patients were divided into 3 groups depending on prescribed anticoagulant (dabigatran, rivaroxaban or apixaban). Duration of therapy with corresponding drug after hip and knee arthroplasty was initiated after surgery and made up 35 and 45 days, respectively. Deep vein US examination was performed to all patients in 3 and 6 months after discharge. In patients on dabigatran the rate of clinically significant deep vein thrombosis development was lower than in patients on rivaroxaban and apixaban, and made up 5% vs 7.7 and 16%, respectively. Rate of nonfatal pulmonary embolism (PE) was comparable. Relapse of deep vein embolism development was diagnosed only in patients who received rivaroxaban. A suggestion on the expediency of a longer thromboprophylaxis after surgical interventions on large joints was made that would require extensive studies.

Despite being thoroughly studied, senile aortic stenosis (AS) remains a disease that is frequently underestimated by Russian clinicians. Meanwhile, its manifestations can not only deteriorate quality of life in patients, but can also be poor prognostic signs. The most common sequels of this disease include heart failure and severe arrhythmias. However, there may be also rare, but no less dangerous complications: enteric bleeding associated with common dysembriogenetic backgrounds, infarctions of various organs, the basis for which is spontaneous calcium embolism, and consciousness loss episodes. The latter are manifestations of cardiocerebral syndrome. Apart from syncope, embolic stroke may develop within this syndrome. There is evidence that after syncope occurs, life expectancy averages 3 years. Global practice is elaborating approaches to the intracardiac calcification prevention based on the rapid development of new pathogenetic ideas on this disease. In particular, it is clear that valvular calcification is extraskeletal leaflet ossification rather than commonplace impregnation with calcium salts, i.e. the case in point is the reverse of osteoporosis. This is the basis for a new concept of drug prevention of both calcification and the latter-induced heart disease. But the view of senile AS remains more than conservative in Russia. The paper describes a clinical case of a rare complication as cerebral calcium embolism and discusses the nature of neurological symptoms of the disease, such as vertigo and syncope.

The paper reviews the literature on the identification of the causes of ischemic stroke and transient ischemic attacks in intracranial atherosclerosis. Symptomatic intracranial atherosclerosis is the cause of an ischemic focus in not only the cortical and subcortical structures due to hypoperfusion or arterio-arterial embolism, but also in the deep structures of the cerebral hemispheres and brainstem. Major artery dolichoectasia may make an accurate diagnosis and treatment choice difficult. Progress in the treatment of patients with symptomatic intracranial atherosclerosis depends on the availability of current brain and vessel imaging techniques and cranial artery angioplasty and stenting methods. The efficiency of aggressive medical prevention, primarily blood pressure reduction and different combinations of antiplatelet drugs, is being intensively investigated.

To study clinical and diagnostic, surgical and morphological properties of pseudotumorous heart formations, possibilities for early diagnostics and to invent optimal treatment strategy. Material and methods. Petrovsky Centre for Surgery has the heart tumours treatment experience of 326 patients during the time from December 1962 till December 2010. Morphologically confirmed were tumours of 259 (79,4%) patients. At the current moment the study includes 67 patients with pseudotumorous formations of the heart, continuously supervised at the Centre from February 1960 till December 2010. Of those 36 were males and 31 females at the age of 2,2-74 (median 34,1±2,1), Results. Total survival not including in-hospital mortality, evaluated by Kaplan-Meier method, gained 100% and 94,3% at the 1st and 24th year of observation, respectively. Analysis of the "life quality" of these patients at the remote periods after operation shows its significant improvement. Treatment results claimed as "good" were set for 62,8%; "satisfactory" for 31,4% and "nonsatisfactory" for 5,8% of cases. Treatment strategy for the patients with morphologically not confirmed voluminous formations (29,9%) was predestinated by smaller sizes (4-10 mm diameter), nonmobility that could be regarded as the risk for embolism, smooth echogenity with sharp border, absence of hemodynamical malfunction and clinical signs. Conclusion. The analysis has shown that on-time diagnostics of voluminous formations of the heart with pseudotumorous and morphologically non-recognizable properties is very complicated. Clinical awareness while interpreting the short clinical anamnesis and specificities of clinical picture made it possible to realise the individualized choice for the algorhythm of further diagnostics taking into account an oncological determinancy. The success of the operations was predicted by the conditions of normo- or hypotermic perfusion and cold-pharmacological cardioplegy, ensuring optimal exposition and adequate protection for the myocardium, following the rules for prophylaxy of "tumours" fragmentation and embolism, and correction of comorbid valve pathology, inherited valve defects and ischemic heart disease.