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To compare efficacy of spontaneous breathing with pressure support and volume-controlled mandatory ventilation during combined general anesthesia using desflurane and without muscle relaxants.Subjects and Methods. 100 patients were included in the study. All underwent low-traumatic operations on the lower limbs under general combined anesthesia using supraglottic air devices without muscle relaxants. Immediately prior to the induction of anesthesia, patients were randomly divided into two groups: Group 1 (VCV) where a mandatory volume control mode was used (n = 50) and Group 2 (PSV) where a pressure support mode was used (n = 50). The following parameters were assessed: hemodynamics, gas exchange, depth of anesthesia before induction, during and after the end of general anesthesia; arterial blood gas composition one hour after induction of anesthesia; indicators of pressure in the respiratory tract during mechanical ventilation, as well as time parameters of awakening.Results. In patients of Group 2 (PSV), according to the analysis of arterial blood gases, a higher level of PaO2 (p = 0.006), Horowitz index (p = 0.005), and carbon dioxide level (p

Introduction. Despite resounding success in treatment of patients with coronary heart disease (CHD), researchers are yet unable to significantly reduce mortality in this disease. With this in mind, there are ongoing studies everywhere, which are aimed at investigating new techniques in order to boost the efficiency of existing standards. One of such promising techniques is cell/regenerative therapy with autologous bone marrow mononuclear cells (ABMMCs). However, even though ABMMCs have been studied for more than 10 years, there are no unambiguous data yet on several issues. Objective: to evaluate the outcome of ABMMC transplantation during coronary artery bypass grafting (CABG) surgery in combined treatment of CHD. Materials and methods. The data of 408 patients admitted to the clinic from 2013 to 2016 for planned surgical treatment of CHD were analyzed. The work included 117 people based on the design of the study. Patients were randomized in 3 groups: Group 0 (control group) – CABG surgery and intramyocardial injection of 0.9% NaCl solution, Group 1 – CABG surgery and intramyocardial injection of ABMMCs, Group 2 – CABG surgery, intramyocardial and intra-graft injection of ABMMCs. The dynamics was assessed 12 months later – functional class of angina pectoris and heart failure, echocardiography, speckle tracking (assessment of the degree of myocardial deformation), treadmill test, 6-minute walk test, daily ECG monitoring, quality of life questionnaires, coronary angiography. Qualitative indicators were calculated using the Pearson’s chi-squared test and Fisher criteria. Quantitative indicators were calculated using the Kruskal–Wallis and Wilcoxon tests. Factor analysis was used to identify certain severity factors and to study data homogeneity. Discriminant analysis was performed to investigate the leading characteristics that determine differentiation between the groups. For analysis of variance, taking into account various factors, the model of variance analysis for dependent samples – Repeated Measures ANOVA – was used. Results. In the observation groups, an improvement in both systolic and diastolic myocardial function was universally noted. A six-minute walk test showed statistically significant increase in Groups 1 and 2 compared with the control Group 0 – 315.06 ± 17.6 (433.54 ± 20.6), Group 1 – 319.8 ± 24.5 (524.4 ± 28.7), Group 2 – 329.9 ± 25.3 (452.7 ± 29.7) meters. A significant decrease in the functional class of exertional angina pectoris in Groups 1 and 2 was noted unlike in the control group. The percentage of functioning coronary shunts after a 12-month follow-up period was 87.6% in Group 0. In Groups 1 and 2, this ratio was 96.2% and 97.3%, respectively. Predictors of overall effectiveness were identified: smoking, initial diastolic myocardial dysfunction, left ventricular ejection fraction. Conclusion. In addition to surgical treatment of coronary heart disease, ABMMC transplantation can improve myocardial contractility, boost exercise tolerance, and increase the duration of the functioning of coronary shunts at the follow-up period of 12 months. The study showed the need for stage-by-stage analytical calculations with the aim of possible correction of further work.

Aim: To evaluate the possibility to augment myocardial protection with desflurane and sevoflurane by prolongation of their delivery into the oxygenator of the cardiopulmonary bypass (CPB) pump during surgical myocardial revascularization.Materials and methods: This randomized prospective study included 75 patients with ischemic heart disease who underwent aortocoronary and mammary coronary bypass grafting with extracorporeal circulation from 2014 to 2017. The patients were allocated into the three study group by means of a random number table generated by Statistica 10.0 software, depending on the anesthetic agent used: group 1, desflurane (n=30), group 2, sevoflurane (n=28), and group 3 (control), propofol (n=17). Desflurane and sevoflurane were delivered into the oxygenator during the artificial circulation. Hemodynamic parameters were assessed, such as cardiac index, total peripheral vascular resistance index, pulmonary artery wedge pressure. Changes in lactate, pyruvate, alanine, glutamate, glutamine, aspartate, asparagine, taurine, leucine, isoleucine and valine levels over time were assessed in blood taken from the heart coronary sinus before aortal clamping, before release of the clamp and after 30 minutes of reperfusion. During the first 24 hours post perfusion, we assessed the incidence of postperfusion heart failure (PPHF), duration of mechanical ventilation and duration of stay in the intensive care unit. Troponin I levels were measured at 12 and 24 hours after the intervention.Results: There were no significant differences in the changes of the hemodynamic parameters over time in all the groups. The PPHF incidence and the course of the postoperative period were similar in all the groups. Irrespective on the type of the anesthesia, lactate and pyruvate levels increased during the CPB, with no significant differences between the groups, as well as the postoperative troponin I levels at 12 and 24 hours after surgery. No differences between the groups were found for the changes of amino acid levels over time, except a significant reduction of alanine levels during the aortal clamp in the group 3.Conclusion: Prolongation of desflurane and sevoflurane delivery into the CPB pump oxygenator does not augment myocardial protection during myocardial revascularization surgery.

Aim: to assess the safety of transplantation of autologous bone marrow mononuclear cells when performing coronary artery bypass grafting in the combined treatment of ischemic heart disease in patients with coronary and heart failure.Materials and methods. During the period from 2013 to 2016 years 117 patients, who meet the established criteria, were included in the work. Randomization was performed in observation groups: group 0 -control group (coronary artery bypass grafting (CABG) and intramyocardial administration of a 0.9% NaCl solution), group 1 - CABG surgery and intramyocardial administration of autologous bone marrow mononuclear cells (ABMMS), group 2 - CABG surgery and intramyocardial and intragraft administration of ABMMS. Clinical, laboratory - CPK MB, myoglobin, troponin I, HCT, Hb, K +, ABC; instrumental (stress tests, echocardiography, speckle tracking, coronary angiography) data were evaluated in these groups. The analysis of the frequency of postoperative complications (hydrothorax, hydropericardium, rhythm disturbances) was performed; the length of stay in the intensive care unit, the length of stay in the hospital and other indicators. After 6 and 12 months, the overall mortality was assessed, major cardiac events - the development of acute myocardial infarction, ventricular arrhythmias, oncological alertness. Number in international register clinical trials Clinical Trial. gov Identifier: NCT02059512.Results. Statistical analysis showed no statistically significant differences in the observation groups for the compared criteria.Conclusion. Transplantation of autologous bone marrow mononuclear cells during aorto-coronary bypass surgery in the combined treatment of coronary heart disease is a safe method.

Goal of the study: to detect the correlation between lactate and pyruvate levels and their ratio (LPR) during ischemia/reperfusion with the post-operative increase of troponin I as a marker of myocardial lesion. Materials and methods. The study was performed among the patients undergoing myocardial revasculization surgery with the use of cardiopulmonary bypass in order to evaluate the prognostic opportunities to predict development of post-perfusional cardiac failure. 56 patients with coronary disease who underwent surgery with cardiopulmonary bypass were examined. The samples of blood for lactate and pyruvate tests were collected from the catheter of heart coronary sinus before aortic compression, before release of the clamps and in 30 minutes after reperfusion. During the surgery the following rates of hemodynamic profile were registered (cardiac index, systolic output index, medium arterial tension, index of peripheral resistance and pulmonary vessels resistance, index of systolic output of the left and right ventricles, pulmonary capillary wedge pressure), oxygen transportation, consumption and extraction co-efficient, arteriovenous oxygen difference. In the early post-operative period the following rates were evaluated: need in inotropic support, duration of artificial pulmonary ventilation and stay in the intensive care department. The level of troponin I was tested in 12 and 24 hours. Correlations were evaluated for the whole group in general, and in certain subgroups the patients were divided into basing on LPR value before aortic compression. Group 1 (LLPR) included 24 patients with LPR lower than the medium level of the cohort (M 17.6), Group 2 (HLPR) included 29 patients with LPR above the medium level. No significant differences were found between the groups. Results. The obtained results confirmed the certain dependence between the lactate level and increase of plasmic troponin I. However it was shown that the strong correlation between them could manifest only if the initial levels per-perfusional lactate level and lactate-pyruvate ratio had been high. The pre-perfusional lactate level did not allow predicting the development of post-perfusional cardiac failure. High values of lactate-pyruvate ratio prior to the start of cardiopulmonary bypass reflected the probability of this complication. This fact allows treating patients with high LPR as a group undergoing the advanced risk of the unfavorable course of the post-operative period. The increase of lactate in blood collected from coronary sinus of such patients during anoxia is to be regarded as an argument for adequate increase of myocardium protection. Conclusion: In order to evaluate the risk of post-reperfusional cardiac failure the routine testing of the lactate level in coronary sinus is to be supplemented by testing of the pyruvate level.

Goal of the study: to evaluate the capability of pyruvate which is endogenously produced during myocardium anoxia to prevent the post-perfusion cardiac failure in the patients undergoing revasculization surgery with cardiopulmonary bypass. Materials and methods. 56 patients with coronary disease who underwent surgery with cardiopulmonary bypass were examined. The samples of blood for anaerobic metabolism tests were collected from the catheter of heart coronary sinus before aortic compression, before release of clamps and in 30 minutes after reperfusion. During the surgery the following rates of hemodynamic profile were registered (cardiac index, systolic output index, medium arterial tension, index of peripheral resistance and pulmonary vessels resistance, index of systolic output of the left and right ventricles, pulmonary capillary wedge pressure), oxygen transportation, consumption and extraction co-efficient, arteriovenous oxygen difference. In the early post-operative period the following rates were evaluated: need in inotropic support, duration of artificial pulmonary ventilation and stay in the intensive care department. The level of troponin I was tested in 12 and 24 hours. Patients were divided into groups depending on the increase of pyruvate level from the start of cardiopulmonary bypass before aortic compression. Group 1 (Pyrx1) included 30 persons with the pyruvate level increase less than twice and Group 2 (Pyrx2) included 26 persons in whom the pyruvate level increased more than twice. No significant differences were found between the groups. Results. Increase of pyruvate concentration in coronary sinus blood does not improve the heart performance in the post-perfusion period. Frequency and speed of consequent regress of post-perfusion heart failure were not principally different in both groups. Post-operative level of troponin I was the same and changed the same manner in both groups. Conclusion. Increased endogenous production of pyruvate in myocardium during anoxia does not improve post-perfusion restoration of the heart function.

Goal of the study: to compare the impact pf sevoflurane and desflurane on metabolism in myocardium when performing aortocoronary bypass with cardiopulmonary bypass. Materials and methods: 56 patients suffering from coronary disease and undergoing myocardial revasculization with cardiopulmonary bypass were divided into two groups as per the type of used anesthetic: the group where desflurane was used (DG, n=28) and the group where sevoflurane was used (SG, n=28). Groups were divided into subgroups basing on lactate/pyruvate ratio (LPR) before aortic compression. The following rates of hemodynamic profile were registered (cardiac index, systolic output index, index of peripheral resistance and pulmonary vessels resistance, index of systolic output of the left and right ventricles, pulmonary capillary wedge pressure), oxygen transportation, consumption and extraction co-efficient. During the first 24 hours of post-perfusion period the following rates were evaluated: frequency of post-perfusion cardiac failure development, need in inotropic support, duration of artificial pulmonary ventilation and stay in the intensive care department. The level of troponin I was tested in 12 and 24 hours. During cardiopulmonary bypass the blood samples were collected from coronary sinus before aortic compression, before release of clamps and in 30 minutes of reperfusion in order to evaluate the expression of anaerobic metabolism in myocardium as per the levels of lactate, pyruvate and LPR. Results: Analysis of hemodynamic profile and gas exchange rates showed no significant difference in the impact of these anesthetics on the investigated parameters in the pre- and post-perfusion periods. The frequency of development of post-perfusion cardiac failure, prompt management of its manifestations and changes in the markers of myocardial injury with the use of sevoflurane and desflurane were no significantly different. When sevoflurane was used during anoxia the patients with initially low LPR demonstrated the increase of LPR in coronary sinus due to the increase of lactate (р < 0.05). When desflurane was used, both lactate and pyruvate went up thus LPR remained on the initial level. After release of clamps from aorta LPR levels were compared when both anesthetics were used as well as the relevant levels of lactate and pyruvate. Conclusion: The investigated anesthetics have similar impact on hemodynamics and possess similar cardio-protective action. However they might have different ways of its implementation.

Goal of the study: working out procedure aimed at the diagnostics of painless myocardial ischemia in the patients expecting surgery on aorta and main arteries of lower limbs. Materials and methods. 72 patients with disorders of aorta and main arteries of lower limbs were enrolled into the study. Depending on factors of risk to develop cardiac vascular disorders as per Lee score they were divided into two groups. Group 1 (n = 38) included patients who had 2 and more risk factors in the pre-operative period, Group 2 included patients (n = 34) who had less than 2 risk factors. All of the patients had holter monitoring, stress echocardiography and coronary arteriography during pre-operative period. Results. The study showed the high efficiency of Lee score of cardiac-vascular complication risks. The patients who had 2 risk factors and more had hemodynamically significant lesions of coronary bed in 97.4% which was detected by coronary arteriography. In Group 2 painless myocardial ischemia was detected almost in 1/3 of patients, which later provided certain impact in the choice of surgical treatment strategy. Conclusions. The results proved low efficiency of holter monitoring in the patients suffering from multi-focal atherosclerosis and high efficiency of stress echocardiography. The latter should be mandatory included into the examination procedure of such patients regardless of the results of Lee score; and coronary arteriography is to be performed in case of 2 risk scores and more. Detection of painless myocardial ischemia can change the plan of surgical treatment and requires amending anesthesia tactics.

Goal of the study: to assess the feasibility of using inhalation anesthetics of desflurane and sevoflurane during cardiopulmonary bypass to reduce the chances of post-perfusion cardiac dysfunction during myocardial revasculization surgeries. Materials and methods: 75 patients suffering from coronary disease and undergoing myocardial revasculization with cardiopulmonary bypass were divided into three groups as per the type of used anesthetic: Group 1 receiving desflurane (n = 30), Group 2 receiving sevoflurane (n = 28) and Group 3 receiving propofol (n = 17). Anesthetics were used at all stages of anesthesia including cardiopulmonary bypass. The rates of the wider hemodynamic profile were registered (cardiac index, systolic output index, index of peripheral resistance and pulmonary vessels resistance, index of systolic output of the left and right ventricles, pulmonary capillary wedge pressure). During cardiopulmonary bypass the blood was collected from cardiac coronary sinus in order to assess changes in the levels of lactate and pyruvate before aortic compression, before the release of clamps and in 30 minutes of reperfusion. During the first 24 hours of the post-perfusion period, the following parameters were assessed: frequency of post-perfusion cardiac failure development, duration of artificial pulmonary ventilation and stay in the intensive care department. The level of troponin I was tested in 12 and 24 hours. Results. The hemodynamic profile, blood levels of lactate and pyruvate during cardiopulmonary bypass did not differ between the groups. The rate of increase of the levels of the above metabolites by the 30th minute of reperfusion was the same for all the groups; lactate-pyruvate ratio was stable during all time of anesthesia. There were no differences in the post-operative level of troponin I between the groups during the first 12 and 24 hours after the surgery. The frequency of post-perfusion cardiac failure and its course were similar for all group. Conclusion. Prolonged administration of inhalation anesthetics during cardiopulmonary bypass does not protect myocardium from ischemic and reperfusion lesions.

Inhalation anesthetics of desflurane and sevoflurane when used in aortocoronary bypass with cardio-pulmonary bypass can reduce the frequency of post-perfusion heart weakness t h rough supporting stable hemodynamic profile of the patients undergoing cardiac surgery. 11 owever the choice between these two medications is often disputable. 43 patients with coronary disease who underwent direct myocardial revasculization with artificial cardio-pulmonary bypass were examined. Desflurane was used as a general anesthetic for 28 patients: sevoflurane was used for 15 patients. During surgery expanded hemodynamic profile data of all patients were evaluated (cardiac index - Cl. stroke volume index - SVI. medium blood pressure - МНР. index of general peripheral resistance - IGPR, index of systolic operation of the left anti right ventricles, pulmonary artery wedge pressure, index of pulmonary resistance) as well as oxygen transporting blood function (delivery, consumption and oxygen extraction co-efficient. oxygen arteriovenous difference) and arterial blood lactate level. The investigated data were recorded before artificial cardio-pulmonary bypass, after reperfusion of myocardium and upon anesthesia completion. Results. Both groups did not have any confident differences in МНР. pulmonary artery pressure, heart rate. In all examined patients С I increased significantly compared to pre-perfusion period due to the increase of stroke volume and systolic discharge of the heart ventricles. And sevoflurane caused more persistent reduction of IGPR after artificial cardio-pulmonary bypass compared to desflurane which required using angiotonic support in 41.1% of patients versus 3.4% of patients in the group where desflurane was used (2criterion with credibility correction, p< 0.01). The bigger need in oxygen when sevoflurane was used during the surgery (p < 0.01) was accompanied by the bigger activation of anaerobic metabolism with increase of lactate concentration in post-perfusion period (p < 0.01) which can be explained by less depression of the global metabolism by sevoflurane compared to desflurane.

OBJECTIVE. The authors developed a low invasive method of bimammary coronary artery bypass grafting (CABG) of minimum two arteries through left-sided thoracotomy. MATERIAL AND METHODS. The left internal thoracic artery was used for bypass grafting of anterior interventricular artery according to V.I. Kolesov method. Anastomosis of the right interventricular artery with conduit (from autoartery or autovein) was performed by using extrapleural way in the second intercostal space from the right of the breast. Conduit was lengthened behind the sternum to pericardium cavity in order to create the second distal anastomosis with branch of coronary artery. RESULTS. The operations (10 cases) were conducted at the period from October 2015 to December 2016. The second distal anastomosis between conduit and coronary artery was performed with diagonal artery in 1 case, with branch of blunt edge in 5 cases and with posterior interventricular branch in 4 cases. Tolerance of operation and early postoperative period were satisfactory. CONCLUSIONS. New method of bimammary coronary artery bypass allowed doctors to perform revascularization minimum of two coronary vessels on working heart by avoiding manipulations on aorta and the sternum.