Aim. To evaluate the relationship between the clinical decision support system use (CDSS) and adherence to clinical guidelines.Materials and methods. Medical records of 300 patients with atrial fibrillation and hypertension from the electronic medical database of the Almazov National Medical Research Center were analyzed. Demographic and clinical data, as well as information on anticoagulant, antiarrhythmic and antihypertensive prescriptions were analyzed. The primary endpoint was adherence of prescribed treatment to current clinical guidelines for each of the three therapies. Firstly, a group of independent clinical experts assessed primary endpoint for retrospective prescriptions. Secondly, new prescriptions were simulated by another group of clinical experts using CDSS and blinded to previous therapy. Primary endpoint at the second step was analysed by independent experts. We compared adherence to relevant clinical guidelines with and without use of CDSS. Additionally, we analyzed predictors of failing to meet the current recommendations in the retrospective records.Results. Out of 300 patients, only 291 (97%) had all characteristics and were included in the analysis. In 26 patients (18%), all three treatment strategies were in accordance with current clinical guidelines. Anticoagulant therapy was adherent to the guidelines in 92% of cases. Experts who used CDSS were 15% (95% confidence interval [CI], 10-21%) more likely to prescribe novel oral anticoagulants and 14% (95% CI, 10-19%) less likely to prescribe warfarin compared to baseline. Antiarrhythmic therapy was adherent to the guidelines in 69% of cases. When the CDSS platform was applied, experts were 14% (95% CI 4-19%) more likely to prefer antiarrhythmic drug (AAD) monotherapy and 32% (95% CI 26-37%) more often prescribed radiofrequency ablation (RFA) of left atrium. At baseline, antihypertensive therapy combinations were adherent clinical guidelines in 28% of cases. The use of the CDSS platform by experts was significantly associated with an increase in the frequency of prescribing dual and triple antihypertensive therapy.Conclusion. CDSS use is associated with improved adherence to current clinical guidelines. Prospective randomized trials are needed to evaluate the CDSS effectiveness in the prevention of cardiovascular events.

Aim. To assess the influence of resting partial pressure of end-tidal carbon dioxide (PetCO2) levels on the long-term results of cardiac surgery.Materials and methods. This prospective cohort study included 454 patients with coronary artery disease who underwent elective coronary artery bypass graft surgery. Before surgery, all patients underwent pulmonary function tests, including body plethysmography, lung diffusion capacity assessment and cardiopulmonary exercise testing with the determination of ventilatory and gas exchange parameters, including PetCO2 at rest. The endpoint was the 2-year survival rate after surgery.Results. Parameters characterizing the obstructive breathing pattern, the lung diffusion capacity, and resting PetCO2 levels had a significant predictor value in relation to long-term survival after cardiac surgery. Among the baseline clinical and functional characteristics, a significant influence on long-term results was shown by the EuroSCORE II (OR 1,69 (1,26-2,27), p=0,001). The highest sensitivity and specificity in relation to long-term mortality risk after coronary artery bypass grafting was shown by resting PetCO2 value equal to 31 mm Hg (area under the ROC curve 0,74 (0,64-0,86), p<0,001).Conclusion. The resting PetCO2 level below 31 mm Hg in patients with coronary artery disease showed a significant effect on the increased long-term mortality risk after cardiac surgery, which is important for patients with exercise intolerance.

The imbalance between oxygen delivery and consumption in the brain can lead to unfavorable post-operative outcomes of cardiac surgery. The authors evaluated the effect of the protocol on management of cerebral oxygenation episodes during the post-operative period in the patients undergoing cardiac surgery and facing a high risk of complications. Subjects: Patients who underwent coronary bypass surgery and/or cardiac valve surgery with cardiopulmonary bypass, were randomly divided into two groups: the interventional group (n = 60), where a special protocol was used to manage desaturation episodes, and the control group (n = 60) where only blinded monitoring of cerebral oximetry was used. Within 30 days after surgery, the development of desaturation episodes during surgery was assessed as well as the occurrence of complications (myocardial infarction, brain damage of the 1st and 2nd types, infectious complications, prolonged artificial ventilation of the lungs, arrhythmia, repeated thoracotomy, acute renal damage) in both groups. Results. The duration and intensity of desaturation did not significantly differ between the groups. The composite outcome was observed in 41 (68.3%) patients in the intervention group and in 38 (63.3%) of them in the control group (p = 0.70), and no significant difference was found in the frequency of individual components of the composite outcome. It was found out that desaturation significantly affected the development of delirium (odds ratio 1.03, 95% confidence interval 1.01–1.05, p = 0.03, to reduce % of the area under saturation curve for the less than 60% of the absolute value per every 5 minutes). Conclusion. The cerebral oximetry correction protocol provided no effect on prevention of complications in high-risk patients undergoing cardiac surgery. However, the reduction of cerebral oximetry turned out to be significant to predict the development of post-operative delirium, and it noted the need to search for ways to manage oxygen imbalance during surgery.

PURPOSE:to assess results of percutaneous coronary intervention (PCI) with contemporary endovascular techniques of recanalization of chronic total coronary artery occlusions (CTO) in patients with ischemic heart disease (IHD). Occlusion (CTO) he procedural and in-hospital outcomes of consecutive patients undergoing chronic total occlusion percutaneous coronary intervention.MATERIALS AND METHODS:We retrospectively analyzed data from 456 consecutive patients (mean age 59.9±7.1 years, 18.2 % women) who underwent CTO PCI procedures (n=477) during 2014-2016 in the E. N. Meshalkin National Medical Research Center. CTO was localized in the right (61.2 %), left anterior descending (23.2 %) and left circumflex (15.3 %) coronary arteries. In one patient CTO was located in the left main coronary artery. According to the J-CTO score, 30 % of lesions were classified as easy, 36.4 % intermediate, 23.7 % difficult, and 18.9 % very difficult.RESULTS:Technical and procedural successes were achieved in 374 (78.4 %) and 366 patients (76.7 %), respectively. Antegrade approach was used in 378 (79.2 %), retrograde approach - in 99 (20.7 %) cases. Retrograde approach as primary strategy was used in 27 cases (5.7 %). Most frequent access for CTO PCI was radial artery, contralateral injection was used in 151 cases (31.6 %). Total number of stents per lesion was 1.6±0.98. The mean fluoroscopy time was 36.2±31 min.CONCLUSIONS:The rate of procedural adverse events in our study was low and similar to the non-CTO PCI series. However, despite the large number of CTO PCIs, the procedural success rate was still lower than in centers with dedicated programs for the management of such patients. Thus, further work is required to overcome this difference. Possible solution of this problem might be development and introduction in clinical practice of an algorithm for CTO recanalization.

Методы. Пациенты, которым выполняли операции коронарного шунтирования и/или коррекции клапанного аппарата сердца в условиях искусственного кровообращения, рандомизированы на две группы: интервенционную (n = 60), где для коррекции эпизодов десатурации использовали специальный протокол, и контрольную группу (n = 60), где осуществляли только ослепленный мониторинг церебральной оксиметрии� Выполнена оценка развития эпизодов десатурации во время операции и возникновения осложнений (инфаркт миокарда, повреждения головного мозга 1-го и 2-го типов, инфекционные осложнения, продленная искусственная вентиляция легких, аритмия, реторакотомия, острое почечное повреждение) в течение 30 дней после операции в обеих группах�

This review continues to investigate the management aspects of main physiological parameters during artificial blood circulation in the adult patients from the position of the evidence based medicine, and the first part of this review was published in the previous issue. This part is devoted to management of temperature, oxygen delivery and pulsation. The authors conclude that currently the majority of recommendations for artificial blood circulation are not based on the relevant evidences. In order to achieve best clinical results it has been offered to review the published data and relate them with the personal experience evaluating benefits and risks. It has been shown that the majority of complications related to artificial blood circulation have various causes and it demands the multi-disciplinary approach to their prevention.

Goal: to investigate the frequency and specific features of respiratory disorders and their impact on the clinical course in the patients having coronary artery bypass graft operation. Materials. 454 patients expecting coronary artery bypass graft operation were enrolled into the prospective cohort study. External respiration function was evaluated prior to the surgery. Pathologic respiration patterns were assessed basing on forced expiratory volume per 1 second (FEV1 ) and forced vital lung capacity (FVLC). The pattern was evaluated as obstructive with the ratio of FEV1 /FVLC < 0.70; and the restrictive pattern was the combination of FEV1 /FVLC≥ 0.70 and FVLC < 80% of "must". Results. Obstructive and restrictive patterns were detected in 72 (15.8%) and 50 (11.0%) patients respectively. Out of 133 patients with compromised external respiration function chronic obstructive pulmonary disease was diagnosed only in 26 patients. Bronchial obstruction was related to the risk of auricular fibrillation, increase of duration of artificial pulmonary ventilation and prolonged hospital stay. Conclusion. It has been demonstrated that it is possible to improve clinical outcomes in the patients undergoing cardiac surgery through diagnostics of respiratory disorders, detection of risk groups and prevention of complications.

Goal of the study: to identify the predictors of continuous hospital stay in adult patients with acquired valvular disease, operated with hypothermic and normothermic cardiopulmonary bypass due definitive repair of the disease. Materials and methods: 140 patients who had surgical treatment of acquired valvular disease with the use of cardiopulmonary bypass were randomly divided into two similar groups where hypothermic and normothermic cardiopulmonary bypasses were used. Peri-operative concentration of NT-proBNP, clinical course of the post-operative period, hospital morbidly and mortality were assessed. Results. No confident difference was observed in the changes of NT-proBNP in the groups, what could provide the evidence of the similar effects of both hypothermic and normothermic cardiopulmonary bypasses on integrative functional rates of cardiovascular system. However it was noted that increase of NT-proBNP plasma concentration during first 24 hours after the surgery, as well as age, chronic obstructive pulmonary disease (COPD), maximum degree of chronic cardiac failure (CCF), duration of artificial pulmonary ventilation (APV), episodes of atrial fibrillation (AF) in the post-operative period were the predictors of continuous hospital stay Conclusion. The degree of the increase in post-operative level of NT-proBNP does not depend on the perfusion temperature. NT-proBNP plasma concentration during first 24 hours after the surgery, age, COPD, maximum degree of CCF, duration of APV, episodes of AF in the post-operative period are independent predictors of continuous hospital stay.

This literature review dedicated to the importance of an integrated assessment of external respiratory function in cardiovascular diseases (CVDs), including an analysis of up-to-date techniques, such as spirometry, body plethysmography, examination of the diffusing capacity of the lung, determination of O2 consumption with evaluation of the effectiveness of pulmonary ventilation. It considers the pathogenetic components of impairments in pulmonary ventilation and gas exchange, which develop in different CVDs, as well as during and after cardiac surgery. The authors analyze the results of international investigations and their own experience, which emphasize the prognostic value of lung function tests and suggest that there is a need for a comprehensive functional assessment of the respiratory system in cardiac surgical patients for their effective preoperative preparation, assessment and reduction of operational risks, and improvement of the prognosis of surgical treatment.

Aim. This study is aimed at evaluating the efficacy and safety of sirolimus-eluting coronary stent “Calypso” in comparison with everolimus-eluting coronary stent “Xience Prime” in patients with ischemic heart disease. Methods. This is a prospective, randomized, single-blind multicenter clinical trial in patients undergoing coronary revascularization with coronary stenting. Seven clinical sites in Russia will enroll 610 patients with coronary artery disease. Patients suitable for coronary stenting will be randomized in group 1 (n=406) to receive coronary stent “Calypso” (“Angioline”, and group 2 (n=204) to receive coronary stent Xience Prime (Abbott). Clinical follow-up will continue for 1 year. By the end of follow-up, a quantitative coronary angiography will be performed in 122 patients (20 %). Conclusion. A randomized trial “PATRIOT” is designed to prove the efficacy and safety of sirolimus-eluting coronary stent “Calypso” in comparison with everolimus-eluting coronary stent “Xience Prime” in patients with ischemic heart disease.Received 5 October 2016. Accepted 6 December 2016.Funding: This study was funded by “Angioline Interventional Devices”, 630090, 18 Inzhenernaya Street, Novosibirsk, Russian Federation. Conflict of interest: The authors declare no conflict of interest.

Objective. In the last few years CTO angioplasty technique has shown high rates of procedural success and low rates of complications, but benefits from CTO recanalization are still not clear. In this report, the authors try to evaluate the effectiveness of CTO recanalization and discuss the diagnostic tool that might improve the appropriateness of CTO percutaneous coronary intervention.Methods. We examined and treated 72 patients, with 39 patients undergoing CTO-PCI of the right coronary artery (Group 1) and 33 receiving medical therapy only (Group 2). The perfusion areas of the CTO vessel and the clinical status of patients were evaluated. The follow-up period was 2 and 12 months. Results. According to stress MRI data, throughout the study, patients who underwent RCA stenting had a significantly higher risk of reducing the functional class of heart failure, the best performance at 6-min treadmill test and a low class of angina (below III), as well as a decreased number of perfusion defect points (less than 5) as compared with those of the control group (p<0.001). In addition, the quality of life of patients in the intervention group consistently exceeded that in the control group.Conclusion. CTO recanalization as compared to medical therapy only noticeably improves clinical outcomes of isolated CTO. Our findings correlate with stress MRI results.

Background: Procedures performed in chronic coronary artery occlusion comprise from 10 to 20% of all transcutaneous coronary interventions, and their efficacy can amount to 90%. Despite this, their appropriateness for this type of disease is still a matter of debate.Aim: To assess efficacy and safety of interventions compared to medical treatment in patients with isolated chronic occlusion of the right coronary artery.Materials and methods: We analyzed results of treatment of 72 patients. From these, endovascular recanalization of chronic occlusion of the right coronary artery was performed in 39 patients (group 1), the rest 33 patients received medical treatment only (group 2). Clinical state parameters and adverse event rate were assessed during a follow-up of 12 months.Results: After 1 year, a notable reduction of functional grade (FG) of exertional angina was seen in the group 1. The number of patients with FG I increased from 3 (7.7%) to 20 (51.3%), р < 0.05; and the number of those with FG III decreased from 22 (56.4%) to 6 (15.4%), р < 0.05. No significant changes of FG of angina were seen in the group 2 (control group) after 2 and 12 months (р > 0.05 at both time points). At 1 year, 94.9% (95% CI: 88,2–99,9%) of patients from the group 1 and 100% of patient in the group 2 were free of adverse clinical events.Conclusion: Transcutaneous coronary angioplasty for chronic occlusion of the right coronary artery significantly improves clinical course of ischemic heart disease at 2 and 12 months, compared to medical treatment, by decreasing FG of exertional angina. From clinical point of view, adverse events reported in the group of endovascular recanalization for chronic occlusion of the right coronary artery are insignificant.

Objective. To investigate the effect of bronchial obstruction syndrome on perioperative characteristics in patients undergoing coronary artery bypass grafting (CABG).Methods. Body plethysmography and spiroergometry at rest were used to study respiratory function and consumption of O2. To evaluate the effectiveness of pulmonary ventilation, the oxygen utilization coefficient of (O2CU) was calculated in 178 patients prior to scheduled surgery. The relationship of external ventilation parameters and perioperative clinical characteristics was analyzed. Results. A bronchial obstruction syndrome was detected in 30 (16.9%) patients, with 21 (11.2%) of them having no chronic obstructive pulmonary disease diagnosis. 4 patients (2.3%) with obstructive pulmonary disease had no bronchial obstruction. Thus, chronic obstructive pulmonary disease was misdiagnosed in 13.5% cases. In patients undergoing isolated CABG, negative relationship was revealed between the Tiffno index and hospital stay (regression coefficient –6.9, 95%, confidence interval –14.4… 0.6; p = 0.07). In patients operated with the myocardium stabilized, bimammary grafting tended to increase hospital stay by an average of 4.3 days (95% CI 1.5–7.1; p=0.003). The majority of patients had a low O2CU. O2CU lower than 16.2 ml/l is associated with an increased risk of postoperative atrial fibrillation (AF) in the postoperative period (OR 2.96; 95% CI 1.01–9.83; p = 0.04). No significant associations were observed between the degree of bronchial obstruction and the number of perioperative complications. Conclusion. The degree of bronchial obstruction could be positively associated with the length of hospital stay. A critically low level of O2CU is explained by an increased risk of postoperative AF. Further research might result in the identification of predictors for respiratory complications and long-term mortality in patients after CABG.

Objective. The aim of the study was to evaluate the perfusion of scar tissue in the concerned basin blood supply before and after PCI in the presence of CTO RCA by using CMRI with delayed contrast enhancement and pharmacological stress test.Methods. The results of prospective randomized study involving two groups of patients with the presence of СТO coronary arteries and PIC (scar) are presented. The first group was with successful PCI, the second group received only conservative therapy. Delayed contrast-enhanced CMRI with a stress test was performed in all patients at baseline and after 2 months.Results. Group 1 had a significantly reduced mean number of segments with the presence of stress perfusion defects in the scar tissue during the control cardiac MRI, from 2.84 (1.64) to 2.00 (1.61), the mean difference was –0.84, 95% CI for the difference –1.23... –0.46, р<0.01. The mean (SD) number of segments with perfusion defects remained unchanged in group 2 and amounted to 2.36 (1.61).Conclusion. According to our data, endovascular recanalization of СТO coronary arteries in patients with PIC improves perfusion in the scar area.

The study was aimed at testing the hypothesis that perioperative infusion of omega-3 polyunsaturated fatty acids would reduce the incidence of postoperative atrial fibrillation in CAD patients operated under CPB. The authors carried out a prospective, randomised, double-blind, placebo-controlled study. 39 CAD patients who had undergone surgery under cardiopulmonary bypass were randomized into 2 groups. 18 patients were infused with omega-3 polyunsaturated fatty acids (Omegaven, Fresenius Kabi, Germany) starting with 200 mg/kg/day before anaesthesia induction for 24 hours followed by 100 mg/kg/day from second to seventh day postoperatively. 21 patients received an equivalent dose of placebo (Intralipid, Fresenius Kabi, Germany). The primary endpoint was freedom from atrial fibrillation at 2-year follow-up. A Reveal cardiac monitor was implanted subcutaneously in all patients. Data from cardiac monitor was collected on the 10th day and at 3, 6, 12 and 24 months postoperatively. Postoperative atrial fibrillation developed in 4 (19%) patients in the control group and in 5 (27.8%) patients in the study group at 10-day follow-up (p = 0.88). At 2-year follow-up, 5 (27.8%) patients in the control group and 6 (35.3%) patients in the study group had atrial fibrillation (p = 0.9). The results of our research do not confirm the efficiency of perioperative infusion of omega-3 polyun-saturated fatty acids to prevent the occurrence of atrial fibrillation.

Целью исследования стала проверка гипотезы о защитном влиянии глутамина на кишечник пациентов при кардиохирургических операциях. В настоящее проспективное, рандомизированное клиническое исследование включено 24 пациента, которым выполняли аортокоронарное шунтирование (АКШ) в условиях искусственного кровообращения (ИК). 12 пациентов получали глутамин (20% раствор N(2)-аланил-L-глутамин) в дозе 0,4 г/кг/24 ч. 12 пациентов получали плацебо (0,9% раствор NaCl) в эквивалентной дозе. Инфузию глутамина либо плацебо начинали после вводной анестезии и продолжали 24 ч. Первичной конечной точкой была динамика плазменной концентрации специфического маркера повреждения кишечника - кишечного белка, связывающего жирные кислоты. Вторичными точками были концентрации печеночного белка, связывающего жирные кислоты, альфа-глутатион-s-трансферазы, белков теплового шока 70. На всех этапах исследования нами не получено достоверных различий изучаемых биомаркеров между группами. Плазменная концентрация кишечного белка, связывающего жирные кислоты (медиана [25-75 процентиль]), в обеих группах значительно увеличивалась во время ИК и сохранялась после операции: 962 (577-2 067) и 883 (444-1 625) нг/мл через 5 мин после прекращения окклюзии аорты, 2 203 (888-3 429) и 1 560 (506-2 657) нг/мл через 2 ч после прекращения Ик, 897 (555-1 424) и 794 (505-951) нг/мл через 6 ч после прекращения ИК в группе с применением глутамина и контрольной группе. Периоперационное назначение глутамина в дозе 0,4 г/кг/24 ч не оказывает защитного влияния на кишечник у кардиохирургических пациентов низкой степени риска.

We conducted a retrospective comparative analysis of 75 patients undergoing video-assisted mitral valve repair with right minithoracotomy over a period from November 2011 to August 2013. The control group comprised 71 patients operated on mitral valve by using median sternotomy during the same period. Median (25th; 75th) times of cardiopulmonary bypass and aortic cross-clamping were significantly longer in the minimally invasive group (180 [139; 224] and 111 [87; 145] min, respectively) as compared to the controls (84 [69; 117] and 62 [49; 81 ] min, respectively), p<0.01. Fatal outcome occurred in 2 (2.7%) cases in the minimally invasive group versus none in the controls. In both cases death resulted from intraoperative aortic dissection. While ventilation time and intensive care unit stay were comparable across the groups, postoperative respiratory failure occurred in 6 (8%) cases in the minimally invasive group versus none in the controls (p<0.05). No other significant differences in the postoperative course were observed between the groups. The results of the present study are generally consistent with the world's tendencies. On the other hand, complication rates observed in the minimally invasive group present a considerable economic burden and require substantial human resources in the postoperative period.

Valve-sparing operations on the aorta has recently been gaining ever increasing popularity due to more detailed study of physiology of the aortic root, as well as promising mid- and long-term results. The world practice uses various techniques making it possible to remove both ascending aortic aneurysm and aortic valve insufficiency. The authors herein describe and analyse their experience in performing reimplantation of the aortic valve in patients with ascending aortic aneurysm and concomitant aortic insufficiency. Specialists of the clinic of the Novosibirsk Scientific Research Institute for Circulatory Pathology during the period from 2003 to 2013 performed a total of 77 operations of reimplantation of the aortic valve in patients with ascending aortic aneurysm and pronounced aortic valve insufficiency. The majority of patients were men (57 males and 20 females), mean age 53.1±12.2 years (range 21-72). 80% of cases had NYHA functional class II-III circulatory insufficiency (degree 2.3±0.7). Preoperative examination revealed in the majority of patients (97.4%) moderate-to-severe aortic valve insufficiency and ascending aortic aneurysm. All patients underwent reimplantation of the aortic valve. The duration of artificial circulation amounted to 202.4±33 minutes, with the average time of aortic occlusion being 164±28 min. Accompanying procedures (annuloplasty of the mitral valve and/or coronary aortic bypass grafting) were performed in 12 (15.6%) cases. Additional plasty of valvular cusps was carried out in 9 (11.7%) patients, with rethoracotomy required in 5 (6.4%) cases due to haemorrhage. The average period of follow up amounted to 53.3±8.5 (3-115) months. During this time total survival amounted to 91%, with freedom from aortic valve prosthetic repair equalling 93%. The obtained findings suggest that aortic valve reimplantation into the prosthesis is a safe intervention and associated with a comparatively low level of operative lethality. Moderate aortic insufficiency at discharge is a predicting factor for repeat surgical intervention, i.e. prosthetic repair of the aortic valve. No association between the preoperative degree of aortic insufficiency, root diameter and durability of the reimplanted valve was revealed.

A pilot double-blind, placebo-controlled, randomized study The aim of this study was to evaluate the efficiency of perioperative administration of glutamine to preserve intestinal integrity in patients undergoing cardiac surgery. 24 patients scheduled for elective coronary artery bypass surgery under cardiopulmonary bypass were included in this prospective, randomized, double-blind placebo controlled pilot study. 12 patients were randomized to receive glutamine (20% solution of N(2)-L-alanyl-L-glutamine) 0.4 g/kg a day, while the remaining 12 patients received an equivalent placebo dose (0.9% solution of NaCl). Infusion of glutamine/placebo was started after the induction of anesthesia and was continued for 24 hours. The primary end-point was dynamics of plasma concentration of a specific marker of intestinal damage, intestinal fatty acid binding protein (I-FABP). The secondary end-points were liver fatty acid binding protein (L-FABP), alpha glutathione s-transferase (aGST), heat shock protein 70 (HSP 70). There were no between-group differences of all the studied biochemical parameters at any stage of the study. Plasma I-FABP levels (median [25-75 percentile]) were markedly elevated during CPB and remained the same postoperatively: 962 (577-2 067) and 883 (444-1 625) г/ml 5 min after un-clamping of aorta, 2203 (888-3 429) and 1 560 (506-2 657) г/ml ² hours post-bypass, 897 (555-1 424) and 794 (505-951) г/ml 6 hours post-bypass in the GLN and control groups respectively. Perioperative administration of glutamine in dose of 0.4 g/kg a day does not appear to preserve intestinal integrity in low risk cardiac surgery patients.