Background and Aims New-onset atrial fibrillation (AF) is the most common complication of cardiac surgery. We aimed to describe the incidence of postoperative AF (POAF), its management, and its relationship to long-term outcomes in a prospective multi-centre cohort, as our current understanding comes primarily from registries and single-centre studies.Methods VISION Cardiac Surgery was a prospective cohort of adults who underwent cardiac surgery in 12 countries. The association of POAF with outcomes occurring between 30 days and 1 year postoperatively was estimated using a multivariable Cox model adjusted for patient and operative characteristics and for antithrombotic therapies.Results Among 12 234 patients (55.3% isolated coronary artery bypass grafting), 31.8% had POAF within 30 days of surgery. The proportion of participants with POAF who received anticoagulation alone at hospital discharge was 15.6%, 54.3% received antiplatelets alone, 23.9% received anticoagulation and antiplatelets, and 6.3% received neither; 48.8% were receiving amiodarone. At 1 year, clinical AF was detected in 6.9% of patients with POAF compared to 0.6% in those without [adjusted hazard ratio (aHR), 11.30; 95% confidence interval (CI) 8.17-15.70]. The primary composite outcome of stroke or vascular death occurred in 2.3% of patients with POAF and 1.5% in those without POAF (aHR 1.32; 95% CI 0.99-1.77). Patients with POAF had a higher risk of all-cause death (3.0% vs 1.7%; aHR 1.54; 95% CI 1.18-2.00).Conclusions New-onset POAF occurs in a third of patients after cardiac surgery; its antithrombotic and antiarrhythmic management varies. Patients with POAF have increased risks of both clinical AF and of all-cause death in the year following surgery.

OBJECTIVES:The most prognostically important complications after cardiac surgery to target for prevention remain uncertain. We aimed to assess the relationship between postoperative complications and mortality at 30 days and 1 year after cardiac surgery and rank the complications by their contribution to mortality. METHODS:We completed an analysis of 15,550 patients from the Vascular Events in Surgery Patients Cohort Evaluation (VISION) Cardiac Surgery Prospective Cohort Study, which enrolled 15,971 patients who underwent cardiac surgery from 24 centers in 12 countries. The primary outcome was all-cause mortality at 30 days and 1 year. Population attributable fractions (PAFs) were calculated to estimate the proportion of deaths potentially attributable to each complication. RESULTS:All-cause mortality occurred in 460 patients (3.0%) at 30 days and in 399 (2.6%) between 31 days and 1 year, totaling 859 deaths (5.5%) at 1 year. The 4 complications occurring within 30 days with the largest PAFs for 30-day mortality were acute kidney injury (2612 patients [16.8%]; adjusted hazard ratio [aHR], 4.47; 95% CI, 3.52-5.67; PAF, 37%), bleeding (1491 patients [9.6%]; aHR, 2.39; 95% CI, 1.87-3.06; PAF, 12%), infection (2260 [14.5%]; aHR, 1.95; 95% CI, 1.47-2.57; PAF, 12%), and myocardial injury after cardiac surgery (1686 patients [10.8%]; aHR, 2.01; 95% CI, 1.58-2.54; PAF, 10%). CONCLUSIONS:This international study suggests that approximately 1 in 3 deaths after cardiac surgery are associated with acute kidney injury. Targeted prevention of acute kidney injury, infections, bleeding, and myocardial injury holds promise for reducing mortality in patients after cardiac surgery.

Importance:Perioperative bleeding is common in general surgery. The POISE-3 (Perioperative Ischemic Evaluation-3) trial demonstrated efficacy of prophylactic tranexamic acid (TXA) compared with placebo in preventing major bleeding without increasing vascular outcomes in noncardiac surgery. Objective:To determine the safety and efficacy of prophylactic TXA, specifically in general surgery. Design, Setting, and Participants:Subgroup analyses were conducted that compared randomized treatment with TXA vs placebo according to whether patients underwent general surgery or nongeneral surgery in the POISE-3 blinded, international, multicenter randomized clinical trial. Participants were 45 years or older, were undergoing noncardiac surgery, had increased cardiovascular risk, and were expected to require at least an overnight hospital admission after surgery. Among 26 581 eligible patients identified, 17 046 were excluded, resulting in 9535 patients randomized to the POISE-3 trial. Participants were enrolled from June 2018 through July 2021. The data were analyzed during December 2023. Intervention:Prophylactic, 1-g bolus of intravenous TXA or placebo at the start and end of surgery. Main Outcomes and Measures:The primary efficacy outcome was a composite of life-threatening bleeding, major bleeding, or bleeding into a critical organ. The primary safety outcome was a composite of myocardial injury after noncardiac surgery, nonhemorrhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism at 30 days. Cox proportional hazards models were conducted, incorporating tests of interaction. Results:Among 9535 POISE-3 participants, 3260 underwent a general surgery procedure. Mean age was 68.6 (SD, 9.6) years, 1740 were male (53.4%), and 1520 were female (46.6%). Among general surgery patients, 8.0% and 10.5% in the TXA and placebo groups, respectively, had the primary efficacy outcome (hazard ratio [HR], 0.74; 95% CI, 0.59-0.93; P = .01) and 11.9% and 12.5% in the TXA and placebo groups, respectively, had the primary safety outcome (HR, 0.95; 95% CI, 0.78-1.16; P = .63). There was no significant interaction by type of surgery (general surgery vs nongeneral surgery) on the primary efficacy (P for interaction = .81) and safety (P for interaction = .37) outcomes. Across subtypes of general surgery, TXA decreased the composite bleeding outcome in hepatopancreaticobiliary surgery (HR, 0.55; 95% CI, 0.34-0.91 [n = 332]) and colorectal surgery (HR, 0.67; 95% CI, 0.45-0.98 [n = 940]). There was no significant interaction across subtypes of general surgery (P for interaction = .68). Conclusions and Relevance:In this study, TXA significantly reduced the risk of perioperative bleeding without increasing cardiovascular risk in patients undergoing general surgery procedures. Trial Registration:ClinicalTrials.gov Identifier: NCT03505723.

OBJECTIVES:In cardiac surgery patients, acute kidney injury (AKI) frequently occurs in the setting of haemodynamic instability and treatment with temporary mechanical circulatory support (tMCS). Recent evidence suggests amino acids (AA) infusion may reduce AKI rate. However, the effect of AA infusion in patients requiring tMCS may be less effective. METHODS:We performed a secondary analysis of the PROTECTION multicentre randomized controlled trial including all patients treated with tMCS. Patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomized to receive 2 g/kg ideal body weight/day of intravenous AA to a maximum of 100 g/day or matching placebo from operating room admission until up to 3 days, receipt of renal-replacement therapy, discharge from ICU or death. The primary outcome of the PROTECTION study was the rate of AKI, as in this secondary analysis. A total of 3511 patients were randomized in the study. RESULTS:We studied 232 patients who received tMCS, 112 randomized to AA infusion and 120 to placebo. The median preoperative serum creatinine value was significantly higher among AA group patients (AA: 1.08, interquartile range 0.90-1.26; placebo: 0.98, interquartile range 0.85-1.15; P = 0.02). The rate of AKI, however, was lower in patients randomized to AA (44.6% vs 60.8%; relative risk 0.73; 95% confidence interval (0.57-0.94); P = 0.01; number needed to treat = 6). We found no significant differences in secondary outcomes. CONCLUSIONS:Short-term AA infusion appears to reduce rate of AKI among patients requiring tMCS. Use of AA in this population at high-risk for renal failure appears justified. CLINICAL TRIAL REGISTRATION NUMBER:ClinicalTrials.gov NCT03709264.

OBJECTIVE:To study the structure and dynamics of anxiety-depressive disorders in patients with dissection/aneurysm of the ascending aorta and aortic arch before and in the long term after surgical treatment and to identify factors associated with disturbances in psycho-emotional status. MATERIAL AND METHODS:We examined 124 patients with dissection/aneurysm of the ascending aorta and arch before and in the long-term period after aortic replacement, assessing anxiety and depression using the Generalized Anxiety Disorder (GAD-7) and Beck Depression Questionnaires. Multivariate regression analysis was used to identify factors associated with clinically significant anxiety and depressive disorders. RESULTS:Average scores on the GAD and the depression scale before surgery decreased from 6.5 (4.0-9.0) and 12.0 (8.0-16.0) to 3.0 (2.0-5.0) and 6.0 (3.0-10.0) (p<0.05) respectively, in the long-term postoperative period. There was no significant decrease in the proportion of patients with clinically significant levels of GAD and depression (p>0.05). Before surgery, clinically significant anxiety and depressive disorders are associated with older age, chronic cerebrovascular insufficiency (CCI) and atrial fibrillation (AF) in the hospital period. After surgery, clinically significant GAD was associated with older age, CCI, and a history of stroke. Depressive disorders were associated with older age and a history of stroke. CONCLUSION:In all patients with aortic disease, GAD and depression of varying severity are recorded; clinically significant GAD and depression are recorded in 19.2 and 23.2% of cases. In the long-term postoperative period, there is no significant decrease in the proportion of patients with clinically significant levels of GAD and depression, which amounted to 10.1 and 13.1%. Clinically significant anxiety and depressive disorders before and after surgery are associated with older age and the history of cerebrovascular disorders. In addition, the baseline clinically significant anxiety and depressive disorders showed an association with the subsequent development of AF in the early postoperative period.

OBJECTIVE:Cardiac surgery can be complicated by the development of a systemic inflammatory response syndrome related to cardiopulmonary bypass. This potentially contributes to the occurrence of postoperative morbidity and mortality. Corticosteroids can be used to reduce such inflammation, but the overall balance between potential harm and benefit is unknown and may be age-dependent. The present meta-analysis aims to evaluate the effects of prophylactic corticosteroids in pediatric and non-elderly adult cardiac surgery patients. DESIGN:Systematic review and meta-analysis of randomized trials. SETTING:Cardiac surgery with cardiopulmonary bypass. PARTICIPANTS:Patients younger than 65 years old (pediatric and non-elderly adults). INTERVENTIONS:Perioperative use of corticosteroids versus placebo or standard care. MEASUREMENTS AND MAIN RESULTS:Two independent investigators searched PubMed, EMBASE and the Cochrane Library from inception to January 20, 2024. The primary outcome was mortality at the longest follow-up available. Secondary outcomes included acute kidney injury, atrial fibrillation, myocardial injury, cerebrovascular events, and infections. Our search strategy identified a total of 17 randomized trials involving 6,598 patients. Mortality was significantly reduced in the corticosteroid group (78/3321 [2.3%] vs. 116/3277 [3.5%]; risk ratio = 0.69; 95% confidence interval, 0.52 to 0.92; P = 0.01; I2 = 0%; NNT = 91). Moreover, the highest postoperative vasoactive inotropic score (VIS) was significantly lower in corticosteroid group (MD: -2.07, 95% CI -3.69 to -0.45, P = 0.01, I2 = 0%). No significant differences in secondary outcomes between the two treatment groups were recorded. CONCLUSIONS:This meta-analysis of randomized trials highlights the potential benefits of corticosteroids on survival in cardiac surgery for patients younger than 65 years old.

Despite considerable investigative efforts, the molecular mechanisms of postoperative delirium (POD) remain unresolved. The present investigation employs innovative methodologies for identifying potential primary and secondary metabolic markers of POD by analyzing serum metabolomic profiles utilizing the genetic algorithm and artificial neural networks. The primary metabolomic markers constitute a combination of metabolites that optimally distinguish between POD and non-POD groups of patients. Our analysis revealed L-lactic acid, inositol, and methylcysteine as the most salient primary markers upon which the prediction accuracy of POD manifestation achieved AUC = 99%. The secondary metabolomic markers represent metabolites that exhibit perturbed correlational patterns within the POD group. We identified 54 metabolites as the secondary markers of POD, incorporating neurotransmitters such as gamma-aminobutyric acid (GABA) and serotonin. These findings imply a systemic disruption in metabolic processes in patients with POD. The deployment of gene network reconstruction techniques facilitated the postulation of hypotheses describing the role of established genomic POD markers in the molecular-genetic mechanisms of metabolic pathways dysregulation, and involving the identified primary and secondary metabolomic markers. This study not only expands the understanding of POD pathogenesis but also introduces a novel technology for the bioinformatic analysis of metabolomic data that could aid in uncovering potential primary and secondary markers in diverse research domains.

Objective To test the hypothesis that levosimendan administration in patients with low cardiac output syndrome after cardiac surgery is associated with improved long-term (5-year follow-up) outcomes. Design Single-center subanalysis of the multicenter randomized CHEETAH trial. Setting Cardiac surgery department of a tertiary hospital. Participants A total of 134 adult patients requiring hemodynamic support for a cardiac index <2.5 L/min/m2 after cardiac surgery with cardiopulmonary bypass (CPB). Interventions Patients were randomized (1:1 ratio) to receive levosimendan (continuous infusion with a starting dose of 0.05 μg/kg/min) or placebo, in addition to standard inotropic care. Measurements and Main Results The primary endpoint was long-term mortality (1-5 years) after randomization. Secondary outcomes were hemodynamic parameters, need for inotropic support, acute kidney injury (AKI), need for renal replacement therapy, duration of mechanical ventilation, intensive care unit (ICU) and hospital stay, and 30-day mortality. No significant between-group difference in long-term mortality (5 years) was observed (hazard ratio, 1.59; 95% confidence interval, 0.81 to 3.11; p = 0.17). There were no significant differences in secondary outcomes, except for the difference in the mean pulmonary artery pressure at 4 to 6 hours after randomization, which was lower in the levosimendan group compared to the placebo group (median, 24 [interquartile range (IQR), 21.8-28] mmHg vs 26 [IQR, 22.2-33] mmHg; p = 0.019). Conclusions Among patients requiring hemodynamic support after cardiac surgery with CPB, perioperative levosimendan infusion did not affect long-term survival (1-5 years) compared with placebo. Levosimendan also had no effect on major clinical outcomes such as AKI, ICU stay, hospital stay, and 30-day mortality.

Background: Clinically important perioperative atrial fi brillation (POAF) is a common cardiac complication after noncardiac surgery. Little is known about how patients with POAF are managed acutely and whether practices have changed over time. Methods: We conducted an observational substudy of patients who had POAF, were at elevated cardiovascular risk, and were enrolled in the PeriOperative Ischemic Evaluation (POISE)-1, 2 and 3 trials between 2002 and 2021. POAF was defined as new, clinically important atrial fi brillation occurring within 30 days after surgery. We assessed the use of rhythm-control and anticoagulation treatment in response to POAF, at hospital discharge and at 30 days after surgery. We assessed for temporal trends using multivariable logistic regression. Results: Of the 27,896 patients included, 545 (1.9%) developed clinically important POAF. Patients received rhythm-control treatment in 48.6% of cases. The level of use of rhythm-control treatment increased over the course of the trials (POISE-1 vs POISE-2 vs POISE-3; 40.9% vs 49.5% vs 59.1%). A later randomization date was associated independently with use of rhythm-control treatment (odds ratio, 1.05 per year; 95% confidence interval, 1.01-1.09). Anticoagulation treatment was prescribed in 21% of POAF cases. The level of anticoagulation treatement use was higher in POISE-3, compared to that in the 2 previous trials (POISE-1 vs POISE-2 vs POISE-3d16.4% vs 16.5% vs 33.6%). A later randomization date was associated independently with use of anticoagulation treatment (odds ratio, 1.06 per year; 95% confidence interval, 1.02-1.11). Conclusions: Despite the absence of randomized controlled trials, the level of use of rhythm-control and anticoagulation treatment for POAF is rising. High-quality trials are needed urgently to determine whether these interventions are safe and effective in this population.

BACKGROUND:Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS:This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS:The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION:The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION:This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

Background This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. Methods An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. Results 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. Conclusions Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

Aim. To study the clinical and functional status and the early postoperative follow-up in elderly patients with chronic thromboembolic pulmonary hypertension (CTEPH).Material and methods. Patients with CTEPH were divided into two groups: group 1 (35 people) – patients ≥65 years old, group 2 (98 people) – <65 years old. The baseline clinical and functional data of both groups and the in-hospital period after pulmonary endarterectomy, were analysed.Results. Patients with CTEPH ≥65 years old compared with patients <65 years old were characterized by a higher comorbidity, a higher incidence of adverse cardiovascular events and the presence of chronic heart failure IV class (p<0.05). Echo-CG data in patients with CTEPH ≥65 years old were characterized by a large size of the left atrium, more pronounced hypertrophy of the right ventricle free wall, interventricular septum and the left ventricular posterior wall compared with younger patients (p<0.05). Also, in patients ≥65 years old, lower values of the left ventricular ejection fraction were found with preservation of global myocardial contractility (p<0.05). The early postoperative period in patients with CTEPH ≥65 years is characterized by a more severe course compared to the group of patients <65 years due to a larger proportion of patients with the development of newly diagnosed atrial fibrillation, multiple organ failure and postoperative bleeding (p<0.05). Despite this, there were no intergroup differences in the length of the hospital period and in-hospital mortality (p>0.05).Conclusion. The early postoperative results of pulmonary endarterectomy in elderly patients with CTEPH showed no differences in the length of hospital stay and in-hospital mortality compared with younger patients, which indicates the feasibility of surgical treatment of this category of patients in the specialized cardiac surgical centers.

Актуальность. Острое повреждение почек развивается в 30–45 % случаев при коррекции врожденных пороков сердца у детей, увеличивает период пребывания пациентов в послеоперационной палате и общее время госпитализации. Используемый для выявления осложнения прирост уровня креатинина в послеоперационном периоде имеет ограничения, поскольку его значительные изменения происходят после утраты более 50 % экскреторной функции почек. Также у детей уровень креатинина зависит от количества мышечной массы, сердечного выброса и других факторов, которые особенно различаются у детей младшего возраста, что затрудняет раннюю диагностику. В недавних исследованиях изучались биомаркеры в качестве потенциальных предикторов кардиохирургически ассоциированного острого повреждения почек на ранних стадиях после коррекции врожденных пороков сердца у детей. Цель. Оценить тканевой ингибитор металлопротеиназы-2 (TIMP-2) мочи в качестве предиктора кардиохирургически ассоциированного острого повреждения почек у детей в возрасте от 1 месяца до 1 года при коррекции врожденных пороков сердца в условиях искусственного кровообращения. Методы. В одноцентровое ретроспективное исследование включили 150 пациентов в возрасте от 1 месяца до 1 года, оперированных в условиях искусственного кровообращения по поводу врожденных пороков сердца. Исследуемую группу составили пациенты с кардиохирургически ассоциированным острым повреждением почек (1-я группа, n = 52), контрольную группу — больные без осложнения (2-я группа, n = 98). Для минимизации систематических ошибок и достижения сопоставимости групп выполнили псевдорандомизацию (n = 52 в обеих группах). Сравнивали дооперационные, интраоперационные и послеоперационные параметры и характеристики. Результаты. Пациенты не различались по базовым и демографическим характеристикам. Кардиохирургически ассоциированное острое повреждение почек диагностировано у 34,6 % больных, из них у 67,4 % (n = 35) — стадия 1, у 28,8 % (n = 15) — стадия 2 и у 3,8 % (n = 2) — стадия 3. Результаты регрессионного анализа демонстрируют снижение кардиохирургически ассоциированного острого повреждения почек на 24 % и увеличение на 9 и 16 % соответственно при росте уровня креатинина на 1 мкмоль/л исходно и на 3-е и 4-е сут. У пациентов мужского пола вероятность развития осложнения меньше на 76 %. Статистически значимого различия в уровне тканевого ингибитора металлопротеиназы-2 в двух группах не выявили. Заключение. Тканевой ингибитор металлопротеиназы-2 мочи у пациентов в возрасте от 1 месяца до 1 года, оперированных в условиях искусственного кровообращения, не продемонстрировал предиктивной способности в ранней диагностике кардиохирургически ассоциированного острого повреждения почек. Поступила в редакцию 24 апреля 2023 г. Исправлена 27 ноября 2023 г. Принята к печати 28 ноября 2023 г. Финансирование Исследование не имело спонсорской поддержки. Конфликт интересов Авторы заявляют об отсутствии конфликта интересов.

Background: The respiratory system is negatively affected by radiation exposure during the comprehensive treatment of breast cancer (BC), which has an effect on the treatment effectiveness and patients’ quality of life.Objective: To evaluate changes in pulmonary ventilation and diffusion characteristics and ventilation effectiveness in patients with BC before and after radiation therapy (RT).Methods: Our prospective cohort study included 232 women with BC admitted to the Meshalkin National Medical Research Center for an adjuvant RT after surgical treatment. Before and after the RT we conducted pulmonary function tests: body plethysmography, lung diffusion capacity testing, and cardiopulmonary exercise testing with measurement of peak oxygen consumption. We used multivariate regression analysis to determine predictors of pulmonary function decline during RT (decrease in the lung diffusion capacity > 5% compared with baseline).Results: Pulmonary function tests prior to RT demonstrated that 15% of the patients with BC had pulmonary ventilation disorders, and 25% of the patients had pulmonary gas exchange abnormalities (most of them were newly diagnosed). In the general group following RT, we saw a significant decrease in the lung diffusion capacity (P = .044) and an increased incidence of obstructive breathing patterns among the examined patients (P = .036). Other pulmonary ventilation parameters, its effectiveness, and reserve capacity of the respiratory system after RT did not change significantly in the study group and corresponded to the reference values. The postradiation pulmonary function was negatively affected by the reduced level of pulmonary diffusion capacity at baseline (≤ 70% of the reference value) [OR 1.15 (1.03-1.34), P = .004], abnormal breathing pattern prior to RT [OR 1.08 (1.01-1.15), P = .029], involvement of regional lymph nodes (N1-3) [OR 1.10 (1.04-1.26), P = .003].Conclusion: Early postradiation respiratory disorders in patients with BC are marked by a decrease in the lung diffusion capacity and an increased incidence of obstructive patterns of pulmonary ventilation. The factors negatively affecting changes in pulmonary ventilation and diffusion characteristics after RT were the baseline pulmonary gas exchange disorders, obstructive breathing pattern prior to RT, and radiation exposure to lymph nodes. Received 28 December 2022. Revised 26 May 2023. Accepted 30 May 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: O.V. Kamenskaya, V.V. Lomivorotov Data collection and analysis: S.S. Porotnikova, E.A. Samoilova, V.G. Tihomirov Statistical analysis: I.Yu. Loginova, A.S. Klinkova Drafting the article: I.Yu. Loginova, O.V. Kamenskaya Critical revision of the article: S.E. Krasilnikov, A.M. Chernyavskiy Final approval of the version to be published: O.V. Kamenskaya, I.Yu. Loginova, A.S. Klinkova, S.S. Porotnikova, E.A. Samoilova, V.G. Tihomirov, S.E. Krasilnikov, V.V. Lomivorotov, A.M. Chernyavskiy

OBJECTIVE:To study cognitive functions in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and in the long-term after pulmonary thromboendarterectomy and to study factors that negatively affect cognitive status.MATERIAL AND METHODS:One hundred and twenty-four patients with CTEPH were examined before and 6 months after surgery with an assessment of cognitive impairment using the Mini-Mental State Examination (MMSE). Multivariate regression analysis was used to identify factors affecting the MMSE indicators before and in the long-term postoperative periods.RESULTS:Initially, patients with CTEPH had a total MMSE score 23.8±1.1. Six months after surgery, the score was 26.1±1.9 (p<0.001). A history of stroke, disability, stress (loss of spouse), and a high Charleson comorbidity index were independent factors affecting MMSE score before surgery. After surgery, the total MMSE score was influenced by a history of stroke, stress (loss of spouse), residual pulmonary hypertension and atrial fibrillation in the early postoperative period.CONCLUSION:Cognitive impairment in the form of mild dementia was observed in patients with CTEPH before surgery. Six months after the operation, an improvement in cognitive status was revealed, which corresponded to moderate cognitive impairment. At the same time, no complete recovery of cognitive functions was recorded. Patients with CTEPH still experienced the greatest difficulties in the following areas: concentration and counting, memory. A history of stroke, disability, stress (loss of spouse), and a high comorbidity index are associated with a decrease in MMSE scores before surgery. Six months after surgery, MMSE score was affected by a history of stroke, stress (loss of spouse), residual pulmonary hypertension and atrial fibrillation in the early postoperative period.

Levosimendan belongs to the class of calcium sensitizers, which exhibits its positive inotropic effects by increasing the affinity of troponin from the myocardium to calcium without additional myocardial oxygen demand, what favorably distinguishes it from catecholamines and their negative effects (myocardial ischemia, arrhythmias, vasoconstriction, hyperglycemia). In 2000, the drug was first used for the short-term treatment of decompensated chronic heart failure. After more than 20 years, the clinical use of levosimendan has covered a wide area among patients with pathology of the cardiovascular system and its use has gone far beyond the primary indications. To date, the drug has been studied in more than 200 randomized trials in patients with various clinical profiles: acute decompensation of chronic heart failure, progressive heart failure, acute myocardial infarction, cardiogenic shock, therapy of low cardiac output syndrome in cardiac surgery, perioperative use in pediatric cardiac surgery, septic shock, pulmonary hypertension, right ventricular failure, Takotsubo cardiomyopathy, patients with mechanical circulatory support devices. This review highlights the pharmacological features of the drug and key randomized clinical trials on the use of levosimendan in various categories of patients, in addition to officially recommended indications. The article also provides a brief overview of current and planned randomized trials.

АКТУАЛЬНОСТЬ: Необходимость независимой оценки рекомендаций перед их плановым пересмотром на основе стороннего мнения компетентных специалистов не вызывает сомнений. Данный анализ позволяет адаптировать реализацию рекомендаций на рабочих местах с учетом особенностей оснащения и знаний специалистов. ЦЕЛЬ ИССЛЕДОВАНИЯ: Провести анализ эффективности, безопасности и доступности выполнения в клинической практике методических рекомендаций «Применение неинвазивной вентиляции легких» с помощью модифицированного метода Дельфи. МАТЕРИАЛЫ И МЕТОДЫ: Экспертная оценка была проведена по инициативе комитета по рекомендациям и организации исследований Общероссийской общественной организации «Федерация анестезиологов и реаниматологов» и состояла из трех этапов. Подготовительный этап заключался в анализе координатором экспертизы методической рекомендации «Применение неинвазивной вентиляции легких» и оформлении анкеты-опросника, состоящей из трех разделов: оценка тезис-рекомендаций; оценка критериев качества медицинской помощи и общая оценка методической рекомендации. На основном этапе разослана анкета, и респондентам предложено оценить положения по десятибалльной шкале Р. Лайкерта. Аналитический этап заключался в расчете средневзвешенной оценки, медианы и моды. При оценке положений и критериев качества оказания медицинской помощи учитывались значение медианы или моды любого положения, средневзвешенная оценка; значение медианы или моды критериев качества оказания медицинской помощи, средневзвешенная оценка. РЕЗУЛЬТАТЫ: В экспертизе приняли участие 15 специалистов. Основные замечания и дополнения заключались в уточнении терминологии, конкретизации отдельных положений и стилистики. Участники дельфийского анализа определили возможность реализации в клинической практике положений методической рекомендации. Дефицит оборудования делает ограниченно выполнимыми лечебные мероприятия. Этот факт подтверждает низкие результаты cредневзвешенной оценки критериев качества оказания медицинской помощи. ВЫВОДЫ: Достигнут консенсус по 20 из 21 тезис-рекомендации, по 4 из 8 критериев качества оказания медицинской помощи и измененным формулировкам отдельных положений. Дельфийский анализ позволил посмотреть на реализацию методической рекомендации с позиции практикующих врачей — анестезиологов-реаниматологов, в том числе в структурных подразделениях с низким уровнем материально-технической оснащенности.

Introduction: Acute kidney injury is a common complication of cardiac surgery after management of congenital heart defects. Cardiac surgery-associated acute kidney injury (CS-AKI) results in longer stays of patients in the intensive care unit and hospital. However, using an increase in postoperative creatinine as a means of detecting AKI has some limitations, since significant changes occur after the loss of more than 50% of renal function. In children, the creatinine level is influenced by various factors such as muscle mass, cardiac output, etc. These factors vary significantly among young children and complicate the early diagnosis of AKI. Recent studies have explored biomarkers as potential predictors for the early detection of CS-AKI after cardiac surgery for management of congenital heart disease in children.Objective: To evaluate the urinary tissue inhibitor of metalloproteinase-2 (TIMP2) as a predictor of CS-AKI following management of congenital heart defects in children aged 1 month to 1 year who underwent cardiopulmonary bypass.Methods: A single-center retrospective study included patients aged 1 month to 1 year who underwent cardiopulmonary bypass for the correction of congenital heart defects. The groups were formed based on the presence of CS-AKI. The study group comprised of patients who had CS-AKI (group 1, n = 52), while those without CC-AKI constituted the control group (group 2, n = 98). To ensure minimal systematic errors and comparability between two groups, propensity score matching analysis was performed (52 patients in groups 1 and 2). Preoperative, intraoperative, and postoperative parameters and characteristics were compared.Results: The results showed no differences in baseline or demographic characteristics between the patients. In the study group, 34.6% of patients were diagnosed with CS-AKI. Among them, 67.4% (n = 35) were stage 1, 28.8% (n = 15) were stage 2, and 3.8% (n = 2) were stage 3. The results of the regression analysis show a decrease by 24% and an increase by 9 and 16% in CS-AKI respectively, with an increase in creatinine levels by 1 µmol/l, at baseline and on days 3 and 4. Additionally, male patients have a 76% lower likelihood to develop CS-AKI. It was observed that there was no significant difference in the tissue inhibitor of metalloprotease-2 levels between the groups with and without CS-AKI.Conclusion: Urinary TIMP2 levels were found to be unable to predict the early onset of CS-AKI in congenital heart defect patients ages 1 month to 1 year who underwent cardiopulmonary bypass surgery. Received 24 April 2023. Revised 27 November 2023. Accepted 28 November 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Aim. To study the dynamics of social and labor status in patients with chronic thromboembolic pulmonary hypertension (CTEPH) 6 months after pulmonary endarterectomy (PEA) and to identify clinical factors affecting the resumption of labor activity in the late postoperative period. Material and methods. The study included 79 patients with CTEPH scheduled for PEA. The average age was 48.6 (39.3-59.4) years. We analyzed clinical and functional data, as well as social and labor status before and 6 months after PEA. Using multivariate regression analysis, the factors influencing the resumption of labor activity after PEA, were studied. Results. In the general cohort of patients with CTEPH, 6 months after surgery, a slight increase in the proportion of working patients of all ages was revealed - from 55.7% to 65.8% (p=0.19). In the subgroup of patients of working age (61 people), the proportion of working patients in dynamics increased significantly – from 67.2 to 85.2% (p=0.03). Multivariate regression analysis showed a protective effect of the 2nd stage of rehabilitation on social and labor status after PEA – OR 4.2 (2.9-8.3 95%CI) (p=0.01). The presence of atrial fibrillation and residual pulmonary hypertension negatively affected the resumption of labor activity in the long-term period after PEA – OR 0.6 (0.3-0.9 95%CI) (p = 0.03) and OR 0.7 (0.2-0.8 95%CI) (p=0.01) respectively. Conclusion. The dynamics of the social and labor status of patients with CTEPH 6 months after PEA is characterized by a significant increase in the proportion of working patients of working age from 67.2 to 85.2% compared with the preoperative level. The leading protective factor for the renewal of labor potential in patients with CTEPH within 6 months after PEE is the underwenting of the 2nd stage of rehabilitation. Residual pulmonary hypertension and atrial fibrillation are limiting factors for resuming of labor activity.