Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be a critically important method for supporting patients with acute STsegment elevation coronary syndrome (STEMI) undergoing percutaneous coronary intervention (PCI) in high-risk settings.Objective: to demonstrate the effectiveness of ECMO in a patient with severe cardiovascular insufficiency against the background of myocardialischemia in conditions of ongoing intensive careClinical observations: a case of the use of VA-ECMO before PCI in a 63-year-old patient with multiple occlusive stenotic lesions of the coronary bed is described. Due to the high risk of complications during planned PCI and ongoing CPR, it was decided to start VA-ECMO to provide mechanical circulatory support. Balloon angioplasty was performed with stenting of the LCA trunk and permanent residence with 2 stents in conditions of extracorporeal life support. After stenting, an effective sinus rhythm was independently restored. On the 4th day, decannulation and excommunication from ECMO were performed. On the 7th day, the patient was transferred from the ICU to the cardiology department. The patient was discharged on the 18th day.Conclusion: the use of ECMO contributed to the stabilization of the patient’s vital signs in conditions of acute myocardial ischemia and made it possible to perform effective recanalization against the background of resuscitation measures.

Acute kidney injury (AKI), especially when caused or accompanied by sepsis, is associated with prolonged hospitalization, progression of chronic kidney disease (CKD), financial burden on the health care system, and increases mortality in various entities. Extended renal replacement therapy (CRRT) is the predominant form of renal replacement therapy (RRT) in intensive care units (ICU) by providing hemodynamic stability in critically ill patients, more precise control of fluid balance, correction of acid-base imbalances, electrolyte disorders and achieving a stable level of osmolarity correction, including in multimorbid patients. This article examines the various aspects of CRRT in critically ill patients with severe AKI with high comorbidity, as well as in patients with sepsis and multiple organ failure. An analytical evaluation of the choice of CRRT over intermittent/intermittent hemodialysis (IHD) in selected clinical settings is being conducted. Filter/dialyzer life is assessed, including assessment of filtration fraction, use of anticoagulation options including regional citrate anticoagulation (RCA), dose of CRRT prescribed and delivered, vascular access management, general criteria, timing of initiation and cessation of CRRT, and initiation of renal replacement therapy for nonrenal indications. with AKI and/or sepsis.

Drowning is the third leading cause of unintentional injury death worldwide. The largest number of victims of drowning falls on the young able- bodied population.Objective. There are no recent intensive care protocols for drowning, it is relevant to formulate guidelines for the treatment of drowning. Clinical observation. A 25-year-old female patient was taken by an ambulance team to the intensive care unit with a directional diagnosis ‘drowning in fresh water’ of three degree of severity. The patient had got on ventilator with closed aspiration system. Emergency bronchoscopy was performed during which 200 ml of fluid aspirated into the lungs was removed. Respiratory support was determined by stepwise increase of the PEEP level and decrease in FiO2 level taking into account respiratory index. Given the development of a pro-inflammatory mediator response, lactatacidosis, hemolysis, hyperhydration, a high risk of infectious complications, it was decided to start extracorporeal treatment early by continuous veno-venous hemodiafiltration and de-escalation of systemic antibacterial therapy with meropenem by prolonged infusion. Against the background of the ongoing treatment, we managed to achieve target respiratory parameters and stabilize central hemodynamic parameters by the end of the first day, prevent the development of renal damage, correct water-electrolyte and metabolic disorders, and avoid severe septic complications. Vasopressor support was discontinued on the 4th day, and on the 5th day the patient was switched to independent breathing. The patient`s stay in the intensive care unit was 6 days.Conclusions. Stepwise respiratory therapy using closed suction systems and urgent bronchoscopy prevent direct damage to the alveoli and ongoing translocation of fluid into the vascular bed. Prescribing broad-spectrum antibiotics prior to the growth of clinical and laboratory signs of infectious lung lesions allows to reduce the risk of severe septic complications with pulmonary destruction parenchyma. Early onset extracorporeal treatment by CVVHDF allows to correct homeostasis disorders, eliminate hypervolemia, prevent the development of acute renal damage as a result of hemolysis.

Introduction. Pain in the intensive care unit is a common problem in patients with acute pancreatitis of various etiologies. Given the severity of the pain syndrome, as well as the low effectiveness of nonsteroidal anti-inflammatory drugs or antispasmodic therapy, it is often necessary to resort to the administration of opioid analgesics or epidural analgesia. Each of these pain management methods has certain disadvantages and contraindications, which makes it urgent to search for a safe and effective method of relieving pain in patients with pancreatitis or pancreonecrosis.Goal. To determine the effectiveness blockade of the nerves of the fascial space of the muscles’ erector spine in acute pancreatitis. Clinical observation. Patient X., 58 years old, was arrived to the emergency department of the V.M. Buyanov State Clinical Hospital with severe pain in the epigastric region (10 points out of 10 on the visual-analog scale).Conclusions. ESPB in a patient with acute biliary pancreatitis complicated by pancreonecrosis allowed to control pain syndrome quickly and safely. Further randomized clinical trials will allow to implement and optimize the technique, improving the clinical outcome.

Introduction and purpose. Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular (LV) wall thickening not associated with increased afterload (hypertension and aortic stenosis), is usually caused by mutations in sarcomeric protein genes, and is inherited in an autosomal dominant manner. Unlike HCM, myocardial hypertrophy in its phenocopies is associated with the accumulation of substances such as amyloid, glycogen, etc. in the myocardium. The aim of our work was to analyze the features of the diagnosis and course of HCM in real clinical practice. Material and methods. A retrospective analysis of medical records of 80 patients (56.3 % of men) discharged with a diagnosis of HCM from a multidisciplinary hospital in Moscow in the period from 2007 to 2021 was carried out. The diagnosis of HCM in all patients was established on the basis of echocardiography data. The median age (25th and 75th percentiles are indicated in brackets) was 57 (48.5; 63) years. The duration of hospitalization was 8 (6; 12.5) days. Results. The reason for hospitalization was angina syndrome in 35 %, suspicion of acute coronary syndrome in 16.3 %, paroxysmal atrial fibrillation (AF) in 11.3 %, decompensation of chronic heart failure in 11.3 %, syncope in 7.5 % %, hypertensive crisis in 3.8 %, coronary angiography in 3.8 %, pacemaker implantation in 2.5 %, consultation with an arrhythmologist in 2.5 %, implantation of a cardioverter-defibrillator in 1.2 %, medical examination to resolve the issue of fitness for military service in 1.2 %, acute cerebrovascular accident in 1.2 %, hypotension in 1.2 %, drug bradycardia in 1.2 % of patients. Before hospitalization, a history of myocardial infarction was diagnosed in 15 %, arterial hypertension — in 53.8 %, chronic heart failure — in 77.6 %, chronic kidney disease — in 21.3 % of patients. Prior to the analyzed hospitalization, a history of myocardial infarction was diagnosed in 15 %, arterial hypertension in 53.8 %, chronic heart failure in 77.6 %, chronic kidney disease in 21.3 % of patients. LV wall thickness ≥1.5 cm was detected in 91.2 %, symmetrical form of hypertrophy — 22.1 %, apical — 5.2 %, papillary muscle hypertrophy — 1.3 %, interventricular septum — 71.4 % of patients. Permanent obstruction of the LV outflow tract (LVOTO) was detected in 62.8 % (9.0 % of patients had a history of septal reduction), transient LVOTO — in 1.3 %, non-obstructive HCM — in 35.9 %. The ejection fraction (EF) of the LV (according to Simpson) was 63 (55-70) %, CHF with reduced LV EF <40 % was detected in 3.8 %, with a moderately reduced LV EF (40-49 %) — in 5 %, with preserved LV EF — in 68.8 % of patients. Anterior systolic movement of the anterior leaflet of the mitral valve occurred in 47.5 %, prolapse of the anterior leaflet of the mitral valve was described in 7.14 %. Mitral regurgitation was registered in 75 % of patients. 45 % of patients with HCM suffered from AF: permanent 15 %, paroxysmal 23.8 %, persistent 6.2 % of patients. During hospitalization, ventricular tachycardia was registered in 7.5 %, supraventricular tachycardia — 3.8 %, conduction disturbances were noted in 36.3 % of patients, of which atrioventricular block in 6.3 %, blockade of the right bundle branch block in 21.3 %, left bundle branch block in 15 %, and Wolff-Parkinson-White syndrome in 1.3 % . Implantation of a pacemaker in history was in 5 %, including in connection with MorgagniAdams-Stokes attacks — in 3.8 % of patients. During a median follow-up of 87 (interquartile range 45–131.5) months, 13.8 % of patients with HCM died. In deceased patients, LVOTO was significantly more common (in the dead 100 %, in the living 58.2 %, p = 0.006) and AF (in the dead 72.7 %, in the living 40.6 %, p = 0.047). Genetic testing and exclusion of HCM phenocopies was not performed during hospitalization and was not recommended for any patient. Conclusion. In real clinical practice, in most cases, only phenotypic diagnosis of HCM is carried out according to echocardiography, and screening for genetic mutations and HCM phenocopies is not performed. It is necessary to widely introduce genetic testing and screening for HCM phenocopies for the timely diagnosis of pathology that requires the appointment of specific pathogenetic therapy to improve the prognosis of patients

Introduction . The relationship between systemic amyloidosis and coronavirus disease 2019 (COVID-19) has not been sufficiently studied to date. This paper presents a case of the persistence of COVID-19 markers in an elderly patient with systemic amyloidosis. Brief description . A 74-year-old patient with heart failure with preserved ejection fraction and type 2 diabetes was repeatedly hospitalized due to decompensated heart failure. Based on the data of protein electrophoresis with immunotyping, biopsy of subcutaneous fat and bone marrow, echocardiographic data, the patient was diagnosed with systemic AL amyloidosis with cardiac involvement. During hospitalizations in April, August and December 2020, positive polymerase chain reaction test for SARS-CoV-2 were obtained, while there were no clinical manifestations of infection for a long time and adequate antibody production. Conclusion. A case report demonstrates multiple SARS-CoV-2 reinfection in a severe comorbid elderly patient, as an unfavorable prognostic factor.

Severe combined trauma is characterized by high mortality both among young people (above 20 %) and among the older age group (about 45 %). Correction of metabolic disorders is the most difficult task, especially in the first hours after injury.Objective. To demonstrate the effectiveness of early initiation of veno-venous hemodiafiltration on the example of successful treatment of a patient with severe combined trauma (ISS is 57 points).Clinical observation. Patient A., 19 years old, was taken to the surgical intensive care unit by an ambulance team with a directional diagnosis of ‘severe combined injury’ as a result of falling from a height of the 6th floor in a state of alcoholic intoxication. Considering the impossibility of correcting waterelectrolyte and metabolic disorders by conservative methods, it was decided to start extracorporeal treatment early in the volume of prolonged venovenous hemodiafiltration with citrate-calcium anticoagulation (Ci-Ca CVVHD). In addition, the patient received therapy within the framework of the current recommendations for the treatment of severe combined trauma. Against the background of the ongoing treatment, there was a distinct positive trend. Vasopressor support was discontinued on day 3, and on day 15 the patient was transferred to independent breathing. In total, one CVVHD session was conducted, with a total duration of 62 hours. The patient’s stay in the intensive care unit was 29 days, in the profile distance – 4 days with subsequent discharge.Conclusions. The use of the CVVHD method in a patient with severe combined trauma in the early period without the phenomena of acute kidney injury contributed to the relief of metabolic disorders with the stabilization of the homeostasis system. However, in order to form conclusions and expand indications for the use of extracorporeal detoxification methods in patients with severe combined trauma, further study of this issue is necessary.

OBJECTIVEMorphological substantiation of laparoscopic suturing of gastric ulcer with formation of a covered perforation.MATERIAL AND METHODSTo analyze morphological tissue reaction in surgical area, we used 12 Chinchilla rabbits. All animals were divided into 2 groups by 6 animals. The main group enrolled rabbits undergoing suturing of perforated gastric ulcer with formation of a covered perforation by anterior stomach wall. In the control group, gastric perforation was sutured by conventional double-row suture. For histological analysis, 2 animals in each group were withdrawn from the experiment after 7, 14 and 21 days. We excised gastric wall within the area of perforation closure. Morphological data on healing process were compared between both groups.RESULTS. STomach deformation after 7 days was more severe in the main group compared to simple suturing. However, these differences were absent after 21 days. Morphological analysis revealed postoperative transmural necrosis after 7 days. Signs of early epithelialization were more obvious in the main group. After 21 postoperative days, we observed almost completely restored differentiation of stomach wall layers in both groups of animals.

Amyloidosis is a heterogeneous group of the diseases caused by the extracellular deposition of amyloid in various organs including a cardiovascular system. Aim . To study the cardiovascular damage in patients with systemic amyloidosis. Material and methods . A retrospective assessment of 38 cases of systemic amyloidosis was carried out. Diagnosis was verified by biopsy in 57,9% (27,3% of these cases were then confirmed by autopsy) and autopsy in 42,1% of patients. Congo red stain and polarized-light microscopy were used. The systemic nature of lesion was diagnosed in the positive biopsies of two or more localizations or in the positive biopsy of one localization in the combination with the clinical picture of amyloidosis at least one organ. Median (interquartile range) of age was 72,5 (64-84) years (women, 65,8%; men, 34,2%). Results . In the medical history, 81,6% of patients with systemic amyloidosis had hypertension, 52,6% — coronary artery disease, 34,2% — myocardial infarction, 36,8% — type 2 diabetes, 44,7% — atrial fibrillation, 26,3% — conduction disorders. Also 13,2% of patients had an implanted pacemaker. According to the electrocardiography, 42,3% of patients had a low QRS voltage. According to echocardiography, left ventricular (LV) hypertrophy was detected in 94,7% of patients. In addition, 31,6% of patients had signs of granular sparkling myocardial appearance, 20% — impaired local LV contractility, 77,8% — increased pulmonary artery reassure, 28,6% — LV diastolic dysfunction, 14,3% — normal diastolic function. LV ejection fraction (LVEF) was 55 (44,5-55)%. LVEF 50% — in 65% of patients. Heart failure was indicated in 71,1% of patients with systemic amyloidosis, chronic kidney disease (CKD) — in 95% of patients. The estimated glomerular filtration rate (CKD-EPI) was 21,2 (13,1-40) ml/min/1,73 m 2 . Proteinuria (1,1 (0,5-3,0) g/l) was detected in 88,9% of patients. Nephrotic syndrome occurred in 27,8% of patients. Conclusion . Patients with cardiovascular lesions of unclear etiology, especially in the presence of LV wall thickening, preserved LVEF, stage 4-5 CKD and proteinuria, require screening for systemic amyloidosis.

Amyloidosis is a heterogeneous group of the diseases caused by the extracellular deposition of amyloid in various organs including a cardiovascular system.Aim. To study the cardiovascular damage in patients with systemic amyloidosis.Material and methods. A retrospective assessment of 38 cases of systemic amyloidosis was carried out. Diagnosis was verified by biopsy in 57,9% (27,3% of these cases were then confirmed by autopsy) and autopsy in 42,1% of patients. Congo red stain and polarized-light microscopy were used. The systemic nature of lesion was diagnosed in the positive biopsies of two or more localizations or in the positive biopsy of one localization in the combination with the clinical picture of amyloidosis at least one organ. Median (interquartile range) of age was 72,5 (64-84) years (women, 65,8%; men, 34,2%).Results. In the medical history, 81,6% of patients with systemic amyloidosis had hypertension, 52,6% — coronary artery disease, 34,2% — myocardial infarction, 36,8% — type 2 diabetes, 44,7% — atrial fibrillation, 26,3% — conduction disorders. Also 13,2% of patients had an implanted pacemaker. According to the electrocardiography, 42,3% of patients had a low QRS voltage. According to echocardiography, left ventricular (LV) hypertrophy was detected in 94,7% of patients. In addition, 31,6% of patients had signs of granular sparkling myocardial appearance, 20% — impaired local LV contractility, 77,8% — increased pulmonary artery reassure, 28,6% — LV diastolic dysfunction, 14,3% — normal diastolic function. LV ejection fraction (LVEF) was 55 (44,5-55)%. LVEF <40% was detected in 15%, 4050% — in 20%, >50% — in 65% of patients. Heart failure was indicated in 71,1% of patients with systemic amyloidosis, chronic kidney disease (CKD) — in 95% of patients. The estimated glomerular filtration rate (CKD-EPI) was 21,2 (13,1-40) ml/min/1,73 m2. Proteinuria (1,1 (0,5-3,0) g/l) was detected in 88,9% of patients. Nephrotic syndrome occurred in 27,8% of patients.Conclusion. Patients with cardiovascular lesions of unclear etiology, especially in the presence of LV wall thickening, preserved LVEF, stage 4-5 CKD and proteinuria, require screening for systemic amyloidosis.

OBJECTIVE:To evaluate the results of endovascular treatment of patients with ischemic stroke caused by acute tandem occlusion of the internal carotid and middle cerebral arteries (ICA and MCA).MATERIAL AND METHODS:Endovascular intervention was performed in 8 patients with tandem occlusion of ICA and MCA. The neurological deficit on admission was 17.4±5.6 NIHSS points and the average ASPECTS score was 9.5±0.8. The time from the onset of neurological symptoms to reperfusion was 224±68 min. Thrombolytic therapy was initiated before brain revascularization and continued intraoperatively in 4 out of 8 patients. ICA stenting after aspiration thrombectomy was required in 6 patients. Both antegrade (n=4) and retrograde (n=2) methods of brain revascularization were used.RESULTS:The rate of detection of tandem lesion in patients with ischemic stroke who underwent endovascular treatment was 5.4%. Technical success in restoring blood flow in the ICA basin at extra-and intra-cranial levels (mTICI 2b/3) was achieved in 7 (87.5%) patients. Intracranial hemorrhagic complications that affected the outcome of the disease were clinically significant in 25% of patients (n=2). The mortality rate was 37.5% (n=3). A satisfactory clinical result (a deficit of 0-2 mRS scores) was achieved at discharge in one of 5 surviving patients.CONCLUSION:Further studies of choosing the optimal surgical tactics for tandem occlusion of ICA and MCA, taking into account its effectiveness and safety, are need.

AIM:To assess an efficacy and safety of brachiocephalic arteries reconstruction at the acute stage of stroke.MATERIAL AND METHODS:Early reconstruction of brachiocephalic arteries was made in 7 patients (mean age 67±9 years). Mean terms of brachiocephalic arteries reconstruction after stroke were 4.6 days (range 2-7 days). Pre- and postoperative neurological state was assessed by NIHSS score (mean preoperative score was 3.9±2.7 in these 7 patients, range 0-7). All patients had ipsilateral cerebral ischemic lesions with stenosis/occlusion of brachiocephalic artery. Their mean dimension was 10 mm (range 4-32 mm). Internal carotid artery stenting was made in 2 patients, carotid endarterectomy - in 4 patients, stenting of the 1st segment of left subclavian artery - in 1 patient.RESULTS:There were no deaths and recurrent postoperative ischemic strokes. Complications developed in 2 patients: postoperative hematoma and intraoperative transient ischemic attack during ICA stenting in 5 days after stroke. There was a positive course of neurological state after brachiocephalic arteries reconstruction: mean score of neurological deficit decreased by almost 2 times (from 3.9±2.7 to 2±1.7).CONCLUSION:Early surgical prevention (within 7 days after stroke) may be effective and safe in certain patients with ischemic stroke (neurological deficit by Rankin score ≤3 and NIHSS ≤7, ischemic focus dimension less than 4 cm). Brachiocephalic arteries reconstruction early after stroke improves neurological state postoperatively by reducing motor and sensitive disorders. However, at present time there are no clear indications for early revascularization depending on either neurological deficit severity and ischemic focus dimension. So, our data should be confirmed by large trials.

The authors share herein their experience of treating a total of eight patients with acute impairment of mesenteric blood circulation, describing both technical and instrumental peculiarities of interventions on the superior mesenteric artery. Technical success defined as restoration of the main blood flow through the superior mesenteric artery was achieved in seven (87.5%) patients. Of these, two (25%) patients required laparotomy and intestinal resection, with the scope of resection being significantly reduced in one case after endovascular thrombectomy. A further two (25%) patients developed respiratory distress syndrome as a complication of reperfusion syndrome. There were two (25%) lethal outcomes. A conclusion was drawn that endovascular interventions might be regarded as an independent method of treatment of patients presenting with acute impairment of the mesenteric blood flow in the stage of intestinal ischaemia. Besides, this technique makes it possible in case of the development of intestinal gangrene to dramatically diminish the scope of intestinal necrotic lesion.

The retrospective analysis of clinical records of 25 patients with the severe combined injury for the purpose of an assessment of influence of changes of volemichesky support on development of sharp injury of lungs is made. Monitoring of haemo dynamics and the volemichesky status carried out by means of technology of the modified PiCCO plus termodilyution (Pulsion Medical Systems, Germany). During the analysis it was revealed that application of haemo dynamic monitoring with use of a transpulmonalny termodilyution and the PiCCO technology, allows to improve authentically oxygenation index indicators, to reduce duration of respiratory support and a ball assessment of weight of a condition of patients, on an integrated scale of SOFA. From this it is possible to draw a conclusion that application of volemichesky monitoring of PiCCO allows to prevent development of the sharp injury of lungs (SIL) in patients with the severe combined injury.

AIM:To evaluate the efficacy and safety of supra-aortic vessels reconstruction within acute period of stroke.MATERIAL AND METHODS:Early surgery was performed in 7 patients aged 67±9 years. Revascularization was made after 4.6 days after ischemic stroke on the average (range from 2 to 7 days). Neurological status before and after surgery was assessed using NIHSS scale, mean preoperative score was 3.9±2.7 (0-7). All patients had ischemic brain lesions (4-32 mm, mean 10 mm) unilateral with carotid stenosis or occlusion. Carotid artery stenting was performed in 2 patients, carotid endarterectomy - in 4 patients and stenting of segment I of the left subclavian artery was made in 1 case.RESULTS:There were no mortality and recurrent postoperative ischemic stroke. Complications occurred in two patients: postoperative hematoma and intraoperative transient ischemic attack that developed during CAS after 5 days of a stroke. There was positive neurological dynamics after revascularization: there was almost 2-fold decrease of mean score of neurological deficit (from 3.9±2.7±1.7 to 2).CONCLUSION:Early surgical prevention of recurrent stroke (up to 7 days) can be performed effectively and safely in carefully selected patients with ischemic stroke (neurological deficit less than 3 Rankin scores and less than 7 NIHSS scores, ischemic lesion dimensions lass than 4 cm). Reconstruction of supra-aortic vessels in acute stage of stroke improves the neurological status and reduces the degree of motor and sensory disorders. However, currently there are no clear criteria for inclusion and exclusion of patients for early revascularization using both degree of neurological deficit and size of ischemic lesion. So our results need to be confirmed by large trials.

The aim of the study was to determine the correlation between blood levels of Nterminal portion of the inactive precursor of natriuretic peptide of Btype (NTproBNP) and hemodynamic, clinical and laboratory parameters in the course of intensive treatment of patients with severe communityacquired pneumonia (CAP).Materials and methods. The study included 12 patients (10 men and 2 women) with severe CAP, age 25—88 (51.5 (41.25; 69)) years. The severity of the condition was as follows (averages and percentiles): on a scale of CURB65 — 3—5 (4; 4,5) scores, APACHE II — 16—33 (23 (18.75; 25)) scores, SOFA — 6—16 (10 (9; 12.75)) points. Concentartions of NTproBNP in venous blood 24—36 h post admission and on day 5 of treatment were determined by analyzer Dimension Xpand Plus (Siemens).Results. Within 24—36 hours after the admission concentration of NTproBNP was 783.5 (460.75; 4150.25) pg/ml. The content of the biomarker remained higher than in norm in 66.7% of patients. By the 5th day the concentration of the biomarker was 537 (376.25, 1334) pg/ml. In surviving patients (66.7%), the concentration of NT proBNP was decreasing (P=0.008) to day 5 of treatment from 918 (560, 8501) to 391 (341, 1010) pg/ml. CAP patients who did not survived later (32.3%) exhibited no decrease of the biomarker concentration. Significant correlation between NTproBNP on admission to ISU and index of total peripheral vascular resistance on day 2 of intensive treatment (r=0.63; p<0.05) and day 5 (r=0.58, P<0.05) was revealed. Echocardiography systolic pulmonary artery pressure correlated with the content of NTproBNP 24—36 hours after admission to the Intensive Care Unit and on the 5th day of treatment.Conclusion. We suggested that the reason for increased concentration of NTproBNP is an overload of the right ventricle myocardium due to pulmonary hypertension as a characteristic of acute respiratory distress syndrome.

The treatment policy concerning patients with lesions of the extra- and intracranial portions of carotid arteries is currently uncertain. The authors share herein their experience in diagnosis and treatment of 5 patients presenting with lesions of the extracranial portions of the internal carotid artery (stenosis/occlusion/pathological tortuosity) combined with arterial aneurysms and arteriovenous malformations of the brain. Of these, two patients were operated on: the first one was primarily subjected to clipping of the cerebral aneurysm then after several months underwent a reconstructive vascular operation on the ipsilateral side (resection of the internal carotid artery with its readdressing). The second patient with subtotal stenosis of the internal carotid artery who initially underwent clipping of the ipsilateral asymptomatic aneurysm of the middle cerebral artery developed occlusion of the internal carotid artery by the second stage of treatment and was not subjected to vascular operation. There were no is-chaemic cerebral complications or lethal outcomes in the operated patients in peri- and post-operative periods at all stages of treatment.

Objective: to assess the specific features of central hemodynamics (CH), extravascular lung water index (EVLWI), and pulmonary oxygenizing function in patients with different outcomes of treatment for severe communityacquired pneumonia (CAP).Subjects and methods. The retrospective study enrolled 57 patients with CAP. According to its outcome, there were 2 groups: 1) 44 patients (33 men and 11 women), whose disease ended in recovery; 2) 13 patients (8 men and 5 women), whose CAP resulted in a fatal out come. The groups did not differ in age (48.1±2.3 and 55.3±4.1 years) and overall disease severity according to the APACHE II (21.5±0.8 and 25.2±2.1 scores) and SOFA (8.7±0.2 and 9.7±1.0 scores) scales (p<0.05). CAP was more severe in Group 2: 3.5±0.1 and 4.4±0.27 CURB65 scores (p>0.05). All the patients received identical antibiotic therapy. They underwent transpulmonary thermodilution according to the standard procedure. The indicators were daily recorded. The data were statistically processed. A corre lation analysis was made calculating the correlation coefficients (r). The significance of differences was estimated by the Student's ttest or Mann-Whitney test.Results. On day 1 of followup, the patients in both groups were prone to arterial hypotension, had tachycardia, lower or nearnormal central venous pressure (CVP). Group 1 versus Group 2 had higher cardiac index (CI) (2.9±0.2 and 2.1±0.1 l/min/m2 ) and global ejection fraction (GEF) (22.5±1 and 15.8±1.7%) (p<0.05) and lower CVP (4.1±0.2 and 5.6±0.4 mm Hg) (p<0.05). On day 3, Group 2 versus Group 1 had higher CVP (p<0.05) and lower CI, GEF, and some other cardiac pump function indicators. Admission EVLWI was virtually equally elevated in both groups. In Group 1, the indicator decreased later on and approached the normal values at 67 days of treatment. In Group 2, EVLWI remained high and did not virtually decrease. The indicator was ascertained to be inversely correlated with GEF on treatment days 1—2 (r=0.35 to 0.58; p<0.01) and 6—7 (r=0.67 to 0.43; p<0.001).Conclusion. In the first 24 hours of treatment, the patients with the unfavorable course of severe CAP are diag nosed as having signs of acute respiratory distress syndrome (ARDS) and impaired CH, which can be interpreted as progressive right ventricular dysfunction. The pivotal role of ARDS in the pathogenesis of CH disorders is borne out by the inverse correlation between EVLWI and integral cardiac systolic function indicator and GEF.