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Routine and emergency switching to artificial circulation in coronary artery bypass surgery
Таблица 3. - Результаты кашлевой пробы и Pad-теста
n (%) осложнений
Показатель TVT TVT-O Gynecare TVT-O Monarch TVT Secur P
Отрицательный тест 154 (92,2%) 335 (93,3%) 96 (91,4%) 62 (92,5%) 0,496
Положительный тест 13 (7,8%) 24 (6,7%) 9 (8,6%) 5 (7,53%) 0,413
Заключение
На основе многолетних наблюдений, крупной выборки пациентов и использования различных вариантов слинговых операций для лечения стрессового недержания мочи у женщин показана высокая эффективность и безопасность этих вмешательств в отдаленной перспективе. При этом был подтвержден тезис, что при большом хирургическом опыте успех
оперативного лечения не зависит от типа слинговой операции. Исходя из этого, выбор варианта слинго-вой операции целесообразно осуществлять, главным образом, на основе опыта (предпочтения) хирурга и стоимости процедуры.
Конфликт интересов У авторов нет конфликта интересов.
Список литературы:
1. Botlero R., Urquhart D.M., Davis S.R., Bell R.J. Prevalence and incidence of urinary incontinence in women: review of the literature and investigation of methodological issues. Int J Urol. 2008,15 (3):230-4.
2. Kwon B.E., Kim G.Y., Son YJ. et al. Quality of life of women with urinary incontinence: a systematic literature review. Int Neurourol J. 2010; 14 (3):133-8.
3. Пушкарь Д.Ю., Касян Г.Р., Колонтарев К.Б. и др. Отдаленные результаты использования свободной синтетической петли в лечении недержания мочи у женщин (восьмилетние результаты). Урология 2010,-2: 32-6.
4. Вирясов А.В., Новикова А.С., Шагинян Г.Г. и др. Изучение ограничений жизнедеятельности у женщин с недержанием мочи. Современные проблемы науки и образования. 2014; 6: 974.
5. Serati M., Salvatore S., Uccella S. et al. Surgical treatment for female stress urinary incontinence: what is the gold-standard procedure? Int Urogynecol J. 2009,20 (6): 619-21.
6. Касян Г.Р., Гвоздев М.Ю., Годунов Б.Н. и др. Анализ результатов лечения недержания мочи у женщин с использованием свободной субуретральной синтетической петли: опыт 1000 операций. Урология. 2013,13: 5-11.
7. Nilsson C.G., Kuuva N., Falconer C. et al. Long term results of the tension free vaginal tape procedure for surgical treatment of female stress urinary incontinence. J Pelvic Floor Dysfunc. 2008,12 (2): 55-8.
8. Novara G., Artibani W., Barber M. et al. Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the surgical treatment of female stress urinary incontinence. Urology. 2010,5 (8): 218-38.
Zhurba Oleg Oleksandrovich, SI"National Institute of Cardiovascular Surgery named after M. M. Amosоv NAMS» (Kyiv) cardiosurgeon, E-mail: olegzhurba2009@yandex.ru
Routine and emergency switching to artificial circulation in coronary artery bypass surgery
Abstract: Ain the National Institute of Cardiovascular Surgery named after M. M. Amosov NAMS in the period from 2009 to 2013 was performed 3958 operations with isolated coronary artery bypass surgery. Patients were divided into 2 groups. In the first group included 82 (2,1%) patients who had required emergency switch to artificial circulation. Patients of the first group were included in to the 3848 cases since they began operation on a beating heart. The second group of 110 patients had the routine switch to artificial circulation.
Keywords: coronary artery bypass surgery, routine and emergency switch to AC. 41
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Section 6. Medical science
Currently coronary artery bypass grafting surgery is a highly effective treatment of coronary artery disease [1]. In surgical practice widely used CABG surgery on a beating heart without CPB (cardiopulmonary bypass) with complete revascularization in patients with many vascular lesions of the coronary arteries using devices required exposure and stabilize the heart. In a number of hospitals without revascularization CPB has taken a leading role in the surgical treatment of patients with coronary artery disease. The proportion of such interventions for all operations bypass surgery is 20-22%, Europe — 50% in Japan — 60% [9]. In some hospitals, this figure exceeds 90% [10]. Recently, however, a significant portion of patients with iscemic heart disease, entering the hospital for surgery, are elderly with existing long-term angina with marked disturbances of myocardial contractile function, symptoms ofcirculatory failure, suffering severe concomitant diseases, and require re-revascularization [7]. These features increase the risk of surgery, significantly increases the likelihood ofpostoperative complications [8]. According to Justin D. Blasberg mortality in isolated CABG using CPB and without CPB, men and women was: 1.8% without CPB,1.3% with CPB- among men and 1.3% without CPB and 4,1% using CPB -among women [11].According to the data of NISSH named after M. M. Amos mortality in isolated coronary artery bypass grafting in 2013 was
0.4%. T. A. Vassiliades et al. obtained good results in more than 90% of patients undergoing CABG surgery, to continue needed transition to CPB due to hemodynamic collapse, while some researchers have found high mortality and a large number ofcomplications in this population [2; 3]. Patients switched to emergency AC definitely have a higher mortality rate and a large number of complications than patients with planned CPB surgery on a beating heart [4; 5; 6].
Materials and methods. In the National Institute of Cardiovascular Surgery named after M. M. Amosova NAMS, in the period from 2009 to 2013 year were performed 3958 surgeries of CABG. Patients were devi-ded into 2 groups. In the group I of the beating heart, which included 3848 patients, were 82 (2,1%) patients, whom began the surgery on a beating heart, but had to proceed to the emergency CPB. Group II-110 patients, the were operated using planned CPB.
In the group I which included patients who needed emergency conversion to CPB was 48 men (58%), 34 women (42%), patients younger 65 years 39 (47%), over 65-43 (53%). In the group of the the routine switch were 89 men (80%), 21 women (20%), patients younger 65 years 83 (76%), over 65 years-27 (24%).
According to the coronary- ventriculography in the group I LMCA (left main coronary artery) trunk stenosis > 70% was observed in 22 (26.8%), three-vessel lesions 60 (73.2%). The group II LMCA trunk stenosis > 70% in 24 (22%) patients, three-vessel lesions in 86 (78%).
Exertional stenocardia and reststenocardia in the group I was observed in 50 (61%) patients in group II in 83 (75.5%) patients.
Diabetes in the group I was sick: type I -1 (1,2%) patient, type II-5 (6.1%) patients; and group II to type I -3 (2,7%) patients, type II-16 (14.5%) patients.
Some of the patients already had some intervention on the heart (coronary artery bypass grafting in history, stenting).In group I, patients who needed emergency conversion to CPB, coronary bypass surgery were 4 (4.8%) patients in group II-2 (1, 8%) patients.Coronary stenting: group I-3 (3.7%) patients in group II-8 (7.3%) patients.
The increased size of the heart, EDV data (EDV> 180 ml.) observed: group I -0 (0%) in group II-16 (14.5%) patients.
Reduced ejection fraction (EF <35%) took place: in the group I-3 (3.7%) patients in group II-0 (0%) patients.
The causes of the immediate transition to AC were: 51 (62%) unstable hemodynamics (irreversible reduction of the systolic blood pressure below 80 mm Hg.), 12 (14.7%) intraoperative arrhythmias (volley ventricular tachycardia, ventricular fibrillation), 2 bleeding (2.5%), 17 (20,1%) ECG changes (ST segment elevation).
The reasons for the planned transition to AC were: 55 (50%) ACS, 13 (12%) preoperative ECG changes with intact troponins, 17 (15.5%) sub-occlusion without clinics, 6 (5.4%) preoperative arrhythmias, 19 (17.1%) reduced ejection fraction.
In the group I were patients: 37 (45%) with stable angina, 27 (33%) with unstable and 18 (22%) without angina. In the group II were patients: 55 (50%) patients with ACS,30 (27%) with stable angina, 25 (23%) without angina.
I n the group I 31 patients (38%) had myocardial infarction, lack 51 (62%). The presence of myocardial infarction on ECG in the group II was observed in 70 patients (64%).
Among of comorbidity the significant part were: hypertension -21 (25%) in the group I,44 patients (40%) in the group II; diabetes had 7 (8.5%) patients in the group I, 26 (23%) patients in the group II; acute cerebrovascular accident in the group I had 5 (6%) patients and 10 (9%) patients in the group II.
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Routine and emergency switching to artificial circulation in coronary artery bypass surgery
Results. The causes of the immediate transition to AC were: 51 (62%) unstable hemodynamics (irreversible reduction of the systolic blood pressure below 80 mm Hg.), 12 (14.7%) intraoperative arrhythmias (volley ventricular tachycardia, ventricular fibrillation), 2 bleeding (2.5%), 17 (20,1%) ECG changes (ST segment elevation).
The reasons for the planned transition to AC were: 55 (50%) ACS, 13 (12%) preoperative ECG changes with intact troponins, 17 (15.5%) sub-occlusion without clinics, 6 (5.4%) preoperative arrhythmias, 19 (17.1%) reduced ejection fraction.
Postoperative mortality in the group I- 6 people died, equaling 7.3% in the group II — 2 patients, equaling 1.8%. Significant impact to the postoperative mortality was preoperative status ofpatients. All patients who died were in 3-4 FC in NYHA.
Among of all 3958 operations with isolated coronary bypass surgery performed in the period from 2009 to 2013 heart weakness I—II degree ranged from 3-6% of patients. Duration of mechanical ventilation ranged from 6 to 8 hours.
Among all 3958 surgeries with isolated coronary artery bypass grafting performed in the period from 2009 to 2013 died 25 patients, representing (0.6%) of the operated. In the group, which performed CABG on a beating heart with the planned AC (110 patients) mor-
tality was 2 (1.8%) patients, and 82 patients in the group who started on a beating heart, but switched to CPB, 6 deaths (7.3%). In the group planned AC 2 patients died, the cause of death was a stroke, and other acute cardiovascular weakness. In the group of emergency AC
4-patients died from transmural myocardial infarction of the left ventricle (4 patients were taken with ACS and increased troponins), one had hemorrhagic stroke and one more- multiorgan failure. Inotropic support for more than 24 hours in the postoperative period in the group planned AC was observed in 24 patients (21.8%) and in the group of emergency AC in 43 patients (52.4%). Patients discharged an average of 10—11 days after surgery without clinical complications.
Conclusions
1. Operation bypass surgery on a beating heart can be a safe method of implementation of interventions for almost all categories of patients requiring surgical correction of coronary heart disease and can be used in 97% of cases.
2. The planned transition to CPB gets better results compared to the emergency, it requires careful analysis and identification of criteria for selecting patients who required transfer to CPB.
3. Main reasons of emegent conversion to CPB: hemodynamic instability during surgery, coronary anatomy, changes ECG.
References:
1. Czerny M., Baurmer H., Kilo J. et al. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass//Eur. J. Cardio-thorac. Surg. — 2000. — Vol. 17 (6). — P. 737—42.
2. Vassiliades T. A. Hemodynamic collapse during off-pump coronary artery bypass grafting/T. A. Vassiliades, J. L. Nielsen, J. L. Lonquist//Ann Thorac Surg. — 2002Jun. — Vol. 73, N 6. P. 1874—79.
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4. Chowdhury R. Risk factors for conversion to cardiopulmonary bypass during off-pump coronary artery bypass surgery./R. Chowdhury [et al.]//Ann Thorac Surg. — 2012 Jun. — Vol. 93, N 6. — P. 1936—41.
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7. Ascione R., Lloyd C. T., Underwood M. J., Gomes W.J., Angelini G. D. On-pump versus off-pump coronary revascularization: evaluation of renal function.//Ann Thorac Surg. — 1999. — Vol. 68 (2). — P. 493—8.
8. Михеев A. A., Клюжев В. M., Кариун Н. A. и др. Операции на коронарных артериях на работающем сердце без искусственного кровообращения у больных ишемической болезнью сердца//Медпрактика. — M. — 2001. — 80 с.
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10. Caus T., Seree Y., Marin P., Khairi M., Bakkali A., Guillen J. C., Bonnet J. L., Metras D. Off-pump coronary surgery in selected patients: better early outcome but more recurrence of angina?//Interact Cardiovasc Thorac Surg. — 2005. — Vol. 4 (4). — P. 322—6. 43
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Section 6. Medical science
11. The role of gender in coronary surgeryjustin D. Blasberg, European Journal of Cardio-thoracic Surgery40 (2011) 715-721.
12. The European Association for Cardio-Thoracic Surgery, Fourth Adult Cardiac Surgical Database report 2010.
Pasieshvili Nana Merabovna, Kharkiv regional clinical perinatal center E-mail: pasonana@mail.ru
Modern approach to reduce perinatal morbidity and mortality in infectious diseases fetus and newborn
Abstract: The article presents an analysis of the causes of perinatal morbidity and mortality in a regional perinatal center of Ukraine. The role of infectious diseases of the fetus and newborn at the present stage was determined, methods of prevention and treatment of intrauterine infections were proposed.
Keywords: fetal infections, perinatal morbidity and mortality, immunotherapy.
Пасиешвили Нана Мерабовна, Харьковский клинический областной перинатальный центр
E-mail: pasonana@mail.ru
Современные подходы к снижению перинатальной заболеваемости и смертности при инфекционных заболеваниях плода и новорожденного
Аннотация: В статье представлен анализ причин перинатальной заболеваемости и смертности в условиях областного перинатального центра Украины. Определена роль инфекционных заболеваний плода и новорожденного на современном этапе, предложены методы профилактики и лечения внутриутробных инфекций.
Ключевые слова: инфекционные заболевания плода, перинатальная заболеваемость и смертность, иммунокоррекция.
В течение многих лет усилия акушеров-гинеколо-гов и неонатологов направлены на поиск путей снижения перинатальной заболеваемости и смертности, улучшения качества медицинской помощи [6,27-29].
В системе здравоохранения Украины пристальное внимание уделяется повышению эффективности профилактических мероприятий, направленных на снижение перинатальной заболеваемости и смертности, особенно в группе беременных с заболеваниями бактериальной и вирусной этиологии, которые нередко ухудшают течение гестационного периода, вызывают инфекционно-воспалительные заболевания у плода и новорожденного [3,15-16; 7,1163-1170].
На сегодняшний день определена роль условно-патогенных возбудителей, бактерий и вирусов в генезе преждевременных родов, дистресса плода, внутриутробных пневмоний, сердечно-сосудистых расстройств, повреждений печени и нервной системы у новорожденных [8,230-237; 9,21-39]. Выявлена связь между развитием внутриутробного инфициро-
вания и нарушением иммунитета матери, плода и новорожденного [1,110-113; 3,16-18; 5,25-29].
Появление в последние годы обьективных методов определения состояния плода позволяет своевременно диагностировать многие наследственные заболевания, гемолитическую болезнь, дистресс плода, однако внутриутробное инфицирование плода можно только предполагать по косвенным признакам при обследовании беременнных [6,236-250].
Создание перинатальных центров в Украине позволило своевременно оказывать помощь беременным группы риска (антенатальная охрана плода), роженицам (интранатальная охрана плода) и новорожденным (постнатальное лечение). Перинатальный центр представляет важнейшее звено повышения качества акушерской и неонаталогической помощи, позволяющий использовать новейшие достижения современной науки, разрабатывать эффективные диагностические и терапевтические методы, способствующие снижению перинатальной заболеваемости и смертности [4,42-47].
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