Importance of extracorporeal membrane oxygenation (ECMO) in therapy for legionella pneumonia in patient with hairy-cell leucosis

Clinical observation of the patient with legionella pneumonia which developed in the setting of hairy-cell leukosis, required use of extracorporeal membrane oxygenation for controlling life-threatening hypoxia is presented. Active diagnostic approach for identification of the etiologic agent (Legionella pneumophila, Acinetobacter baumannii) that caused pneumonia, allowed to choose an optimum set of antibacterial agents and medicines for specific therapy of hemoblastosis (BRAFV600E mutation and use of Zelboraf). After correction of respiratory insufficiency and discontinue the patient from ECMO, we could reach hematologic remission and transfer the patient to the Institute of Hematology for further treatment

СЛУЧАЙ УСПЕШНОГО ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ КОНСТРИКТИВНОГО ПЕРИКАРДИТА ПОСЛЕ ТРАНСПЛАНТАЦИИ СЕРДЦА

Heart transplantation became a widespread and effective method of terminal heart failure treatment. Simultane- ously with accumulation of experience and knowledge, physicians face complications both specific and nonspe- cific for heart transplant patients – such as constrictive pericarditis. There are only several cases of constrictive pericarditis after heart transplantation described, and mortality among such patients is quite high. We present one case of constrictive pericaditis, that was diagnosed 11 months after the heart transplantation was performed. The subtotal pericardectomy was performed. Postoperatively, significant improvement in hemodynamic parame- ters – the decrease in CVP and LA pressure, the increase in end-diastollic LV size – indicated the effectiveness of procedure. Трансплантация сердца (ТС) стала общепринятым методом лечения терминальной стадии седечной не- достаточности во всем мире. Но одновременно с накоплением опыта врачи сталкиваются и с различными осложнениями, в том числе и традиционными для кардиохирургии – такими как констриктивный пери- кардит. В литературе описаны единичные наблюдения, при этом летальность в этой группе больных вы- сока. В нашем сообщении описан случай констриктивного перикардита, развившегося через 11 месяцев после трансплантации сердца. Больному была выполнена операция – субтотальная перикардэктомия. Значительное улучшение гемодинамических параметров (снижение ЦВД, увеличение КДР ЛЖ, сниже- ние АД ЛА) свидетельствовали о хорошем результате вмешательства.

СЛУЧАЙ УСПЕШНОГО ПРИМЕНЕНИЯ ЭСТРАКОРПОРАЛЬНОЙ МЕМБРАННОЙ ОКСИГЕНАЦИИ ПРИ КРИТИЧЕСКОМ МИТРАЛЬНОМ СТЕНОЗЕ С ТРОМБОЗОМ ЛЕВОГО ПРЕДСЕРДИЯ

Extracorporeal membrane oxygenation is considered either as a linking procedure restoring functioning of an organ or as a link to organ grafting. If there is no expectancy to bring back pulmonary or cardiac functioning and grafting is out of feasibility, one should consider ECMO to be meaningless. In this paper we have demonstrated a successful application of ECMO in a 55 y. o. female patient with terminal stage of critical mitral valve stenosis with left atrial thrombus and her left ventricular ejection fraction (LVEF) was 16%. Following 4-day perfusion due to a noticeable positive dynamics the patient underwent mitral valve replacement and LA thrombus removal. In fi ve days after the surgery ECMO was disconnected. At discharge LV ejection fraction was 43%.Conclusions: we believe ECMO should be more widely applied in cardiac surgery.Процедура ЭКМО рассматривается либо как «мост» к восстановлению функции органа, либо как «мост» к трансплантации органа. Если же надежды на восстановление функции сердца или легких нет, а возможность их трансплантации отсутствует, то рассматривать подключение ЭКМО бессмысленно. В данном сообщении мы приводим случай успешного применения ЭКМО у пациентки 55 лет в терминальной стадии критического митрального стеноза с тромбозом левого предсердия и фракцией выброса левого желудочка (ФВ ЛЖ) 16%. После 4 дней перфузии на фоне выраженной положительной динамики пациентке было успешно выполнено протезирование митрального клапана и тромбэктомия из левого предсердия. Через 5 суток после операции отключена ЭКМО. На момент выписки из стационара ФВ ЛЖ составляла 43%.Выводы: ЭКМО может более широко применяться в кардиохирургической практике

ФИЗИОЛОГИЧЕСКИЕ ПАРАМЕТРЫ ИСКУССТВЕННОГО КРОВООБРАЩЕНИЯ С ТОЧКИ ЗРЕНИЯ ДОКАЗАТЕЛЬНОЙ МЕДИЦИНЫ. ЧАСТЬ I

Abstract. Artificial blood circulation is a main supporting technique of cardiac surgery. This review is devoted to the management aspects of main physiological parameters during artificial blood circulation in the adult patients from the position of the evidence based medicine. Искусственное кровообращение является основным методом обеспечения кардиохирургических операций. Данный обзор посвящен аспектам управления основными физиологическими параметрами во время искусственного кровообращения у взрослых пациентов с позиции доказательной медицины.

ФИЗИОЛОГИЧЕСКИЕ ПАРАМЕТРЫ ИСКУССТВЕННОГО КРОВООБРАЩЕНИЯ С ТОЧКИ ЗРЕНИЯ ДОКАЗАТЕЛЬНОЙ МЕДИЦИНЫ (часть 2)

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. В обзоре продолжено рассмотрение аспектов управления основными физиологическими параметрами во время искусственного кровообращения у взрослых пациентов с позиции доказательной медицины, начатое в предыдущем номере журнала. Данная часть посвящена управлению температурой, доставкой кислорода и пульсацией. Делается заключение, что в настоящее время большинство рекомендаций по проведению искусственного кровообращения не имеют серьезной доказательной базы. Для достижения наилучших клинических результатов предложено отслеживать публикуемые данные и соотносить их с собственным опытом с учетом соотношения польза/риск. Показано, что в основе большинства осложнений, связанных с искусственным кровообращением, лежат разные причины, и это диктует необходимость мультидисциплинарного подхода к их предотвращению.

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

ASSESSMENT OF RELATIONSHIP FOR GRACE SCORE AND CORONARY LESION SEVERITY IN YOUNG PATIENTS WITH ACUTE CORONARY SYNDROME

Aim. The analysis of relationship between coronary arteries lesion, patients’ age, type of acute coronary syndrome (ACS) and risk level by GRACE.Material and methods. Totally, 179 patients included at the age 24-65 y.o. (mean age 51,2±7,0), hospitalized for ACS. All patients underwent coronary angiography during hospitalization.Results. In ST elevation ACS two-vessel disease was more common (28,6%), comparing to those with non-ST ACS (15,1%), р=0,031. Regardless the correlation of GRACE risk with age, there was no relation of coronary lesion with age in our study. Mean calculated points by GRACE in non-ST ACS were 95,9±3,3, low risk patients predominated (66,2%). Also, among those with low risk by GRACE, in 48,9% coronary arteriogram showed high risk coronary anatomy.Conclusion. Low calculated risk by GRACE in young patients has low predicting ability for severe coronary lesion, which is important to note in management of non-ST elevation ACS

HIGH RISK STRATEGY EFFICACY IN PROGNOSIS OF PRIMARY ONSET OF ISCHEMIC HEART

High morbidity and mortality from ischemic heart disease (CHD) in RF presupposes the significance of individual prognosis of cardiovascular risk and of primary prevention.Aim. To analyze the level of risk that could be calculated in patients with CHD debut just before the manifest of the disease and therefore to evaluate the opportunities for the CHD debut by standard scores; to evaluate the relation of a real volume of primary prevention events to current Guidelines.Material and methods. In 122 patients hospitalized with CHD debut as an acute coronary syndrome, a retrospective cardiovascular risk evaluation, which could be found just before the onset of the disease.Results. The prevalence of traditional risk factors among persons with CHD onset was high: 88% patients had ≥3 risk factors. However, before the onset of acute coronary syndrome 68% patients at Framingham scale and 47% by SCORE could have been under the low and moderate calculated risk that shows low sensitivity for the real CHD risk. Calculated risk by the scores has not correlated with the severity of coronary vessels lesion. In analysis of primary prevention events in was found that in the studied group drug therapy of dyslipidemia was not being performed as primary prevention, though it is indicated by the standards for at least 82% patients.Conclusion. The data shows that the use of the main risk scores underestimates real chance of CHD development in the exact patient. Also even for the patients, who require statin prescription for the aim of primary prevention, this therapy is not prescribed