Опыт применения чрескожного обхода правого желудочка в раннем периоде после имплантации системы левожелудочкового обхода (клиническое наблюдение и обзор литературы)

Implantable left ventricular assist device (LVAD) is a state-of-the-art treatment for adults and children with end-stage heart failure. The early and late period after LVAD implantation can be severely complicated. Right ventricular failure (RVF) still remains a common complication after LVAD implantation. RVF is the cause of reduced post-implant survival. We suggest that an additional temporary or permanent right ventricular assist device (RVAD) is an effective treatment for LVAD-associated RVF. In this clinical case report, we describe the medical history of a pediatric patient (14 years old) with severe heart failure (PediMACS Level 1) against a background of dilated cardiomyopathy. The patient required peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) prior to urgent LVAD (HM3) implantation. In the early post-LVAD implantation (1 POD) period, the patient presented with hemodynamic and echocardiographic events of acute RVF that was resistant to drug therapy (inotropic/vasopressor support, iNO) and required mechanical circulatory support (MCS) with a preoperatively implanted VA-ECMO. In the LVAD-associated RVF scenario, VA-ECMO as a means of total cardiac bypass is a non-physiological MCS method and, therefore, undesirable. In this clinical situation, our solution was to use a paracorporeal centrifugal blood pump for temporary right heart support. A RVAD was assembled using percutaneous cannulation in two sites and a modification of the pre-existing VA-ECMO circuit. For RVAD, we used an ECMO cannula previously installed through the femoral vein (26 F) and added a reverse venous cannula (22 F) through the right internal jugular vein into the pulmonary trunk. To facilitate the passage of the return cannula into the pulmonary artery, we used a contralateral sheath (6 F, 40 cm) and an Amplatz Super Stiff guidewire under radiological control. The oxygenator was removed from the circuit on day 2 of RVAD. Central hemodynamics (reduction in right atrial pressure (RAP) to 10 mm Hg, increase in pulmonary capillary wedge pressure (PCWP) to 14 mm Hg), as well as right ventricular (RV) and left ventricular (LV) volume characteristics all improved. These observations allowed us to optimize the performance of the implantable LVAD (increase in flow rate to 4.2 l/min or 2.1 l/min/m2). The duration of paracorporeal RVAD after LVAD implantation was 7 days with an average flow rate of 2.3 ± 0.2 l/min. Postoperative treatment in the intensive care unit (ICU) lasted for 15 days. The patient was discharged from the hospital on postoperative day 34.Система имплантируемого левожелудочкового обхода (LVAD) - это современный метод лечения взрослых и детей с сердечной недостаточностью в терминальной стадии. Ранние и поздние периоды после имплантации LVAD могут серьезно осложняться. Дисфункция правого желудочка (Д11Ж) по-прежнему остается одним из самых частых осложнений у пациентов с LVAD и причиной низкой постимплантационной выживаемости. Мы предполагаем, что дополнительное временное или постоянное вспомогательное устройство для правого желудочка (RVAD) является эффективным методом лечения LVAD-ассоциированного ДПЖ. В данном клиническом случае мы описываем историю болезни педиатрического пациента (14 лет) с тяжелой сердечной недостаточностью (Pedimacs Level 1) на фоне дилатационной кардиомиопатии, которому потребовалась периферическая ВА ЭКМО перед срочной имплантацией LVAD (HM3). В раннем постимплантационном (1 POD) периоде LVAD у этого пациента наблюдались гемодинамические и эхокардиографические явления остро развившейся ДПЖ, резистентной к медикаментозной терапии (инотропная/ вазопрессорная поддержка, iNO) и потребовавшей механической поддержки кровообращения с помощью предоперационно имплантированного ВА ЭКМО. В сценарии LVAD-ассоциированной ДПЖ ВА ЭКМО как средство полного шунтирования сердца является нефизиологическим методом МПК, и следовательно, нежелательным. В этой клинической ситуации нашим решением было использование паракорпорального центробежного насоса для временной поддержки правых отделов сердца. Вспомогательное устройство для правого желудочка (RVAD) было собрано с использованием метода чрескожной канюляции в двух местах и модификации ранее существовавшего контура ВА ЭКМО. Для RVAD мы использовали канюлю ЭКМО, установленную ранее через бедренную вену (26 F), и добавили возвратную венозную канюлю (22 F) через правую внутреннюю яремную вену в ствол легочной артерии. Для облегчения прохождения возвратной канюли в легочную артерию мы использовали контралатеральный интродьюсер (6 F, 40 см) и проводник типа Amplatz Super Stiff под рентгенологическим контролем. Оксигенатор был удален из контура на вторые сутки RVAD. На фоне ПЖО мы отметили улучшение показателей центральной гемодинамики (снижение ДПП до 10 мм рт. ст., увеличение ЗДЛА до 14 мм рт. ст.) и объемных характеристик ПЖ и ЛЖ, что позволило оптимизировать функционирование иЛЖО (увеличение производительности до 4,2 л/мин, или 2,1 л/ мин/м2). Продолжительность паракорпорального ПЖО после имплантации ЛЖО составила 7 суток при усредненной производительности 2,3 ± 0,2 л/мин. Период послеоперационного лечения в условиях ОРИТ составил 15 суток. Пациент выписан из стационара на 34-е послеоперационные сутки

Трансплантация легких при первичной легочной артериальной гипертензии: особенности периоперационного периода

Lung transplantation (LT) for idiopathic pulmonary arterial hypertension (IPAH) now is the only radical treatment of this disease.Aim: to analyze own experience of performing LT in patients with IPAH.Materials and methods. 8 adult IPAH patients, who underwent LT between 2014 and october 2018, were included. In 7 of 8 patients undergoing bilateral lung transplantation on intraoperative venoarterial extracorporeal membrane oxygenation (VA ECMO) with prolongation into the postoperative period.Results. VA ECMO support was prolonged into postoperative period 6 and 7 days respectively in 2 (25,0%) patients and 3 days in 6 (75,0%) patients. Hospital mortality in IPAH patients was 1.Conclusions. Own experience demonstrates that LT is an effective method of treatment in patients with IPAH. Hospital, 1- and 3-year survival rates for the patient collective were 87.5, 75.0 and 75.0% respectively.Первичная легочная артериальная гипертензия (ПЛАГ) – необратимое заболевание, единственным методом радикального лечения которого является трансплантация легких (ТЛ).Цель исследования: анализ собственного опыта выполнения ТЛ у пациентов с ПЛАГ.Материалы и методы. В исследование включили 8 взрослых реципиентов, которым была выполнена ТЛ в период с 2014-го по октябрь 2018 г. Всем реципиентам была выполнена двусторонняя последовательная трансплантация легких. У 7 из 8 реципиентов ТЛ осуществляли в условиях периферической ВА ЭКМО.Результаты. В послеоперационном периоде первичная дисфункция 3-й степени по классификации ISHLT развилась у 2 (25,0%) из 8 реципиентов, которая проявилась невозможностью прекращения ВА ЭКМО. Общая продолжительность применения ЭКМО у этих пациентов (n = 2) составила 6 и 7 суток. У других 6 (75,0%) реципиентов проявления ранней дисфункции пересаженных легких не носили столь напряженного характера (2-я степень по классификации ISHLT), и продолжительность послеоперационной ВА ЭКМО составила 3 суток. Госпитальная летальность у реципиентов легких, оперированных по поводу ЛАГ, составила 1 наблюдение.Заключение. Собственный опыт демонстрирует, что ТЛ является эффективной лечебной мерой у пациентов с ПЛАГ с показателями госпитальной, 1- и 3-летней выживаемости соответственно 87,5; 75,0 и 75,0%

Imperio : Diario de Zamora de Falange Española de las J.O.N.S.: Año XXIV Número 7127 - 1959 Mayo 08

Argonne National Lab. Annealing experiments of highpurity C --U alloys in the gamma region in an Ar atmosphere show that the metal is subject to decarbinization. Fourteen binary U--Pd alloys were prepared and examined. Pd solubility in gamma U is less than 1 wt.% at 890 deg C. Seventeen binary alloys of U-Ru were prepared and examined in the as-cast condition. The corrosion resistance after irradiation of U--Si alloys was tested. Homogeneous U- -Ta alloys have not been obtained. Th-rich U alloys were found to be more stable under irradiation than the best U alloys. The effect of heat treatment on microstructure is being studied as part of the effort to understand the effect of alloying on corrosion resistance in Ti--U alloys. Crystal and corrosion studies on U--Zr alloys are reported. Armour Research Foundation. Small ternary additions were found to greatly affect the transformation characteristics of U-- Nb alloys, and a hardness change was noted for this alloy. Preliminary data for U--Nb--Zr alloy demonstrated a relationship between the strained matrix and the physical properties of the alloy. Battelle Memorial Institute. Phase relationships between the intermediate delta phases of the U--Mo and U--Ti systems were conducted. U--Zr, U--Mo, and U--Nb alloys were evaluated for use as high-temperature reactor fuels. The kinetics of the betato-epsilon decomposition of Zr--U alloys are being investigated. The mechanism of aqueous U corrosion is being studied. Mallinckrodt Chemical Works. In the production of Nb--U alloy by co-reduction there was an indication of insufficient heat. Thermal boosters and a redesigned bomb for improving heat conservation will be investigated. National Bureau of Standards. Experimental work on the U-- Pt system is completed. Thermal analyses on U--Pd alloys did not show the U transformations present. Metallographic examination revealed an apparently singlephase structure. Thermal analysis data were collected for U--Ru and U--Rh systems. Attempts to prepare U--Sr alloys by high-frequency induction methods were unsuccessful. Nuclear Metals, Inc. Corrosion tests on Zircaloy2-clad U alloys were made. Sylvania Electric Products, Inc. Thermal cycling and mechanical propenties of U- rich alloys sufficiently stable to permit reactor operating temperatures in excess of 1200 deg F were studied. Mo--U alloys are the most stable toward alpha- beta cycling. Westinghouse Atomic Power Division. Transformation kinetics of the U-- Zr alloys were studied. Serrated stress-strain curves in U-- Zr alloys were studied. Alloys in the epsilon and gamma conditions as well as aged and prestrained conditions were studied from room temperature to 600 deg C. (F.S.

URANIUM ALLOY NEWSLETTER NO. 13

Argonne National Lab. Results are summarized from irradiation and corrosion tests on alloys of U--Pu, U--Nb-Sn, and U- Zr-Nb, and U-- Si systems. Armour Research Foundation. Studies of the transformation kinetics of Ubase alloys have been completed, and results are summarized. TTT diagrams are presented for 2 Nb--U alloys. Battelle Memorial Inst. Phase studies, heat treatment studies, and preparation of U-- Zr alloys are described. The study of the properties and preparation of various U alloys for use as fuel elements are continuing. Techniques for melting and casting Al--U alloys and for melting U-- Zr alloys are being developed. Hanford Atomic Products Operation. Results of metallographic and phase studies on U-- Th alloys are reported. The corrosion resistance of several Th--U-- Zr alloys has been studied. National Bureau of Standards. The preparation and phase relations of alloys of U with the platinum metals are being studied. North American Aviation, Inc. The feasibility of fabricating specific U alloys for fuel elements on a semi-production scale is being investigated. Nuclear Metals, Inc. Studies of the thermal properties of U- -Nb--Zr alloys and of the corrosion of U-- Si systems are reported. Fabrication behavior and microstructures in cast, extruded, and heat treated U alloys are being examined. Sylvania Electric Products, Inc. Data are presented on the mechanical properties and dimensional stability under thermal cycling of various powder metallurgy binary U alloys. Corrosion rates in water and densities are reported of some powder metallurgy Si-- U systems. Westinghouse Atomic Power Div. The changes in dimensions, density, electrical resistivity, and hardness of irradiated U--Mo and U--Nb alloys are tabulated. The effects of irradiating prototype fuel rods of U and U--Zr alloy are reported. (W.L.H.

Uranium Alloy Newsletter No. 14

Ames Lab. Studies of Nb--U alloys, phase studies of the U----Z--system and the solubility of U in Zn, are summarized. Argonne National Lab. Phase studies of C -- U systems and Nb--U alloys, the effects of radiation on Mo--U alloys, corrosion and irradiatron of Sr--U systems and Nb--U--Zr alloys are reported. Battelle Memorial lnst. The stabrlit.v and existence range of the intermediate epsilon phase, heat treatment, and radiation damage of U--Zr alloys were investigated. A study of the physrcal properties of Mo--U alloys, U alloys for slug-type fuel elements, low-melting U alloys for reactor fuels is presented. The preparation of Al--U alloys is outlined, and corrosion studies of U--Zr alloys were made. Hanford Atomic Products Operation. A series of experiments covering the testing of irradiated U alloys and the transformation kinetics of Si- -U systems were initiated. Knolls Atomic Power Lab. Irradiation stability and the equilibrium phase diagram of U--Zr alloys, and fission gas diffusion in Al--U alloys are being investigated. National Bureau of Standards. A brief summary of the work on Pt--U alloys is given. Nuclear Metals, Inc. Cladding of unalloyed U with either Zr or zircaloy by coextrusion and the preparation of Si--U systems were reported. Sylvania Electric Products, Inc. The preparation of enriched Mo-- U alloys, investigation of the fabrication of epsilonized Si--U system by powder metallurgy and corrosron rates in 600 deg F water are being studied. Westinghouse Atomic Power Division. Study of powder films of diffusion areas in Zr clad-U/sub 3/Si, preparation of fuel elements by brazing extruded reds of Si-- U inside zircaloy tubes, mechanism of corrosion of ueclad U/sub 3/ Si, radiation of Mo--U alloys, and Mo--U phase diagrams are reported. Atomics International (NAA). Results of thermal cycling as cast U alloy slugs are presented. (J.E.D.

NACA Technical Notes

Note presenting an experimental program to study the subject of metal fatigue and to determine and evaluate the fundamental factors which influence the behavior. The statistics of the fatigue-fracture curves and endurance limits were determined for a variety of metals and the effects of some metallurgical factors on the statistical nature of fatigue properties were shown

A Phase I Trial of Chlorambucil Administered in Short Pulses in Patients with Advanced Malignancies

Abstract We carried out a phase I trial with chlorambucil. Thirty patients with advanced cancer were entered in six dose levels: 36, 48, 60, 84, 108, and 144 mg/m2. The drug was given in six divided oral doses every 6 hours and the regimen was repeated every 3 weeks. The median age was 62 years (31-84), median Kamofsky performance status (KPS) 60 (40-90). All patients but one had received prior radiation therapy, chemotherapy, or both. Central nervous system toxicity was dose limiting, occurring in 5 of 6 patients at 144 mg/m2. It was characterized by transient seizures, hallucinations, lethargy, stupor, and coma. Metoclopramide was successful in controlling nausea and vomiting, which was severe if the antiemetic was not used. Leukopenia (3 patients) and thrombocytopenia (2 patients) were mild. One patient with colorectal carcinoma had a minor response, and two patients with non-small cell lung cancer had stable disease. A safe dose for phase II trials is 108 mg/m2 in six 6-hourly oral doses

High-dose cisplatin and vinblastine infusion with or without radiation therapy in patients with advanced non-small-cell lung cancer.

Non-small-cell lung cancer (NSCLC) patients with locally advanced or metastatic measurable disease were given a combination of cisplatin, 200 mg/m2 divided in five daily doses, and simultaneously, vinblastine, 7.5 mg/m2 as a continuous intravenous (IV) infusion over five days. Five courses of chemotherapy were planned. Afterwards or on progression, patients were randomized to receive maximally tolerated radiation to all sites of disease v observation only. Forty males and seven females were entered. Median age was 60 years (range, 37 to 74), median Karnofsky performance status was 70 (range, 30 to 90). Five patients had previous brain radiation therapy for metastatic disease, all others were previously untreated. Side effects in the 87 courses of chemotherapy administered included leukopenia (WBC less than 1,000/microL following nine courses) and thrombocytopenia (platelets less than 20,000/microL following four courses). Ten patients became septic, nine of them while leukopenic. Elevations of serum creatinine followed eight courses; in all cases the level was less than 3.0 mg/dL. Nausea and vomiting were mild to moderate. Five patients experienced mild hypoacusis and six had sensory polyneuropathy. The deaths of three patients were considered drug-related. The response rate was 28%. The median survival for the group was 22 weeks, 63.2 weeks for responders and 17.9 weeks for nonresponders. Twenty-six patients received radiation therapy, 16 randomized to this arm as planned, ten to palliate symptoms. Median survival of all irradiated patients was 24.8 weeks. Seven responders to chemotherapy were randomized to receive radiotherapy; their median survival was 25 weeks. In six responders randomized not to receive radiation, the median survival was 77.8 weeks (P greater than .3). Among nonresponding patients, the median survival of those radiated was 22.2 weeks, while that of nonradiated patients was 11 weeks. This regimen is cumbersome and toxic. It has offered no major survival benefits, or improvement in response rates, therefore, we do not recommend it for the standard treatment of NSCLC