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Issue. Articles

№2(42) // 2013

 

Обкладинка

 

1.

 

Comparative evaluation of the effects of radical surgical treatment of acute varicothrombophlebitis and lower limb varicosity in a prospective three year observation using quantitative scale VSS V.G.

Mishalov, L.Yu. Markulan, S.V. Beychuk

The purpose — a comparative evaluation of the effects of radical surgical treatment of patients with acute varicothrombophlebitis and lower limb varicosity in a prospective three-year observation using quantitative scale VSS.

Materials and methods. The study was conducted at Oleksandrivska City Clinical Hospital in Kyiv from 2001 to 2010. It included 211 patients (main group) hospitalized for emergency indications with a clinical picture of acute varicothrombophlebitis and 79 patients (comparison group) with chronic varicose veins of the lower limbs. All patients had chronic venous disease grade not higher than C5 on the CEAP. The patients in the groups did not differ significantly by age, gender and defeat of the venous pools. Varicothrombophlebitis period ranged from one to 29 days, an average (6.8 ± 0.3) days. Type I was in 137 (65 %), type II — in 40 (19 %), type III — in 22 (10 %), type IV — in 12 (6 %) patients. All the patients underwent radical phlebectomy. Combined therapy was performed after the operation: venotonics (Detralex, tight bandaging of limbs, non-steroidal anti-inflammatory drugs), in the main group — anticoagulants (enoxaparin sodium, Clexane in the prophylactic dose). Long-term results of treatment were followed for three years using a quantitative scale VSS. Statistical analysis was performed by program SPSS 13 using the methods of analysis appropriate to the kind and nature of the variables.

Results and discussion. In the early postoperative period, there were no significant differences in the mean pain scores between the groups according to a visual analogue scale. Patients of the main group, compared with those of the comparison group, more commonly had chylorrhea — 12 (5.7 %) vs. 2 (2.5 %), respectively, necrosis of the skin edges of the wound in the leg — 8 (3.8 %) vs. 1 (1.3 %), violation of the sensitivity of the leg skin — 8 (3.8 %) vs. 2 (2.5 %), respectively, but the differences were not statistically significant (all p > 0.05). There were no significant differences between the two groups in the scale VSS indexes during the period of observation. After the radical phlebectomy there were no cases of deep vein thrombosis, recurrent varicothrombophlebitis, and not a single patient was operated on for recurrent varicose veins of the lower limbs.

Conclusions. Results of radical phlebectomy performed in an emergency in patients with acute varicothrombophlebitis and routinely — in patients with varicose veins of the lower limbs against conservative therapy were not significantly different in the early postoperative period and over a three year period of observation. According to the integrative scale VSS, in three months after radical phlebectomy, the index of severity of venous pathology in patients with varicothrombophlebitis reduced by 3.5 times compared with the baseline, in 6 months it reduced by 5.1 times, in a year — by 9.4 times, in 3 years — by 12.9 times; in patients with varicose veins of the lower limbs it reduced by 2.9; 4.7; 8.8; 10.0 times, respectively.

Keywords: varicothrombophlebitis, varicose veins of the lower extremities, phlebectomy, long-term results, scale VSS.

2.

 

Comparative evaluation of the effects of radical surgical treatment of acute varicothrombophlebitis and lower limb varicosity in a prospective three year observation using quantitative scale VSS V.G.

Mishalov, L.Yu. Markulan, S.V. Beychuk

The purpose — a comparative evaluation of the effects of radical surgical treatment of patients with acute varicothrombophlebitis and lower limb varicosity in a prospective three-year observation using quantitative scale VSS.

Materials and methods. The study was conducted at Oleksandrivska City Clinical Hospital in Kyiv from 2001 to 2010. It included 211 patients (main group) hospitalized for emergency indications with a clinical picture of acute varicothrombophlebitis and 79 patients (comparison group) with chronic varicose veins of the lower limbs. All patients had chronic venous disease grade not higher than C5 on the CEAP. The patients in the groups did not differ significantly by age, gender and defeat of the venous pools. Varicothrombophlebitis period ranged from one to 29 days, an average (6.8 ± 0.3) days. Type I was in 137 (65 %), type II — in 40 (19 %), type III — in 22 (10 %), type IV — in 12 (6 %) patients. All the patients underwent radical phlebectomy. Combined therapy was performed after the operation: venotonics (Detralex, tight bandaging of limbs, non-steroidal anti-inflammatory drugs), in the main group — anticoagulants (enoxaparin sodium, Clexane in the prophylactic dose). Long-term results of treatment were followed for three years using a quantitative scale VSS. Statistical analysis was performed by program SPSS 13 using the methods of analysis appropriate to the kind and nature of the variables.

Results and discussion. In the early postoperative period, there were no significant differences in the mean pain scores between the groups according to a visual analogue scale. Patients of the main group, compared with those of the comparison group, more commonly had chylorrhea — 12 (5.7 %) vs. 2 (2.5 %), respectively, necrosis of the skin edges of the wound in the leg — 8 (3.8 %) vs. 1 (1.3 %), violation of the sensitivity of the leg skin — 8 (3.8 %) vs. 2 (2.5 %), respectively, but the differences were not statistically significant (all p > 0.05). There were no significant differences between the two groups in the scale VSS indexes during the period of observation. After the radical phlebectomy there were no cases of deep vein thrombosis, recurrent varicothrombophlebitis, and not a single patient was operated on for recurrent varicose veins of the lower limbs.

Conclusions. Results of radical phlebectomy performed in an emergency in patients with acute varicothrombophlebitis and routinely — in patients with varicose veins of the lower limbs against conservative therapy were not significantly different in the early postoperative period and over a three year period of observation. According to the integrative scale VSS, in three months after radical phlebectomy, the index of severity of venous pathology in patients with varicothrombophlebitis reduced by 3.5 times compared with the baseline, in 6 months it reduced by 5.1 times, in a year — by 9.4 times, in 3 years — by 12.9 times; in patients with varicose veins of the lower limbs it reduced by 2.9; 4.7; 8.8; 10.0 times, respectively.

Keywords: varicothrombophlebitis, varicose veins of the lower extremities, phlebectomy, long-term results, scale VSS.

3.

 

Surgical treatment of combined coronary and valve pathology: problems of miocardial protection

V.I. Ursulenko, A.V. Kupchinskiy, A.A. Beregovoy, I.I. Prudkiy, K.V. Yaschuk, L.S. Dzakhoeva, L.A. Klimenko, S.G. Klimenko, N.S. Osipenko

The purpose — to assess the results of the use of a modified method of antegrade delivery of cardioplegic solution to the myocardium after prior coronary artery bypass grafting on a beating heart.

Materials and methods. Clinical material consisted of 53 successive operations in patients with combined valve and severe coronary artery disease. The comparison group consisted of 20 patients in which all surgery stages were performed with cardioplegia and cardiopulmonary bypass.

Results and discussion. Analysis of the results of surgical treatment of combined coronary and valve pathology with the use of two different approaches showed significant benefits of the proposed method of myocardial protection in patients with complex coronary and valve disease.

Conclusions. The results obtained by means of the developed method demonstrate its effectiveness. It may be recommended for correction of heart valves in combination with multiple lesions of the coronary arteries and reduced left ventricular systolic function.

Keywords: ischemic heart disease, coronary artery bypass grafting, heart valve abnormality, cardioplegia, enzyme activity in blood serum.

4.

 

Specific features of changes in myocardial electrical homogeneity in interrelation with parameters of structural and functional state of heart in elderly hypertensive patients after ischemic stroke

V.E. Kondratiuk, L.M. Yena

The purpose — to identify the specific features of violations in myocardial electrical homogeneity in interrelation with changes of structural and functional state of heart in older patients with uncomplicated essential hypertension and after ischemic stroke, depending on the localization of lesions of the brain in the recovery period.

Materials and methods. The study included a total of 85 hypertensive patients after ischemic stroke (43 men and 42 women, mean age 62.7 ± 3.0 years): in the left (38 patients; mean age 63.4 ± 1.4 years), right (23 patients, mean age 64.6 ± 2.0 years), middle cerebral arteries and vertebro-basilar system (24 patients, mean age 60.9 ± 2.2 years) and 179 hypertensive patients (73 men and 106 women; mean age 66.1 ± 1.7 years). All of them underwent a standard electrocardiography (ECG), vectorECG, dopplerechocardiography and high resolution electrocardiography (HR ECG).

Results and discussion. Post-stroke patients compared to hypertensive patients without cerebral complications revealed a more marked disturbance of the myocardium electric homogeneity of atriums and ventricles displayed by worsening of HR ECG results and higher frequency of late potentials in ventricles (72.3 vs 37 %, p < 0.05). The post-stroke patients, compared to the hypertensive patients, are characterized by an increase in left ventricular myocardial mass index (159.1 ± 3.6 g/m2 vs 147.7 ± 2.6 g/m2; p < 0.05), a more frequent detection of eccentric LV hypertrophy (43.5 vs. 29.6 %, p < 0.05), bigger diastolic sizes of the right ventricle and the right atrium (2.30 ± 0.03 cm and 3.27 ± 0.07 cm vs. 2.21 ± 0.02 cm and 3.05 cm ± 0.04 cm, respectively; both p < 0.05), bigger diastolic size of the left atrium (4.24 ± 0.06 cm vs. 4.11 ± 0.03 cm, respectively; p < 0.05), the deterioration of LV systolic function (ejection fraction of 60.2 ± 0.6 vs. 62.6 ± 0.4 %; p < 0.05), which was associated with an impaired ventricular repolarization, that is increased space angle of QRS-T, total and in the frontal plane (23.1 ± 6.7 and 117.0 ± 23.8 vs. 6.6 ± 3.6 and 77.7 ± 12.5, respectively; both p < 0.05). Post-stroke patients of older age were characterized by the relationship between the localization of the lesion and the frequency of ventricular late potentials: it was higher in case of lesion in the left and right medial cerebral arteries than in vertebrobasilar system (76.3; 60.9 vs. 41.5 %; χ2 = 6.2, respectively, p < 0.05), which was associated with a more pronounced diastolic LV dysfunction (the ratio of rates of early and late diastolic filling of LV was 0.82 ± 0.05, 0.77 ± 0.05 vs. 0.96 ± 0.07; p < 0.05) and no increase in the bioelectric activity of the ventricular myocardium: total maximum QRS-loop vector was (4.015 ± 0.234) and (3.643 ± 0.215) mV vs. (4.418 ± 0.196) mV, respectively (p < 0.05).

Conclusions. Patients after an ischemic stroke combined with essential hypertension, compared to patients with essential hypertension without cerebral complications are characterized by more severe violations of atrial electrical homogeneity, most of all, ventricular, which is associated with a greater degree of LV hypertrophy, larger cavities of the heart and worsening of its systolic function. Post-stroke patients are characterized by the relationship between the localization of the lesion of the brain and the types of violation of the ventricular electric homogeneity: hemispheric localization compared with vertebrobasilar one is characterized by a higher frequency of ventricular late potentials, associates with a greater quantitative discrepancy between the bioelectric activity and the degree of left ventricular hypertrophy, a more severe violation of its diastolic function. For the purpose of early detection of myocardial electrical homogeneity, it is expedient to perform a complex noninvasive study of hypertensive patients which includes HR ECG with the identifying of early and late potentials of atriums and ventricles; ECG with the recording of dispersion of QT and QRS intervals and in case of pathological changes – to recommend Holter monitoring ECG.

Keywords: ischemic stroke, high resolution electrocardiography, bioelectrical activity of myocardium, essential hypertension.

5.

 

Clinical efficiency and influence of ivabradine on the indexes of systole function and remodeling of the left ventricle of patients with postinfarction cardiosclerosis in combination with obesity and arterial hypertension with preserved ejection fraction

Yu.N. Коlchyn, J.S. Kapranova

The purpose — to define clinical efficiency and influence of ivabradine on the indexes of systolic function and remodeling of the left ventricle of patients with postinfarction cardiosclerosis in combination with obesity and arterial hypertension (ejection fraction > 45 %) under strict control of heart rate (HR).

Materials and methods. 100 outpatients with postinfarction cardiosclerosis and accompanying arterial hypertension and obesity were under our supervision. The terms of supervision averaged (14.3 ± 4.2) months. Age of the patients ranged from 51 to 74 years (mean age 61.17 ± 0.5 years). All the patients were divided into two groups. The main group consisted of 50 patients whose standard therapy was complemented with ivabradin (Coraxan). The group of comparison (50 patients) were treated with standard therapy only. The patients of the two groups were matched by clinical description (all p > 0.05) and basic treatment. Office HR at rest, office arterial hypertension according to Korotkov, ECG were measured on the 1st, 3rd and 6th months of supervision. End-diastolic and end-systolic dimension, end-diastolic (EDV) and end-systolic volume (ESV), left ventricular myocardial mass and left ventricular myocardial mass index (LVMMI) were recorded on the 1st and 6th months.

Results and discussion.Within the period of inclusion in the research, the HR of patients with a postinfarction cardiosclerosis and accompanying obesity was (81.74 ± 1.06) per minute in the main group and (79.38 ± 1.08) per minute in the group of comparison (p > 0.05). Also there were no distinctions between average values of systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) (p > 0.05). Patients in the group of comparison after 6 months of treatment manifested the decrease in HR by 14.7 % (p < 0.001), SAP — by 13.65 % (p < 0.001) and DAP — by 14.92 % (p < 0.001). In patients of the main group, during the same period HR decreased by 26.55 % (p < 0.001), SAP — by 13.65 % (p < 0.001) and DAP — by 12.12 % (p < 0.001). At the time of completion of supervision, the HR of patients in the main group was 11.86 % lower (p < 0.01) than that of the patients in the group of comparison with identical average values of SAP and DAP (p < 0.05). EDV and ESV reduced by 11.62 % (p < 0.05) and 20.02 % (p < 0.01), respectively, and EF increased by 6.25 % (p < 0.01) in patients of the main group as compared with the patients of the group of comparison. LVMMI in the group of comparison decreased by 14.58 % (p < 0.01) and at the time of completion of supervision did not significantly differ from the indexes in the main group, which corresponded to identical expressiveness of decrease in AP in both groups.

Conclusions. For patients with postinfarction cardiosclerosis and concomitant obesity, EF > 45 %, chronic heart failure of І stage and sinus rhythm > 70 per minutes, strict control of HR with the addition of ivabradine (on the average up to 60.04 ± 0.75 per minute ± 0.75 per minute) to complex treatment renders an additional antianginal effect and is associated with reduced EDV and increased EF as compared to a less hard control.

Keywords: postinfarction cardiosclerosis, arterial hypertension, obesity, ivabradine.

6.

 

Structural and functional changes of cardiomyocyte mitochondria under the influence of Ca2+ channel blocker of dihydropyridine line of dimeodipin induced by doxorubicin cardiomyopathy

S.V. Pakrishen, N.A. Mokhort, E.N. Kylymnyk

The purpose — to study the cardioprotective properties of dimeodipin during the doxorubicin-induced cardiomyopathy development with the assessment of quantitative and qualitative changes in mitochondria of cardiomyocytes and myocardial energy metabolism.

Materials and methods. The experiment was held on 35 white nonlinear adult rats of both sexes weighing 140—270 g. The animals were divided into three groups. The first group (6 rats) included intact animals. The animals of the second and third groups were injected with doxorubicin in a dose of 5 mg/kg four times once a week with the following two-week exposure for the second group of animals (18 rats) (cardiomyopathy model). The animals of the third group (11 rats) took dimeodipin orally in a dose of 1.5 mg/kg for a 28 days' period after the third injection of doxorubicin (on day 14). The animals of all groups were killed in 14 days after the last administration of doxorubicin. Ultrastructural changes of mitochondria in myocardium were investigated and morphometric comparative analysis was conducted. The activity and localization of succinate dehydrogenase (SDH) and lactate dehydrogenase (LDH) were studied by histochemical methods.

Results and discussion. A significant reduction in all the studied mitochondrial morphometric parameters of cardiomyocytes was registered after the application of doxorubicin compared with intact animals (р < 0.05): mitochondrial square cut reduction from (41.72 ± 2.06) to (35.11 ± 1.51) 10–2/mkm2, quantitative density from (41.72 ± 2.06) tо (35.11 ± 1.51) 10–2/mkm2, bulk density from (30.6 ± 2.9 %) tо (21.14 ± 1.60 %), i.e. by 16.20 and 31 %, respectively, indicating expressed alterative changes in ultrastructure of myocytes. The morphometric characteristics of mitochondria (square cut and quantitative density) after dimeodipin appliance were not significantly different from those of intact animals (р > 0.05) but had significant difference from mitochondrial morphometric parameters of untreated animals (р < 0.05): increase in cut area by 5 % and in bulk density of mitochondria by 25 %, indicating the mitochondrial structure restoration and consequent recovery of energy processes.

Conclusions. Itra-abdominal injection of doxorubicin in a dose of 5 mg/kg once a week with the following two-week exposure resulted in alteration changes: substantial reduction in mitochondrial square cut, quantitative density, bulk density and energy deficiency (weakened response to succinate dehydrogenase and increased activity of lactate dehydrogenase as compared with intact animals). The use of Ca2+ channel blocker of dimeodipine eliminates negative effects of doxorubicin on mitochondria of cardiomyocytes: mitochondrial square cut, bulk density, succinate dehydrogenase and lactate dehydrogenase activities were not significantly different from the reference indicators of intact animals (р > 0.05).

Keywords: mitochondria, doxorubicin-induced cardiomyopathy, dimeodipin, Са2+ antagonists.

7.

 

Influence of treatment with olmesartan on central aortic pressure parameters in patients with arterial hypertension

V.I. Tseluyko, T.R. Bregvadze, N.E. Mishchuk, T.F. Berezhna, N.M. Belous, V.M. Khodin

The purpose — to study the effects of therapy with olmesartan on central aortic pressure parameters in patients with arterial hypertension.

Materials and methods. 66 hypertensive patients aged 25—84 years (mean age 54.8 ± 1.3) were examined. The patients were divided into 2 groups. I group consisted of 38 patients receiving olmesartan in the dose of 20 mg daily as monotherapy (20 patients) or in combination with other antihypertensive agents (18 patients). II group included 28 patients who received other antihypertensive agents in different combinations in mean therapeutic doses. Clinical characteristics did not differ in the two groups. Treatment continued for 6 months. The patients were examined with electrocardiography, echocardiography, ambulatory blood pressure monitoring, biochemical determination of serum lipids and creatinine with calculation of creatinine clearance, as well as measurement of central aortic pressure with applanation tonometry of radial artery using SphygmoCor device.

Results and discussion. Office blood pressure and diurnal blood pressure significantly decreased in both groups with no significant difference between groups. Central aortal pressure (CAP) parameters after treatment showed significant differences between the two groups. In I group, all indexes of CAP decreased significantly: central systolic aortal pressure — by 10.7 mm Hg (p < 0.001), central pulse aortal pressure — by 5.1 mm Hg (p < 0.05), augmentation pressure — by 3.4 mm Hg, augmentation index — by 5 %, and normalized augmentation index — by 3 % (p < 0.01), while in II group, CAP dynamics was not so favorable: augmentation pressure significantly increased by 3.1 mm Hg, and augmentation index increased by 5 % (p < 0.05).

Conclusions. Treatment of hypertensive patients with olmesartan provides significant decline in office and diurnal arterial pressure, comparable with the effects of other first-line antihypertensive agents, and as well provides pronounced positive effect on the parameters of CAP.

Keywords: arterial hypertension, antihypertensive agents, olmesartan, central aortic pressure, augmentation index.

8.

 

Differential diagnosis of paroxysmal tachycardias

K.M. Amosova, Yu.V. Rudenko

The lecture presents the latest data on the differential diagnosis of paroxysmal tachycardias in accordance with the current guidelines of the Ukrainian Association of Cardiology, the European Society of Cardiology, the American College of Cardiology, the American Heart Association. The importance of the objective clinical examination and instrumental methods for recognizing certain types of paroxysmal tachycardias is emphasized. We have presented principles of the differential diagnosis of paroxysmal tachycardias with narrow QRS complexes: different types of sinus and atrial tachycardia, atrial flutter and fibrillation, atrioventricular reciprocal tachycardia, atrioventricular tachycardia associated with additional ways of conducting and nonparoxysmal atrioventricular tachycardia. Particular attention is paid to the differential diagnosis of paroxysmal tachycardias with wide QRS complexes, i.e., ventricular tachycardia, supraventricular tachycardia with violation of intraventricular conduction, and supraventricular tachycardia accompanied by an increase in the width of QRS complex due to antegrade conduction of impulses along an extra atrioventricular path or retrograde conduction through the atrioventricular node or another complementary path. The lecture presents algorithms of differential diagnosis of paroxysmal tachycardias with wide QRS complexes developed by the European Society of Cardiology, the American College of Cardiology, the American Heart Association (2003), R. Brugada et al. (1991) and the algorithm of differential diagnosis of ventricular tachycardia and antidromic reciprocal atrioventricular tachycardia of P. Podrid and P. Kowey (1996).

Keywords: paroxysmal tachycardia, supraventricular tachycardia, ventricular tachycardia, atrioventricular tachycardia.

9.

 

Tumors of the heart. Possibilities of clinical diagnosis

L.F. Konopleva, S.L. Kushnir

The lecture deals with the specific features of clinical picture of heart tumors which constitute 0.05 % of tumors of various localizations but are only diagnosed in 5—10 % of cases. They are divided into primary, including benign (myxoma, rhabdomyoma, fibroma, angioma, leiomyoma, teratoma) and malignant (sarcoma, rhabdomyoma, endtelioma, mesothelioma), secondary malignant (sarcoma, melanobastoma, lymphosarcoma, lymphogranuloma, myeloma) and leukemic processes. The most common primary cardiac tumors are myxomas which are located in the cavities of the heart. The clinical manifestations include the rapid development of heart failure with no apparent reason. Patients with localization of myxoma in the left atrium suffer from cardiac asthma; the prevalent symptoms of patients with myxoma in the right region of the heart are those of systemic venous congestion. In 25 % cases a myxoma is manifestated as embolism resulting from fragmentation of the tumor and clots with the development of pulmonary embolism and pulmonary hypertension, stroke or transient ischemic attacks, myocardial infarction. Rhabdomyomas as small nodules in the myocardium and endocardium are more common in childhood and cause heart block or impairment of the cardiac rhythm and conduction as well as heart failure. Fibroma is a tumor of the connective tissue of subendothelial layer of heart valves that causes the symptoms of subaortic stenosis, valvular or infundibular stenosis of the pulmonary artery. Primary malignant cardiac tumors, mostly sarcomas, occur mainly in men of any age. Secondary (malignant) tumors of the heart are metastases of other tumors. Treatment is only surgical.

Keywords: cardiac myxoma, benign tumors of the heart, primary malignant tumors of the heart, secondary malignant tumors of the heart.

10.

 

Postnatal endothelial progenitor cells as biological markers of neoangiogenesis and reendothelization

A.Е. Berezin, A.A. Kremzer

The basic mechanisms of differentiation and mobilization of postnatal endothelial progenitor cells are discussed in the review. The main data regarding their role in regulation of neoangiogenesis and reendothelization are presented. Possibilities of estimating the levels of cycling postnatal endothelial progenitor cells as markers of endothelial dysfunction, vascular damage and risk of adverse clinical outcomes are considered.

Keywords: postnatal progenitor cells, neoangiogenesis, reendothelization, prognosis, clinical implication.

11.

 

Factors of cardiovascular risk in patients with morbid obesity and ways of their medicamental, non medicamental and surgical correction

О.I. Mitchenko, A.S. Lavrik, V.Yu. Romanov, I.V. Chulaevskaya, A.A. Shkreba

Obesity is the most common metabolic disease in the world. Currently, 1.1 billion adults are overweight, 312 million of them suffer from obesity. In the course of many clinical studies, a link has been found between high blood pressure, myocardial hypertrophy, impaired lipid and carbohydrate metabolism and weight gain. It was proved that obesity significantly increases the risk of coronary heart disease, ischemic stroke, and death from cardiovascular diseases. The treatment of obesity is a multi-stage process that includes changing the way of life, diet therapy, medicamental and surgical treatment. Conservative therapy for obese patients is effective only in the initial stages of the disease. With obesity of II and III degrees the efficiency of such treatment is low. Surgical treatment is recommended for patients with a body mass index over 40 kg/m2 (body mass index greater than 35 kg/m2 with severe comorbidity).

 

Keywords: cardiovascular diseases, obesity, body mass index, medicamental and surgical treatment.

12.

 

Can nitric oxide precursors improve the results of surgical treatment of patients with chronic critical lower limb ischemia?

O.L. Tkachuk, O.I. Gudz

Chronic critical lower limb ischemia (CCLLI) remains one of the unsolved problems of vascular surgery at present. Early results of reconstructive surgery in CCLLI are often unsatisfactory because of deep microcirculatory changes in the area of ischemia; in the long term period, there is a high risk of stenosis in the reconstruction area caused by the development of neointima hyperplasia. This paper presents an overview of recent publications in the world literature on the use of nitric oxide precursors for correction of hyperperfusion syndrome which occurs after revascularization operations. Experimental and clinical studies have shown that nitric oxide donators can reduce the depth of regional blood flow disorders and prevent the development of systemic complications in the early postoperative period. We have also analyzed the results of the studies that evaluated the possibility of systemic and local effects of nitric oxide precursors on the formation of neointima in the area of arterial reconstruction in the remote postoperative period.

Keywords: nitric oxide, chronic critical ischemia, lower limbs, treatment.

13.

 

Auscultation in modern cardiology: the continuation of 200 year old history

Ya.V. Shpak, T.V. Martyniuk, I.V. Kolesnikov

Despite significant development of visualizing cardiac technologies, cardiac auscultation remains relevant in the clinical practice and along with other components of the physical examination is a powerful diagnostic tool. Using clinical examples, authors reveal additional capabilities of a digital stethoscope as also draw readers' attention to certain problems associated with the use of this device. Particular emphasis is placed on the analysis of spectral phonocardiograms as a more practical technique compared to conventional oscillations. Presented information can be especially relevant for the users of digital stethoscopes which are relatively new diagnostic devices.

Keywords: heart auscultation, digital stethoscope, phonocardiography.

14.

 

Сравнительная оценка результатов радикального оперативного лечения больных острым варикотромбофлебитом и варикозной болезнью нижних конечностей в проспективном трехлетнем наблюдении с использованием количественной шкалы VSS

В.Г. Мишалов, Л.Ю. Маркулан, С.В. Бейчук

Цель работы — сравнительная оценка результатов радикального оперативного лечения больных острым варикотромбофлебитом и варикозной болезнью нижних конечностей в проспективном трехлетнем наблюдении с использованием количественной шкалы VSS.

Материалы и методы. Исследования выполняли на базе Александровской городской клинической больницы г. Киева с 2001 по 2010 г. В исследование вошли 211 больных (основная группа), госпитализированных по экстренным показаниям с клинической картиной острого варикотромбофлебита, и 79 больных (группа сравнения) хронической варикозной болезнью нижних конечностей. У всех больных был класс хронического заболевания вен не выше С5 по СЕАР. Больные в группах статистически не отличались по возрастным, гендерным показателем, поражению венозных бассейнов. Срок варикотромбофлебита составлял от одних до 29 сут, в среднем (6,8 ± 0,3) сут. Первый тип варикотромбофлебита был у 137 (65 %) больных, второй — у 40 (19 %), третий — у 22 (10 %), четвертый — у 12 (6 %). Всем им выполнили радикальную флебэктомию. В послеоперационный период проводили комплексную терапию: венотоники — «Детралекс», тугое бинтование конечностей, нестероидные противовоспалительные препараты, в основной группе — антикоагулянты (эноксапарин натрия, «Клексан» в профилактической дозе). Отдаленные результаты лечения прослежены в течение 3 лет с использованием количественной шкалы VSS. Статистическую обработку результатов проводили с помощью программы SPSS 13, используя методы анализа, соответствующие виду и характеру переменных.

Результаты и обсуждение. В ранний послеоперационный период достоверных отличий среднего значения балла боли, согласно визуальной аналоговой шкале, между группами не было. У больных основной группы чаще, чем у пациентов группы сравнения, отмечали лимфорею — у 12 (5,7 %) и 2 (2,5 %) соответственно, некроз кожных краев раны на голени — у 8 (3,8 %) и 1 (1,3 %), нарушение чувствительности кожи голени — у 8 (3,8 %) и 2 (2,5 %) соответственно, однако различия не были статистически значимыми (все р > 0,05). Не было достоверных различий в показателях шкалы VSS между группами в контрольные сроки наблюдения. После радикальной флебэктомии не зарегистрировано случаев тромбоза глубоких вен, рецидива варикотромбофлебита, и ни один больной не был прооперирован по поводу рецидива варикозной болезни нижних конечностей.

Выводы. Результаты радикальной флебэктомии, выполненной в экстренном или срочном порядке у больных острым варикотромбофлебитом и плановом у больных варикозной болезнью нижних конечностей, на фоне консервативной терапии достоверно не отличаются в ранний послеоперационный период и в течение 3 лет наблюдения. Согласно интегративной шкале VSS, через 3 мес после радикальной флебэктомии показатель тяжести венозной патологии у больных варикотромбофлебитом уменьшается в 3,5 раза по сравнению с исходным, через 6 мес — в 5,1 раза, через год — в 9,4 раза, через 3 года — в 12,9 раза; у больных варикозной болезнью нижних конечностей — в 2,9; 4,7; 8,8 и 10,0 раза соответственно.

Keywords: варикотромбофлебит, варикозная болезнь нижних конечностей, флебэктомия, отдаленные результаты, шкала VSS.

Current Issue Highlights

№4(60) // 2017

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K. M. Amosova 1, I. I. Gorda 1, A. B. Bezrodnyi 1, G. V. Mostbauer 1, Yu. V. Rudenko 1, A. V. Sablin 2, N. V. Melnychenko 2, Yu. O. Sychenko 1, I. V. Prudkiy 1&a

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