Transplantation and artificial organs

До 80-річчя члена-кореспондента НАН України НИКОНЕНКА О. С.

O.S. Nikonenko — Wed, 27 Oct 2021 00:00:00 +0300

Selection Criteria for Heart Transplantation in Patients with End-Stage Heart Failure

K. V. Rudenko, O. Yu. Dudnyk, M. I. Rzhanyi — Wed, 27 Oct 2021 00:00:00 +0300

Today, heart transplantation remains the gold standard of treatment for patients with end-stage heart failure (HF). As the number of donors is limited and the risk of intervention is quite high, the key to achieving optimal outcomes and reducing the incidence of complications is the proper selection of patients who meet clearly defined criteria for inclusion in the waiting list for heart transplantation. This review presents the latest knowledge on indications and contraindications for inclusion recipients in the waiting list for heart transplantation, including the latest clinical guidelines of The International Society for Heart and Lung Transplantation (ISHLT) published in 2016.

Thus, the absolute indications are dependence on intravenous inotropic and mechanical circulatory support; inoperable heart diseases or a history of volume reducing operations; refractory angina or life-threatening refractory arrhythmias despite maximal drug therapy and/or surgical correction; reduction of maximum oxygen consumption up to <12-14 ml/kg/min when performing the maximum cardiopulmonary exercise test. While including patients in the waiting list for heart transplantation, it should be noted that the low left ventricular ejection fraction <30%, a history of documented NYHA class III-IV HF, low maximum oxygen consumption as the only criterion of terminal HF and poor prognosis for annual survival in HF calculated on prognostic scales are not sufficient indications. Absolute contraindications include a systemic disease with a life expectancy of less than 2 years and irreversible pulmonary hypertension.

The current procedure for the distribution of recipients by urgency status for heart transplantation is presented according to the updated recommendations of the United Network for Organ Sharing (UNOS) published in 2018 which consists of 6 degrees, compared with the 1999 edition which contained 3 degrees.

The Influence of Risk Factors on Perioperative Results of Multivessel Coronary Artery Bypass Grafting Through the Left Anterior Minitoracotomy

Wed, 27 Oct 2021 00:00:00 +0300

Multivessel coronary artery bypass grafting (CABG) through the left anterior minitoracotomy using the technique of total coronary revascularization via left anterior thoracotomy (TCRAT) is routinely performed in our institution since July 2017. This technique is used in all patients regardless of the number of anastomoses, quality and location of coronary targets, body mass index, age, comorbidities and predicted postoperative risk.

The aim. To present the results of 349 consecutive patients with isolated multivessel coronary artery disease who underwent minimally invasive CABG. To compare perioperative outcomes of minimally invasive CABG in patients with existent risk factors for CABG and to identify possible contraindications to the use of this CABG technique.

Materials and methods. From July 2017 to January 2020, 357 consecutive patients were underwent multivessel CABG at our institution. Eight (2.3%) patients in whom CABG was performed through the median sternotomy were excluded from the study. The remaining 349 (97.7%) patients underwent complete myocardial revascularization through the left anterior minitracotomy using TCRAT technique (peripheral cannulation for cardiopulmonary bypass (CPB), cold blood cardioplegia). All the patients were divided into groups according to the presence of risk factors (obesity, old age, diabetes, risk of postoperative mortality greater than 2.0 calculated by EuroSCORE II scale) to analyze the impact of these factors on intraoperative and postoperative parameters.

Results. Intra- and postoperative parameters in patients of all groups were within safe limits. There was no statistically significant difference between the patients older and younger than 70. Diabetic and obese patients had a longer total operation time (on average by 5%, p = 0.003 and 7%, p = 0.019, respectively), CPB time (on average by 8%, p = 0.002 and 11%, p = 0.0001, respectively) and intensive care unit stay (on average by 15%, p = 0.004 and 17%, p = 0.013, respectively) compared to the patients without these conditions. The patients with EuroSCORE II risk more than 2.0 were had longer main phase of the operation (on average by 12 minutes, i.e. 8%, p = 0.013), they required longer ventilation time (by 27%, p = 0.036), longer stay in the intensive care unit (by 23%, p = 0.0004), had a longer hospital stay (by 15%, p < 0.0001), they were more likely to have acute kidney damage that required hemodialysis, and mortality was observed only in this group of patients. However, even in this group of severe patients, the incidence of complications and mortality did not exceed the predicted rates.

Conclusions. The technique of minimally invasive CABG through the left anterior thoracotomy allow the possibility to avoid median sternotomy in 97.7% of patients with multivessel coronary artery disease.

The technique of minimally invasive multivessel CABG through the left anterior thoracotomy is universal and does not require patient selection, because it can be used effectively and safely regardless of obesity, diabetes or old age.

This technique can be performed in patients with any EuroSCORE II rate without the mortality rate increase.

Development of National Arthroplasty (Results of 30-Year Research)

O. Ye. Loskutov , O. Ye. Oliinyk , O. O. Loskutov , D. A. Syniehubov — Wed, 27 Oct 2021 00:00:00 +0300

Abstract. Development of modern arthroplasty in Ukraine, according to Academician of the National Academy of Sciences and the National Academy of Medical Sciences of Ukraine O.O. Korzh, began thanks to the activities of O.Ye. Loskutov (Dnipro) who managed to create his own Ukrainian endoprosthesis on the basis of the relevant enterprises of the city and establish specialized endoprosthetic clinic. The article reflects 30 years of experience in the de velopment of national arthroplasty. To solve the problem of development of national arthroplasty, the Orthopedic Joint Replacement initiative program (ORTEN) has been developed. For this purpose, an intersectoral problem laboratory was created which united the efforts of the scientists of different specialties and key enterprises of the Dnipro region. Biomechanical researches on native studying of mechanical properties of articular sites of bones have been carried out through mathematical modeling. Estimation of a stress-strain state of subchondral, spongy bone and various sites of long bones in "bone-implant" system has been carried out in order to define primary and secondary stability of different kinds of the developed im plants. Numerous biochemical, histochemical and toxicological studies on laboratory animals have been performed to evaluate the effects of implant materials and the developed types of protective coatings. X-ray morphometric and anthropometric studies of articular surfaces of bones were used in various pathologies of the joints for the development of implants; technical methods were used to assess the mechanical properties of implants under load. The developed designs of endoprostheses have passed certification and have been brought into pro duction. Clinical introduction of domestic endoprostheses was implemented in the Ukraine’s first specialized department of joint arthroplasty which was opened in Dnipro. The developed methods and methodological support for the use of the elaborated designs of endoprostheses allowed to organize the basic training of Ukrainian specialists through the Basic Course of Prof. O.Ye. Loskutov which was taken by almost 350 Ukrainian orthopedists.

Cell Technologies in the Treatment of Chronic Wounds in Patients with Diabetes Mellitus

Wed, 27 Oct 2021 00:00:00 +0300

Materials and methods. The results of treatment of 8 patients with chronic wounds and diabetes mellitus (DM) type 2 and stage IV chronic ischemia of the lower extremities by Fontaine were analyzed, in 2 cases there was a combination of venous and arterial insufficiency. Revascularization of the lower extremities was performed through open (2), endovascular (4) and hybrid surgery (2). In case of venous insufficiency, sclerotherapy of perforator veins was performed.

After surgical treatment of the purulent focus, specific bacteriophages were used (after microflora identification). Hydrogel dressings were applied daily, alongside with transplantation of 5,000,000 mesenchymal stem cells (MSC) (CD73+, CD90+, CD105+ and CD45-, CD34-, CD14-, CD79-) by injection into muscle tissue around the wound, then the wound surface was closed with hMSC-fibroblast matrix.

Results. After the closure of the wound surface with fibroblast matrix, the patients noted the disappearance of the pain syndrome. The surface area of the wounds averaged 91.3 ± 30.42 cm 2 before the start of treatment, 89.8 ± 34.21 cm 2 on day 5 and – 73.95 ± 21.2 cm 2 on day 12. Spontaneous epithelialization was achieved in the period from 35 to 141 days (depending on the initial state of the wounds). The average hospital stay was 22.6 ± 2.4 days.

Discussion. It is known that human epithelial cells (hECs) and human mesenchymal stem cells (hMSCs) suppress proliferation, production of inflammatory cytokines and differentiation of T cells. At the same time, they stimulate the formation of regulatory T cells (Tregs). Soluble factors secreted by hECs, including PGE2, TGF-β, Fas-L, AFP, MIF, TRAIL and HLA-G, block differentiation of dendritic cells and M1 macrophages and promote differentiation of monocytes into the anti-inflammatory M2 phenotype. Moreover, hECs and hMSCs are known to be responsible for modulating the host immune system, mainly by suppressing TNF-α, IFN-γ, MCP-1 and IL-6 and increasing the level of anti-inflammatory cytokines. In vitro and in vivo results show increased cell migration and epithelialization leading to accelerated wound healing.

Expectations and Reality in Surgical Rehabilitation of Cataract Patients

N. S. Lutsenko, O. A. Isakova, O. A. Rudycheva, T. S. Kyrylova — Wed, 27 Oct 2021 00:00:00 +0300

The aim. To study the effect of surgical treatment of cataracts on the quality of life of patients and assess satisfaction with the results after implantation of a monofocal or multifocal intraocular lens (IOL), depending on the initial refraction.

Materials and methods. We examined 140 patients (280 eyes) who underwent phacoemulsification with IOL (bilateral) according to the standard technique using multimodal anesthesia. The observation groups were divided depending on the initial type of refraction and the type of intraocular correction (mono- or multifocal IOL). The analysis of

the results of surgical treatment of cataracts with IOL was assessed taking into account the initial refraction according to objective data, i.e. determination of distance and near visual acuity, and subjective data, i.e. the NEI-VFQ-25 quality of life questionnaire, patient questionnaire survey and assessment of the quality of vision in general, as well as distance, near, and night vision.

Results and discussion. Before surgery, the mean values of indicators by all scales of the questionnaire of the quality of life related to the quality of vision ranged from 40 to 60 points and averaged 47 ± 0.5 points. After cataract surgery, the numerical indicator by each of the scales shifted to the range of 85 to 100 points. The difference in values by the scales “activity associated with distance vision” and “driving a car” was obtained. In patients with multifocal IOL, these indicators were lower compared with monofocal implantation. Dissatisfaction with distance vision was observed during the implantation of a multifocal IOL only in patients with hyperopia (12.5%), dissatisfaction with near vision was noted only in patients with myopia (16.7%), and no cases of dissatisfaction were observed in the group of patients with emmetropia. Analysis of night vision in patients with emmetropia also revealed the minimum percentage (2.5%) of cases of dissatisfaction in patients with hyperopia (5.0%) and the maximum in those with myopia (16.7%).

Conclusions. IOL implantation is a single cataract treatment option that provides a high level of the patient’s satisfaction with the quality of life and visual functions. However, careful individual approach is required to select the type of implantable IOL, taking into account the patient’s needs and baseline refraction.

Stem Cells in the Treatment of Renal Allograft Diseases

O.S. Nikonenko, I. V. Rusanov, T. N. Nykonenko, S. R. Vildanov — Wed, 27 Oct 2021 00:00:00 +0300

In recent years, there has been growing interest in the use of stem cells as a therapeutic agent for the restoration of the damaged tissues and organs.

We present a clinical case. Male, 39 y.o. Diagnosis: Glomerulonephritis. On 10/09/2012, he underwent heterotopic renal allotransplantation from a live relative donor. On 09/23/2020, he was admitted to the hospital due to renal allograft pyelonephritis. On 10/28/2020, a cell based donor umbilical cord blood product was infused. Cell therapy enabled to minimize the consequences of the graft damage, to preserve the graft function and satisfactory condition of the recipient.

The Diagnosis of Brain Death

S. M. Gritsenko — Wed, 27 Oct 2021 00:00:00 +0300

Organ transplantation is impossible without donation which is performed both intra vitam and posthumously. Each case of multi-organ collection provides help to 4 to 6 patients. We believe that presentation of modern algorithms for diagnosing brain death is quite feasible, and such information can be useful not only for anesthesiologists, but also for doctors of other specialties. This paper presents materials related to organ donation. Diagnostic criteria for human brain death, as well as the procedure for ascertaining human brain death and the actions of doctors of healthcare institutions in relation to persons who are in these institutions and who have clinical indications for the diagnosis of brain death, are determined by "The procedure for cancellation of active measures to maintain the patient's life…". Active measures (ventilation, infusion therapy and vasopressor support, etc.) to support the patient's life are cancelled after the patient's brain death is ascertained, except for cases where the deceased person is considered a potential donor. Verification of the human brain death is carried out by the case management team of the healthcare institution involving, if necessary, members of consultative and diagnostic mobile team, specialists of other healthcare institutions. The head of the healthcare institution is responsible for timely and proper engagement and work of the case management team. The responsible person determines the membership of the case management team by making an appropriate entry in the case record and is responsible for its work.

An anesthesiologist and a neurologist (neurosurgeon) who have at least 5 years of practical experience in the specialty are engaged in the case management team to ascertain brain death in persons over 18 years of age.

Physicians involved in the removal of human anatomical materials and transplantation thereof, as well as transplant coordinator, may not be included in the case management team.