The resolution of the Expert Council on current issues of the use of acetylsalicylic acid for the purpose of primary prevention of cardiovascular diseases in the light of new scientific data and updated clinical guidelines

Expert Council: Drapkina O. M., Vavilova T. V., Karpov Yu. A., Kobalava Zh. D., Lomakin N. V., Martynov A. I., Roitman E. V., Sychev D. A.Scientific communities: the Russian Society for the Prevention of Non-Communicable Diseases (ROPNIZ), the Russian Scientific Medical Society of Therapists (RNMOT), the Russian Antithrombotic Forum (RAF), the National Association for Thrombosis and Hemostasis (NATH).

[Serum brain damage biomarkers as a diagnostic and prognostic tool in ischemic stroke]

OBJECTIVE

To study serum quantities of neuron specific enolase (NSE), glial fibrillary acidic protein (GFAP) and NR2-antibodies (NR2-ab) in various cerebrovascular pathology and assess their value as a panel used as a diagnostic and predictive tool for stroke.

MATERIAL AND METHODS

NSE, GFAP and NR2-ab serum levels were measured twice for 84 patients with ischemic stroke (IS) and 8 patients with hemorrhagic stroke (HI), once for 8 patients with transient ischemic attack (TIA), 26 patients with chronic brain ischemia (CBI), 27 healthy volunteers (HV).

RESULTS

NSE and GFAP levels were significantly higher in IS than in CBI and HV patients, and NR2-ab levels in IS were higher than in TIA and lower than in HV. In patients with more pronounced neurological deficiency and less favorable functional outcome by day 10-14 of IS, the levels of NSE, GFAP and NR2-ab were higher. Sensitivity and specificity of biomarker panel was higher than with their separate application.

CONCLUSION

The NSE, GFAP and NR2-ab biomarkers have a diagnostic and predictive value for IS.

Сalprotectin in the blood plasma as a new biomarker for assessing the activity of rheumatoid arthritis

Aim. To study the potential use and information value of calprotectin in the blood plasma as a new biomarker for determining the activity of rheumatoid arthritis (RA).

Materials and methods. The study included 113 people. The treatment group consisted of 79 patients diagnosed with RA; the average age was 58 (± 11.66) years, the median duration of the disease was 10 [6; 15] years. The control group encompassed 34 healthy volunteers; the average age was 40 (± 11.14) years. RA activity was determined according to the Disease Activity Score (DAS) 28 and the Clinical Disease Activity Index (CDAI). The concentration of calprotectin in the blood plasma was determined by the solid-phase enzyme-linked immunosorbent assay. The obtained results were compared with laboratory and clinical parameters, as well as with composite indices (DAS28, CDAI) of RA activity. For mathematical data processing, Spearman’s rank correlation coefficient, linear discriminant analysis, and ROC analysis were used.

Results. In the group of patients with RA, the level of calprotectin in the blood was higher than in the control group. A statistically significant relationship was revealed between the level of calprotectin in the blood and all standard parameters of RA activity. The ROC analysis showed that the sensitivity, specificity, and diagnostic accuracy in assessing articular syndrome, as well as moderate and high RA activity according to the composite indices DAS28 and CDAI were higher for calprotectin than for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The linear discriminant analysis showed that a combination of ESR and calprotectin levels was the most informative; following it, the probability of correct classification of RA activity, according to the DAS28 index, was 71%. For the CDAI index, only one marker, calprotectin, resulted in a statistically significant classification with a probability of 70.5 %.

Conclusion. Сalprotectin in the blood plasma is a promising laboratory biomarker for assessing synovitis activity in RA demonstrating higher accuracy, sensitivity, and specificity than traditional acute-phase reactants.

[Integral tests of the hemostasis system in assessing the efficiency of acetylsalicylic acid in patients with ischemic heart disease]

Despite the fact that acetylsalicylic acid (ASA) is the "gold" standard for the prevention of cardiovascular complications in patients with coronary heart disease (CAD), a number of patients still have risks of atherothrombosis. In the present study, the antithrombotic effect of ASA in patients with CAD was assessed in platelet-rich plasma (PRP) using integral tests of the hemostasis study: the T-TAS system (Total Thrombus-formation Analysis System) and the thrombin generation test (TGT). The study involved 34 patients with stable CAD (11 women, 23 men) and people (15 women, 18 men) in the control group. As a result of assessing the activity of thrombus formation using the T-TAS system, a significant decrease in the area under the curve (AUC10) was found in the group with CAD patients compared with the control (135.6 [88.0-222.3] and 260.5 [217.3-301.9], respectively, p.

Thrombotic and hemorrhagic complications during pregnancy, delivery and the postpartum period in females with prosthetic heart valves

Background/Introduction

Women with mechanical prosthetic heart valves are at greatest risk of developing complications.The main reason is that mechanical prosthetic heart valves require lifelong anticoagulation to reduce the high risk of associated thrombotic and hemorrhagic complications.

Purpose

The main goal of this study was to estimated risk factors and frequency of thrombotic and hemorrhagic complications during pregnancy, delivery and the postpartum period in women with prosthetic heart valves

Methods

According to retrospective cohort analyses in this study were included 70 patients with prosthetic heart valves who delivered in a specialized perinatal center from October 2010 to February 2020. All the patients were divided into two groups depending on prosthesis type: mechanical prostheses (44 deliveries in 44 patients), biological prostheses (22 deliveries in 19 patients). All patients were performed ECHO (Vivid 7, GE, USA). The average age were 30.7±5.2 years. The N-terminal brain natriuretic propeptide (NT-proBNP) concentration was determined by the quantitative electrochemiluminescence method using a Cobas E 411 analyzer (Roche, Switzerland). The activity of the anti –Xa factor was measured by chromogenic assays.

Results

In 9 (21.4%) pregnants with a mechanical valve prosthesis (MVP), prosthetic thrombosis was recorded until 2016. In 1 patient with mechanical valve prosthesis (2%) during pregnancy was complicated by an acute cerebral circulation disorder. Since 2016 there were monitored the activity of the anti –Xa factor. In 7 patients on the background of a change in anticoagulant therapy, pregnancy stopped in the early stages. Before pregnancy, 31.4% of the patients didn't have heart failure clinical manifestations, but in 12 (17.1%) patients during pregnancy had increase in NYHA Class maximum to NYHA Class III.

The average NT-proBNP concentration was 912.3±1586.6 pg / ml. The frequency of the cesarean section in both groups was high: in patients with mechanical valve prosthesis in 78.5% and in the group of patients with biological valve prostheses in 68.1% of cases. There were not registered any new cases of prosthetic thrombosis after delivery, however, 9 patients had hemorrhagic complications in the early postpartum period, which required relaparotomy and blood transfusions. Regardless of frequent complications during pregnancy and in the postpartum period, no fatal outcomes have been reported.

Conclusion

The absence of mortality over the 9-years old observation and delivery in patients with valvular prostheses demonstrates the feasibility of monitoring and delivery of this category of patients in a specialized multidisciplinary medical center with experience in managing patients during pregnancy with valvular prostheses on anticoagulant therapy.

Funding Acknowledgement

Type of funding sources: None.

Thrombogenicity in patients with ischemic stroke and pre-existing polycythemia vera

Thrombogenicity and its causes in patients with ischemic stroke (IS) and pre-existing polycythemia vera (PV) is a significant clinical concern. The aim of this study was to identify the range of factors associated with increased thrombogenicity in patients with IS and pre-existing PV. We performed a physical examination and laboratory tests on 127 patients in the hyperacute stroke stage and 16-18 months after. Of them, 68 patients had PV (the main group) and 59 did not have this condition (the comparison group). Laboratory tests were conducted to evaluate blood rheology, hemostasis, endothelial function, angiogenesis, proinflammatory cytokine levels; we also tested patients for the presence of the V617F mutation in the JAK2 gene and analyzed the contribution of all studied parameters to the development of thrombotic and hemorrhagic complications. We found that the neurological picture did not differ between the groups: mean NIHSS scores were 12 and 13 points, respectively. Morphological and functional characteristics of red blood cells and platelets, hemostasis and cytokine profiles were compared between patients with IS and pre-existing PV and the comparison group. One of the key elements in potentiating thrombotic complications in patients with IS and PV was JAK2 V617F allele burden. The obtained data suggest the cumulative effect of the identified factors promoting thrombus formation in post-stroke patients with PV and overpowering the effect of antiplatelet therapy.

Arterial hypertension in adults. Clinical guidelines 2020

Arterial hypertension in adults. Clinical guidelines 2020

[The possibility of using neuron-specific enolase as a biomarker in the acute period of stroke]

The article presents a review of the literature on neuron-specific enolase (NSE) as a biomarker of stroke. It is shown that NSE does not allow differentiation of the ischemic and hemorrhagic process in stroke, but is suitable for determining the extent of brain tissue destruction both in the first hours of stroke and in the dynamics. The HSE analysis can be useful for monitoring the course of the disease, control of the dynamics of the pathological process, including when the size of the lesion increases, for evaluating the effectiveness of therapy and as a prognostic biomarker.

[Anticoagulant activity of direct factor Xa inhibitors as a tool to ensure the effectiveness and safety of drugs intake]

The thematic review presents modern solutions using oral anticoagulants with a focus on direct coagulation factor X inhibitors. It contains information about the pharmacodynamics and pharmacokinetics of apixaban and rivaroxaban against the background of different drug intake regimens - twice and once per day. There are shown studies of concentration dynamics and the corresponding functional response, measured using the integral method - the thrombin generation test, which is widely used in scientific research to describe hemostatic processes based on an objective quantitative assessment of the thrombin formation - a key coagulation cascade serine protease. The logical relationship between the pharmacodynamics of anticoagulant action and the clinical presentation of the effectiveness and safety of drugs is traced. The review provides links to actual literature and current clinical guidelines.

[Increase in GP IIb-IIIa and P2Y12 Receptors in Activated Platelets as the Possible Indicator of de novo Protein Synthesis]

Although platelets lack nuclei, they are capable of de novo protein synthesis. We speculate that key platelet receptors are involved in the regulation of this process, and the changes in their number indicate the de novo protein synthesis in platelets. The object of our study was native platelets obtained from healthy donors. Using flow cytometry and Western blot, we determined the number of GP IIb-IIIa receptors (fibrinogen receptor) and P2Y12 receptors (ADP receptor) on the surface of platelets upon their activation with ADP and collagen. To verify the approaches and techniques used, we studied IL-1β protein, which was previously shown to be synthesized de novo in activated platelets. GP IIb-IIIa receptor numbers correlate with the number of P2Y12 receptors on the cell surface (R = 0.45, p = 0.03). It was demonstrated that the platelet receptor numbers are higher on the surface of the cells with high functional activity. According to the data obtained by Western blot, upon the cell activation with ADP, the number of GP IIb-IIIa and P2Y12 receptors increases, which may serve as evidence of these proteins being synthesized in the activated platelets. It was observed that the level of P2Y12 and IL-1β was lower in the samples where GP IIb-IIIa receptor was blocked by the selective inhibitor, i.e., the Fab fragment of the antibodies that specifically recognizes the GP IIb-IIIa complex. This suggests the important role of GP IIb-IIIa receptor in the regulation of protein synthesis.

[The molecular mechanisms of platelets activation in patients with cerebrovascular disease]

Cerebrovascular disease is a main cause of mortality and one of the big medical problems. After the vascular wall's damage the endothelial cells secrete the von Willebrand factor which then connects with its platelet's receptor GP Ib-V-IX. There are two polymorphisms Thr145Met and T(-5)C of the GP Iba gene associated with arterial thrombosis development. Also the difference in platelets' genes expressions was shown in patients with various clinical course of ischemic heart disease. The aim of this study was to investigate the role of platelet's receptor for von Willebrand factor in platelets' activation in patients with cerebrovascular disease. 123 patients with cerebrovascular disease and 97 healthy donors were included into the study. We analyzed the level of receptor for von Willebrand factor on platelet's membrane by flow cytometry, Thr145Met and T(-5)C GP Iba polymorphiams by PCR-RFLP, the GP Iba gene expression by RT-PCR and ADP-induced platelet aggregation by Born method. We have shown: 1) the 145Met GP Iba allele prevalence in patients with atherotrombotic stroke development due to macroangiopathy; 2) the pre-mRNA transform into the mature mRNA in activated platelets and this process may be stopped by the antiplatelet therapy by acetylsalicylic acid.

[The clinical laboratory diagnostic as a part of clinical medicine.]

The rapid development of laboratory technologies and their translation directionality permit developing principles of personified medicine. The article considers new paradigm of manpower policy for developing necessary level of clinical laboratory consultation.

[Laboratory assessment of haemostatic parameters in patients taking a direct thrombin inhibitor]

The problem of prevention and treatment of thromboembolic complications has a significant place in clinical practice for many years. The gold-standard agents in long-term protection from embologenic strokes, secondary prevention of venous thromboses and embolisms still remain vitamin K antagonists (in Russia - warfarin). However, despite high efficacy, administration of warfarin is fraught with dangers and associated with a series of inconveniences. A direct thrombin inhibitor, dabigatran etexilate (hereinafter referred to as dabigatran) was approved in the Russian Federation for prevention of thromboembolic complications in orthopaedic practice (2009), for prevention of ischaemic embologenic stroke in atrial fibrillation (2011) and for treatment of recurrent thrombosis of deep veins and pulmonary artery thromboembolism (2014). A characteristic feature of a therapeutic agent possessing an anticoagulation effect is correlation between intensity of hypocoagulation and haemorrhage. The effect of dabigatran on the laboratory parameters of haemostasis has been studied insufficiently, with no practical guidelines on assessing these alterations for prediction of the risk for haemorrhagic and thromboembolic complications. The present study included a total of 65 patients with non-valvular aetiology atrial fibrillation, taking dabigatran during from 6 to 18 months. All patients underwent laboratory assessment of the coagulation level and measuring blood coagulation activation markers in dynamics 10-14 days, 1, 6, 12 and 18 months after taking the agent. Thromboembolic and haemorrhagic risks were also assessed. It was revealed that administration of dabigatran leads to alterations in the main parameters of coagulogram. Determination of prothrombin (in % according to Quick's method) and activated partial thromboplastin time may be used for qualitative assessment of hypocoagulation. During the follow up period no statistically significant changes in the coagulation activation markers level were observed.

[Gender differences in clinical and hemoreologic disorders in elderly patients with non-cardioembolic ischemic stroke]

Clinical manifestation and platelet homeostasis parameter results in elderly patients with atherothrombotic and lacunar strokes are presented. There is platelet activation in these patients manifested by increasing of P-selectin expression in response to adenosindiphosphate induction on flow-cytometry. Agregometry method was not informative for platelet activity estimation in these patients. Von Willebrand factor receptor expression on the platelet may have prognostic value for acute period. The fibrinogen receptor expression on the platelet was increased in women with stroke comparing with men.

[Apoptosis of peripheral blood lymphocytes in patients with LRRK2-assoctated Parkinson's disease]

Mutations in the Leucine Reach Repeat Kinase 2 (LRRK2) gene are the most frequent cause of familial Parkinson's disease (PD). Although the precise physiological and pathological role of LRRK2 is unclear, a direct link between mutant LRRK2 and apoptosis has been suggested. Using flow cytometric analysis (PI+Annexin V(FITC)) we showed increased spontaneous apoptosis of peripheral blood lymphocytes in patients with LRRK.2-associated PD compared to controls after 24 (P < 0.016) and 48 (P < 0.031 ) h of incubation (5 % CO2, 37 degrees C). We found the increased FAS mRNA level in peripheral blood lymphocytes of patients with LRRK2-associated PD compared to controls (P < 0.05) and to sporadic PD (sPD) (P < 0.002). Significant difference in FAS expression between patients with LRRK2-associated PD and controls remained after three years and was detected after 1 and 24 h during lymphocyte incubation (P < 0.03 and 0.05, respectively). Increased spontaneous lymphocytes apoptosis along to increased FAS expression in patients with LRRK2-associated PD suggest that LRRK2 mutations may lead to the activation of extrinsic apoptotic way.

[The preanalytical stage of studying the hemostatic system]

The efficiency of applying precision devices and multiple laboratory methods devised to reveal the causes of bleeding and thromboses significantly depends on whether a wide range of rules of the preanalytical stage of the study is observed. The paper gives detailed information on conditions for taking blood samples, their transport, and preparation for examination of the hemostatic system. The given information is based on the worldwide recommendations and many years' experience gained by the authors at the laboratory of hemostasis.

[Clinical and laboratory criteria for diagnosis in antiphospholipid syndrome: what is it important for a practitioner to know (a lecture)]

The antiphospholipid syndrome (APS) is antibody-induced thrombosis, whose diagnostic basis is the obligatory presence of serological markers along with clinical manifestations. Its laboratory markers are antiphospholipid antibodies (aPAs), the highest informative value has been proven for lupus anticoagulant (LA), cardiolipin antibodies, fl-glycoprotein 1. LA should be determined at a laboratory in accordance with the recommendations of the International Society on Thrombosis and Hemostasis. Obstetric abnormality in APS should be regarded as a thrombotic complication and its management in this case does not differ from that and prevention of thrombosis, aPAs may be detectable in various illnesses, but their blood presence is not an indication for immunosuppressive therapy. The paper describes a case of primary APS in a female patient.

[Evaluation of D-dimer in outpatients: clinical value and specific features]

D-dimer as an activation marker of coagulation and fibrinolysis is a recognized diagnostic criterion of deep vein thrombosis, pulmonary thromboembolism, and disseminated intravascular coagulation. In recent years, this laboratory test has been most frequently used for other purposes: to detect the activation of coagulation, to predict the course of diseases, and to determine the duration of anticoagulant therapy. Our investigation examined 1514 D-dimer measurements in 1370 outpatients without acute abnormalities, including 72 patients receiving warfarin and 32 patients after myocardial revascularization. 36.1% of cases were found to have values of more than 0.5 mkg/ml. Adequate anticoagulant therapy (INR 2-3) caused a reduction in the level of D-dimer that is an important additional laboratory test for the evaluation of antithrombotic defense. Further investigations are needed to determine cutoff values for various clinical situations.

[Genetic variants of platelet ADP receptor P2Y12 associated with changed platelet functional activity and development of cardiovascular diseases]

The key role in platelet aggregation is played by the platelet ADP receptor P2Y12, which is the target for antiaggregant drugs, clopidogrel and ticlopidine. At present, only sporadic data on genetic variants of platelet ADP receptor P2Y12 are available from literature, and their association with thromboembolic and cardiovascular diseases still remains obscure. Analysis of the group of subjects with high platelet reactivity resulted in identification of two nucleotide substitutions, C18T and G36T, in the coding region of the P2Y12 gene. The frequency of the P2Y12 T1 8 allele was higher in control group than in the group of patients survived from myocardial infarction at the age under 45 years (39% versus 28%, respectively, P = 0.04). Moreover, in the T18 carriers, platelet aggregation activity was lower than in the carriers of the wild-type genotype (0.84 +/- 0.05% versus 1.01 +/- 0.08%, respectively, P = 0.03). In the group of patients with early myocardial infarctions, a tendency towards the increased frequency of 16T allele in comparison with control group (20 and 12%, respectively, P = 0.07) was observed. The rate of ADP-induced platelet aggregation in the carriers of 16T allele from the control group was somewhat higher than in the subjects with the GG36 genotype (1.31 +/- 0.16% versus 1.12 +/- 0.06%, respectively, P = 0.07). The nucleotide substitutions identified were in absolute disequilibrium, i.e., allele T18 conformed to allele G36. On the contrary, allele C18 conformed to allele T36. Haplotype T18G36 was found to be responsible for the decreased risk of myocardial infarction and decreased platelet reactivity. It is suggested that polymorphisms of the P2Y12 gene identified can be used for determination of the risk group for myocardial infarction in the young males.

[Novel mutation of the GPIIIa gene in the Russian population, Leu40Arg, linked to the Leu33Pro]

Glycoprotein IIb/IIIa complex, a platelet surface fibrinogen receptor, plays a key role in producing primary hemostasis. At present, only a single mutation in the GPIIla gene, Leu33Pro, and a single mutation in the GPIIb gene, lle843Ser, has been described. The mutations are known to enhance signaling functions of the receptor and are associated with the development of arterial thromboses. In the present study, we describe a novel GPIIIa mutation, which is T to G nucleotide substitution in position 1585, resulting in the replacement of Leu for Arg in position 40 of the amino acid sequence of the protein.

[Clinical value of allele variants of cytochrome CYP2C9 gene for anticoagulation therapy with warfarin]

Warfarin is metabolized by cytochrome CYP2C9 and its pharmacokinetic properties depend on structural polymorphisms of CYP2C9 gene. We studied frequencies of allele variants of CYP2C9 gene and associations of individual reaction to warfarin intake with genotype of CYP2C9 gene. Population frequencies of CYP2C9x1, CYP2C9x2, CYP2C9x3 alleles of CYP2C9 gene in St-Petersburg were 82.66, 11.11, and 6.32%, respectively. Carriers of CYP2C9x2 and CYP2C9x3 alleles more rapidly achieved therapeutic levels of hypocoagulation and required significantly lower weekly doses of warfarin.

[Models of inter-group difference of the homeostasis system in patients with artificial heart valves and the set of laboratory parameters]

Patients with artificial heart valves (AHV) belong to a unique multi-component model of the homeostasis system presenting an interaction of activated coagulation processes and pharmacological effects, on the one hand, and genetic peculiarities functioning homeostatic mechanisms, on the other hand. The described method was evaluated on the basis of multi-factor mathematic analysis by information-metry. The data obtained provided for isolating the most information-dense laboratory indices and some genetic polymorphisms describing the shaping of continuous intravascular coagulation of stage III in AHV patients. The clinicians and laboratory experts are offered a practical instrument for the diagnosis (prognostication) of the above condition. It was proven as necessary to examine (by the morphofunctional method) the intravascular activation of platelets and to determine the D-dimer in the remote period after prosthesis of heart valves.

[Hydrodynamic investigations of the current mechanical artificial heart valves]

The work presents results of comparative investigations of the integral hydrodynamic characteristics of the best for today domestic mechanical heart valve (MHV) Medinzh-2 (MI-2) and the turn-disk domestic MHV--LIKS-2, EMIKS (E) and foreign MHV--Medtronic-Hall, Bjork-Shiley (BS), Sorin (SO) and bicuspid valves--St. Jude Medical (SJ), Carbomedics in the stationary and in the pulsatile flows. It was found that according to the main hydrodynamic characteristics including the outlet flow structure, MHV MI-2 was substantially superior to MHV E, BS and SO, and by certain characteristics it approximated to the best foreign MHV SJ. Like all mechanical heart valves, the valve MI-2 disturbs the uniformity of the inlet flow and forms a complex non-stationary flow with detached zones, areas of great shear stresses, with vortex structures of different types, and hence the task of hydrodynamic optimization of its construction is thought to become actual. The comparison of clinical parameters of work of the valve MI-2 with its hydrodynamic characteristics confirms its high hemodynamic effectiveness and thrombo-resistance in patients at long-term periods of follow-up, taking into account the adequate correction of disbalance of hemostasis.

[The influence of hereditary thrombophilic mechanisms on the degree of permanent intravascular coagulation in patients with artificial heart valves]

The genotyping of 40 patients with artificial heart valves (AHV) was performed after prosthesis of the mitral and aotic valves with bicuspid AHV (Medinzh-2 and CarboMedics). The patients took phenylin and varfarin. The patients' genotype was estimated by the thrombophylic genes: factor V Leiden (FVL), prothrombin G20210A, methylene tetrahydrofolate reductase C677T, G/A--455FGB, 4G/5G PAI-1, PI A1/A2 GPIIIa. The genes determining the thrombocytic activity or the vascular wall state substantially influence the third degree of the intensity of the permanent intravascular coagulation (PIC-3) independent of the degree of correction of hemostasis of oral anticoagulants. The addition of anti-aggregants to therapy is the only that can normalize functional activity of thrombocytes in patients with AHV having such defects. The laboratory detection of the genetic defects is of great practical importance for the determination of risk groups of formation of PIC-3 and the strategy of antithrombotic protection of patients with AHV.

[Two approaches to correction of disturbed hemostasis in patients with mechanical artificial heart valves at the long-term follow-up]

The investigation of the hemostasis system performed in 47 patients with mechanical heart valves (MHV) at the terms of (3.50 +/- 0.25) years included 30 men and 17 women. There were 24 cases of aortal MHV and 23 cases of mitral MHV, I-II functional class (NYHA). The patients were given oral anticoagulants: phenylin to 35 patients (0.009 mg/day), varfarin to 12 patients (52.6 mg/a week). The primary examination of the patients has revealed insufficient anticoagulation protection and clinically asymptomatic permanent intravascular coagulation of the third degree (PIC-3), with the signs of activation of thrombocytic and/or coagulation link of hemostasis. It has been found that a complex assessment of the hemostasis system state including the vascular-thrombocytic link is an obligatory condition of the right choice and timely correction of the PIC-3 in patients with MHV. The methods of correction of impaired hemostasis depend on the primary involvement of the vascular-thrombocytic and/or coagulation link of hemostasis. The pathogenetically selected antithrombotic therapy for patients with MHV allows timely arrest of PIC-3 and less risk of the development of thrombosis and thrombo-embolic complications at long-term periods of observation.

[Prophylaxis of thrombosis and thromboembolic complications in patients with domestic mechanical artificial heart valves (AHV) "Medinzh-2" in remote terms of observation]

The observation included 40 patients (20 men and 20 women) with the rheumatic heart diseases acquired at the age of (45.9 +/- 8.7) years after isolated prostheses of the aortal (n = 25) and mitral (n = 15) valves with bicuspid constructions of AHV "MedInzh-2" in remote terms in (2.52 +/- 0.48) years, I-II functional valve (NYHA). It was shown that only a permanent control not rarer than once a month and an adequate correction by means of anticoagulation and antiaggregation therapy using standard methods for patients with the bicuspid AHV made it possible to avoid the development of thromboses and thromboembolic complications during three years of observation.

[Indices of chronic intravascular hemolysis in patients with different prosthetic heart valves in long-term follow-up]

An examination of 153 patients with valve replacement was performed at late stages of (6.8 +/- 0.2) years, in 84 patients the mitral valve replacement (MVR) was fulfilled, in 64--the aortic replacement (AVR) and in 5--two valve replacement were performed. Higher indices of hemolysis were noted in patients with AVR, in cases of two valve replacement and in patients with the paravascular fistula. The lowest indices of hemolysis take place in patients with bileaflet prostheses (MEDING/CarboMedics, St. Jude Medical), especially in patients with AVR. The complications of intravascular hemolysis are: cholelithiasis, anemia, hemosiderosis of the kidneys, sideropenia. The timely diagnosis, treatment and prophylactics are necessary to prevent these complications.

[Turbidimetric express method in the assessment of the hemostasis parameters in patients with prosthetic bileaflet heart valves]

Thirty patients of medium (47 +/- 3) years of age with prosthetic bileaflet heart valves without any specific complications of the I-II functional classes and with the postoperative period after mitral (11) and aortal (19) valve replacements during (2.52 +/- 0.48) years were studied. The defects of coagulation and fibrinolytic systems were found in 9 patients with high prothrombin index (93.21 +/- 9.8)% and low INR (0.9-1.7). The activation of fibrinolysis, low platelets, hypofibrinogenemia, D-dimer which are the risk factors of thrombogenic complications were found in these patients. The updated turbo-dynamic express-method which helps to activate fibrinolysis in short terms and to make its correction is proposed.

[Activity of free radical lipid oxidation and the state of antioxidant system in patients with ischemic heart disease during myocardial revascularization]

It has been established that aortocoronary bypass surgery is characterized by imbalance in lipid peroxidation and antioxidant defense system. These changes are more pronounced in patients with the most severe forms of ischemic heart disease. During surgery the greatest intensity of lipid peroxidation is observed at the end of assisted circulation period. To prevent these disturbances it is necessary to minimize surgical trauma, reduce the duration of operation stages, refuse pronounced normobaric hyperoxia during cardiopulmonary bypass.

[Early postoperative period in patients subjected to surgery for noncorrectable obesity]

The early postoperative period after jejunoileoshunting for high degree of the alimentary-constitutional obesity was found to have a number of specific features and to be an important period greatly responsible for the outcome of the operation. The very early active management of such patients was shown to improve the postoperative course and to reduce the number of pulmonary complications. In 85 patients an original technique of jejunoileoshunting was used.