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118.Детские болезни сердца и сосудов №4 2013

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E-mail: izdinsob@yandex.ru
http: //www.bakulev.ru
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2013. ? 4. 1?72
ISSN 1810-0686
??????? ???????
?????? ? ???????
CHILDREN?S HEART
AND VASCULAR DISEASES
????????????? ??????-???????????? ??????
??????? 1 ??? ? ??? ??????
??????? ? 2004 ?.
.
4 2013
??????? ???????? ?.?. ???????
???????????? ????????
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?.?. ??????????? (????????????? ?????????),
?.?. ?????????, ?.?. ?????????, ?.?. ???,
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?.?. ??????? (???. ???????? ?????????)
???????????? ?????
?.?. ???????, ?.?. ???????, ?.?. ??????,
?.?. ??????????, ?.?. ???????
Мк??й 500 ?ма.
?????? ?????? ? ???????? ????????????? ????????????? ??????? ???????,
??????????? ? ?????????? ?????????, ? ??????? ????????????? ??????????
???????? ??????????? ??????????? ?? ????????? ?????? ??????? ??????? ?
????????? ???? ?? ????????
Хс?ткрлсх кл?бмр 84550
?????? ??????? ? ?????????? ?????? ???????? ???????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
Nauchnyy tsentr serdechno-sosudistoy
khirurgii imeni A.N. Bakuleva Rossiyskoy
Akademii Meditsinskikh Nauk
DETSKIE BOLEZNI
SERDTSA I SOSUDOV
CHILDREN?S HEART
AND VASCULAR DISEASES
Peer-reviewed scientific ?practical journal
Published once in three months
.
Founded in 2004
4 2013
EDITORIAL BOARD
E.D. Bespalova,
E.L. Bockeria,
I.V. Vasilevskaya
(executive secretary),
M.L. Ermolenko,
M.A. Zelenikin,
A.I. Kim,
I.V. Kokshenev,
M.R. Tumanyan,
K.V. Shatalov
(assistant editor)
EDITORIAL COUNCIL
A.A. Baranov,
N.N. Volodin,
Yu.F. Isakov,
L.R. Plotnikova,
M.P. Chernova
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
??????????
CONTENTS
??????? ?.?., ????????? ?.?., ???????? ?.?.,
?????????? ?.?., ?????????? ?.?., ??????? ?.?.
????? ??????????????????? ????? ?????
??. ?.?. ???????? ???? ? ???????? ???????
?????
7
Bockeria L.A., Podzolkov V.P., Kokshenev I.V.,
Plotnikova L.R., Zemlyanskaya I.V., Glyantsev S.P.
Contribution of A.N.Bakoulev Scientific Center for
Cardiovascular Surgery of the Russian Academy of
Medical Sciences school of cardiac surgery into
tetralogy of Fallot surgery
16
Prasolov S.Yu., Kupryashov A.A., Dedushkina N.Yu.,
Zelenikin M.A. The repair of tetralogy of Fallot in
early childhood. Have the indications for pulmonary arterioplasty changed?
???????? ?.?., ???????? ?.?., ????????? ?.?.,
????????? ?.?. ?????????? ?? ????????? ? ????????????? ???????? ??????? ??? ???????????
????????? ??????? ????? ? ?????? ?????????
????????? ?.?., ??????? ?.?., ????????? ?.?.,
????? ?.?., ?????? ?.?., ???????? ?.?.,
??????? ?.?., ???????????? ?.?. ??????????
?????????? ??????? ?????? ?????? ??????? ?????? ? ??????? ? ?????????? ???????????????????
????????
??????? ?.?., ????????? ?.?., ??????????? ?.?. ????????? ?.?., ????????? ?.?. ???????????????? ????????????? ????? ??????????
1 ????? ??? ????????????? ?????????? ??????
??????
???????? ?.?., ????????? ?.?., ????????? ?.?.,
?????? ?.?. ?????????? ?????????? ????????? ?
???????? ??????? ? ????????????? ? ?????????
??? ?.?., ??????? ?.?., ?????? ?.?., ?????????? ?.?. ??????? ????????????? ????????? ??????? ???????? ??????? ? ???????? ??????????????? ??????????? ? ????? ??????? ???? ?????
Podzolkov V.P., Kovalev D.V., Zelenikin M.M.,
Yurlov I.A., Putyato N.A., Mavlyutov M.Sh.,
Dontsova V.I., Vladimirskaya M.V. Long-term
results of the right heart bypass in patients with the
pathology of atrioventricular valves
23
Bockeria L.A., Podzolkov V.P., Baryshnikova I.Yu.,
Simogaeva E.B., Berishvili D.O. Biventricular
reconstruction after hybrid stage 1 in left heart
obstructive lesions
32
37
Boriskov M.V., Efimochkin G.A., Karakhalis N.B.,
Serova T.V. Results of the use of conduits in the
pulmonary position in neonates and infants
45
Kim A.I., Khamitov R.R., Rogova T.V., Grigor'yants T.R. Staged repair of pulmonary atresia
with ventricular septal defect in infants in the first
year of life
3
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
??????? ?.?., ??????? ?.?., ????????? ?.?.,
??????? ?.?., ??????????? ?.?., ????????? ?.?.
?????????????? ??????????? ??????? ? ?????
??????? ????????
?????? ?.?., ???????? ?.?., ???????? ?.?., ???????? ?.?. ?????? ?????? ????????? ?????????????? ????? ? ????????? ?????????-??????????? ????????
Bockeria L.A., Shatalov K.V., Arnautova I.V.,
Makhalin M.V., Vasilevskaya I.V., Ermolenko M.L.
Mitral valve replacement in young children
51
Ivanov A.S., Glamazda S.V., Lebedeva A.V.,
Rodionov A.S. A rare case of connective tissue
dysplasia ? mitral-aortic aneurysm.
58
???????????? ?.?., ?????? ?.?., ?????? ?.?.,
?????????? ?.?. ??????? ????????? ?????
???????????? ?????? ? ??????? 4 ??? ????? ???????? ????????????? ????? ?????????? ???????
? ?????
62
??????? ??? ???????
67
4
Astrakhantseva T.O., Rogova T.V., Putyato N.A.,
Yurpol?skaya L.A. Complex arrhythmias ishemicski
genesis of the child, 4 years after the operation of
aortic reimplantation the left coronary artery
Instruction for authors
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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?????? ???????????? ??????? ????? ?????????? ?????????. ? 1999 ?. ?? ?????????? ?????????? ? ??????? ?????????????? ??????? ?????????? ???????
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???????? ??? ? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????,
?????????? ?????????, 121552
??????? ??? ?????????, ???????? ??? ? ????, ????????;
????????? ???????? ????????, ???????? ????, ???. ?????????;
???????? ????? ??????????, ?. ?. ?., ?????????, e-mail:cardiokok@gmail.com;
?????????? ??????? ??????????, ?. ?. ?.;
?????????? ???? ????????????, ?. ?. ?.;
??????? ?????? ????????, ?. ?. ?., ?????????.
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?? ???? ???????? ???? ?.?. ???????????, ? ?????????????? ????? ????????? ???? ?.?. ??????? ? ?.?. ?????????, ?????????? ?.?. ???????????, ?.?. ??????-??????????, ?.?. ????????, ?.?. ?????????, ?.?. ?????, ?.?. ???, ?.?. ??????? ? ??.
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???????? ?????: ??????? ?????; ??????????? ?????????; ???????????? ????????; ??????? ????????.
CONTRIBUTION OF A.N.BAKOULEV SCIENTIFIC CENTER FOR CARDIOVASCULAR
SURGERY OF THE RUSSIAN ACADEMY OF MEDICAL SCIENCES SCHOOL
OF CARDIAC SURGERY INTO TETRALOGY OF FALLOT SURGERY
L.A. Bockeria, V.P. Podzolkov, I.V. Kokshenev, L.R. Plotnikova, I.V. Zemlyanskaya, S.P. Glyantsev
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of Medical
Sciences; Roublevskoe shosse, 135, Moscow, Russian Federation, 121552
Bockeria Leo Antonovich, Academician of the Russian Academy of Sciences and Russian Academy
of Medical Sciences, Director;
Podzolkov Vladimir Petrovich, Academician of the Russian Academy of Medical Sciences, Deputy Director;
Kokshenev Igor' Valer'evich, MD, DM, Professor, e-mail: cardiokok@gmail.com;
Plotnikova Lyudmila Rafaelevna, MD, PhD;
Zemlyanskaya Inga Vladimirovna, MD, DM;
Glyantsev Sergey Pavlovich, MD, DM, Professor.
For more than 70 years that have passed since the emergence of surgery for congenital heart anomalies in the USSR, several schools of
scientific research and practical pediatric surgery have developed, the largest of them is A.N. Bakoulev Scientific Center for Cardiovascular
Surgery of the Russian Academy of Medical Sciences school. Its foundations were laid by the great pediatric heart surgeon of the country
of XX century an academician of the Russian Academy of Medical Sciences V.I.Burakovskiy, and his legacy was continued by the academicians of the Russian Academy of Medical Sciences V.A. Bukharin and V.P. Podzolkov, professors G.E. Fal'kovskiy, V.V. AleksiMeskhishvili, M.R. Chiaureli, M.A. Zelenikin, V.N. Il'in, A.I. Kim, K.V. Shatalov and the others who became his followers and successors.
The objective of this work ? is to present the contribution of A.N.Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy
of Medical Sciences school of scientific research and practical pediatric cardiac surgery into the surgery of one the most frequent cyanotic congenital heart disorder ? tetralogy of Fallot. But at first we refer to the background and history of surgical treatment of this heart anomaly.
At the present time there is a doctrine of treatment of tetralogy of Fallot, which comprises diagnosis procedure of the heart disorder, strategy and
tactics of the choice of treatment method, indications for operation and the types of surgical procedures, as well as post-operative complications,
prognosis, long-term results etc. The representatives of A.N. Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of
Medical Sciences school of cardiac surgery made a considerable contribution into the establishment and acknowledgement of this doctrine.
Key words: tetralogy of Fallot; radical correction; palliative surgery; history of medicine.
7
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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?? ????? ??? 70 ???, ????????? ? ??????? ?????? ???????? ? ???? ???????? ?????????? ??????? ?????? (???), ? ?????? ?????????????? ????????? ??????-???????????? ???? ? ??????? ??????? ??????????????, ????? ??????? ?? ???????
???????? ????? ????? ??. ?.?. ???????? ????.
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????????? ???????????? ????????? ?????? ??????-???????????? ????? ????? ??. ?.?. ???????? ???? ? ???????? ?????? ?? ????? ???????????????? ????????????? ??? ? ??????? ????? (??).
Йкр. 1. C. Walton Lillehei (1918?1999 ??.) ? ткслб? ???км?н╦лсх мс??бм?кк збз???? Н?ннс
Йкр. 2. днбмр?л?? днбмр?л??с?к? гк╞лб?рмкх (1906?1975 ??.) ?
с?кл ка ткслб?с? ?к?ш??кк рб???? ? КККЙ, ткслб? стб???кх
л? рб???б ? шрнс?к?? крмшррз?бллс?с м?с?сс╥???блк?
Йкр. 3. Гкмсн?х Ек??хнс?к? досрс? (1913?2013 ??.) ? с?кл ка
ткслб?с? ?к?ш??кк рб???? ? КККЙ
8
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? ????? 1944 ?. ?????? ???????? ??? ???????????? A. Blalock ?? ??????? ???? ? ?????????
??????? ???????? ? ??????? ????? ????????????
??????? ??, ??????? ?????? ???????? ????????
???????????-????????? ??????????. ? 1947 ?.
T.H. Sellors ? ????????? ???????? ???????? ? ???????? ??????? ????????????? ???????? ? ??, ???????? ???????? ???????? ?????????????.
31 ??????? 1954 ?. C.W. Lillehei ? ????????? ??
???????????? ????????? (???. 1) ??????????? ???????? ??????????? ????????? ?? ? ????????
????????????? ?? ????????????? ??????????????,
??????? ????????????????? ? ?????? ??????
??????????????? ??????????? (????) ????????.
C.W. Lillehei ? ??????? ???? ????????????? ???
9 ???????, 5 ?? ??????? ?????? [1]. 22 ?????
1955 ?. ??????????? ????????? ?????? ? ????????
?????????????? ?????????????? (??) ?? ????????
??????????? J.H. Gibbon c ???????????????????
????????????? ?????? ? ??????? ???? ? ?????????
J.W. Kirklin [2].
??????? ? ???? ???????? ???????? ??? ??
???? ????????? ? 1952 ?. ? ??????? ?????????????
???????? 2-?? ???? ??. ?.?. ???????. ?.?. ??????
???????? ???????? ???????? ?????????????. ?????? ????????????? ? ????????????????? ??? ????????? ?????? ????????? ?.?. ?????????? ?
?.?. ??????????? ? ????? 1957 ?. ? ????????? ???????? ??. ?.?. ??????????? ??? ????, ? ??????
??????????? ???????? ??? ?? ? ?????? 1961 ?. ?
???????? ? ????????? ???? ??????? ?.?. ??????????? ? ???? ??? ???? ? ?.?. ?????? ? ????????
??? ??????????? ? ??????? ???????? ?? ????
(???. 2, 3).
?????????? ????????????????? ???????? ???????????? ?????????? ?????? ????????? ????????? ???????. ? 1959 ?. J.W. Kirklin (???. 4) ????????? ? ??????? ? ??????? ????????? ??????? ?????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
Йкр. 4. John W. Kirklin (1917?2004 ??.) ? ткслб? ???км?н╦лсх
мс??бм?кк МН
Йкр. 6. гкз?нкх днбмрбб?к? еш???кл (1930?2001 ??.) ? с?кл
ка срлс?стснсйлкмс? ?к?ш??кк гХК ? КККЙ к Йсрркк
???????? ????????? ?????? ??????? ?????????
(??) ? ??????? ??????? [3].
?????? ? ???? ???????? ?????????????? ???????? ?? ??? ?? ???????? ? 12-?????? ??????? ??
???????? ???????? ??????? (??) ? ???? 29 ????
1962 ?. ???????? ?.?. ??????????? (???. 5). ???
???? ???? ??? ??????????? ??????????????? ?????? ?? ??????? ??????????? ?.?. ???????? [4]. ?????? ???????? ?????????????? ??????? ?? ??????? ???????? ??? ??????????? ????????? ??
20 ?????? 1965 ?. ?????? ?.?. ???????? ?? ???
??????????? ? ????????????????? ????????
?? ????? [5].
?????? ?????? ???????? ?? ???????? ??????????????? ????? ?? ???????????? ????????? ? ???????? ????? ??????????. ? ????????? ???? ???????? ??????? ? ??? ????, ??? ? ???????? 1975 ?. ?
???? ??. ?.?. ???????? ??? ???? ???? ????????? 69 ???????? ?????????????? ???????? ?? ?
Йкр. 5. гн??кок? Ю??лс?к? еш??мс?рмкх (1922?1994 ??.) ?
ткслб? ???км?н╦лсх мс??бм?кк МН ? КККЙ к Йсрркк
??????? ? ??????????? ?????? ????? ?? ??, ??
??? 13 ???????? ??????? ??????? ? ??. ?????
?????????? ????????? 43 %, ??? ???????? ???????
?????????? ?? ?????????????? ???????? ?? ??? ??
[6]. ? ???????? ???????????? ????? ????????? ???????? ?? ??????????????? ???????? ? ????????????, ??????? ? 1965 ?. ?????????? ? ????? ?????????? ??????????? ? ??????? ? ??????? ?.?. ??????? ?? ???? ??? ???? (???. 6) [7].
? ?????? ???????? ???????????? ?????????????? ??????? ?????? ? ???? ? ??? ??????? ????????? ?????. ? ???????? 1965 ?. ?????? C.W. Lillehei
?? ???????????? ????????? 335 ??????????? ???????? ??? ?? ? ???????????? 11,3 %. ???? ????????? ?????????? ??????? ?????? ???? ??? ????,
??????? ????????? ?.?. ???????????, ? 1965 ?. ????????? 80 ???????????? [8].
? 1969 ?. ? ????????? ??????????? ???
149 ??????? ? ?? (127 ? ????????? ???????????
?????????, 22 ? ??????????? ?????????) ? ???????????? 18 %. ? ?? ?? ????? ? 1954 ?? 1967 ?. ? ????????? ??. ?.?. ??????????? ??? ???? ????????? ????? 600 ???????? ??? ??, ?? ? ???????????
????? ??? ???? ???????????? ????????. ?? ?????
??????? ? ?????? ???? ? ????? 1960-? ????? ???
???????? ? ?????? ?????????????? ??????? ??????? ?????? ??? ??????????? ? ??????? ????????
??. ?.?. ????????? ? ?????, ??????? ???????????
?.?. ?????????. ? 1971 ?. ?????????? ???? ???????, ??????? ????????????? ??????? ??? ?.?. ??????, ????????? 312 ??????????? ????????? ?? ?
???????????? ????? 10 % [9].
????????????? ? ?????????? ???????? ?????
????? ???????? ??????????? ????????? ?? ? ????
????? ???? ????????? ?????. ? 1976 ?. ?????????? ???? ?????? (???? ??? ???? ? ??????, ???
??????????? ? ??????? ???????? ?? ???? ? ?????
? ???????????? ????????????? ??????? ???????????? ???) ??????? ? ????? ????????? 976 ?????9
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
Йкр. 7. г?тснл?бзр? стб???к? ? ╥??сстб???ксллсх. Итб?к?ш?з Ц.д. есмб?к?, Е.Е. Абнблкмкл
??????? [10]. ? 1980-? ????? ?????????? ????????
?????????? ? ???????? ?????? ??????????? ????????? ?? ??????????? ?? 352 ? 1984 ?. ?? 690
? 1987 ?., ? 1990-? ????? ? ?? 407 ? 1990 ?. ?? 322
? 1998 ?., ? ? 2000-? ? ?? 575 ? 2000 ?. ?? 448 ?
2004 ?.
28 ??????? 1970 ?. ?.?. ??????????? ? ?.?. ??????? ?? ???? ??. ?.?. ???????? ??? ???? ????????? ?????? ? ?????? ???????????? ???????? ???????? ? ?? ? ???????? ??????????????? ???????????
(???) (???. 7). ? ?????? 1971 ?. ?.?. ??????? ?
?.?. ??????? ??????? ?????? ???????? ????????
???? ? ???????? ??? ? ??, ? ? ??????? ??????????
??????????? ??? ?????????? ????????? ????? ???????? ???????? ? ??? (?????????? ? ?.?. ???????) ?
??????????? ??? (???????????? ? ?.?. ???????)
?????????? ?????????????? ? ?????????? 3 ??????? ? ??. ? ?? ???? ??? ???? ?????????? ????????,
????????? ???? ???????? ???????? ???? [11, 12].
Й?а??╥сзм? ?срзштс? м яЕэХ
к аслб рзблса? Цд
????????, ??? ?????????? ??????????????? ?
???????? ?????? ?? ?????? ? 1954?1955 ??. ???????? C.W. Lillehei. ?????????????? ????? ??????
? ???, ??? ?????????? ?????? ???????? ?????? ??
????????? ? 1961 ?. F. Gerbode ?? ???-?????????
[2]. ?? ????? ???? ?????????? ?????? ?????? ????????? ??????? ??????. ???, ? ????????? ????????,
??????? 11 ??? 1959 ?. ?????? ? ????????? ???????
???????? ??? ???? W. Cleland, ???????: ╚? ????? ?
???, ??? ?????????? ?????? ????????????? ??????? ????????? ?????? ??????? ?????????, ????????
????????? ??????? ?????????? ???????? ????????? ??????????? ? ??????????? ???? ?????????
? ?????????? ???????????╩ (?????? ???. ? ???.).
????, F. Gerbode ?? ??? ?????? ? ?????????? ??????????? ???????. ?? ?? ?????? ????????? ?????????? ??????? ?????????????? ?????????? ??????????????? ?? ????????? ? ??????????. ??????
???????????? ??? ?????? ??? ?????? ???????????
????????? ?? ????????????? [13].
10
?????? ????? ?????? ?????????? ? ??????????
?????????? ??????? ??????????????? ??????? (??
???? ?.?. ???????????) ??????? ????????????????? ? ??????? 1961 ?. ?? 47-? ????????? ????????????? ?????????????? ???????? ?.?. Albert ?? ?????? ???????. ?????? ????????? ? ???????-?????? 1961 ?. ?????????? ? ??? ?.?. ????????
??????? ???? ?????? ? ????? ??????. ????????????
?????????, ??? ???? ??????, ????????? ??? ?????????? ??????? ??, ?? ?????? ???????????? ??????????? ???????????? ??? ????????? ??????, ???????
????? ???????? ???? ??? ?????????? ???????????????? ??????? ???????? ?? ??????? ????????????? ????????? ? ?????????? ??? ??????????
??????????? [13].
? 1982 ?. ?.?. ?????? ? ?.?. ??????????? ??
??????? ????????? ???????? ??? ??????????? ?
??????? ???????? ?? ???? ????????, ??? ? ??????? ??????? ??? ????????? ?????????? ??????????????? ???????????? ???????? ?? [14]. ??????
?-???????? ?????? ??? ???????????? ? ?? ??????
???????????.
? 1961 ?. Longenecker ??????? ??????? ?????????? ??????????? ?????????? ??????? ??? ??????????? ????????? ??. ??? ?????????????? ?????
?????????? ???????? ????????? ?? ???????????
??? ?????? ??????? ??????????? ?????????? ?????????? ??????? (??). ??? ?????????? ??????? ???? ?? ??? ?????????? ?????????? ??????? ??????????????? ?????? ????????? ???????????? ????????
?????? ??. ??? ?????? ???????????? ???????????? ???????? ????? ??????? ????????? ?? ?????????? ??????????????? ???? ?? ?????? ?????????
???????? ?? ????? ?????? ?? ????? ?? ? ??????????? ????????? ???????? [15]. ? 1973 ?. D. Cooley
????????? ?????? ? ???? ????? ?????????? ??????, ? ??? ?????? ?. Pacifico ???? ????????? ??????
????????? ?????? ?? ????? ????????? ?????? ???
??????? ????????? ?????? [16].
? ?????? ????????????? ?????????? ?????????
?????? ?? ? ?????? ?? ? 1964 ?. ?.?. ??????? ?????? ????? ??????????? ????????? ?????????? ??
? ??????????? ???????? ??? ??? [17]. ? 1983 ?. ???
??????????????? ?????????? ????????? ??????
??????? ????????? ?.?. ????????? ?? ????
??. ?.?. ???????? ??? ???? ????????? ??????? ?
???? ?????? ???????. ?????? ? ???? ??????? ??? ????????? ? ????????? ?? ? ????????? ????????? ?? ???.
? 1999 ?. B. Dandolu ??????? ???????? ??? ??,
???????????? ? ?????????? ????????????? ??,
??????, ??????? ?????? ??????????? ??????
Y. Lekompte ??? ????????? ???????????? ????????????? ???????. ??? ????? ???????? ????? ?? ??
????????? ??????, ????????? ???????????????
???? ????? ??????????? ?? ? ??????? ????? ?? ?
?????????? ????? ????????????????? ???????. ?????? ????????? ???????????????????? ???????
[18]. ????????? ????? ??????? ???????????????
??????? ?????? ?????? ? ???????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
??????? ??? ???????????? ?? ? ???????? ????????? ?????? ?? ??????? ?????? ???????? ??????????? ?????????????????? ???????? ????? ??
? ??????? ?? [15].
Й?а??╥сзм? обзс?с? а?м??зк? яЕэХ
??? ? ?????? 1960-? ????? ???? ??????????
????? ???????? ???????? ???? ??? ???????????
????????? ??, ??????? ?????????? ????????, ?????????, ?-???????? ? 8-???????? ???? ?? ??????????, ? ????? ????????? ????????? ?? ????????????? ??????????.
??? ?? ??????? ??????????, ??? ? ????? ??????
???????? ???????? ???? ??? ?????? ??????? ??
?????????????? ?????????, ??, ?????? ?????, ???
?????? J.W. Kirklin ? 1957?1958 ??., ???????????
???????????? ??????? [19].
?? ????? ??????, ?????? ? ?????? ????????
???????? ???? ????????????? ???????? ?? ?????????? ? ???????? ? ?? ??????? 7 ?????? 1961 ?.
?.?. ??????????? ? ?.?. ???????. ?? ???? ???????
??????? ???????, ??????? ? ?????? ???????? ???
???????, ??????????? ?-???????? ??? ??? ?????????. ????? ??? ?????? ????????? ??????? ? ???????? ?? ???? ? ????? ???????. ????????? ??????? ?????????????? ??????????? ?????????? ???????
??? ?? ???? ???????????, ? ???? ??????? ???? ????
???????? ????????? ?? ?????????? ??????. ???
????????? ??????????????????? ??????? ????????? ?????????? ?? ??????????? ??? ??????? [20].
? 1964 ?. ?.?. ??????? ????????????? ??????
?????. ????????? ???? ? ???????? ??????? ??
?????????? 3/4 ?? ?????????? ????????? ?? ????????????? ??? ?????????????? ??????. ???????????? ?????? ????????? ?????? ????? ?????????????? ??????????? ????????? ??????????. ?????
?????? ?? ?????? ???????? ???????????? ?????
??????? ?????? ? ?????? ?????????????? ????????? ??????????, ?? ? ????? ?????? ???????? ???????? ??????? ?? ??. ??? ???????????? ??????????? ????? ????, ???????????????? ? ???????????????? ???????? ?? ???????????? ???? ???????
??? ??, ? ?-???????? ??? ????? ????????? ?????????? ????? ??????????????? ???????????, ? ????????? ???? ??????????? ??????????? ???? ???????, ????? ??? ?? ???????????? ? ?????? ????.
??? ?????????????? ??? ??????????? ? ??????????? ???????? ??????? ??? ??????????? ?? ?????
??????? ?? ??????????? ? ?????????? ?? ? ???? ???????, ?? ?????? ?? ?????? ??????? ???????????.
??? ???????? ?????????? ????? ?????? ?????????? ??????? ?????? ??????????? ??????? ????
????? ???? ? ???? ??? ????????? [17].
?????? ????? ???????? ??????????? ?????????
???????? ?????????? ????? ??????? ?-?????????
????? ?? ?????????? ??????????. ?????? ??? ??????????? ? ???????????????? ?? ??????? ???? ????????? ? ???????????. ???????? ????????? ???-
?????? ??? ???? ? ???? ???????????? ??????????
???????. ??? ???????????, ???????? ?? ???? ??????????? ? ?????? ? ??????? ?? ?????????????????
?? ??????. ???? ?????? ?????????? ???? ???????
????????? ????????? ??????? ?? ????? ???????????? ?????????????? ??????? ??????????????? ???????, ?? ??? ???????????, ???????? ???? ?? ???????
??????? ?????????? ? ??????? ?? ????? ?????????
??????, ? ?? ????? ???????????? ?????? [16].
?????????????? ??????? ???????? ??????
???????? ??????? ?? ???? ???????? ??????????? ????, ????????????? ? ???????? 1960-? ????? ? ????????? ?????? ? ???????? G. Holman,
Z. Bladwell ? D. Cooley.
Х?коблблкб ?мрз??м???к?н╦л?? мсл?шкзс?
т?к мс??бм?кк МН
? 1963 ?. W.W. Klinner ?? ??????????? ???????????? ????????????? ???????????? ??????? ?? ??????? ????? ?? ? ?? ???????? ? ???????? ?? ?
????. ? 1965 ?. J.W. Kirklin ?? ???????????? ??????? ? ?????????? ??? ??? ?? ?????? ??????? ???????? ??????? ?? ??????????????? ??????. ? 1966 ?.
D. Ross (Guy?s Hospital, London) ??? ????????? ????????? ?????? ?? ??? ?? ??????? ???????????
?????? ?????????????? ??????? ????????????????
????? ? ???????? [18]. ? 1967 ?. G.C. Rastelli ?? ??????? ???? ??????? ?? ????????????????? ????????????, ? ??????? ?????????????? ??????? ???
???????? ??? ????????? ?????? ?????????????
??????. ? ??? ?? ???? D. McGoon ??????? ???????
???????? ??? ???????? ? ??????? [21, 22].
? 1972 ?. ??????? ?? ????????????? ???????????? ? ???-????? ??? ???????????? J. Malm ??????????? ??????? ?? ?????????? ??????, ??????????
??????????? [23]. ? ??? ?? ???? ???? ???????, ?????????? ??? ?????????????? ??? ??????? ?
╚Hankock's conduit╩, ?????? G. Danielson ?????????
??? ????????? ?? [18].
? 1975 ?. ?.?. ??????????? ???????? ?????? ?
????? ?????? ???????? ??????????? ?????????????????? ???????? ? ???????? ? ??, ? ? 1981 ?.
?????? ? ?????? ???????? ??????????? ?????????
?? ? ?????????????? ?????????????????? ???????? ??????????? ?.?. ????????? [24].
??????????? ?????????? ? ????????? ????????? ??????????? ???? ????????, ??????? ????????????? ????????????? ???????, ??????? ? ???????
?.?. ???????? ? ?.?. ?????????? [16].
? 1986 ?. ?????? G. Danielson ??????????????
65 ??????? ? ??, ??????? ???? ??????????????
????????? ???? ?????????. ?? ?????????? ????????? ??? ????????????, ??? ? ?????????????????
???????. G. Danielson ?????? ????? ???????? ????????????? ???????? ?????????, ??? ??????? ????????? ?????????? ?? ??????????, ????????? ??????? ? ???????? ???????? ?????? ???????? ???????? ?? ????????????? [18].
11
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
? ?????? ?????????? ?????? ?????????? ????????? ??? ????????????? ??????? ?? ???????????
????????? ???????? ????? ???????? ???????? ? ???
????? ??. ?.?. ???????? ???? ??? ????????????
????????? ???? ?.?. ??????????. ? 1975 ?? 2012 ?.
? ????????? ????????? 32 ???????? ????????.
??????? ??????????? ????????? ??? ??????????? ????????? ????????? ???? ?? ?????? ????? ?
??????? ??????? ???? ??????, ???????????? ????????????? ???????? ??????? ???. ????????????? ????? ?????? ?? ???????? ???????? ? ??????
??????????? ? ???????????? ???????????? ???????? ? ??????? ??.
Хс?зс?л?б т?ннк?зк?л?б стб???кк
к ?з?тлсб нб?блкб МН
? 1953 ?. H. Taussig ? S. Bauersfeld ?? ????????
????????? ? ????????? ??????? ???????? ? ????????? ???????????? ????????? ??? ?? ????? ?????
??????????? ???????????-????????? ??????????
?? Taussig?Blalock. ????????? ?? ?????????? ???? ????????? ????????? ????????, ????????????? ??????????????? ??????? ??? ????????????
?????????????? ?????????, ? ????? ?????????
????????? ????????????? ???????. ? 1958 ?.
?. Campbell ??????? ?????? ????????? ?????????
????????????? ????????? ?????????? ?????????????? ????????????????? ??????????????? ?????????? ?????? ???????? ? ?????????? ??????? ??,
?????????????? ???????????? ????????????.
? ???????? ????????? ???????? ?.?. ?????????? ?
?.?. ???????? ? 1969 ?. ????????????? ???????????
????????????????? ????????? ?? ?????????????????????????????????????? ??? ???????????-???????? ????????? ? ???????? ?? ????????????????????? ? ??????????? ????? ????????? ? ?????? [25].
? ???????? 1960-? ????? J.W. Kirklin ??????????
????????? ???????????? ??????? ? ???????????
????????? ??, ????? ?????? ?????? ???????????
????????-???????? ?????????, ? ?????? ?????????
??????????? ????????? ?????? [3]. ???????????
????????????? ???????? ??????? ??????, J.W. Kirklin
???????, ??? ???????????? ????????, ? ????? ???????, ???????????????? ???????? ???????????????
????????? ? ??????, ? ? ?????? ? ???????????? ???????????????? ???????????????? ??????? ??????
?? ??????? ????????? ?????? ??. ?????????????,
??? ???????? ????????-????????? ?????????? ????????? ???????? ????? ????? ??????????. ???????
J.W. Kirklin ???????????? ????????? ???????????
???????? ? ??????? 5 ??? ????? ????????????.
? ???? ??? ???? ?????????? ? ????? ?????????
?.?. ??????????? ? ?.?. ???????. ? ? ?????? 1968 ?.
? ?????????? ?.?. ???????? ?? ????????????? ??????? ??? ?????????????????? ?????? ? 2 ????????????????? ???????? ??????? ???????? ??????????? ????????? ?? ????? 5 ??? ????? ????????? ?????????????????? ?????????? [25].
12
Дс??бм?к? МН ш лс?с?сй?блл??
к ?бзбх тб??с?с ?с?? йкалк
? 1960?1970-? ???? ? ???? ? ????? ??????? ???? ?????, ?????????? ?? ??, ????????? ??????
???????? ???????????? ?????????????. ?????? ?
????? ?????? 15 ???????? ?????????????? ?????????? ?? Potts ??? ?? ? ????? ?????? ??????? ????? ????????? ?????????? ????????? ??? ????
??? ???? ??? ???????????? ?.?. ???????????? ?
1964?1965 ??. ??????????? ????????? 26,6 % [8].
? 1978 ?. ?.?. ??????-?????????? ? ?.?. ????????? ???????????????? ?????????? ?????????????? ??????? ?? ? 65 ????? ??????? ???? ?????,
???????????????? ? ???? ??. ?.?. ???????? ???
???? ? 1965 ?? 1976 ?. ??? ???? ? ???? ???????
???? ????????? ???????????? ????????. ?????
??????????? ????????? 29,2 %. ????????? ?????????? ???????? ????? ????????? ?????????? ??
Waterstone?Edwards?Cooley. ??????????? ? ????
?????? ????????? ????????? 16,3 %. ??????????,
??? ? ????? ??????? ?? ????? ??????????? ???????? ? ?????????? ? ????????? ??????? ?? ???? [26].
? 1977 ?. A. Castaneda ?? ???????? ????????? ?
??????? (???. 8) ???????, ??? ??????????? ????? ??????????? ????????? ?? ?? ??????? ?? ?? ????????, ?? ?? ??????????? ????? ??????. ?????? ??
?????, ?? ?????? ? ??????????? ? ?????????????
?????????? ????????? ??????????? ????????? ?
?????? ??????? ? ???? ? ??????? ????????. ?????
???????, ??? ???????????? ????????? ?????? ?
???? ???????? ???????? ????????????? ? ?????????
??????? ????????? ???? ???????????????? ????????? ??? ??????????? ?????????? ?????? ?????
?????? ?????? [27]. ? ????????? ????? ??? ????
??????????? ? ???????? ?? ? ????????????? ? ????? ??????? ???? ?????.
?? ?????? J. Caspi (1999 ?.), ??? ????????? ??????????? ????????? ?? ??????????? ???? ??????-
Йкр. 8. Aldo Castaneda ? ткслб? ???км?н╦лсх мс??бм?кк МН
ш ?бзбх ??ллб?с ?са??рз?
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
??? ????????, ? ?????? ???????????? ?????????
????????? ???????????? ??????????? ????????
???????-????????????? ??????, ?????????????
??????????? ??, ???????? ????????????? ?????????????? ??????? ? ?????????? ????? ????? ?
??????????? ?????????? ????????????????.
????????????????? ????????? ??????????? ? ??????????? ??? ????????? ???????? ??????? ???????????? ? ???????? ?????????? ???????????? ? ??????????? ????????? ????? ??????????, ??? ???????????
??????????? ?? ??? ?????????? ? ?????????????????? ???????? [28].
?? ???????? ?????????? ?????????? ??????????? ?? ???? ????? ?????? ?????????? ???????? ?????????? ??????????? ??????? ? ??. ? 1994 ?.
A. Chang ? V. Starnes ???????? ? ????? ???????? ?
?????????? ? ?????? ???? ?? 3 ?? [29]. ? 1999 ?.
V. Reddy ??????? ??????????? ?????????? ??????????? ????????? ?? ? ?????????????? ????????? ? ?????? ???? 700 ? [30].
??? ?? ?????, ????????????? ????????? ???????? ??????? ??, ?????? ??????? (S. Kaushal ?
?????. [31], ?.?. ????????? ? ?????. [32, 33]) ?????????? ???????, ??? ????? ??????????? ???????????? ????????????? ?? ????????? ???????????????? ??????? ?? ?????????? ???????????
?????????, ???? ????????? ??? ?????????? ? ??????????? ????????? ????????? ????????????.
? 2000 ?. V. Rao ?? ???????? ????????? ? ??????? ????????? ????????????? ???????. ? ?????
?????????? ??????? ?? ?? ???????? ?????????
????????? ? ???????? 3?11 ???, ???????? ??????????????? ??????, ?? ???????? ????????????????? ???????? ??????. ?? ?????? ??????, ?????????? ???????????? ????????? ????? ???????? ?????
?? ????? ????????????? ???? ?????????? ??????
?? ??????????? ???????? ???????. ?????????? ?????????? ??????? ?? ??????????? ?? ???? ?????????? ?????????? ?? ??????? ????????? ?????? ? ??????????????? ? ??????????????? ?????? ? ????????? ? ?????????????? ????????? ??????? ??
?????????. ??? ?????????? ?????????? ???????
??, ??? ???????????? ????????????? ???? ????????,
????? ???????? ??????????????? ???????? [29].
Й?а?кзкб обзс?с? мс??бм?кк МН
ш ╥сн╦л?? р ?ктстн?акбх Цд
????????? ?? ? ??????????? ?? ? ???? ?? ????? ??????? ????????? ??????? ?????? ??? ??? ??????????? ?????????. ??????? ???? ???????? ????????????????? ?? ???? ??????????????
C.C. Gill ? ?????. [34] ? J.W. Kirklin ? ?????. [35] ??
??????????? ????? ?????? ? ???? ?????????? ???????? ????????????? ????? ?????? ?? ?? ??? ???????? ???? ? ???????? ??. ??? ???? ??????? ????? ?????? ? ??????? ??????? ? ??????????? ??????? ??. ???????? ????????? ??? ?????????
??????, ??????????? ??????? ?? ╚?????╩ ?????? ???
Йкр. 9. гн??кок? Хбз?с?к? Хс?аснмс? ? с?кл ка срлс?стснсйлкмс? ?к?ш??кк гХК ? Йсрркк
?????????? ????????????? ???????. ??? ???? ???????? ?????????? ???????? ????????? ?????? ??
? ?????? ??, ? ????? ????????? ????????????? ???????.
? ?????? ????????? ?????????? ?????? ????????, ?????????? ???????????? ?? ?????????????
???????, ???????? ?? ? ????????? ??????? ???????
??????????? ?.?. ?????????? (???. 9). ? 1983 ?.,
??????????????? ?????????? ?????????? ????????, ????? ???????, ??? ? ??????? 6 ??? ????? ???????? ?????????? ?????????? ???? ??, ??? ??????????? ????????? ??????????? ?????????? ??????????? ????????? ?????? [36].
????????? ?????? ??? ????, ????? ????????
????????????? ??????? ??? ????????????? ?????????? ?????? ? ?????????????? ?????? ?????? ??,
????????? ???????? ????? ???????-?????????????
?????? ?????????? ?????????. ??? ???? ???? ??
??? ???????????? ? ?????? ?????? ?? ?? ??????????? ?????? ?????? ?? ?? ??????????? ?????? ?????
??, ? ?????? ? ? ???????? ????? ?? ? ????? ??
[14, 16]. ?????? ???????? ???????? ?????????????? ??????? ??????????? ?????????? ? ????????? ???????, ?? ?????????? ????? ????????????,
??????? ? ????????? ????? ??????????? ????????
???????????? ??????? ??????? ??????.
???????????? ???????? ? ??????? ??????? ??
??????? ??????? ?? ???????? ????????? ???????
??, ??????? ????? ???? ??????? ???????? ?????????????? ???????????. ? 1977 ?. R. Sade ????????? ????????? ????????? ????????? ?????? ?? ?
?????????? ?????, ? 1980 ?. N.Tatsuta ? ?????????
?????????? ?????? ????? ? ??, ? 1984 ?. W. Lass ?
????????? ???????? ?????? ?? ? ?????????? ??????. ?????? ???????????? ?????? ?????? ???????
?????????? ?? ?? ???? ????????????.
? 1979 ?. ?????????? ?????? ???????? ??????????? ???????????? ??? ??????? ??????? ? ??????????? ??????????? ????????? ?? ??????????
13
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? ???????? ???????? ??????????? ??????????????
?????????? ???????? ????????? ????? ?????????
???????? ??????? ? ???????? ?????????? ?????
[37]. ????????? ??? ????, ? 1985 ?. ?.?. ?????????
?? ???? ??. ?. ?. ???????? ??? ???? ??????????
? ???????????? ????????? ??????? ?????? ???????? ???????-????????????? ?????? ?? ???? ???????.
??? ?????? ????????????????? ?? ????????? ???????????? ????????? ????????? ????????? ???????? ?? ? ???????? ?????????? ????? [38].
? 1988 ?. ????? ?????????? ? ????????? ?????
?????? ?????? ?????????? ??????? ?? ?????????
S. Nakata, ??, ? ?????????, ?? ?? ???? ????????????? ? ????????? ?????? ?? ? ????????????? ??????? ?? ?????? [39].
3.
4.
5.
6.
7.
8.
9.
А?мн??блкб
????? ???????, ???????? ?? ????????? ???? ??
????????????????? ????????????? ????????????? ??????????? ? ?????????? ???????????? ?????????? ?????? ? ???????????? ???????. ????? ?
? ???????????? ? ??????????????? ????????? ??
???????? ?????? ??, ???????? ?????? ? ?????? ??,
??????? ?????????? ????????? ????? ?????????????? ?????? ??. ?? ????, ????????? ? ???????
?????? ???????? ??? ??, ? ???? ???????? ???????? ???? ??????? ???????? ???????, ????????
??????? ?????????? ? ??????????? ??????, ??????????? ????????? ???????? ????????????, ??????????? ? ??????? ????????.
? ????????? ????? ? ??????? ???????? ????
??????????? ??????? ??? ??????????? ?????????
?? ?? ????????? 2?4 % [16]. ??? ???? ???? ??????? ???????????? ????????????? ????? ???????????? ? ??????????, ? ?????? ? ????????? ??????? ????????????, ? ????? ? ??????????? ????????. ?????? ?????????? ???????????????, ??? ?
??????????? ??????? ????????? ?????? ??????? ?
???????????? ??? ???????? ?????????? ??????.
?????? ?????????????? ????????? ??????? ?????
????????? ??????????????? ??????????? ?????????? ?? 4 ?? 5 ???.
?? ???? ????, ? ????????? ????? ??????? ??????
? ??????? ?????, ?????????? ??????? ??????????? ??????, ????????? ? ??????? ?????? ?????? ???????, ????????? ? ????????? ? ????????? ?????????????, ????????????????? ??????????, ????????, ?????????? ??????????? ? ?. ?. ? ? ????????
????? ?????? ??????? ????? ?????? ?????????????
??????????????????? ????? ????? ??. ?.?. ???????? ????.
10.
11.
12.
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14.
15.
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??????????
1.
2.
14
Lillehey C.W. Cardiopulmonary bypass and myocardial protection. In: Stevenson L.W., Ruggiero R. Heart Surgery
Classics. Boston; 1994: 121?41.
???????? ?. ???????? ???????? ?? ???????? ??????.
? ??.: ??????? ????????-?????????? ????????. ?.: ?????
??. ?.?. ???????? ????; 1997: 40.
24.
25.
Kirklin J.W., Barratt-Boyes B.G. Cardiac Surgery. NY: Wiley
Med. Publ.; 1986.
??????? ?.?., ??????? ?.?., ???????????? ?.?. ???????????? ??????? ????? ?????????????? ???????? ????????
???????: ???????? 1756-?? ????????? ?????????????? ???? ?????? ? ????. ???. ?? 26 ??????? 1962 ?. ????????.
1963; 7; 151.
?????????? ?.?., ???????? ?.?., ??????? ?.?. ?????????????? ???????? ??????. ?.; 1966.
??????????? ?.?., ??????? ?.?., ??????? ?.?. ?????????????? ???????? ??? ?????????? ??????? ??????. ???????
???. 1977; 1: 3?9.
??????? ?.?. ??????????? ????????????? ??????? ???????
? ???????? ?????: ???????. ???. ? ?-?? ???. ????. ?.; 1967.
??????????? ?.?., ??????? ?.?., ?????? ?.?. ? ??. ????????????? ??????? ?????????? ??????? ?????? (????
???????? ???????? ? 1960 ?. ?? ???? 1965 ?.). ????????.
?????? ??. ?.?. ????????. 1966; 9: 103.
????????? ?.?., ?????? ?.?., ???????? ?.?., ??????? ?.?.
????????? ???????????? ? ?????????? ????? ????? ??????????? ????????? ??????? ?????: ???. ? ????. ?????????
?? ????.-?????. ????????????, ??????, 26?28 ??????? 1971 ?.,
?.; 1971: 103.
Amosov N.M., Bukharin V.A., Korolev B.A. Long-term results
of complete correction of tetralogy of Fallot. USA????? 3d
Joint Symposium on Congenital Heart Disease. Bethesda,
Maryland, April 14&15, 1977. Washington; 1977: 27?34.
??????? ?.?. ??????????????? ??????????? ? ?????????????????? ????????. ? ??.: ??????? ????? ??. ?.?. ???????? ????. ?.: ????? ????; 2002: 338.
??????? ?.?., ??????? ?.?., ?????? ?.?. ?????????? ?????? ? ??????? ???????? ?????? ? ???????? ???????????
???????? ?????????. ????????? ?????? 1976 ?. ?????? ???.
2004; 6: 7?17.
??????????? ?.?., ?????????? ?.?. (???.) ??????? ???????? ??????????? ?????? ? ???????. ?.: ????????; 1967.
?????? ?.?., ??????????? ?.?. ????????????? ???????
??????? ?????. ????: ??????'?; 1982.
????????? ?.?., ????????? ?.?., ??????? ?.?. ????????????????? ???????? ? ????????????? ??????? ???????
?????????? ??????? ??????. ?.: ????? ??. ?. ?. ???????? ????; 2000.
??????????? ?.?., ??????? ?.?. (???.). ????????-?????????? ????????: ???????????. 2-? ???. ?.: ????????; 1996:
181.
??????? ?.?. ??????????? ????????????? ??????? ??????? ? ???????? ?????. ??????? ???. 1964; 3: 13?4.
?????????? ?.?. ????????????????? ????????: ??????????, ?????????? ?????????? ? ??????????? ???????: ?????? ????????-???????????? ????????? ?? ?????????? ??????? ??????, ??????, 12?13 ??? 1986 ?. ?.; 1987: 5?15.
?????????? ?.?., ???????? ?.?., ???????? ?.?. ???????
?????. ?.; 1969.
??????????? ?.?. ???????? ??????? ?????????????? ??????? ?????????? ??????? ??????. ??????? ??? ????.
1962; 10: 19.
McGoon D.C., Rastelli G.C., Ongley P.A. An operation for the
correction of truncus arteriosus. JAMA. 1968; 205: 59?73.
Rastelli G.C., Titus J. L., McGoon D. C. Homograft of ascending aorta and the ajrtic valve as a right ventricular outflow: An
experimental approach to the repair of truncus arteriosus.
Arch. Surg. 1967; 96: 698?707.
Bowman F.O., Hankock W.D., Malm J.R. A valve-containig
Dacron prosthesis^ Its use in restoring pulmonary artery-right
ventricular continuity. Archives. Surgery. 1973; 107: 724?8.
????????? ?.?. ?????????????? ????????? ?????? ? ???????? ?????????? ??????? ??????: ???. ? ?-?? ???. ????. ?.; 1991.
??????? ?.?., ????????? ?.?., ??????? ?.?., ???????? ?.?.
??????? ???????? ??????? ?????. ????? 1. ??????? ??????? ?????? ? ???????. 2005; 2: 3?13.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
??????-?????????? ?. ?., ????????? ?. ?. ????????????? ??????? ??????? ????? ? ????? 1-?? ???? ?????. ??????? ???. 1978; 6: 3?9.
Castaneda A., Freed P., William P., Norwood W. Tetralogy of
Fallot, pulmonary atresia and diminutive pulmonary arteries.
J. Thorac. Cardiovasc. Surg. 1977; 74 (3): 372?81.
Caspi S., Zalstein E., Zucker N. et al. Surgical management of
tetralogy of Fallot in the first year of life. Ann. Thorac. Surg.
1999; 68: 1344?8.
Rao V., Kadletz M., Hornberger L.K. et al. Preservation of the
pulmonary valve complex in tetralogy of Fallot: how small is
too small? Ann. Thorac. Surg. 2000; 69: 176?9.
Reddy V.M., McElhinney D.V., Sagrado T. et al. Results of
102 cases of complete repair of congenital heart defects in
patients weighing 700 to 2500 grams. J. Thorac. Cardiovasc.
Surg. 1999; 117 (2); 324?31.
Kaushal S.K., Iyer K.S., Sharma R. et al. Surgical management
of pulmonary stenosis in tetralogy of Fallot. Intern. J. Cardiol.
1996; 56 (1): 35?40.
????????? ?.?., ?????????? ?.?., ???????? ?. ?????????? ??????????? ????????? ??????? ????? ????? ????? ???????????? ?????????? ???????????????. ??????? ? ????????-?????????? ????????. 1991; 1: 25?9.
????????? ?.?., ???????? ?.?. ??????? ?????. ?.: ?????
??. ?. ?. ???????? ????; 2008.
Gill C.C., Moodie D.S., McGoon D.S. Staged surgical management of pulmonary atresia with diminutive pulmonary arteries.
J. Thorac. Cardiovasc. Surg. 1977; 73: 436?52.
Kirklin J.W., Bargeron L.M., Pacifico A.D. et al. The enlargement of small pulmonary arteries by preliminary palliative
operations. Circulation. 1977; 56: 612?7.
???????????? ?.?., ????????? ?.?., ?????? ?.?. ???????? ??????? ?????. ?.: ??? ╚????????╩; 1995.
??????????? ?.?., ????????? ?.?. ????????????????
???????????? ??????????? ?????? ??????????????. ????????? ????????-???????????? ????????? ?? ??????????
??????? ??????, ??????, 24?25 ???????? 1980 ?. ?.: ???;
1981: 204.
????????? ?.?., ????????? ?.?., ??????? ?.?., ????? ?.?.
?????? ???????? ???????? ??????? ??? ??????? ?????.
??????? ? ????????-?????????? ????????. 1985; 4:
67?72.
Nakata S.Y., Jmai Y., Takanashi Y. et al. A new method for the
quantitative standartization of cross-sectional areas of the pulmonary arteries in congenital heart diseases with decreased pulmonary blood flow. J. Thorac. Cardiovasc. Surg. 1984; 88: 610?9.
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????????? 26.09.2013
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??? 616.131-089.844:616.12-007-053.1-053.31-089
?????????? ?? ????????? ? ????????????? ????????
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? ?????? ?????????
?.?. ????????, ?.?. ????????, ?.?. ?????????, ?.?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ?
???????? ??? ? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????,
?????????? ?????????, 121552
???????? ?????? ???????, ?. ?. ?.;
???????? ??????? ???????????, ?. ?. ?., ???????????? ?????????,
e-mail: kupriashov2007@rambler.ru;
????????? ??????? ???????, ?. ?. ?.;
????????? ?????? ???????????, ?. ?. ?., ?????????.
????????. ??????? ? ????????????? ???????? ??????? ??? ????????? ??????? ????? ???? ?????????????? ? ?????????? ???????? ??????????????? ????? ? ???????? ? ??????????? ????????.
????. ??????? ????????????? ?????????? ????? ????????????? ???????? ? ?????????? ?????????? ?? ?????? ??????? ??????
????????? ?????? ??? ??????????? ????????? ??????? ????? ? ??????? ?????? ??? ?????.
???????? ? ??????. ? ??????????? ?????? ???????? 43 ???????? ?????? ??? ????? ? ???????? ?????, ??????? ? 2005?2012 ??.
??????????? ??????????? ????????? ?????? ? ?????????????? ???????? ???????. ?????? ???????? ????????? 102 ??????? ??
??????? ??????? ?????????????, ???????????????? ? ?????? ? 1991 ?? 2000 ??.
??????????. ?? ???????????? ????? ? ??????????? ?????? ????????? ??????? ?? ????, ? ?????? ???????? ?????? 12 (11,8 %) ??????? ?? 102, ?=0,044. ?????????? ???????????? ? ??????? ?? ?????????? ???? ???????. ??????????? ?????? ????????????? ????????????? ???????? ??????? ??????? ? ???????? ???????????? ??????????? ??? ?????????? ??????? ????????? ????????????.
??????????. ????????????? ??????? ????????? ???????? ???????????????? ?????????? ??? ?????????? ?????????? ??? ???????? ??????? ??????????.
???????? ?????: ??????? ?????; ??????????? ?????????; ????????????? ????????????? ???????? ???????; ?????????;
????????? ?????????????; ????? ?????????????; ?????? ???????.
16
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
THE REPAIR OF TETRALOGY OF FALLOT IN EARLY CHILDHOOD. HAVE THE
INDICATIONS FOR PULMONARY ARTERIOPLASTY CHANGED?
S.Yu. Prasolov, A.A. Kupryashov, N.Yu. Dedushkina, M.A. Zelenikin
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of Medical
Sciences; Roublevskoe shosse, 135, Moscow, Russian Federation, 121552
Prasolov Sergey Yur'evich, MD, DM;
Kupryashov Aleksey Anatol'evich, MD, DM, Chief of Department,
e-mail: kupriashov2007@rambler.ru;
Dedushkina Natal'ya Yur'evna, MD, PhD;
Zelenikin Mikhail Anatol'evich, MD, DM, Professor.
Introduction. The approaches to the pulmonary arterioplasty in the repair of tetralogy of Fallot were developed from the results of previous studies and were implemented in clinical practice.
Objective. The evaluation of the effectiveness of the approaches previously used to remove the obstruction of main pulmonary arteries in
the repair of tetralogy of Fallot in infants.
Material and Methods. The study group comprised 43 infants with tetralogy of Fallot who had undergone the repair for heart anomaly with
pulmonary arterioplasty in 2005?2012. The control group consisted of 102 patients with the same extent of surgery who had been operated in the period from 1991 to 2000.
Results. There were no in-hospital deaths in the study group, but 12 patients of 102 (11.8%) from the control group died, p=0.044.
Long-term survival and freedom from reoperations were similar in group comparison. The limitation of the extent of surgical pulmonary arterioplasty led to the decrease of in-hospital mortality rates without increasing the frequency of repeated surgical interventions.
Conclusion. The adoption and implementation of surgical approaches described above improved the immediate results though with no
expected effect on reoperation rates.
Key words: tetralogy of Fallot; repair; surgical pulmonary arterioplasty; restenoses; repeated surgical interventions; extent of surgical arterioplasty; early childhood.
г?б?блкб
??????? ????? (??) ? ?????????? ????? ??????, ????????????? ?????????? ??????? ???????????? ? ????????? ??????? ????????? ?????? ??????? ????????? (????), ???????? ? ???????? ????????? ????????? [1, 2]. ????????? ??????????????
???????? ????? ?? ????????, ?????????????? ??????????? ???????????? ??????? ?????? ? ???????????? ????????????? ????????? ???????? ??????? (??), ??????????? ??????? ????????? ? ?????? ?????????? [2?4].
???? ???????????? ? ?????? ?????????????
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?????? ? ?????????????? ???????? ???????. ?????? ???????? ????????? ???????? ?? ??????? ??????? ?????????????, ???????????????? ? ?????? ?
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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??????????????? ????????? ??????? 3?4-? ??????? ? ?????????? ??????? ????????? ? ????????????? ???? [2, 7, 8]. ????? ????, ????????? ?????????? ? ???????? ??????????? ????????? ????????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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???????? ?????????????? ????????????? ????????????, ??????? ????? ? ??????? ?????????????, ???????????? ?? ? ????????? ?????, ? ?????
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?? ???????????? ????? ? ??????????? ??????
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19
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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Йкр. 1. Изршзрз?кб тсм?а?лкх м тс?зс?л?о ?об╞?збн╦рз??о (р?с╥с?? сз ?бстб???кх) тсрнб ЙДМН р ?бмслрз?шм?кбх Цд:
? ? р?с╥с?? сз ?рб? ?бстб???кх, ?=0,992; ╥ ? р?с╥с?? сз ?бстб???кх ? р??ак рс рзблса?ок нб?с?л?? ??зб?кх, ?=0,317
М?╥нк?? 2
гк?? тс?зс?л?? ?об╞?збн╦рз? ? кррнб?шбосх ??шттб (2005?2012 ??.)
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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Йкр. 2. К???лблкб р?с╥с?? сз ?бстб???кх ? ??шттб мслз?сн?
(1991?2000 ??.) ш т??кблзс? р ?бмслрз?шм?кбх Цд л? т?сз?йблкк тс сзлс╞блк? м ??ш?ко зкт?о ?бмслрз?шм?кк Цд,
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?????????? ????????????????? ?? ? ?????????
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?????????? ?? ??????????? ?? ???????????? ???????? ?????? ?????????? ?????????????????? ??????? (??. ????. 1). ?????????? ???????????? ????? ????? ?????????? ????????????????? ?????????? ?????????, ?????? ??? ?? ????????? ?? ??????
??????????????. ?????????? ????? ???????? ???????? ???????????? ???????????? ?????????? ?
??????????? ?????? ?? ????????? ? ???????????.
??????? ?? ?????????? ?????????? ?? ??????????? ????? ????????. ? ??????????? ??????
(2005?2012 ??.) ????????? ? ????????? ?????????????? ???? ??????????? ????????????/???????????? ??????????? ?? ?????? ?? ? ???? (??. ???. 1),
????? ??? ? ??????????? ???????????? ????? ??????????????? ????????? ??????? ? ?????????????
????. ??????? 1, ? ????????????? ????? ??????
????????? ????????? ? ??????????? ? ????? ? ??????????? ?? ? ???? ? ??????????? ?????? ??
????????? ? ???????????.
??????? ?????????????? ??????? ?????? ?? ??
?????????? ?? ????????. ??????? ????????? ????????????? ? ???? ????, ??????????? ????????? ?
???????????? ?????????????? (?????? ?????????),
???????? ? ??????????????? ?????? ??????? 2.
??????? ????? ???????? ???????????? ??????? ??????? ?????????? ??? ???????? ?????? ?? ???????????????? ?????????/?????????.
????, ???????????? ?????????? ?????????????
??????? ??????? ? ????????? ???????????. ????
???????? ???????????? ??????????? ?? ???? ?????? ????????? ?????? ???????????? ?????????????,
?????? ???????? ????? ?????????? ?????????????? ?????????. ??????????? ?????? ?????????????
?? ?? ??????? ? ????? ????? ????????? ????????????, ?????? ?????? ??????????? ??????????
???? ?????????.
???????????? ?????? ???? ???????????? ╚?????????????? ??????????╩ ??????????????? ????????, ????????, ??????? ????? ?????? ?? ╚???????????╩ ????????????? ????????? ???????? ???????????????? ??????????, ?????? ?????? ????????
????? ????????????? ????????? ????????. ???
??????? ????? ??? ?? ???????????? ??????? ? ????????? ???????? ????????? ??????? ?????? ?????????????? ??????? ???????? ??????????
[2?4]. ??? ?? ?????, ???????? ?? ??????????? ????????? ??????????????? ??????????, ?????????
?????????? ?? ????????????? ????????????? ?? ?
????????? ??????? ???? ?? ???????? ??-?? ????????????? ????????? ?????????? ???????????????? ???????????. ?????????? ?? ????????? ???????? [11] ?? ??????? ??????????? ? ???????????.
?????????????, ??????????? ????????? ????????
???????????? ?????: ? ?????? ???????????? ??????21
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??????? ??????? ?????? ? ???????, ? 4, 2013
?????? ??????????????? ?????????? ?????????? ????????? ? ????????????? ????????????? ??, ?? ?????
???????, ???? ???????????????? ?????????, ????????
???????? ?? ????????? ?? ????? ?????????????? ?
???????????? ?????????????. ???????? ?????, ???
????????? ??????? ????? ? ????????????? ???????,
?????? ???? ????? ???????? ????????????? ?? ???????????, ?????????????? ?????????? ???????? ????????? ? ????????????? ???????? ???????? ???????, ??????? ?? ????????? ?????????????? ? ????????? ?????:
1. ??? ?????????? ????????? ?????? ????????
???????, ????? ?????????? ????? ????????? ??????
???????? ????? ????? ?????? ?????????????????
????????, ??????? ???????? ?????? ?? ????? ?????
?? [8, 12]. ??? ????????? ???????? ?????????? ???????? ? ???????? ????? ?? ? ?????????? [13].
2. ??? ?????????? ??????????????? ??????????
???????? ??????? (?????? ????? ????? ?? ? ?????????? ? ??????????? ??????????? ???????? ????????? ??????) [3?5]. ????????????? ??????? ?????????? ?????? ????????? ????? ???????????? ????
?????????? ????? ?? ?? ?? [2, 4, 8, 9].
3. ????????????? ??? ?????????????? ????
???????? ?????? ? ??????? ?????????? ?????????????? ?????????, ??????? ????? ????????? ???????? ????? ????? ?? ????????? ???????? ? ????????? ? ??????????????? ????????? [8].
4. ? ????????? ?? ???????? ?????? ?? ?? ?????????? ????????? ???????? ?? ?????. ???????? ????? ?? ?? ?????????? ?????????, ??? ??? ??? ????? ????????. ????? ????, ?? ????? ????????????
?? ????????? ? ??????? ?????????? ?????. ? ??????
????????? ?? ??????? ? ??????? ? ???????? ?????????????? ???????? ????? ?? ??. ?????????????? ?? ?????????????? ???????? ? ??????? ??????? ?????????? ??? ?????????????? [10, 14, 15].
5. ????????????? ???????? ?? ? ???? ?????????? ???????? ??? ?????????? ??????????? ????????? ????????, ????????????? ?? ?????????????
[16]. ? ????????? ?????? ??????????????? ???????
????? ???? ??????????? ???????????????? ???
?????????????? ????? ?????????, ?? ?? ??????,
??? ????? 6 ?????? [17, 18].
??????????????? ???????? ???????????? ?? ???????? ? ?????? ???? ??????? ???????????? ? ??????????
???????????? ????????. ????? ????, ?????? ???????????? ?? ????????????? ????? ????????? ???????? ?
?????????????? ?? ??? ??????? ?????, ??? ??? ?????????? ??????? ?????????, ??????? ??? ???? ?? ??????????? ????????????? ?? ? ??????? ? ?????????? ????? ????? ????????? ????? ????????? ? ?????????? ?????????? ? ?????? ????????, ?? ???????? ? ??????.
А?мн??блкб
???????????? ? ????????? ????? ??????? ? ??????? ??????? ? ?? ? ??????????? ???????? ??????? ???????????? ?????????? ?????????? ???????????????? ???????????, ?????? ?? ?????????
22
???????????? ?? ???????? ??????? ?????????? ?
??????????. ????????? ????? ?????????????? ???????, ??????? ?????? ?? ??????????? ? ??????
???????????? ????? ???????? ? ???????????? ??? ??????????????? ???????????? ????????? ?????????
?????????? ??? ?????????? ?????????????? ? ?? ????????? ??????????? ??? ???????? ??????????.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
??????? ?.?., ????????? ?.?. ????????????? ????????
??????. ?. 3. ?.: ????? ??. ?.?. ???????? ????; 2006: 7?81.
???????? ?.?. ???????????????? ????????? ????????????? ? ????????????? ??? ????????????? ????????? ???????? ??????? ? ??????? ? ??????????? ???????? ??????:
???????. ???. ? ?-?? ???. ????. ?.; 2002.
???????? ?.?. ????? ???????? ? ?????????????? ??????? ??????? ??????? ???????? ? ???????? ?????: ???????. ???. ... ?-?? ???. ????. ?.; 2011.
Di Donato R., Jonas R., Lang P. et al. Neonatal repair of tetralogy of Fallot with and without pulmonary atresia. J. Thorac.
Cardiovasc. Surg. 1991; 101: 126?37.
????????? ?.?., ??????????? ?.?. ?????????? ?????????? ???????? ???????. ????? ????????, ?????????? ? ???????????. 1985; 7: 51?5.
????????? ?.?., ????????? ?.?., ??????? ?.?.,????? ?.?.
?????? ???????? ???????? ??????? ??? ??????? ?????.
??????? ????????. 1985; 4: 67?72.
??????? ?.?., ????????? ?.?., ??????? ?.?., ??????? ?.?.
??????? ? ?????????? ????????? ???????? ????? ?????
??????????? ??????????? ????????? ?????????? ??????? ?????? ? ????? ??????? ????????. ??????? ? ?????????????????? ????????. 2004; 5: 4?10.
Hennein H., Mosca R., Urcelay G. et al. Intermediate results
after complete repair of tetralogy of Fallot in neonates.
J. Thorac. Cardiovasc. Surg. 1995; 109 (2): 332?43.
????????? ?.?. ?????????? ????????????? ??????? ?????? ???????? ??????? ??? ??????????? ????????? ???????
????? ? ????????? ??????? ????????: ???????. ???. ?
????. ???. ????. ?.; 2004.
McElhinney D., Parry A., Reddy M. et al. Left pulmonary
artery kinking caused by outflow tract dilatation after transannular patch repair of tetralogy of Fallot. Ann. Thorac. Surg.
1998; 65: 1120?26.
Mitropoulos F., Laks H., Kapadia N. et al. Intraoperative pulmonary artery stenting: an alternative technique for the management of pulmonary artery stenosis. Ann. Thorac. Surg.
2007; 84: 1338?42.
Murphy D., Winlaw D., Cooper S., Nunn G. Successful early
surgical recruitment of the congenitally disconnected pulmonary artery. Ann. Thorac. Surg. 2004; 77: 29?35.
Kaneko Y., Okabe H., Nagata N., et al. Lay-open pulmonary
arterioplasty for postoperative hilar pulmonary artery stenosis.
J. Thorac. Cardiovasc. Surg. 1997; 114 (3): 406?12.
Robinson J., Rathod R., Brown D., Del Nido P., Lock J.,
McElhinney D. et al. The evolving role of intraoperative balloon
pulmonary valvuloplasty in valve-sparing repair of tetralogy of
Fallot. J. Thorac. Cardiovasc. Surg. 2011; 142: 1367?73.
Sellke F., Del Nido P., Swanson S. Sabiston&Spencer Surgery
of the Chest. 8th ed. Saunders Elsevier; 2010.
Faidutti B., Christenson J., Beghetti M., Friedli B., Kalangos A.
How to diminish reoperation rates after initial repair of tetralogy of Fallot? Ann. Thorac. Surg. 2002; 73: 96?101.
????????? ?.?., ?????????? ?.?., ???????? ?.?. ???????????????? ?????????? ??????????? ????????? ????????? ????? ??????? ????? ? ????????? ?????? ?????????
??????. ??????? ? ????????-?????????? ????????. 1993;
1: 14?8.
Kirklin J., Barratt-Boyes B. Cardiac surgery. 3rd ed. New York:
Churchill Livingstone; 2003.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
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Vol.3. Moscow: A.N. Bakoulev Scientific Center for
Cardiovascular Surgery of the Russian Academy of Medical
Sciences; 2006: 7?81 (in Russian).
Pursanov M.G. Transluminal balloon angioplasty and stenting
for pulmonary artery obstruction in the patients with congenital heart disease. Author's Abstract of Ph.D. Thesis in Medical
Sciences. Moscow; 2002 (in Russian).
Prasolov S.Yu. The choice of approaches to the surgical treatment of patients of early age with tetralogy of Fallot. Author's
Abstract of Ph.D. Thesis in Medical Sciences. Moscow; 2011
(in Russian).
Di Donato R., Jonas R., Lang P. et al. Neonatal repair of tetralogy of Fallot with and without pulmonary atresia. J. Thorac.
Cardiovasc. Surg. 1991; 101: 126?37.
Berishvili I.I., Fal?kovskiy G.E. Normal nomogram of the pulmonary artery. Arkhiv anatomii, gistologii i embriologii.
1985; 7: 51?5.
Berishvili I.I., Kirakosyan S.V., Garibyan V.A. Il?in V.N.
Measurement of pulmonary artery diameter in tetralogy of
Fallot. Grudnaya khirurgiya. Grudnaya khirurgiya. 1985; 4:
67?72 (in Russian).
Bockeria L.A., Zelenikin M.A., Bockeria G.D., Shatalov K.V.
The causes and results of reoperations after initial repair
of congenital heart disease in infants. Grudnaya i
serdechno-sosudistaya khirurgiya. 2004; 5: 4?10 (in
Russian).
Hennein H., Mosca R., Urcelay G. et al. Intermediate results
after complete repair of tetralogy of Fallot in neonates. J.
Thorac. Cardiovasc. Surg. 1995; 109 (2): 332?43.
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Arnautova I.V. Outcomes of the reconstruction of the main
branches of pulmonary artery in tetralogy of Fallot repair in
patients of early age: Author's Abstract of Ph.D. Thesis in
Medical Sciences. Moscow; 2004 (in Russian).
McElhinney D., Parry A., Reddy M. et al. Left pulmonary artery
kinking caused by outflow tract dilatation after transannular patch
repair of tetralogy of Fallot. Ann. Thorac. Surg. 1998; 65: 1120?26.
Mitropoulos F., Laks H., Kapadia N. et al. Intraoperative pulmonary artery stenting: an alternative technique for the management of pulmonary artery stenosis. Ann. Thorac. Surg.
2007; 84: 1338?42.
Murphy D., Winlaw D., Cooper S., Nunn G. Successful early
surgical recruitment of the congenitally disconnected pulmonary artery. Ann. Thorac. Surg. 2004; 77: 29?35.
Kaneko Y., Okabe H., Nagata N., et al. Lay-open pulmonary
arterioplasty for postoperative hilar pulmonary artery stenosis.
J. Thorac. Cardiovasc. Surg. 1997; 114 (3): 406?12.
Robinson J., Rathod R., Brown D., Del Nido P., Lock J.,
McElhinney D. et al. The evolving role of intraoperative balloon
pulmonary valvuloplasty in valve-sparing repair of tetralogy of
Fallot. J. Thorac. Cardiovasc. Surg. 2011; 142: 1367?73.
Sellke F., Del Nido P., Swanson S. Sabiston&Spencer Surgery
of the Chest. 8th ed. Saunders Elsevier; 2010.
Faidutti B., Christenson J., Beghetti M., Friedli B., Kalangos A.
How to diminish reoperation rates after initial repair of tetralogy of Fallot? Ann. Thorac. Surg. 2002; 73: 96?101.
Podzolkov V.P., Plotnikova L.R., Kokshenev I.V. Immediate
results of the primary repair of tetralogy of Fallot with pulmonary artery branch plasty. Grudnaya i serdechno-sosudistaya khirurgiya. 1993; 1: 14?8 (in Russian).
Kirklin J., Barratt-Boyes B. Cardiac surgery. 3rd ed. New York.
Churchill Livingstone; 2003.
????????? 26.09.2013
╘ ????????? ???????, 2013
??? 616.126.4:616.12-089.168
?????????? ?????????? ??????? ?????? ??????
??????? ?????? ? ??????? ? ??????????
??????????????????? ????????
?.?. ?????????, ?.?. ???????, ?.?. ?????????, ?.?. ?????, ?.?. ??????,
?.?. ????????, ?.?. ???????, ?.?. ????????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ?
???????? ??? ? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????,
?????????? ?????????, 121552
????????? ???????? ????????, ???????? ????, ???. ?????????;
??????? ??????? ??????????, ?. ?. ?., e-mail: kovalevdv@mail.ru;
????????? ?????? ??????????, ?. ?. ?., ?????????;
????? ???? ?????????????, ?. ?. ?.;
?????? ?????? ???????????, ?. ?. ?;
???????? ????? ??????????;
??????? ???? ????????, ?. ?. ?.;
???????????? ?????? ????????????.
????. ??????????? ?????????? ?????????? ???????? ??????? ? ??????? ? ?????????? ??-????????.
???????? ? ??????. ? 1983 ?? 2011 ?. ? ????????? ???????? ????? ???????? ???????? ? ??????????? ???????? ?????? (???)
???????? ??????? ???? ????????? 73 ??????? ? ???????????????? ??-????????. ???????? ???? ???????????? ??????????
23
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
????????????? ????????? ??????: ???????????? ????? (n=15), ???????????? ?????? (n=6), ???????? ???????????????? (n=3) ?
??????????? (n=3) ????????, ????? ???????? ??????????????????? (??) ???????? (n=12), ????????? ???????????? (n=6) ? ??????? ??? (n=11). ??????? ??????? ???????? ?? 4 ?? 38 ??? (? ??????? 11,2 ╠ 6,4 ????). ? 5 (7 %) ??????? ???????? ????????????
I ??., ? 28 (42 %) ? II, ? 31 (42 %) ? III, ? 9 (9 %) ? IV. ????????? ??-??????????????? ??????????? 29 ???????.
????? ??????? ???????? ??? ??????: 1-? ? ???????? ? ??-???????????????? 1?2-? ??????? ??? ????????????? ?? ??-???????;
2-? ? ???????? ? ???????????????? 3?4-? ??????? ??? ????????????? ?? ??-???????; 3-? ? ???????? ? ???????????????? 3?4-?
???????, ??????? ??????????? ????????????? ?? ??-???????.
??????????. ???? ?????????? ????? ???????? ???????? 0,6?19 ??? (? ??????? 4,7 ╠ 4,07 ????). ????????????? ??????? ?? ??????? ???? ?????????: 27 ????????? ??????? ? 1-? ??????, 6 ? ?? 2-?, 21 ? ? 3-?. ?????????? ??????????? ????????? 14,8 %, ??
???????: ? 1-? ? 11 %, ?? 2-? ? 33 %, ? 3-? ? 14 %. ????????? ??????????? ????????? ??????? ?? ???? ??????? ??????? ??????????????? ?????????????? (??), ????????????? ?????????? ??-?????????????. ??????????? ?????????? ??????????? ? 14 %
???????, ????????? ??????? ???? ?? ? 75 %, ????????? ????? ? ? 25 % ???????. ?? ???? ??????? ??????????? ????????? ? ?????????? ??????? ??-????????????: ? 30 % ??????? ? 1-? ??????, ? ???? ????????? ?? 2-?, ? 15 % ? 3-? ??????. ? I?II ?? ?? NYHA
?????????? 88 % ??????? 1-? ?????? ? 89 % ??????? 3-?. ?? 2-? ?????? 50 % ??????? ???????? ?? II ??. ?????????? ???????????? ? 5, 10 ? 19 ????? ????????? 80, 79 ? 78 % ?????????????? ?? ???????: ? 1-? ? 80 % ? 19 ?????, ?? 2-? ? 42 % ? 16 ?????, ? 3? ? 72 % ? 15 ?????. ???????????? ? ???????????????? ??????????? ? ????????????????? ???????? ????????? 69 ? 62 % ??????????????, ??? ???????? ??-??????? ? 56 %; ???????????? ??????? ? ?? ? ?? ????????? 69 ? 52 % ??????????????.
??????????. ??????????????? ?????????? ??-??????? III?IV??. ???????? ???????????? ???????? ????? ?????????? ???????????
? ??????? ????? ???????? ??????? ? ??????? ????????????? ????????????? ?????????, ??? ????????? ??????? ?????????? ??????????? ? ???????? ?????????????? ????????? ?????????.
???????? ?????: ??????????????? ??????????????????? ????????; ???????????? ????????? ??????; ???????? ???????.
LONG-TERM RESULTS OF THE RIGHT HEART BYPASS IN PATIENTS WITH THE
PATHOLOGY OF ATRIOVENTRICULAR VALVES
V.P. Podzolkov, D.V. Kovalev, M.M. Zelenikin, I.A. Yurlov, N.A. Putyato,
M.Sh. Mavlyutov, V.I. Dontsova, M.V. Vladimirskaya
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of Medical
Sciences; Roublevskoe shosse, 135, Moscow, Russian Federation, 121552
Podzolkov Vladimir Petrovich, Academician of the Russian Academy of Medical Sciences, Deputy
Director;
Kovalev Dmitriy Viktorovich, MD, DM, e-mail: kovalevdv@mail.ru;
Zelenikin Mikhail Mikhailovich, MD, DM, Professor;
Yurlov Ivan Aleksandrovich, MD, PhD;
Putyato Niiole Al'fonsovna, MD, PhD;
Mavlyutov Mirat Shamil'evich;
Dontsova Vera Ivanovna, MD, PhD;
Vladimirskaya Marina Vladimirovna.
Objective. The objective of the work is to present the results of the Fontan operation in patients with the pathology of atrioventricular valves.
Material and Methods. The Fontan operation was performed on 73 patients with atrioventricular valve regurgitation from 1983 to
2011 in the Department of surgery for children and adolescents with congenital heart disease. The diagnoses included the following
forms of single heart ventricle: double-inlet left ventricle (n=15), double-inlet right (n=6), tricuspid atresia (n=3) and mitral valve atresia (n=3), common atrioventricular valve (n=12), heterotaxy syndrome (n=6) and the other congenital heart defects (n=11). The
patients' age ranged from 4 to 38 years (the average age was 11.2 ╠ 6.4 years). Regurgitation of grade 1 was detected in 5 (7%) cases,
of grade 2 ? in 28 (42%) cases, of grade 3 ? in 31 (42%) cases, of grade 4 ? in 9 (9%) cases. Atrioventricular valve repair was performed in 29 patients.
The patients were divided into three groups: group 1 included patients with atrioventricular valve regurgitation of grade I?II without
atrioventricular valve surgical intervention; group 2 ? patients with atrioventricular valve regurgitation of grade III?IV without atrioventricular valve intervention; group 3 ? patients with regurgitation of grade III?IV who had undergone atrioventricular valve surgery.
Results. The follow-up period after surgery was 0.6?19 years (in the average ? 4.7╠ 4.07 years). The patients were distributed into
the following groups: group 1 was composed of 27 patients, group 2 ? of 6 patients, group 3 ? of 21 patients. Long-term mortality
made up 14.8% and with the distribution by groups: group 1 ? 11%, group 2 ? 33%, group 3 ? 14%. The cause of the majority of
deaths in all the groups was circulatory insufficiency due to advanced atrioventricular regurgitation. Non-lethal complications
occurred in 14% of cases, and they were caused by circulatory insufficiency in 75% of patients, by arrhythmia ? in 25% of patients.
The patients of all the groups showed the tendency of increasing grade of atrioventricular regurgitation: in group 1 ? 30% of patients,
group 2 ? all the patients, group 3 ? 15%. 88% of patients from group 1 and 89% of patients from group 3 were classified in NYHA
Class I?II. 50% of patients from group 2 were placed in NYHA Class II. Long-term survival rates 5, 10 and 19 years after surgery were
80, 79 and 78% respectively, and by groups they were: in group 1 ? 80% 19 years after operation, group 2 ? 42% 16-year survival,
group 3 ? 72% 15-year survival. Survival rates with tricuspid and mitral valve regurgitation were 69 and 62% respectively, and with
an open atrioventricular valve ? 56%; survival rates in the patients with single left and single right ventricle were 69 and 52% respectively.
Conclusion: Systemic atrioventricular valve regurgitation of grade III?IV is a substantial risk factor for long-term mortality in patients
after the Fontan operation and it requires timely surgery that will contribute to a reduction of long-term mortality and to an improvement of functional condition of patients.
Key words: atrioventricular valve regurgitation; single ventricle; the Fontan operation.
24
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
г?б?блкб
????? ???????????????? ????????? ?????????? ??????? ?????? ? ????????????????? ????????????? ??????? ?? ???????? ?????????? ?????????
??????????????, ???????????? ??? ? ????? 70-?
????? ???????? ???? [1]. ??? ???? ??????????? ? ????????? ????? ???????? ???? ??????????. ?????? ?
??? ????? ?? ???????? ???????? ????????, ??????????? ????????????????? ????? ?????????,
?????????? ?????????? ??? ?????????????? ?????????? ?????????????, ???????? ??????????????? ??????????????????? (??) ???????? [2?4].
????? ?????????? ???????????? ???????? ?????????? ??????? ?????????? ??????????? ????????
??????? ? ??????? ? ???????????????? ??-????????.
Е?зб?к?н к обзс??
? 1983 ?? 2011 ?. ? ????????? ???????? ?????
???????? ???????? ? ??? ???????? ??????? ????
????????? 410 ???????. ? 73 (18 %) ?? ??? ?????????? ??????????????? ??-????????. ???????? ????????? ???? ???????????? ?????????? ??????????
???????????? ??? ????????????? ?????????????
????????? ??????: ???????????? ????? ? ??????
????????? ?????? (????, ????) ? ? 15 (20,5 %) ?
6 (8,2 %) ??????? ??????????????; ??????? ???????????????? (???) ? ??????????? ???????? (???) ?
? 20 (27,4 %) ? 3 (4,1 %) ??????? ?????????????; ????? ???????? ??????????????????? ?????
(?????) ? ??????????????????? ??????????? ?????? ? ? 12 (16,5 %) ???????; ??????? ???????????? ???????????? ? ? 6 (8,2 %) ??????? ? ?????? ???????
???, ???????????????? ??????????? ?????? ??
??????????, ? ? 11 (16,1 %) ???????. ??????? ????????? ????????? ?? 4 ?? 38 ??? (? ??????? 11,2 ╠
6,4 ????). ????????? ???????? ???? ???? 39, ???????? ? 34. ????? ???? ????????? ? ??????? ?????????? 35,7 ╠ 23,6 ??. ???????????? ?? ????? ??-??????? ???????? ? 16 ???????, ?? ??????????????? ?
? 26, ?? ?????????? ? ? 30, ? ?????? ???????? ? ???????????? ?? ? ?? ????? ??-????????.
???????? ? ????????????? ?????????? ??????
?????? ???????? ???????????? ????, n (%):
Situs solitus . . . . . . . . . . . . . . . . . . . . . . . . . 66 (90 )
Situs inversus . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (2 )
Situs ambiguous . . . . . . . . . . . . . . . . . . . . . . . . 6 (8 )
????????????? . . . . . . . . . . . . . . . . . . . . . . . . 8 (11 )
?????????? . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (3 )
????????????????? ??????:
?? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 (51)
?? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 (11)
???????????????? ??????:
??????????? ?? . . . . . . . . . . . . . . . . . . 17 (23)
??????????? ?? . . . . . . . . . . . . . . . . . . 11 (15)
????? ??????????: . . . . . . . . . . . . . . . . . . . 10 (13)
??? ??-??????? . . . . . . . . . . . . . . . . . . . . . . 34 (46)
???? ?????? . . . . . . . . . . . . . . . . . . . . . . . . . 23 (32)
????? ??-?????? . . . . . . . . . . . . . . . . . . . . 16 (22)
????????????? ??-?????? . . . . . . . . . . . . . . 9 (12)
??-??????????????? . . . . . . . . . . . . . . . . . . 19 (26)
??-??????????????? . . . . . . . . . . . . . . . . . . 33 (45)
??????? ?????????? ?????????????
??????? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 (26)
??????? ???????? ??????? . . . . . . . . . . . . . . . . 2 (3)
????????????? ??????? ????? ???? . . . . . . . . . 2 (3)
?????????? ??????????? ????????
?????? ????? ???? . . . . . . . . . . . . . . . . . . . . . 3 (4)
?????????? ?????? ???????? ???:
????????? . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (1)
????????? . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 (3)
???????? ???????????? ?????? . . . . . . . . . . . 2 (3)
??????? ???????????? ??-????????? ??????????? ??????????? ????- ? ?????????? ???????????????, ??????? ????????? ??????????, ??? ? 5 (7 %)
????????? ??????????????? ??????? ?????????
I ???????, ? 28 (42 %) ? II, ? 31 (42 %) ? III ? ? 9 (9 %) ?
IV. ??? ???????? ?? ???????? ?????????? ???? ? III,
???? IV ?????????????? ??????? (??) ?? NYHA.
????? ??????????? ??????? ?????? ?????? ????????? ??????????? ????????? ???????????? ?????????????: ???????? ??????? ? ? 4 ???????, ???????? ??? ?????????? ???? ? ? 4, ????????? ???????? ????????-???????? ??????????? ? ? 33,
????????????????? ????????? ? ? 46, ??????????????? ????????????? ? ? 3 ???????.
???????? ??????? ??????????? ? ?????????
????????????. ? 47 (64 %) ????????? ????????????? ????????????????? ??????? ?? ???????????????????? (Gore-Tex╝). ? 3 ??????? ??? ??????
???????? ??????????? ????????? ??????????
???, ? 2 ??????? ????????? ??????????? ???????????? ? ???. ??????? ?????????????????? ???????? ????????? ? ??????????? ?? ????? ? ???????
??????????? ???? ???????? ? ??? ? ???????? ?? 18
?? 22 ??.
? 1 (1 %) ?????? ?????????? ??????????-???????????? ?????????, ? 18 (25 %) ? ????????? ????????????????? ?????????, ????????????? ???????????? ?????????????????? ??????? ? 11 ?????????, ? 7 (10 %) ??????? ? ??????????-????????
?????????. ????????? ??-??????????????? ?? ????? ?????????? ???????? ??????? ????????????? ?
29 ???????: ???????? ???????????????????? ??????? ? ? 4 (14 %), ???????? ????????????????????
??????? ???????? ? ? 2 (7 %) ???????, ?????? ???????????????? ? ? 8 (28 %) ???????, ?????????????
?????????????? ??????????? ? 4 (14 %) ???????, ?
6 (20 %) ????????? ???????????????? ?????????? ?
?????? ???????????????, ?????????????? ??-??????? ??????????? 5 ???????.
????? ???????????????? ?????????? ???????????????? ?????????, ??? ???????? ???? ????????? ?? ??? ?????? ? ??????????? ?? ???????? ??????? ??????????????? ??-??????? ? ????????? ????????????? ?? ???????:
25
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
? 1-? ?????? ? 33 (45 %) ???????? ? ?????????
???????????????? ?? ??-??????? I ? II ???????, ??????? ?? ??????????? ????????????? ?? ??-???????;
? 2-? ?????? ? 11 (15 %) ????????? ? ?????????? ???????????????? ?? ??-??????? III ? IV ???????, ??????? ????? ?? ??????????? ????????? ???????????????;
? 3 ?????? ? 29 (40 %) ????????? ? ??????????
???????????????? ?? ??-??????? III ? IV ???????,
??????? ?? ????? ?????????? ???????? ???????
??????????? ????????????? ?? ????????? ??-???????.
? ??????? 2-? ?????? ? ?????????? ??-???????????????? III-IV ??????? ????????????? ????????? ???????????? ?? ???????????, ????????? ??????????? ????? ????????? ???? ?????????????? ??
?????? ?????? ???????? ???? ???????? ? ? ?????
80-?????????? 90-? ????? ???????? ????????. ? ??
????? ?? ???? ???????? ????? ?????????? ???????????? ???????? ?? ??-???????? ??? ???????????? ????????? ??????, ???????? ??? ?????
??-???????. ?????? ?????????? ??????? [5] ??????????????? ? ???????? ???????? ???????? ??
???????????? ????????? ?????? ????? ??????????
???????????????? ?????????, ? ??? ????????? ?
? ????????? ???????? ??????? ??-????????????.
???????-???????????????? ?????????? ????????? ?? ??????? ????? ??????????? ???????? ??????? ???????????? ? ???????.
?????????????? ????????? ????????? ????????????? ? ?????????????? ???????????? ??????????? SPSS ?????? 11.0.1., Statistica'99 ? ???????
?????????????? ??????? ? ???????? Microsoft
Access ??, Microsoft Excel ??. ??? ????????? ?????????? ??????????? ? ??????????????? ???????
????????????? ???????????????????? ????????
(?=?/n), ??????????? ?????????? ?? ???????????
???????????? (?), ??????? ?????? (m=?/?n). ?????????? ?????????????? ?????? ??????? ???????.
????????????? ????? ????????????? ????????
(?) ???????????? ?? ??????? ?????????, ????????
????? ????????????? ???????? ????????? ???????????? ??? ? < 0,05, ? ?????????????? ??????????? ????????? ???????????? ??? r > 0,6. ????????? ?????????? ???????????? ?????????????? ?
??????? ?????? Kaplan?Meier.
Йбашн╦з?з?
? ?????????? ????? ?? 1 ?? 19 ??? (? ???????
4,7 ╠ 4,07 ???? ) ??????????? 54 (83 %) ???????? ?
???????? ?? 6 ?? 37 ??? (? ??????? 17,1 ╠ 6,3 ????).
? 1-? ?????? ???? 27 ?????????, ?? 2-? ? 6. ? 3-?
??????, ? ??????? ??????????? ????????? ??-???????????????, ????? 21 ???????.
????? ?????????? ??????????? ????????? 14,8 %
(n=8), ? ?? ???????: ? 1-? ? 11 % (n=3), ?? 2-? ?
33 % (n=2), ? 3-? ? 14 % (n=3). ???????? ?????????
??????? ? 1-? ? 2-? ??????? ??????? ??????????????? ?????????????? (??). ? 3-? ?????? 1 ??????? ???? ????? ?? ??, 1 ? ?? ??????????? ??????????????? ? 1 ? ?????????? ????????????? ????????
???????.
??????????? ?????????? ??????????? ? 14 %
???????. ?? ???? ??????? ???????? ???????? ??????????? ?????????? ???? ??????????????? ??????????????. ????????? ????? ?????????? ? ??????? ?????? ? 1-? ?????? ? ? ???????? ????????? 3-?
??????.
??? ?????? ?????????? ??????????? ???????
???????? ??????? ??????????????? ??????????
??-??????? ?? ?????????????, ????? ????? ???????? ? ? ?????????? ?????. ?? ??????? 1 ?????, ???
??????? ??????????????? ??-???????? ?? ?????????? ???????? ??????? ? ??????? ?????? ????
?????, ? ??????? ?? ??????????? ?????????????
?? ???????, ??????????? ?? ?????????? ?? ????????? ?? ???????? ???????????? ?? ?????? ???????.
? 3-? ?????? ???????? ????????????? ????????
??????? ??????????????????? ???????????????
????? ?? ?????????: ????? ????????? ??????? ?
3,3 ╠ 0,4, ????? ???????? ? 1,1 ╠ 0,8 (?<0,05). ? ?????????? ????? ??????????? ????????? ? ?????????? ??????? ???????????? ?? ???? ???????:
c 1,9 ╠ 0,2 ?? 2,4 ╠ 0,5 ? 1-?, ? 3,0 ╠ 0,0 ?? 3,5 ╠ 0,5
?? 2-?, ? 1,1 ╠ 0,8 ?? 1,4 ╠ 1,1 ? 3-?. ??????? ????????, ??? ??????? ??????????????? ??-???????? ?
??????? 1-? ?????? ? ?????????? ????? ?????????? ?? ????????? ?? ?????????? ? 8 (29,6 %)
???????, ???? ?? ??? ??????. ?? 2-? ?????? ?? ? ????? ?????? ?? ???????? ?????????? ??????? ??????????????? ??-???????????? ????? ????????, ?
???????? ?????????? ?????????? ?? ????????????????. ? ????????? 3-? ?????? ????????????? ??
Юр?с?л?б мнклкмс-?бос?кл?ок?брмкб тсм?а?збнк ш т??кблзс? ??анк?л?? ??штт
тб?б? ??тснлблкбо стб???кк Нслзбл?
??????
1-? (n=33)
2-? (n=11)
3-? (n=29)
???????, ???
??????????, ?/?
11,2 ╠ 5,4
13,4 ╠ 9,7
10,6 ╠ 5,1
172,7 ╠ 30,3
161,6 ╠ 25,2
169,7 ╠ 28,3
SaO2, %
77,5 ╠ 6,2*
81,7 ╠ 4,1*
80,2 ╠ 5,7
*p<0,05 ??? ????????? ?????????? SaO2 ? 1-? ? 2-? ???????.
26
??, %
??. ???,
?? ??. ??.
???, ??
60,5 ╠ 6,5
58,1 ╠ 4,2
59,9 ╠ 6,1
13,4 ╠ 3,8
14,3 ╠ 5,9
15,5 ╠ 4,8
3,0 ╠ 1,2
3,1 ╠ 0,8
3,4 ╠ 1,0
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
p < 0,05
p > 0,05
4,0
3,5
3,3╠0,4
3,0╠0
3,0╠0
p > 0,05
3,0
2,4╠0,5
2,5
2,0
3,5╠0,5
1,8╠0,3
1,9╠0,2
1,4╠1,1
1,5
1,1╠0,8
1,0
0,5
0
2-? ??штт?
1-? ??штт?
яс стб???кк
3-? ??штт?
Хсрнб стб???кк
г сз??нблл?х тб?кс?
Йкр. 1. якл?окм? лб?срз?зс?лсрзк ркрзболс?с дг-мн?т?л? ?с стб???кк Нслзбл?, л? особлз ??ткрмк ка рз??ксл??? к ? сз??нблл?б р?смк
80, 79 ? 78 % ??????????????, ? ?? ???????: ? 1-? ?
80 % ? 19 ?????, ?? 2-? ? 42 % ? 16, ? 3-? ? 72 % ?
15 ?????.
???? ???????????? ????????? ?????? ?????????? ???????????? ????????? ????? ??????????
??????? ?????? ?????? ? ?????? ????? ??????????
????? (???. 2), ??????? ??????????, ??? ????????
??? ??????????? ?????????? ?? ?????? 2?5 ??? ????? ????????, ????? ????? ???????? ??????? ?
1-? ? 3-? ??????? ?????????? ?????????????.
? 5 ????? ? 1-? ?????? ? ????? ???????? 80 %, ??
2-? ? 82 % ? ? 3-? ? 72 % ?????????. ???????? ???????? ???????? ???????? ???????????? ?? 2-?
?????? ? ? 16 ????? ? ?????????? ????? ??? ????????? ?????????? ??-??????????????? ???????? ?
????? 42 % ?????????, ? ?? ????? ??? ? 3-? ??????,
1,0
0,9
Дшошн?зк?л?? ?сн? ??йк?╞к?
?????????? ??????????????? ?????????? ??-??????? ??????? ??????? ???????????. ? 93 % ????????? (? 27 ?? 29) ??????? ??????? ??????? ???????????? ?? ??-???????. ? ??????????, ??????, ??????????? ????????? ??????????????? ??????? ? ? 15 %
(3/20) ??????? ?????????? ???????????? ??????????????.
????? ????????????? ??????? ?? ?????????????? ??????? ? ???????????? ? ??????????????
NYHA ? ?????????? ????? ????? ???????? ???????
?????? ?????? ??????? ?????? ???? ?????????:
I ?? ? 19 (41 %) ?????????, II ? 20 (44 %), III ? 4 (9 %),
IV ? 3 (6 %). ??? ????????????? ??????? ?? ??????????????? ?????? ????????? ????????? ???????
? 1-? ? 3-? ???????, ??? ?????????? ?????????, ??????????? ? I?II ?? ?? NYHA, ????????? 88 ? 89 %
??????????????, ?? 2-? ?????? 50 % ??????? ???????? ?? II ??.
??? ??????????? ????????, ???????? ?? ??????? ??????????? ?????????????????? ???????,
????????? ????????? ???????? ???????-???????????????? ??????????? ? ????????? ? ???????????
???????????? ?????????? ? ?????????? ????? (I ?
II ??) ? ? ??????? ? ??????????? ????????????
(III ? IV ??). ??????????? ????????? ???????? ??
??????? ??????????????? ?????????? ??-???????
(1,6 ╠ 0,9 % ? ????????????? ? 3,1 ╠ 0,06 % ? ??????????? ???????, p<0,05) ? ?? ?????????? ????????? (56,5 ╠ 4,9 % ? ????????????? ? 47,1 ╠ 2,2 %
? ??????????? ???????, p<0,05). ?? ?????????
???????-???????????????? ??????????? ???????????? ???????? ?? ???????? (p>0,05). ???? ????????? ? ?????????? ????? ????? ???????? ???????
????????????? ?????????? ?????????????? ????????????: ????????????? ?????? ?? (n=2) ? ?????????????????? ???????? (n=2), ???????? ????????????? ?????? ?? (n=2), ??????????? ???????
????????????? ???????????? (n=3).
????? ?????????? ???????????? ??????? ????? ???????? ??????? ? 5, 10 ? 19 ????? ?????????
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
2
6
8 10 12 14 16 18
Хб?кс? л?╥н??блк?, нбз
1-? ??штт?
2-? ??штт?
3-? ??штт?
4
20
22
Йкр. 2. дмзш??л?б м?к??б сз??нбллсх ??йк??босрзк т??кблзс? тсрнб стб???кк Нслзбл? р лб?срз?зс?лсрз╦? ркрзболс?с
дг-мн?т?л? тс ??штт?о (p<0,05 т?к р???лблкк 1-х к 3-х
??штт рс 2-х)
27
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
?????????? ?????????? ????????? (?>0,05), ????
???????????? ??????? ? ?????????????? ?? ???? ????, ??? ? ?????????????? ??. ?????????????
?????????? ???? ????????? ???????????? ??????? ? ???????? ?????????????? ????????? ? ????????????? ???????????? ????????? ????? 9 ?? ??. ??.
?? ????????? ? ????????, ? ??????? ??? ???? ????? 9 ?? ??. ??. (?=0,037).
1,0
Дшошн?зк?л?? ?сн? ??йк?╞к?
0,9
0,8
0,7
0,6
0,5
0,4
И╥ршй?блкб
0,3
0,2
0,1
0,0
0
2
ИдгД
4
10 12 14
6
8
Хб?кс? л?╥н??блк?, нбз
Гб?срз?зс?лсрз╦ МД
16
18
20
Гб?срз?зс?лсрз╦ ЕД
Йкр. 3. Из??нблл?? ??йк??босрз╦ т??кблзс? тсрнб стб???кк
Нслзбл? р лб?срз?зс?лсрз╦? ркрзболс?с дг-мн?т?л? ? а??кркосрзк сз б?с ос?ыснс?кк (p>0,05 т?к р???лблкк ??штт
обй?ш рс╥сх)
??? ??????????? ????????? ?????????? ??-????????????, ? 72 % ???????? ? 15 ?????, ??? ????????? ????, ??? ? ???????? ? 1-? ?????? ? 80 %.
??????? ?????????? ???????????? ????????? ?
??????????? ?? ?????????? ?????????? ??-??????? (???. 3), ?????????? ?????????? ????????? ?
????????? ??????????????? ???????? (???) ? ????????? ????????? ?????? (???. 4, 5). ?????????,
??? ???????????? ????????? ? ????????????????
?? ? ?? ????, ??? ? ????? ??-????????, ? ?????????? 69 ? 62 % ??????????????, ? ????????????
??????? ? ????? ??-???????? ? 56 %. ?? ???? ???????? ????????????? ??????????? ??????? ?????????? ???????????? ????????? ? ??????????? ??
? ??????? ????????? ???? ??????????? ?????????? ???????????? ????????? ?????????????? ??????? ????????? ? ????????????? ???????????? ?????????? ??????. ??????? ????????? ????????????
??????????? ? ? 24-61 % (? 1980-? ????) ?? 0?5 % ?
?? ????????? ????? [3, 6?10], ?????????? ?????????? ?????????? [11?13]. ??? ?????? ??????????
??????????? ?????????? ??????? ???????????? ?????????? ???????????? ??????? ? ?????????? ????? ????? ????????, ?????????? ? ???????? ????????????? ??????????, ?????????????? ????? ?????????, ? ????? ???????? ??-????????????.
?? ????? ??????, ????? ?????????? ?????????
???????????? ??????? ?? ???????? ??? ? ???????????????? ?????????? ??-??????? ????? ???????? ??????? ? 5, 10 ? 19 ????? ????????? 80, 79 ?
78 % ??????????????. ??? ????????? ???????????? ????????? ? ?????? ??????? ???????? ?? ????
???????? ???????????? ?????????? ? 15?16 ?????
? 1-? ?????? ????????? (??? ????????? ?????????
??-????????????) ? ? 3-? ?????? (? ?????????? ?????????? ??-????????????) ? 80 ? 72 % ??????????????, ? ?? ????? ??? ???????????? ? ??????? ???
????????????? ?? ??-??????? ??? ?????????? ???????????? ????????? ??????????? ???? ? 42 %.
?????? ?????????? ?????? ????? ?????????
1,0
0,9
Дшошн?зк?л?? ?сн? ??йк?╞к?
Дшошн?зк?л?? ?сн? ??йк?╞к?
1,0
0,8
0,7
0,6
0,5
0,4
0,3
p>0,05
0,2
0,9
0,8
0,7
0,6
p>0,05
0,5
0,1
0,4
0
2
4
6
8
10
12
14
16
18
20
Хб?кс? л?╥н??блк?, нбз
Цэ
Хэ
Йкр. 4. Из??нблл?? ??йк??босрз╦ т??кблзс? тсрнб стб???кк
Нслзбл? р лб?срз?зс?лсрз╦? дг-мн?т?л? ? а??кркосрзк сз
ос?ыснс?кк ркрзболс?с йбнш?с?м?
28
0
2
4
6
8
10
12
14
16
18
20 22
Хб?кс? л?╥н??блк?, нбз
Дяя>9 оо ?з. рз.
Дяя<9 оо ?з. рз.
Йкр. 5. Из??нблл?? ??йк??босрз╦ т??кблзс? тсрнб стб???кк
Нслзбл? р лб?срз?зс?лсрз╦? дг-мн?т?л? ? а??кркосрзк сз
Дяя ? ркрзболсо йбнш?с?мб
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
? ????? ??????? ?? ?????? ???????????? ????????? ??? ??-???????????????. ???, N. Ohuchi ? ?????.
[10], ??????? ???? 405 ???????? ??????? ? ????????? ????????????, ???????? 23-?????? ???????????? ??????? ? ?????????? ??-?????????????
? ??? ???, ??????? ????????? 68 ? 80 % ??????????????. ???????????? ???????????? ?????????? ???????????, ?? ?? ??????, ??????? ???????????????? ??-???????, ??????? ???????????? ???????????? ? ?????? ?? ??????. ?? ?????? J.G. Kwak ?
?????. [14], ???????????? ????????? ? ??????????
??-??????????????? ????????? ? 10 ????? 86 %, ?
????????? ????????? ??????? ??????? ?????????
????????? ?????? ?? ??????????? ??????? ? ??,
??? ???? ?????? ???????? ??????? ???? ? ????????? ???????????? ????????????. ? ????????????
N. Ota ? ?????. [15] ???????????? ??????? ? ????? ?? 12 ??? (? ??????? 6,2 ????) ????? ?????????
??-???????????? ????????? 64 %, ?? ????? ???????? ?????????, ? ??????? ???????????? ????? ????????????? ? ?????????? ????? ???????? ?????????, ? ???????? ? ?????????? ?????????????,
???????????? ????????? 88,2 ? 12,5 % ??????????????. ????????? ????? ?????????? ???????????
??????? ??????? ??????? ?????? 3 ???, ????? ???? ????? 4 ??, ??????? ?????????? ?????? ??????,
??? ???? ?????? ????????, ??? ??????? ??????????? ??????? ??? ?? 1 ????. ?? ??????????? ?????? Y. Imay ? ?????. [16] ?????????, ??? ??????????
10-?????? ???????????? ????????? ? ??-???????????????? ????????? 84 %, ??? ?????? ??????? ???
??????????????????? ??????????????? ? 93 %.
??????????? ??????? ?????????? ??????????? ?
?????????? ???? ???????: ? 1-? ?????? ???????????
????????? 11 %, ? ?? 2-? ? 3-? ? 33 ? 14,2 % ??????????????. ????????? ????????? ??????? ? ?????????? ????? ? 75 % ????????? ??????? ??, ????????????? ? ??????????? ??????? ?????????????????
??? ????????? ??-???????????? ? ????????? ??????
??????????, ??? ???????-?????????? ???????????.
? ?????? ???????? ??????? (12,5 %) ???????? ?????????? ?????? ? ?????????? ??????? ?????????
????????????? ???????? ??????? ? ??????????? ???????????????, ????????????? ??????????.
?????? ???????? ??-???????????????, ??????????? ? ??????, ??????? ???????????????? ??-???????????? ? ?????????? ????? ????? ????????
??????? ? 30 % ??????? 1-? ?????? ? ? ???? ????????? 2-? ??????. ? ?? ?? ????? ? 3-? ?????? ? ?????????? ????? ????? ???????? ??????? ?????? ?
15 % ??????? ?????????? ????????? ???????
??-???????. ?? ?????? ??????????, ??????? ???
???????????????? ??-???????????? ??????????? ?
12?30 % ??????? [12?14], ? Y. Imay ? ?????. [16] ???????? ????????????? ????????? ???????? ?? ??????? ???????? ???????????? ? 11 % ??????? ??? ??
???????????? ?????.
? ??????????? ?? ???????? ??-???????? ???????????? ????????? ? ???????????????? ?? ? ??
????????? 69 ? 62 % ??????????????, ??? ????, ???
? ????????? ? ????? ??-????????, ? ??????? ???
????????? 56 %. ? ????? ????? 15 ??? ???????????? ??????? ? ?????????????? ?? ?????????
????????? ?????, ??? ???????????? ??????? ?
?????????????? ?? ? 70 ? 50 % ??????????????.
?? ?????? J.S. Tweddell ? ?????. [17], ???????????? ??????? ? ???????????? ?????????? ??????
????? ???????????????? ????????? ? ???????????
?? ?????????? ????????? ????????? ? 10 ????? ?
?? ? 75 % ? ? ?? ? 67 %. ? ????????? ????? ????????? ??????, ? ??????? ??? ??????? ?????????
??????? ?????????? ?????????? ????????? (??
??? ??) ? ???????? ? ?? ?? ????????????, ?? ?????? ?? ????????? ????? ?????????? ???????????,
??? ?????????????? ????? [10, 17]. ?????? ??????????? ???????? ??????????????, ????????? ?????????? ??????? ?????????? ?????, ????????????????? ?? ???????? [18]. ?? ????? ??????, ?????????? ???? (????? ? 2 ????) ???? ???????????? ?
???????, ? ??????? ??? ? ????????????? ???????????? ????????? ?? ????????? 9 ?? ??. ??. ??
????????? ? ????????, ? ??????? ??? ???? ?????? 9 ?? ??. ??. ? 88 ? 47 % ??????????????.
C. Mavroudis ? ?????. [18], ????????? ??????????
????????? ????????, ??????????? ? ??????????
??????? ????? ???????? ???????, ?????? ? ??????????, ??? ????????? ????? ???????? ???????????? ?????????? ???????? ??????? ?????????
(?????? 25 ???), ?????? ??? ???????????????????? ????????? ??????, ????????? ????? ??? ?????????? ???????? ??????? ????? 100 ???.
??? ?????? ??????????????? ??????? ????? ???????? ???????? ????????????? ???????? ??? ?
?????, ??? ? ?? ??????????? ???????. ???? ?? ???????? ??? ???????? ?????????? ? III?IV ?? ??
NYHA (51 ? 49 % ??????????????), ?? ????? ???????? ??????? ? ?????????? ????? ? I?II ?? ???? ???????? 85 %, ? ? III?IV ?? ?? NYHA ? 15 % ?????????. ?? ?????? S.J. Kim ? ?????. [19], ? ??????????
????? ????? ???????? ??????? ? ???????????
?????????????????? ???????? ? I?II ?? ??????????
90?95 % ????????? ? 10 ????? ??????????. ?? ??????????? ???????????? J.G. Kwak ? ????? [14]
?????????????? ????? ????????? ? ??????????????? ???????????????? ??-???????? ????? ???????? ??????? ???????? ?????????? ??????? ? ?
10 ????? ? ??????? ?????????? 1,07 ╠ 0,2. ????????? ?????????????? ????????? ????????? ?? ????
???????, ??????? ???????? ???????????? ???????
??????????? ? I?II ?? ?? NYHA: 88 , 50 ? 89 % ??????????????. ??? ???? ??????? ???????, ??? 50 %
??????? 2-? ?????? ?????????? ?????? ?? II ??. ????? ???????????? ????????? ??????????????? ????????? ????? ?? ????? ??????? ????????? ????????? ? ?????????? ????? ????? ????????? ??
?????? ???????????? ???????????? ??????????????, ?????????????? ? ??????????????, ?? ?, ? ?????? ???????, ??????????? ???????? ???????????29
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
??????? ???????? ? ???????? ?????? ???????? ??????? ??????, ? ????? ??????????? ???????????
??-????????????. ??????????? ??????? ??????????, ??? ???????? ????? ???????, ??????? ????????? ???????? ??????? ? ??????????? ?????????????????? ????????, ????????? ? ????? ???????
?????????????? ?????? [20, 21].
?????????? ???? ?????????? ? ?????????? ??????? ??????????? ? 14,8 % ?????????. ? ?????? ????????? ? ????????? ??-????????????? (1-? ??????) ??
24 ????????????? ????????? ?????????? ????????
? 16 % ???????, ??????????????? ?????????????? ?
? 75 %, ????????? ????? ? ? 25 % ???????. ??
2-? ?????? ????????? ? ?????????? ??-???????????????? ??? ?? ????????? ? 33,5 % ????????? ??????????? ?????????? ??????????, ? 50 % ???????
????????????? ???????????????? ??????????????. ? 3-? ??????, ????????? ?? 18 ?????????, ??????? ??????????? ?????????? ???????????????
??-???????, ??????????? ?????????? ?????? ?????????? ? 2 (9,6 %) ????????? ? ?????????? ? ?????
?????? ????????? ????????????????, ? ? ?????? ?
?????????? ?????.
? ???? ??????? ? ???????????????? ?????????????? ?????????? ?????????? ??-???????????? ?
????????? ?? ??????. ???????? ?????????????
??????? ????????????? ????????? ?????? ?????
???????? ??????? ??????????? ? 2?9 % ?????????
[9, 19]. ?? ?????? ??????????, ?????????? ????????????? ????????? ? ???????????????? ??????????????? ?????????? ??-??????? ??????? ? ?????
??-????????, ?? ? ?????????????? ??, ?? ?????????? ????????? ??????????????? ? ????????
?????????? ?????????. ??????? ????? ????????, ???
???????? ?????? ?????????? ?? ? ?????????? ??????? ????? ???????? ??????? ? ???????-?????????? ??????????? (???) ? ????????? ?????- ? ???????????, ??????. ??? ???? ????????????????
???????? ?????? 4 (66 %) ?? 6 ????????? ? ?????????? ????? ?? ?? ? 4 (57 %) ?? 7 ??????? ? ???????????????? ??????????????. ???????? ?? ??, ??? ?
?????????? ??????? ????? ???????? ??????? ???
??????????? ? 14,8 % ???????, ??????????? ??? ??
???????? ????????? 50 %.
????????? ??????????????, ????? ?????????, ??? ???????? ??????? ?????? ???????? ??????? ?????? ??? ????????????? ???????????? ????????? ?????? ? ????????? ? ????????????????
??-???????? ?????????????? ???????? ??????????? ????????????. ??????????? ??????? ????????? ? ????? ??????? ?????????????? ?????, ???????? ?? ????? ??????????. ?????? ?????????? ?????????? ????????????, ??????? ?????????????
?????????? ? ?????????? ????? ?????????? ? ????????? ? ????????? ????????????? ??? ????????????? ?? ??-??????? (1-? ??????) ? ? ?????????
????? ????????? ?????????? ??-????????????
(3-? ??????). ???????? 2-? ?????? ? ????????????????? ?????????? ??-???????????????? ??????30
????? ?? ???? ???????? ????????????? ??????
??????????. ??????? ????? ????????, ??? ?? ????
???? ??????? ? ????????? ?????????? ??????????? ???????? ?????????? ??????? ??????????????? ??-????????, ??? ??????? ??????????? ????????????? ?????????? ?? ????? ??????????. ?????
????????, ???????? ?? ??????? ??????????? ?????????????????? ??????? ? ??????? ? ?????? ??????? ??????, ????????????? ??????????? ???????
??????? ??????????????? ?????????? ??-??????? ?
?? ?????????? ?????????. ?????????? ?????? ???
??? ???????????? ??? ????, ??? ?????????? ??????????????? ?????????? ??-??????? ???????? ?????????? ?????????? ???????????????? ?????????,
??????? ????????? ? ????????????? ?????????.
А?мн??блкб
??????????????? ?????????? ??-??????? III?IV ??.
???????? ???????????? ???????? ????? ?????????? ??????????? ? ??????? ????? ???????? ??????? ? ??????? ????????????? ????????????? ?????????, ??? ????????? ??????? ?????????? ??????????? ? ???????? ?????????????? ?????????
?????????.
??????????
1.
2.
3
4.
5.
6.
7.
8.
9.
10.
11.
Choussat A., Fontan F., Besse P. et al. Selection criteria for
Fontan's procedure. In.: Anderson R.H., Shineborne E.A.
(eds). Pediatric cardiology. Edinburgh: Churchill Livinstone;
1978: 559?66.
????????? ?.?., ???????? ?.?., ????????? ?.?., ????? ?.?.
????????????? ??????? ?????????? ??????? ?????? ??????? ???????????????? ?????????. ?.: ????? ??. ?.?. ???????? ????; 2007.
Earing M.G., Cetta F., Driscoll D.J. et al. Long-term results of
the Fontan operation for double-inlet left ventricle. Am. J.
Cardiol. 2005; 96 (2): 291?8.
Ando M., Takahashi Y. Edge-to-Edge repair of common atrioventricular or tricuspid valve in patients with functionally single ventricle. Ann. Thorac. Surg. 2007; 84: 1571?7.
Mahle W.T., Cohen M.S., Spray T.L., Rychik J. Atrioventricular
valve regurgitation in patients with single ventricle: impact of
the bidirectional cavopulmonary anastomosis. Ann. Thorac.
Surg. 2001; 72: 831?5.
De Leval M.R., Kilner P., Gewilling M. et al. Total cavopulmonary connection: a logical alternative to atriopulmonary
connection for complex Fontan operation. J. Thorac.
Cardiovasc. Surg. 1988; 96: 682?95.
Driscoll D.J., Offord K.P., Feldt R.H. et al. Five- to fifteen-year
follow-up after Fontan operation. Circulation. 1992; 85:
469?96.
Cetta F., Feldt R.H., O'Leary P.W. et al. Improved early morbidity and mortality after Fontan operation: the Mayo Clinic experience, 1987 to 1992. J. Am. Coll. Cardiol. 1996; 28: 480?6.
Stamm C., Friehs I., Duebener L.F. Improving results of the
modified Fontan operation in patients with heterotaxy syndrome. Ann. Thorac. Surg. 2002; 74: 1967?78.
Ohuchi H., Kagisaki K., Miyazaki A. Impact of the Evolution of
the Fontan Operation on Early and Late Mortality: A SingleCenter Experience of 405 Patients Over 3 Decades. Ann.
Thorac. Surg. 2011; 92: 1457?66.
D'Udekem Y., Iyengar A.J., Cochrane A.D. et al. The Fontan
procedure: contemporary techniques have improved longterm
outcomes. Circulation. 2007; 116 (Suppl): 157?64.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Kerendi F., Kramer Z. B., Mahle W.T. et al. Perioperative Risks
and Outcomes of Atrioventricular Valve Surgery in
Conjunction With Fontan Procedure. Ann. Thorac. Surg.
2009; 87: 1484?9.
Sano S., Fujii Y., Arai S. et all. Atrioventricular Valve Repair for
Patient With Heterotaxy Syndrome and a Functional Single
Ventricle. Semin. Thorac. Cardiovasc. Surg. Pediatr. Card.
Surg. Ann. 2012; 15: 88?95.
Kwak J.G., C. S. Park,. Lee C.H, Lee C.l. Early Surgical
Correction of Atrioventricular Valvular Regurgitation in SingleVentricle Patients. Ann. Thorac. Surg. 2010; 90: 1320?3.
Ota N., Fujimoto Y., Hirose K., Tosaka Y. Improving results of
atrioventricular valve repair in challenging patients with heterotaxy syndrome. Cardiol. Young. 2010; 20: 60?5.
Imai Y., Seo K., Terada M. et al. Valvular repair for atrioventricular regurgitation in complex anomalies in modified Fontan
procedure with reference to a single ventricle associated with a
common atrioventricular valve. Semin. Thorac. Cardiovasc.
Surg. Pediatr. Card. Surg. Ann. 1999; 2: 5?19.
Tweddell J.S., Nersesian M., Mussatto K.A. Fontan Palliation in
the Modern Era: Factors Impacting Mortality and Morbidity.
Ann. Thorac. Surg. 2009; 88: 1291?9.
Mavroudis C., Stewart R.D., Backer C.L. et al. Atrioventricular
valve procedures with repeat Fontan operations: influence of
valve pathology, ventricular function, and arrhythmias on outcome. Ann. Thorac. Surg. 2005; 80: 29?36.
Kim S.J., Kim W.H., Lim H.G. et al. Outcome of 200 patients
after an extracardiac Fontan procedure. J. Thorac.
Cardiovasc. Surg. 2008; 136: 108?16.
Mahle W.T., Wernovsky G., Bridges N.D. et al. Impact of early
ventricular unloading on exercise performance in preadolescents with single ventricle Fontan physiology. J. Am. Coll.
Cardiol. 1999; 34 (5): 1637?43.
Ito M., Takagi N., Sugimoto S. et al. Pregnancy after undergoing the Fontan procedure for a double outlet right ventricle:
report of a case. Surg. Today. 2002; 32: 63?5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
References
1.
2.
3
4.
5.
Choussat A., Fontan F., Besse P. et al. Selection criteria for
Fontan's procedure. Anderson R.H., Shineborne E.A. (eds).
Pediatric cardiology. Edinburgh: Churchill Livinstone; 1978:
559?66.
Podzolkov V.P., Chiaureli M.R., Zelenikin M.M., Yurlov I.A.
Surgery for congenital heart defects performed by the method
of hemodynamic correction. Moscow: A.N.Bakoulev
Scientific Center for Cardiovascular Surgery of the Russian
Academy of Medical Sciences; 2007.
Earing M.G., Cetta F., Driscoll D.J. et al. Long-term results of
the Fontan operation for double-inlet left ventricle. Am. J.
Cardiol. 2005; 96 (2): 291?8.
Ando M., Takahashi Y. Edge-to-Edge repair of common atrioventricular or tricuspid valve in patients with functionally single ventricle. Ann. Thorac. Surg. 2007; 84: 1571?7.
Mahle W.T., Cohen M.S., Spray T.L., Rychik J. Atrioventricular
valve regurgitation in patients with single ventricle: impact of
the bidirectional cavopulmonary anastomosis. Ann. Thorac.
Surg. 2001; 72: 831?5.
17.
18.
19.
20.
21.
De Leval M.R., Kilner P., Gewilling M. et al. Total cavopulmonary connection: a logical alternative to atriopulmonary
connection for complex Fontan operation. J. Thorac.
Cardiovasc. Surg. 1988; 96: 682?95.
Driscoll D.J., Offord K.P., Feldt R.H. et al. Five- to fifteen-year
follow-up after Fontan operation. Circulation. 1992; 85:
469?96.
Cetta F., Feldt R.H., O'Leary P.W. et al. Improved early morbidity and mortality after Fontan operation: the Mayo Clinic
experience, 1987 to 1992. J. Am. Coll. Cardiol. 1996; 28:
480?6.
Stamm C., Friehs I., Duebener L.F. Improving results of the
modified Fontan operation in patients with heterotaxy syndrome. Ann. Thorac. Surg. 2002; 74: 1967?78.
Ohuchi H., Kagisaki K., Miyazaki A. Impact of the Evolution of
the Fontan Operation on Early and Late Mortality: A SingleCenter Experience of 405 Patients Over 3 Decades. Ann.
Thorac. Surg. 2011; 92: 1457?66.
D'udekem Y., Iyengar A.J., Cochrane A.D. et al. The Fontan
procedure: contemporary techniques have improved longterm
outcomes. Circulation. 2007; 116 (Suppl): 157?64.
Kerendi F., Kramer Z. B., Mahle W.T. et al. Perioperative Risks
and Outcomes of Atrioventricular Valve Surgery in
Conjunction With Fontan Procedure. Ann. Thorac. Surg.
2009; 87: 1484?9.
Sano S., Fujii Y., Arai S. et all. Atrioventricular Valve Repair for
Patient With Heterotaxy Syndrome and a Functional Single
Ventricle. Semin. Thorac. Cardiovasc. Surg. Pediatr. Card.
Surg. Ann. 2012; 15: 88?95.
Kwak J.G., C. S. Park, Lee C.H, Lee C.l. Early Surgical
Correction of Atrioventricular Valvular Regurgitation in SingleVentricle Patients. Ann. Thorac. Surg. 2010; 90: 1320?3.
Ota N., Fujimoto Y., Hirose K., Tosaka Y. Improving results of
atrioventricular valve repair in challenging patients with heterotaxy syndrome. Cardiol. Y. 2010; 20: 60?5.
Imai Y., Seo K., Terada M. et al. Valvular repair for atrioventricular regurgitation in complex anomalies in modified
Fontan procedure with reference to a single ventricle associated with a common atrioventricular valve. Semin.
Thorac. Cardiovasc. Surg. Pediatr. Card. Surg. Ann. 1999;
2: 5?19.
Tweddell J.S., Nersesian M., Mussatto K.A. Fontan Palliation in
the Modern Era: Factors Impacting Mortality and Morbidity.
Ann. Thorac. Surg. 2009; 88: 1291?9.
Mavroudis C., Stewart R.D., Backer C.L. et al. Atrioventricular
valve procedures with repeat Fontan operations: influence of
valve pathology, ventricular function, and arrhythmias on outcome. Ann. Thorac. Surg. 2005; 80: 29?36.
Kim S.J., Kim W.H., Lim H.G. et al. Outcome of 200 patients
after an extracardiac Fontan procedure. J. Thorac.
Cardiovasc. Surg. 2008; 136: 108?16.
Mahle W.T., Wernovsky G., Bridges N.D. et al. Impact of early
ventricular unloading on exercise performance in preadolescents with single ventricle Fontan physiology. J. Am. Coll.
Cardiol. 1999; 34 (5): 1637?43.
Ito M., Takagi N., Sugimoto S. et al. Pregnancy after undergoing the Fontan procedure for a double outlet right ventricle:
report of a case. Surg. Today. 2002; 32: 63?5.
?????????26.09.2013
31
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
╘ ????????? ???????, 2013
??? 616.124-089.844:616.12-007.271
???????????????? ????????????? ????? ??????????
I ????? ??? ????????????? ?????????? ?????? ??????
?.?. ???????, ?.?. ?????????, ?.?. ???????????, ?.?. ?????????, ?.?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ?
???????? ??? ? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????,
?????????? ?????????, 121552
??????? ??? ?????????, ???????? ??? ? ????, ????????;
????????? ???????? ????????, ???????? ????, ???. ?????????;
e-mail: vppodzolkov@heart-house.ru;
??????????? ????? ???????, ?. ?. ?.;
????????? ????? ?????????, ????-?????????;
????????? ????? ????????, ?. ?. ?.
? ?????? ???????????? ?????????? ?????????? ???????????????? ????????? ?????? ? 7 ????? ? ?????????????? ????????????? ????? ??????? ?????? ? ????????? ? ?????????? ???????? ??????????? ?????? ????????? ??? ????????.
???????? ?????: ??????? ?????????? ????? ??????? ??????; ????????? I ????; ???????????????? ?????????; ???????????
????????? ?????? ??????; ?????????????.
BIVENTRICULAR RECONSTRUCTION AFTER HYBRID STAGE 1 IN LEFT HEART
OBSTRUCTIVE LESIONS
L.A. Bockeria, V.P. Podzolkov, E.B. Simogaeva, I.Yu. Baryshnikova, D.O. Berishvili
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of Medical
Sciences; Roublevskoe shosse, 135, Moscow, Russian Federation, 121552
Bockeria Leo Antonovich, Academician of the Russian Academy of Sciences and Russian Academy
of Medical Sciences, Director;
Podzolkov Vladimir Petrovich, Academician of the Russian Academy of Medical Sciences, Deputy Director;
e-mail: vppodzolkov@heart-house.ru;
Baryshnikova Irina Yur?evna, MD, PhD;
Simogaeva Elena Borisovna, Cardiologist;
Berishvili David Olegovich, MD, DM.
The article presents the results of biventricular repair of combined left heart obstructive lesions and severe left ventricular hypoplasia
present at birth in 7 children.
Key words: hypoplastic left heart syndrome; hybrid stage I; biventricular repair; critical congenital heart defects; neonates.
г?б?блкб
??????????? ?????????? ????????? ?? ??????? ????????? ????????????? ??????? ? ??????????? ???????? ???????? ???????? ? ????????
??????????? ????????? ? ????????????? ? ?????????????? ??????????? ????? ??????? ??????. ????????????? ??????????????? ????????????? ???????????? ? ???????????? ??????? ?
??????????? ????????? ? ?????????????? ?????????????? ??????????? ????? ??????? ?????? ???????? ? ????????????? ????????????? ?????????????? ????????????? ???????, ???????
?????? ??????????? ????????? ???????. ?????? ?????????? ?????? ??????????? ??????????
32
??????? ??????, ????????????????? ????????
???? ???????? ??????, ??????? ????????? ????????????, ?? ??????????? ???????????????, ???
?? ????????? ????????? ????????????? ??????????? ????????? ??????. ? ????????? ?????
??????? ?????????? ??????????? ???????? ???????????????? ?????????????? ???????? ??????
?????? ? ??????????? ????????? ??? ??????????? ???????????????? ????????? ??????.
????????????? ???????????? ????? ???????????? ???????? ????? ???? ??????????? ?????,
??? ????? ?????????????????, ?? ?????????
?????????????? ???????? ? ????????????? ?
?????????????? ??????????? ????? ???????
?????? [1?4].
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
Е?зб?к?н к обзс??
???????????? ???????? 7 ??????? ??????????
???????????????? ????????? ????? ????? ???????????? ?????????? ????????????? ? ???????????
????????? ???????? ??????? ? ????????????? ????????? ????????????? ???????. ??? ???????? ????????? 8,7 % ???? ????????????? ? ?????????????? ??????????? ?????? ??????, ??????? ? ???????????? ???????? ??? ???????? I ????????? ????
???????????????? ?????????. ???? ????????? ???????? ?????????:
1) ??????? ?????????? ????? ? ???????? ??????? ?? ??????? ????????? (??? ??), ?????? ??????????????? ??????????? (????), ??????? ????
????? (?), ?????????? ??????????? ???????, ???????? ???????? ???? (???), ???????? ????????????
?????? (???);
2) ???????? ?????????? ?????? ?????? (???) ?
??????????? ??????????? ? ??????????? ????????,
??????? ???? ????? (?), ???, ???;
3) ????, ?????????? ????? (????), ?????????? ??????? ?????, ?????????? ??????????? ???????, ???, ???;
4) ???????? ??? ? ??????????? ??????????? ?
??????????? ????????, ?????? ????????? ?????? ?????? ?????????, ???, ???;
5) ?????????? ??????? ?????, ????, ????,
???, ???;
6) ??????? ??? ? ???????? ??????? ????? ? ??????????? ??????????? ???????, ????, ????,
???, ???;
7) ???????? ?????????? ?????? ??????, ????,
???, ???.
? ????? ? ??????????? ?????????? ?? ???? ??????????????? ????????? ???????????? ? ??????????? ????????? ????????? ???? ????????? ????????? ???????? ????????? ?????????? ?????????
?????? ? ????? ???????? ??????? ? ?????????????
???.
? ?????????? ?????? ?????????? ?????????
????????? ?????? ???????????? ????????? ?????????, ??????????? ???????????????????? ???????????? ??????? ??????, ? ??? ????? ??????? ????????????? ? ?????????????? ???????? ????????
???????? ?????? ? ??????? ??????????, ????????????? ??????????. ?????????? ???????? ????????????? ?????????? ???????? ??????? ??????
??? ????? 20 % [5].
???? ?????????? ????? ???????????????? ????????? ????????? ?? ???????, ????????????
Rhodes (1991 ?.).
?????? = 14,0 BSA + 0,943 ROOTi + 4,78 LAR +
0,157 MVAi ? 12,03,
??? BSA ? ??????? ??????????? ????, ?2; ROOTi ?
??????????????? ?????? ????? ?????; LAR ? ????????? ????? ?? ? ????? ??????; MVAi ? ??????????????? ??????? ????????? ??????????? ???????.
??? ???????? ??????? ?????? -0,35 ????????????-
?? ??????? ??????????? ?????? ????? ???????????????? ????????? ?????? [6]. ??? ?????? ??????????? ???????????????? ????????? ????????? ? ?????? ?????????: Z-????? ??????????????????? ?????????? ????????? ??????????? ?
??????????? ????????, ???????????????? ??????
?? [7]. ??????????????? ????? ???????? ??
(?/?2); ??????????? ??????? ???? ?????? ? ??????? ??????????; ??????? ????????????? ????????
(0 ? ???, 1 ??. ? ????????? ?????? ???????????
????? ??????????? ???????, 2 ??. ? ????????? ??????????? ????? ??????????? ??????? ? ?????????????? ??????????? ????????? ??, 3 ??. ? ???????? ?????????? ????????? ??) ????? ??????? ???????????????? ????????? [5, 8, 9]. ??? ??????????
? ????????? ??????? ???????????? ???? ? ??????????? ?????? ? ?????????? ?????.
Йбашн╦з?з?
??????????? ? ????????? ?????????????? ????????? ????? I ? II ?????????? ???????????? ? ???????.
?????? ????????? ?????????? ???????? ?????? ? ???? ????????? ?? ????????? ????????? ? ?
4 ????? ????? ????????????? ?????????? ??????.
????? ?????? ????????? ???????? Rhodes ???
???? ??????????? ???????? ? ????????? ??? ? 1
? ??? ? 6, ???????? ?? ??? ???????????????? ????????? ?????? ?? ???? ?????????.
???????? ???????? ???????? ?? ? ?? ? ?????
? ?????????????? ????????????? ?????? ?????? ??
?????????? ?? ??????????? ???????? ????? ??? ??
?????????? ?????????. ? ???????? ??? ? 6 ? ???????????? ???? ?? ???? ??????? ?????????? ???????? ?????????? ???????? ????????????? ?????????? ???????? ?? (? ??????? 5 %) ? ??????????
???????? ????????????? ?????????? ???????? ??
(? ??????? 35 %). ? 6 ?????? ????????? ? ?????????????? ????????????? ?????? ?????? ????????????? ?????????? ???????? ?? ???? ?????????????
??????? ? ????????? 18 ╠ 4 % ??? ????????? ????????? ?????????? ???????? ?? (???. 1).
?????????, ???????????? ? ????????? ? ?????????? ???????, ???????? ? ???????.
????????? ???????????????? ?????????????
???? ????????? ????????? ????? 5?7 ??? ?????
I ?????????? ?????:
? ??????? ??? ? 1 (???. 2): ????????? ???
?? ? ????????????? ??????????? ???????? ????
?????;
? ??????? ??? ? 2: ???????? ???? ? ????????????? ??????????? ???????? ???? ?????;
? ???????? ??? ? 3 ? ??? ? 5: ????????
????, ?????????? ????;
? ??????? ??? ? 4: ?????????? ????, ????????? ?????????????? ???????, ?????????????? ??????? ????? ???????????? ????????????????????
???????? ????????? 10 ??;
33
34
2
7
7
7
5
2
?2
?3
?4
?5
?6
?7
4
6,5
5
6
9
5
7
II ???
2,9
3,0
2,9
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??
Z-?????
??????
Rhodes
? ? ? ? ? ? ? ? ? ?. ?? ? ?????????? ??????; ??? ? ?????????? ?????; ???? ?? ? ???????? ?????????????? ????? ?????? ?????????; ??????????????? ?? ???????
??????????? ????; ??? ? ????? ????????, ??????????????? ?? ??????? ??????????? ????; ?? ? ?????????? ??????; ?? ? ????????????; L ??/?? ? ?????????
?????????? ??? ?????? ????????? ? ?????????? ??? ???????.
5
I ???
?1
???????
???????
Ебз?к?брмкб ??лл?б т??кблзс? л? особлз ?к╥?к?лсх стб???кк (I) к тб?б? ??ш?йбнш?с?мс?сх мс??бм?кбх (II)
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
?
╥
Йкр. 1. М??лрзс??м?н╦л?б ??с???оо? ? т?сбм?кк 4 м?об? ? ?бйкоб зм?лб?сх ?сттнб?с???ыкк:
? ? ?быс?о??к? оксм???? нб?с?с к т???с?с йбнш?с?мс? (Strain, %) ш т??кблз? тс? ? 4 р мн?ррк?брмко КиЦК, сзоб???зр? ????йбллсб рлкйблкб ркрзснк?брмсх ?быс?о??кк нб?с?с йбнш?с?м? (╠ 5 %) к лс?о?н╦л?б ал??блк? ?быс?о??кк оксм???? т???с?с йбнш?с?м? (?35 %, абнбл?? нклк?);
╥ ? ?быс?о??к? оксм???? нб?с?с йбнш?с?м? ш т??кблз? тс? ? 7 (мсотнбмр иЦК, ал??ко?? ?ктстн?ак? окз??н╦лс?с к ?с?з?н╦лс?с мн?т?лс?; Дсдс, ИИИ,
ИдХ), ркрзснк?брм?? ?быс?о??к? оксм???? Цэ лбал??кзбн╦лс рлкйбл? к рсрз??н?бз 15 %
Йкр. 2. дл?кс???оо? т??кблз? тс? ? I тб?б?
???км?н╦лсх мс??бм?кбх тс?см?:
?
╥
? ??????? ??? ? 6 (???. 3): ???????? Yasui,
?????????? ??????????? ???????? Damus ?
Rastelli, ? ??????????? ??????????????????? ????????????????? ???? ? ????????? ??????????????????? ???????;
? ??????? ??? ? 7: ???????? ???? ? ?????????? ???????? ?????? ? ???????? ?????? ? ?????? ?
????? ?????? ???????? ??????? ??? ??????????????
?????????????? (??).
?? ???? ??????? (?? ??????????? ???????? ???
? 7) ???????? ?????? ??????????? ????? ????????? ??? ?????? ? ??? ? ???????????? ????????
?????. ? ???????? ??? ? 7 ???????? ???????
?????? ??? ????????? ? ????????, ? ??????????
????? ??????? ? ???????????? ?????. ????????
?????? ? ???????? ??????? ??????????? ????????
???????? ??????? ? 2 ???????. ?? ???? ?????????
?????????????? ?????????????? ?? ? ????? ??????. ???????? ???? ????????? ? ???????? ????????????? ???????????? ???????? (?? ???????????
???????? ??? ? 7).
? ? ? нб?сх тб?б?лбх мсрсх т?сбм?кк т?б?рз??нбл? ?ср?с????? ?с?з? (1), т????? (2) к нб??? (3) с╥?кб рслл?б ??зб?кк; рзблз (4), ??рм??з?х ? т?сбм?кк сзм??зс?с ??зб?к?н╦лс?с т?сзсм?; ╥ ? ? нб?сх ╥смс?сх т?сбм?кк т?б?рз??нбл? нб?с?л?? ??зб?к? (1), т?с?снй?????р? ?б?ба
рзблзк?с??лл?х ИдХ (2) ? лкр?с???ш? ?с?зш (3), сз мсзс?сх сз?с??з нб??? (4) к ?╥б???лзл?? т????? (5) тс?мн??к?л?б ??зб?кк
????? ?????????????? ?????????????? ????????? ?? 117 ?? 240 ???, ????? ????????? ????? ?
?? 35 ?? 90 ???. ????????? ???????? ????????
?? ? ????????????? ???????? ????????? ????? ??
????????? 35 ??? ?? ? ????? ?? ???????. ??????????? ??????????? ???? ? 24 ╟C. ???????????????? ??????????? ???? ????????? ? 3 ?????????.
? ?????? ????????????????? ??????? ??????
2 ????????: ??????? ??? ? 6 ? ??????? ??? ? 4,
???????? ??? ? 6 ???? ????????? ???????? Yasui.
? ?????????? ????????? ????????? ?????? ????????? ?? ???? ??????????? ????????? ???????? ????????? ???????? ????????? ???? ????????????
???? ? ??????????????? ?????? ??????????????????? ???????, ??????????????? ???????????????????? ????????. ?????????? ????? ????? ????????? ????????????? ?????????? ? ???????? ????????? ?????????????? ???????? ????? ?? ? ??????
? ???????????? ????????? ???????????????? ???????????????. ??????? ??? ? 4 ? ???????? 2-?
???????? ????????????? ???? ? ?????????? ???35
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
ЦЦд
Дсл?шкз
Хэ/Цд
ЦХ
ХХ
Хэ
?
Цэ
А?тн?з? ЕэХ
? ? тб?боб?блкб лбс?с?з? ? нб??х йбнш?с?бм; ╥ ? рса??лкб ???с?? ? нб?с?лш? ??зб?к? ка т???с?с йбнш?с?м?
╥
?????????? ?????????? ? ?????????????????? ?
????????????????? ??????? ????????? ???????????????? ??????? ? ? ?????? ?????? ????????? ?
???????????????? ????????? ???? ?????????.
????? ???????, ???????????? ????? ???????????????? ????????? ????????? 71 %.
И╥ршй?блкб
??????????? ?????????? ????????????? ????????? ?????? ? ????????? ? ?????????????? ????????????? ????? ??????? ?????? ????? ??????????????. ?????? ?????????? ????????? ????????????? ???????? ?????????? ???????? ? ??????
????? ??????????????, ?????????? ????????? ? ???????????????? ????????? ??????, ? ????? ??????????????? ???????? ?????????? ?? ? ????????????? ????????????? ???????????? [2, 10?13].
??????? ????????? ?????????????? ????????
??????, ???? ??? ?? ?????????? ??????????, ????????? ????????? ?? ??????????? ?? ???????? ? ???????? ??????? ???? ??? ??????????? ???????????????? ???????? [14]. ????? ????????? ? ????????
???????? ?????? ???? ??????????? ?????????
???????????????? ????????? ??????. ?????????? ?????? ?????? ?????????? ????????????? ????????? ??????? ??????????? ????????????, ??????????????? ???????????? ?????????, ? ?????????
?????????? ???????? ? ???????? ?????????????
????????? ? ??????? ??????? ?? ??????? ??????????????? [3, 11]. ? ??????????? ??????? ??????????? ? ??????????? ?????????? ????? ???? ????????
? ??????? ??????????????? ????????????.
????????? ?????? ??? ?????? ???? ?????????????? ??????? ???????? ???????? ???????????? ?????????? ??? ????????????? ? ?????????????? ??????????? ????? ??????? ??????. ????????????
????????????? ?????????????? ????? ?????????
????????? ????????? ???????????????? ????????????????? ???????? ? ???????????? ???????? ??36
Йкр. 3. К?бо? ???км?н╦лсх мс??бм?кк тс?см? тс
Yasui ш т??кблз? тс? ? 6
(ркл??со иЦК р ?з?бакбх
мн?т?л? ?с?з? к ?ктстн?акбх окз??н╦лс?с мн?т?л?, яЕэХ, мс??мз??к?
?с?з?, ИИИ, ИдХ):
??????????????? ????? ??????? ??????. ?????????? ?????????? ??????????? ??????? ?????? ?????????, ??????????? ? ??????????? ???????? ???????? ????????? ?????? ??? ?????? ??????????? ?????????? ???????????????? ?????????.
г??с??
? ????????? ????? ????? ?????? ?????????????? ??????? ????????? ? ???????????? ?????????????? ????????????? ?????? ?????? ????????????
?? ??????????? ?????? ??????????? ? ???????????? ?????? ????????????? ? ???????????????
????????. ??????????????? ???????? ???????? ?
??????????? ??????? ????????????, ??????????
???????????? ??? ??????????? ????? ????????
?????? ? ??????????????? ???????? ???????????????? ?????????. ????????? ?????? ? ??????????? ????????????? ????????? ? ?????? ?????????
???????????????? ?????????? ?????? ? ???????.
??????????? ???????????????? ????????? ?????????? ??????? ?????? ? ?????????????? ??????????? ?????? ?????? ?????????????? ??????????????????? ????????????.
??????????/References
1.
2.
3.
4.
Alsoufia B., Al-Haleesa Z., Manlhiotb C. et al. Intermediate
results following complex biventricular repair of left ventricular
outflow tract obstruction in neonates and infants. Eur. J.
Cardiothorac. Surg. 2010; 38: 431?8.
Ballard G., Tibby S., Miller O. et al. Growth of left heart structures following the hybrid procedure for borderline hypoplastic
left heart. Eur. J. Echocardiogr. 2010; 11(10): 870?4.
Brown S., Boshoff D., Eyskens B., Gewillig M. Hybrid
approach as bridge to biventricular repair in a neonate
with critical aortic stenosis and borderline left ventricle.
Eur. J. Cardiothorac. Surg. 2009; 35 (6): 1080?2. doi:
10.1016/j.ejcts.2009.02.012
Gehrmann J., Kraseman T., Kehl H., Vogt J. Hypoplastic leftheart syndrome the first description of the pathophysiology in
1851; Translation of a publication by Dr. Bardeleben from
Giessen, Germany. Chest. 2001; 120: 1368?71.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
5.
6.
7.
8.
9.
10.
Bijnens B., Cikes M., Claus P., Sutherland G. Velocity and
deformation imaging for the assessment of myocardial dysfunction. Eur. J. Echocardiogr. 2009; 10: 216?26.
Rhodes L., Colan S., Perry S., Jonas R., Sanders S. Predictors
of survival in neonates with critical aortic stenosis. Circulation.
1991; 84: 2325?35.
http://parameterz.blogspot.com/
Colan S.D., McElhinney D.B., Crawford E.C., Keane J.F.,
Lock J.E. Validation and re-evaluation of a discriminant model
predicting anatomic suitability for biventricular repair in
neonates with aortic stenosis. Am. Coll. Cardiol. 2006; 47;
1858?65.
Lofland G., McCrindle B., Williams W. et al. Congenital heart
surgeons society critical aortic stenosis in the neonates multiinstitutional study of management, outcomes, and risk factors.
J. Thorac. Cardiovasc. Surg. 2001; 121: 10?27.
Emani S.M., Bacha E.A., McElhinney D.B. et al. Primary left
ventricular rehabilitation is effective in maintaining two-ventri-
11.
12.
13.
14.
cle physiology in the borderline left heart. J. Thorac.
Cardiovasc. Surg. 2009; 138 (6): 1276?82.
Hammela J., Kim F., Danford D., Kutty S. Two-stage biventricular rehabilitation for critical aortic stenosis with severe left
ventricular dysfunction. Eur. J. Cardiothorac. Surg. 2013; 43
(1): 143-8. doi: 10.1093/ejcts/ezs197
Pizarro C., Kolcz J., Derby C. et al. Hard choices for high-risk
patients with critical left ventricular outflow obstruction:
contemporary comparison of Hybrid versus surgical strategy. World J. Pediatr. Congen. Heart Surg. 2010; 1 (2):
187?93.
Tchervenkov C., Tahta S., Jutras L. et al. Biventricular repair in
neonates with hypoplastic left heart complex. Ann. Thorac.
Surg. 1998; 66: 1350?7.
Serraf A., Piot J., Bonnet N., Lacour-Gayet F. et al.
Biventricular repair approach in ducto-dependent neonates
with hypoplastic but morphologically normal left ventricle. J.
Am. Coll. Cardiol. 1999; 33: 827?34.
????????? 26.09.2013
╘ ????????? ???????, 2013
??? 616.131-053.31-089.168
?????????? ?????????? ????????? ? ????????
??????? ? ????????????? ? ?????????
?.?. ????????, ?.?. ?????????, ?.?. ?????????, ?.?. ??????
???? ╚??????? ??????????? ???????? ? 1 ??. ?????????? ?.?. ???????????╩ ??
?????????????? ????, ??. 1 ???, ?. 167, ?????????, ?????????? ?????????, 350912
???????? ?????? ????????????, ?. ?. ?., ???. ??????????;
????????? ??????? ??????????, ????-????????-?????????? ??????;
e-mail: georgith@rambler.ru;
????????? ??????? ?????????, ????-????????????-????????????;
?????? ??????? ??????????, ????-??????? ?????????
????????. ??????? ?????????? ????????? ? ????????-?????????? ???????? ??? ????? 100 ???. ? ???????? ??????? ??? ??????????? ? ????????????? ? ????????? ??? ????????? ??????? ?????????? ??????? ??????. ?????????? ????????? ????
?????????, ?????? ???????????? ????? ╚??????????╩ ?????? ??-?? ??????? ??????? ????????? ????????????? ????????????
?? ?????????? ????? ????????.
??????. ? ?????? 2006 ?? ??????? 2013 ?. 34 ????????? ????????? ????????????? ????????? ?????? ??????? ????????? ?
?????????????? ????????? ?????????. ??????? ????????? ? ?? 14 ???? ?? 1 ???? (4,82 ╠ 4,09 ???), ????? ???? ? ? ???????
4,7 ╠ 2,3 ?? (2,9?9,7 ??).
????. ??????????? ?????????? ???????? ? ?????????????? ????????? ? ???????? ??????? ? ????? ?? 1 ????. ??????????? ??
?????????? ???????? ???????????????? ? ????????????? ?????????? ?????? ???????, ???????????? ???? ?????????.
??????????. ????? ??????????? ????????? 14,7 % (n=5). ? ???? ?????????? ???????, ?? ?????? ?????, ??????? ????????
????????? ?? ???????? ???? 2,42 ╠ 0,72 (?? 1,3 ?? 3,9) ?/?, ? ??????? ???????? ? 22,22 ╠ 17,17 (?? 4 ?? 60) ?? ??. ??. ????????? 16 ????????? ????????. ?????? ?????????? (? ??????? 1 ???? ????? ?????????? ?????????????) ????????????? 3 (8,82 %)
???????, ???????? ? 2 ??????? ???????? ?????? ????????, ? 1 ???????? ????????? ????????? ??????? ?????????.
??????. ????? ???????? ??? ??????????? ? ???????? ??????? ?????????? ?????????? ????????? ????????? ??? ???????
??????? ?????????? ??????? ?????? ? ????????????? ? ?????????. ??????? ????????? ? ????????? ?????????? ?? ??????? ?? ???? ???????????? ??????????? ???????.
???????? ?????: ???????; ??????? ?????????? ?????? ??????; ??????????? ? ???????? ???????.
37
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
RESULTS OF THE USE OF CONDUITS IN THE PULMONARY POSITION IN
NEONATES AD INFANTS
M.V. Boriskov, G.A. Efimochkin, N.B. Karakhalis, T.V. Serova
S.V.Ochalovskiy Regional Clinical Hospital ? 1 of the Ministry of Healthcare of Krasnodarskiy
Region, ul. 1 Maya, 107, Krasnodar, Russian Federation, 350912
Boriskov Maksim Valentinovich, MD, PhD, Chief of Department;
Efimochkin Georgiy Alekseevich, Cardiovascular surgeon; e-mail: georgith@rambler.ru;
Karakhalis Nikolay Borisovich, Anesthesiologist-Intensivist;
Serova Tat'yana Viktorovna, Pediatric cardiologist.
Introduction. Conduits have been used in cardiovascular surgery for more than 100 years. They are used in neonates and infants in
the pulmonary position for the repair of complex congenital heart defects. There are different types of conduits, however, the ongoing search for an ?ideal? graft still continues that is due to high incidence of multiple reoperations over patient's lifetime.
Materials and Methods. From January 2006 to February 2013 34 patients underwent right ventricular outflow tract reconstruction
using various types of conduits. The age of patients ranged from 14 days to 1 year (4,82 ╠ 4,09 months), the average body mass
was 4,7 ╠ 2,3 kg (2,9?9,7 kg).
Objective. To present the outcomes of surgery with the use of conduits in the pulmonary position in infants under one year of age.
At the same time we aimed to compare the immediate and mid-term results received in other medical centers that deal with this
problem.
Results. Totally 5 patients died (the overall mortality rate was 14,7 %). Patients discharged from the hospital were examined with
echocardiographic imaging of coronary arteries which showed the mean blood flow velocity in conduit being 2,42 ╠ 0,72 m/s (ranges
from 1,3 to 3,9 m/s), and mean gradient being 22,22 ╠ 17,17 mm of mercury (ranges from 4 to 60 mm of mercury). 16 reoperations
were performed. 3 patients (8,82%) required early reoperations (within one year after the primary intervention), in 2 cases reoperations were performed due to conduit stenosis and one patient developed right ventricular aneurysm.
Conclusions. The choice of conduit for grafting in the pulmonary position remains a serious problem in the treatment of complex congenital heart defects in neonates and infants. The incidence of conduit-related complications doesn't depend on the type of modern grafts used.
Key words: conduit, complex congenital heart defects; graft in the pulmonary position.
г?б?блкб
??????? ?????????? ????????? ? ????????-?????????? ???????? ??????????? ??? ????? 100 ??? ?
?? ??????? ?????? ????????? ??????????? ? ????????? ??????????? ? ???????????? ?? ???????, ??????? ?????????? A. Carrel [1]. ? ????????? ?????
?????????? ????????? ????????, ?????? ???????????? ????? ?????????? ?????? ??-?? ??????????
? ?????????? ? ??????????????, ? ????? ? ????? ?
?????????? ????????? ? ???????????????? ?? ????????, ????????? ?????? ??????????, ??? ???????
?????????? ????????? ????????????. ?????? ???????????? ??? ??????????? ??? ??????? ?????????? ????????? ??????? ??????????????? ? ??????? ???? ?????. ???????? ? ???????? ??????? ? ?????
?? 1 ???? ??????????? ??? ????????? ?????????
??????? ?????????? ??????? ??????, ?????????
???????? ?????? ?? ??????? ?????????. ????? ???????, ????? ????????? ????? ? ????????? ?????????
???????? ??? ????? ????? ? ?????? ? ????????
????????? ? ????? ??????? ????????.
???? ?????? ????????? ? ??????????? ?????????? ???????? ? ?????????????? ????????? ? ???????? ??????? ? ????? ?? 1 ????. ??????????? ??
?????????? ???????? ???????????????? ? ????????????? ?????????? ?????? ???????, ???????????? ???? ?????????.
?????? ???????? ???????? ????????? ????????
? 60-? ???? ???????? ????, ????? ??????? W. Klinner
[2] ??????????? ?????? ?? ????????????? ??? ????????? ??????? ????? (1964 ?.), ????? G. Rastelli [3]
?? ??????? ???? ? 1965 ?. ????????? ??????????
38
????????? ? ??????? ????? ?????? ?????????? ?
???????? ???????? ??? ????????? ??????? ?????
? ???????? ????????. ??????????? D. Ross ?
J. Somerville [4] ????? ? ?????????????? ? 1966 ?.
??????? ? ????????? ?????????? ?????????? ???
???????? ???????. ? ?????? 1970-? ????? ????? ?????????? ?????? ? ???????????????????? ????????????????? ????????. ?????????? ?? ??????????? ??????? ? ???????????????? ?????? ???????? ?????? ???????? A. Carpentier [5?7].
? ????????? ??????????? Y. Brown [8] ??????????? ?
???????? ????????? ????????? ????? ??????? ????,
?????????? ??????, ? ????????? ????? ?????????
??? ╚Contegra╩ (╚Medtronic╩, ???????????, ??) [9].
? ????????? ????? ??????????? ??? ????? ???????????? ????????, ???????????????? ?????? ???????? ?? ????????????, ??????????? ? ?????????.
? ????? ????????? ?? ????????? ????????????? ???????????????????? ?????????? (╚??-????-????????╩ (????????), ╚??????-2╩ (??????) ?
??????? ╚Contegra╩).
Е?зб?к?н к обзс??
? ?????? 2006 ?? ??????? 2013 ?. 34 ????????? (14 ????????? ? 20 ???????) ? ???????? ??
1 ???? ????????? ????????????? ???? ?????? ??
??????? ????????? ? ?????????????? ?????????
?????????. ????????? ???????, ??????? ?????????, ?????????? ???????????? ????????????? ?
???????????? ??????? ???????????? ? ??????? 1.
??????? ??????? ?? ?????? ???????? ????????
4,82 ╠ 4,09 (?? 15 ???? ?? 12) ???, ????? ???? ??
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
М?╥нк?? 1
О???мзб?крзкм? т??кблзс? (2006?2013 ??.)
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??????-2 (13)
?? ??
??????-2 (15)
?? ??
??????-2 (13)
??????-2 (15)
?? ??
╩
╩
╩
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
5
6
1,5
7
12
5
3
12
1,5
1,5
0,1
1,5
12
1,5
2,5
8
0,5
2
?
?
?
????? ??? (3)
?
?
?
???? (7 ???), ??. ??
?
?
?
?
????? ??? (4 ???)
?
?
???? (6 ???), ??. ??
?
?
╩
╩
╩
╩
??????-2 (21)
??????-2 (15)
?? ??
??????-2 (21)
??????-2 (15)
?? ??
╩
╩
Contegra (16)
Contegra (12)
?? ??
Contegra (16)
??????-2 (19)
??????-2 (15)
? ? ? ? ? ? ? ? ? ?. ??? ? ??????? ???????? ???????, ??? ? ??????? ?????????? ????????????? ???????, ?? ? ????????
???????, ??? ? ????? ???????????? ?????, ?? ? ?????, ???? ? ??????????? ????????? ??????? ?????, ?? ? ???????
?????, ??? ? ???????? ???????????? ??????, * ?????????????? ???????????????? ????????????? ??? ??????.
?????? ???????? ? 4,7 ╠ 2,3 (2,9?9,7) ??. ? 30
??????? ???????????? ????????????????????
????????????????? ???????? ╚??????-2╩
(n=29), ╚??-????-????????╩, ???????? (n=1),
? 4 ? ???????? ╚Contegra╩ (???????? ? 2012 ?.).
???????? ????? ????????????? ???????
╚??????-2╩ (15 ??). ???????????? ????????
????????? ? 8 ??????? (4 ????????-????????
??????????, 4 ????????????? ???), 2 ??????? ?
????????? ??????????? ????????? ??????? ????? (??. ????. 1).
??? ????????? ???????? ??????????? ?????
????????? ??????????? ? ???????? ??????????-
???? ?????????????? (??????????? ?????????) ?
???????????????? ???????????? ???????????
40 ??/?? ??????????. ??????? ????? ?? ????????? 172,51 ╠ 79,45 ??? (105?500 ???). ????? ?????? ? ? ??????? 94,25 ╠ 27,87 (53?182) ???.
??????????? ???????? ??????????? ???????????
? ???????? ??????????? ?????????? ? ??????????? ???????? ???????, ???????????? ??????????????? ? ?????????????? ?????????? ? 1,5?2 ????
?????? ?????????? ???????? ????????. ??????
???????? ?????????? ? ?????? z-?????????? ???
??????? ????????, ??????? ???????? z-?????????? ? 3 ╠ 0,32 (2,67?3,54). ????? ????????????
39
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
М?╥нк?? 2
Кстшзрз?ш??кб ?к?ш??к?брмкб т?с?б?ш??
???????
????????????? ?????????
?????
?????????, n
???, ???, ??
?? ? ????????? ??????? ??
??? ? ?????????? ?????????? ??
??? (??? ?4) ? ?????????? ????? ????? (??? 2)
???????? ?????? ? ????? ???????? ???????
????????? ???????? ???????? ???????? ???????
???????? ????????? ?????????? ?????
????????????? ???? ?????
11
6
1
1
Д
д
Хэ
Йкр. 1. длб??као? ???с?лс?с сз?бн? т???с?с йбнш?с?м?:
д ? ?лб??као?; Д ? мсл?шкз; Хэ ? т????х йбнш?с?бм
дД
ИКд
гЭг
глД
Йкр. 2. И╥л?йбл? рсрш?? ╞бк рт????, т????? с╥??? рслл??
??зб?к? (ИКд), т????? ?лшз?блл?? ??бол?? ?бл? (гЭг); ??зб?к? м?л?нк?с??л? ?с?з?н╦лсх м?л?нбх (дД) 10Fr ?б?ба
рсрш?крз?х т?сзба ╚ис?-Мбмр╩ 4 оо, ?бл? ? тб?кыб?к?брмсх
?блсалсх м?л?нбх (глД) 14Fr
40
???????? (n = 8) ?????? ??????????? ????????
??????, ????? ???????? ??????? ? ??????????
???????? ?? PTF 0,4 ?? ??? ?????????? ???? ??????? ???????? ???????. ??? ??????? ????? ? ????????? ??????? ???????? ??????? ???????????
???????? ?????????????? ???????? ??????? ?????????? ????????. ?????? ???????? ? ??? ??
??????? ?????????, ???????? ???????? ??????? ?
?????????? ??????????? ?????? ?????, ???????
?????????? ?????????? ?????? ? ??????? ??????, ???? ????????? ???????? ????????????????
???????????? ??????? ??????????? ?????? ?????
? ??????????? ?????? ???????????. ???? ??????? ????? ???????????? ???????? (n = 9), ? ????? 2 ??????? ? ??? ?????????? ???????? ??????? ??????????? ???????? ?? ePTFE. ??????
???????? ? ??? ??? ?4 ???????????? ??????????? ????????????? ???? ????? (????. 2).
? ?????? ????????????????? ??????? ??????
5 ??????? (????? ??????????? ? 14,7 %). ?????????
??????????? ?????????: ???????-???????????????
????? (n=2), ?????? ????????-?????????? ??????????????? (n=2), ????????????????? ???????????????
(n=1). ? ???? ?????????? ???????, ?? ??????
?????, ??????? ???????? ????????? ?? ???????? ????????? 2,42 ╠ 0,72 (?? 1,3 ?? 3,9) ?/?, ? ??????? ???????? ? 22,22 ╠ 17,17 (?? 4 ?? 60) ?? ??. ??.
?????? ?????????? (? ??????? 1 ???? ????? ?????????? ?????????????) ????????????? 3 (8,82 %)
???????, ???????? ? 2 ??????? ???????? ??????
???????? ????? 8 ? 10 ??? ????? ???????? (????????
???????? ? 84 ? 98 ?? ??. ??. ??????????????), ?
1 ?????? ? ???????? ????????? ????????? ?????? ??
? ???????? (???. 1). ????????? ??????? ?? ????.
??-?? ???????????? ??????? (7 ??) ? ????????
??????? ????????? ?? ???????????? ?????????????? ??????????? ???????? ?? ????? ?????????
??????? ??? (???. 2).
?????? ?????????? ???????? 1284 ????????/??????, ? ??????? 42,8 ???. ? ?????????? ??????? ????????? 13 ??????????? ???????????? ? ?????? ???????? (n=2), ???????????????? ?????????
???????????????? (?????) ??????? (n=2), ????????????? ???????? ??????? (n=1). ????? ?????????? ???????????? ? ???????? ???????? ???????????? ? ??????? 3.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
М?╥нк?? 3
К?смк к т?к?кл? ??тснлблк? тс?зс?л?? ?об╞?збн╦рз?
????????
?????? ????? ???????????
?????????, ???
1?3
3?5
?????? ????????
3
7
????? ????????
????????????? ?????? ??
2
1
?
?
???????
?????? ???????? (n=7), ????????? ?? (n=1),
????????? ?? ? ???????? (n=1)
?????? ???????? (n=2)
?????? ?????? ?? (n=1)
Йкр. 3. Кзблзк?с??лкб
т???сх ?бз?к нб?с?лсх
??зб?кк
????????? ????? ?????? ???????? ? ???? ??????????? ?????????? ? 11 ???????, ??????? ???????? ???????? ???????? ? ??????? 88,45 ╠ 22, 71 (??
68 ?? 129) ?? ??. ??.; ????????? ??????? ????????? ?
? 1, ????????? ??????? ????????? ? ???????? ?
? 1 ??????. ?????? ???????? ????????? 3 ????????? ?????? ????????, ??????? ?????? ??????????? ??????????????? ?????????, ?????? ????????? ?????? ???????? ? ????????????? ?????? ???????? ???????. ??? 1 ????????? ????? ?????
????????? ????????, ???????? ???????? ??????.
????????????? ????????? ???????? ???????? ????? ????? ????????????????????? ?????????????
(???. 3). ?? ?????????????? ???????????? ????????
????? ??????????? ?????? ? ????? ?????? ???????? ??????? ???????? ?., 3 ???, ???????? ? ??????? ??????????????? ????????????? ??????? ╚??????-2╩ 15 ?? ??
?????? ????????? ?????? ????????????? ??????. ????? 10 ??? ???????? ????????? ?????? ???????? ?
??????????? ?????????? ???????? ??????? ????????
?? ePTFE ?? ??????? ╚??????-2╩ 21 ??, ????? 18 ??? ?
????????????? ????? ?????? ???????? ???????.
41
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
Йкр. 4. Кзблм? т???с?с йбнш?с?м?, рмнб?са к ?срт?нблкб.
в10
??? ??????????????? ????????????, ???????
??????????? ???? ????????????? ?????????, ??????? ?????????? ??????? ? ?????????? ??????
??????? ????????? ? ???? ?????????????? ?????????? (???. 4), ???, ?? ?????? ??????, ?????? ???????? ????????????? ????????? ? ??????? ???????
?????????.
И╥ршй?блкб
???????? ????????? ??????? ?????????? ??????? ?????? ? ?????????????? ?????????????
????????? ???????? ??????????, ???????? ? ?????
??????? ???? ?????. ??????? ??????? ?????????
???????? ? ????????? ????????????????? ??????? ??????? ?? ???????? ??????????? ?????? ?????
????? ?????????. ?? ??????? ????? ? ??????????? ???????? ???????????? ????????? ???????????? ?????? ?????? ???????. ???????? ??????????
???????? ?????????????? R.A. Jonas [10]: ?? ?????? ???? ??????????????, ??????????, ?????????????????? ?, ??????????, ??????????.
? ??? ???????????? ???????? ?????????? ? ???????? ???????????. ????????? ????????????????? ?????? ???????????? ? ??????????? ?????? ?
???????? 1980-? ?????. ??? ?? ????? ??????- ?
???????????? ??????????? ???????????? ?????????????????? ???????? ?????????? ? ???? ????????? ? ????????? ?????? ??????????????? ?? ??????? [11?13]. ??????? ????????, ??? ??? ??????????????? ??????? ??????? ??????????? ???
????????????? ????? ????????? (????? 15 ??) ?
????????? ?? 1 ???? [14]. ?????????? ???????????
???????????? ? ?????????? ? ???????? ??????????, ??????????????? ????????? ? ???????? ?? ????.
????????, ??????? ??????????? ? ??????????? ???????????????? ?????? ?? ?????????????? ??????
????????? ? ????? ??????????? ?????????? ? ????????????? ??????. ???????? ????????????? ???42
???????? ???? ? ?????????? ???????????, ??????,
??-?? ???????? ?????????? ???????? ? ?????? ?????. ???????????? ?? ?????????? ????????? ?????????? ???????? ??? ??????? ??????????? [15, 16].
?????????? ????? ?????????? ?????? ???????????????? ??? ????????? ???????????. ??????????
??????? ????????? ????????? ??????? ??????????
? ???????? ????????, ??? ???????????? ???????????
?? ?????????? ?????????? [17].
? ?????? ?????????? ?????? ??????????? ??????????????? ??????????? (?? ????? 10 % ?? ???????????) ???????????? ??????? ????? ? ?????????? ???????????? ?????? ? ?????? ?????????????? ???????. ?????????? ????? ??????????? ?
???????????? ?? ??????? ???? ???? ╚Contegra╩ ?
?????????? ????????? ╚Hancock╩ ?? ?????? ?????????????.
?????????? ????? ???????, ??????? ??? ????????? ?????? ????????? ???????? ? ????????
???????, ??????? ?????????????? ?????? ? ???????????, ???????? ??? ????????? ?????????.
? ??????? ????????? ???? ??????????? ?????????????? ????????? ?????????????????? ? ??????????????? ??? ??????????????? ????????????.
???????????? ??????? ????? ???????????? ?????????? ╚Contegra╩ ? ??????? ???? ???? ? ????????
(╚Medtronic╩). ???????????? ?????????? ???????????, ??????????? ?????????????? ???????????? ??????? ?????????????????? ?????? ? ????????????? ?????????? [18?21]. ??? ?? ????? ???????? ????????? ? ??? ????????? ? ??????
??????????? ??????????, ????????? ?????????? ?
??????????????? ??????? ????? ???? ???????????????? [22?24]. ? ????????????? ????????? Marie
Lannelongue (France) [25] ??????????? ╚Contegra╩
?????????????? ? ??????? ?? ?????????, ??????
?????????? ???? ?????????????? ??-?? ????? ??????? ????????????????? ?????????? ? ??????? ???????? ?????????? ????????. ? 2006 ?. ╚Contegra╩, ?
????? ????????? ????????????? ??????????, ????? ???? ??????? ? ????????????? ???? ????????,
?? ? ?????? ????????????? ??? ????????? ??????????? ?????????? (?????? ?????? ? ??????) ?
??? ?????????? ?????????? ????????????? ? ???????????????? ??????????. ??????????? ? ????????????? ?????????:
? ?? ???????? ??? ????????????? ??-?? ???????? ??????? ???????;
? ?????????????? ??????? ????? ???????? ?
?????????????? ? ??????????? ???????;
? ?????????????? ??? ??????? ???????? ??????????? ??? ???????????? ???????? ??????????
?????, ??? ?????????????? ??????? ????? ???????? ????????.
? ????????? Marie Lannelongue (France) ???????? ????? ???????????? ?????????? ????????
╚Hancock╩ ?? ?????? ?????????????. ?????????
??????????? ??????? ???????? ???????????? ???
????????????? ???? ???????? ? ?????????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
М?╥нк?? 4
Йбашн╦з?з? кртсн╦ас??лк? ??анк?л?? зктс? мсл?шкзс?
???????????
(?????????
?/? ??????)
??????, ??????????
??? ????????
??????? ?.?., ?????
??. ?.?. ???????? ????,
?????? (2009 ?.)
Afksendiyos Kalangos,
Geneva (2010 ?.)
R.S. Fortuna, D.M. Geiss,
University of Illinois et
Colorado (2011 ?.)
A.Serraf, Marie Lannelongue
Hospital, France
W.H. Williams, Atlanta,
Georgia (2002 ?.)
M.W. Turrentine, Indiana
(2005 ?.)
???????????????????? ???????
? ?????????????? ????????
(n = 95)
?????????? ????????? (n = 120),
╚Contegra╩ (n = 85)
??????????? ????????? (n = 61),
?????????????????????
????????? (n = 39)
?????????? ???????? ?? ??????
????????????? ╚Hancock╩
??????????? ?????????? ?????????
(n = 17), ???? ?? 3 ???
??????????? ?????????? (n = 23) ?
???????? (n = 94) ??????????
??? ????????? ? ????????????? ?????? ????????????? ?????? ????????????? ????????? ??????
??????? ????????? ??? ???? ?????????????? ???
???????? ???? ????? ??????? ?????????? ??? ? ??????? PTFE-???????? ? ????????????.
? ?????? ??????????????? ????????????? ????????, ??-????????, ????? ??????? ? ????????????
??????????. ?????????, ?????????? ? ???????????? ?????????, ??????????? ?? ???? ????? ???????????????????, ???? ? ? ?????????????? ?????????????. ????????? ??????????? ???????? ?????
??????? ?????????? ??????????? ??????? ??????????, ???? ????? ????? ?????????? ?????????? ???????? ??????? ???????? ?? PTFE.
?????????? ???????? ?????????? ????????????? ?? ???????? ????????? ? ???????? ??????????
??????? ?????? ? ????????????? ? ????? ?? ????.
?????????????? ?????? ??????? ?? ???????????,
? ???????? ?????? ?????? ? ?????????????? ??????? ????????. ?????????? ???????? ╚Hancock╩
?? ?????? ????????????? ????????? ???????????? ? ???????? ???????? ? ???????? ??????? ??-??
??????????? ????????? ??????????? ????????????? ??? ???????????? ??????????? ??????????
????????. ???????????? ??????????? ??????? ?
??????? ???????????? ???????? ??????????????
????????????? ????????? ??????? ????????. ?
?????? ????????????? ??????????? ???????? ????????? ?????????? ?????? ? ?????? ??? ????????
?? ????? ????????? ????????, ?????????????
?????? ?? ????????? ??????. ?????????? ??????? ?? ?????? ????????????? ╚Hancock╩ ????????
????????????? ?????????????????? ??? ????????????? ????. ??? ????? ????????????? ??? ????????????? ? ?????? ???????????????, ??? ???????????? ???????? ?????????? ????? ??? ?????????? ???????? ?????????? ?????????????
??? ?? ??????????, ??? ???????????????????
??????? ????????????????????.
??????? ??
??????
?????????? ?
??????????
(?? 1 ????), % ??????? 5 ???, %
24
3
11
6
12,73
6,7
1,1
8
82,14
63?85,7
89
69
5
2
82
3
2
81
0
24
65
16
?
60
?????????? ???????? ???????? ????????????
??? ????????? ????????? ╚Hancock╩ ? ??????? ?????? ?????- ? ??????????????????? [25].
? ?????? ? ???????? ???????????? ??????????????????. ????????????? ? ????? ??. ?.?. ???????? ???? ???????????????????? ????????????????? ??????? ╚??????╩ ? ??? ??????????? ??
????????? ?? ??????????? ??????? ?????? ╚??????-2╩ ?????????? ???????????????? ? ?????????? ??????????, ???????????? ? ???????? ????????? [26]. ???????????? ?????????? ?? ????????,
??????? ??? ????????????? ??????? ╚??????-2╩
?????? ???????? (????? 15 ??), ????????? ???????
????? ? ???, ??? ?????? ??????? ????? ?????????????? ? ????????? ?? 1 ???? (????. 4) [27?29].
г??с??
1. ????? ???????? ??? ??????????? ? ????????
??????? ?????????? ?????????? ????????? ????????? ??? ??????? ??????? ?????????? ???????
?????? ? ????????????? ? ?????????.
2. ??????? ????????? ? ????????? ?????????? ??
??????? ?? ???? ???????????? ??????????? ???????.
??????????
1.
2.
3.
4.
5.
6.
Carrel A. Ultimate results of aortic transplantations. J. Exp.
Med. 1912; 15: 389.
Klinner W. Indikationsstellung und operative Technik fur die
Korrektur der Fallotschen Tetralogie. Langenbecks Arch. Klin.
Ehirurgle. 1964; 308: 40.
Rastelli G.C., Ongley P.A., Davis G.D. et al. Surgical repair for
pulmonary valve atresia with coronary-pulmonary artery fistula: Report of case. Mayo Clin. Proc. 1965; 40: 521.
Ross D.N., Somerville J. Correction of pulmonary atresia with
a homograft aortic valve. Lancet. 1966; 2: 1446?7.
Emery R.W., Landes R.G., Moller J.H., Nicoloff D.M.
Pulmonary valve replacement with a porcine aortic heterograft. Ann. Thorac. Surg. 1979; 27: 148?53.
Carpentier A., Deloche A., Relland J., Fabiani J.N., Forman J.,
Camilleri J.P., Soyer R., Dubost C. Six-year follow-up of glu-
43
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
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20.
21.
22.
23.
24.
25.
44
taraldehyde-preserved heterografts. With particular reference
to the treatment of congenital valve malformations. J. Thorac.
Cardiovasc. Surg. 1974; 68: 771?82.
Carpentier A., Lemaigre G., Robert L., Carpentier S., Dubost ?.
Biological factors affecting long-term results of valvular heterografts. J. Thorac. Cardiovasc. Surg. 1969; 58: 467?83.
Scavo V.A., Turrentine M.W., Aufiero T.X., Sharp T.G., Brown J.W.
Valved bovine jugular venous conduits for right ventricular to
pulmonary artery reconstruction. ASAIOJ. 1999; 45: 482?7.
Breymann T., Thies W.R., Boethig D., Goerg R., Blanz U.,
Koerfer R. Bovine valved venous xenografts for RVOT reconstruction: results after 71 implantations. Eur. J. Cardiothorac.
Surg. 2002; 21: 703?10.
Jonas R.A. Comprehensive surgical management of congenital heart disease. Ahnold; 2004.
Forbess J.M., Shah A.S., St. Louis J.D., Jaggers J.J.,
Ungerleider R.M. Cryopreserved homografts in the pulmonary
position: determinants of durability. Ann. Thorac. Surg. 2001;
71: 54?60.
Dearani J.A., Danielson G.K., Puga F.J., Schaff H.V., Warnes C.W.,
Driscoll D.J. et al. Late follow-up of 1095 patients undergoing
operation for complex congenital heart disease utilizing pulmonary ventricle to pulmonary artery conduits. Ann. Thorac.
Surg. 2003; 75: 399?411.
Brown J.W., Ruzmetov M., Rodefeld M.D., Vijay P., Turrentine M.W. Right ventricular outflow tract reconstruction with an
allograft conduit in non-Ross patients: risk factors for homograft dysfunction and failure. Ann. Thorac. Surg. 2005; 80:
655?64.
Wells W.J., Arroyo Jr. H., Bremner R.M., Wood J., Starnes V.A.
Homograft conduit failure in infants is not due to somatic outgrowth. J. Thorac. Cardiovasc. Surg. 2002; 124: 88?96.
Tweddell J.S., Pelech A.N., Frommelt P.C., et al. Factors
affecting longevity of homograft valves use in right ventricular
outflow tract reconstruction for congenital disease.
Circulation. 2000; 102 (Suppl 3): 130?5.
Bielefeld M.R., Bishop D.A., Campbell D.N., Mitchell M.B.,
Grover F.L., Clarke D.R. Reoperative homograft right ventricular outflow tract reconstruction. Ann. Thorac. Surg. 2001; 71:
482?8.
Ruzmetov M., Shah J.J., Geiss D.M., Fortuna R.S.
Decellularized versus standard cryopreserved valve allografts for
right ventricular outflow tract reconstruction: A single-institution
comparison. J. Thorac. Cardiovasc. Surg. 2012; 143: 543?9.
Corno A.F., Qanadli S.D., Sekarski N. et al. Bovine valved
xenograft in pulmonary position: Medium term follow-up with
excellent hemodynamics and freedom from calcification.
Ann. Thorac. Surg. 2004; 78: 1382?8.
Brown J.W., Ruzmetov M., Rodefeld, M.D., Palaniswamy V.,
Darragh R.K. Valved bovine jugular vein conduits for right ventricular tract reconstruction in children: An attractive alternative to pulmonary homograft. Ann. Thorac. Surg. 2006; 82:
909?16.
Morales D.L.S., Braud B.E., Gunter K.S. et al. Encouraging
results for the Contegra conduit in the problematic right ventricle-to pulmonary artery connection. J. Thorac. Cardiovasc.
Surg. 2006; 132: 665?71.
Bove? T., Demanet H., Wauthy P. et al. Early results of valved
bovine jugular vein conduit versus bicusp homograft for right
ventricular outflow tract reconstruction. Ann. Thorac. Surg.
2002; 74: 536?41.
Boudjemline Y., Bonnet D., Agnoletti G., Vouhe P. Aneurysm
of the right ventricular outflow following bovine valved venous
conduit insertion. Eur. J. Cardiothorac. Surg. 2003; 23: 122?4.
Zavanella C., Portela F. Early failure of bovine jugular vein
conduits. J. Thorac. Cardiovasc. Surg. 2004; 127: 610.
Corno A.F., Mickaily-Huber E.S. Comparative computational
fluid dynamic study of two distal Contegra conduit anastomoses. Int. Cardiovasc. Thorac. Surg. 2008; 7: 1?5
Belli E., Saliholu E., Leobon B., Roubertie F., Ly M., Roussin R.,
Serraf A. The performance of hancock porcine-valved dacron
26.
27.
28.
29.
conduit for right ventricular outflow tract reconstruction. Ann.
Thorac. Surg. 2010; 89: 152?8.
??????? ?.?., ????????? ?.?., ?????????? ?.?., ???????? ?.?., ???????????? ?.?., ????? ?.?., ??????? ?.?.,
??????? ?.?., ??????? ?.?., ??????? ?.?., ???????? ?.?.
????????????? ?????? ??????????? ????????????? ???????????????????? ???????????? ?????????????? ????????? ??? ????????? ??????? ?????????? ??????? ??????.
??????? ? ????????-?????????? ????????. 2010; 6: 4?10.
??????? ?.?., ??????? ?.?., ??????? ?.?., ???????????? ?.?., ??? ?.?. ? ??. ?????????? ??????????? ?????????????????, ???????????????????? ?????????????? ????????? ?????? ???????? (?15 ??) ? ????????? ? ??????????? ???????? ??????. ??????? ? ????????-??????????
????????. 2009; 2: 4?10.
????????? ?.?., ???????? ?.?., ??????? ?.?. ??????? ???????? ??????? ? ???????? ??????????????? ???????????. ?.; 2003.
??????? ?.?., ??????? ?.?., ??????? ?.?., ???????????? ?.?., ??? ?.?. ? ??. ?????????? ??????????? ????????????????? ???????????????????? ????????? ? ?????????????? ???????? ? ????????? ? ??????????? ???????? ??????. ??????? ? ????????-?????????? ????????.
2009; 6: 29?37.
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Rastelli G.C., Ongley P.A., Davis G.D. et al. Surgical repair for
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Ross D.N., Somerville J. Correction of pulmonary atresia with
a homograft aortic valve, Lancet, 1966; 2: 1446?7.
Emery R.W., Landes R.G., Moller J.H., Nicoloff D.M.
Pulmonary valve replacement with a porcine aortic heterograft. Ann. Thorac. Surg. 1979; 27: 148?53.
Carpentier A., Deloche A., Relland J., Fabiani J.N., Forman J.,
Camilleri J.P., Soyer R., Dubost C. Six-year follow-up of glutaraldehyde-preserved heterografts. With particular reference
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Cardiovasc. Surg. 1974; 68: 771?82.
Carpentier A., Lemaigre G., Robert L., Carpentier S., Dubost ?.
Biological factors affecting long-term results of valvular heterografts. J. Thorac. Cardiovasc. Surg. 1969; 58: 467?83.
Scavo V.A., Turrentine M.W., Aufiero T.X., Sharp T.G., Brown J.W.
Valved bovine jugular venous conduits for right ventricular to
pulmonary artery reconstruction. ASAIOJ 1999; 45: 482?7.
Breymann T., Thies W.R., Boethig D., Goerg R., Blanz U.,
Koerfer R. Bovine valved venous xenografts for RVOT reconstruction: results after 71 implantations. Eur. J. Cardiothorac.
Surg. 2002; 21: 703?10.
Jonas R.A. Comprehensive surgical management of congenital heart disease. Ahnold; 2004.
Forbess J.M., Shah A.S., St. Louis J.D., Jaggers J.J.,
Ungerleider R.M. Cryopreserved homografts in the pulmonary
position: determinants of durability. Ann. Thorac. Surg. 2001;
71: 54?60.
Dearani J.A., Danielson G.K., Puga F.J., Schaff H.V., Warnes C.W.,
Driscoll D.J. et al. Late follow-up of 1095 patients undergoing
operation for complex congenital heart disease utilizing pulmonary ventricle to pulmonary artery conduits. Ann. Thorac.
Surg. 2003; 75: 399?411.
Brown J.W., Ruzmetov M., Rodefeld M.D., Vijay P.,
Turrentine M.W. Right ventricular outflow tract reconstruction
with an allograft conduit in non-Ross patients: risk factors for
homograft dysfunction and failure. Ann. Thorac. Surg. 2005;
80: 655?64.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
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Wells W.J., Arroyo Jr. H., Bremner R.M., Wood J., Starnes V.A.
Homograft conduit failure in infants is not due to somatic outgrowth. J. Thorac. Cardiovasc. Surg. 2002; 124: 88?96.
Tweddell J.S., Pelech A.N., Frommelt P.C. et al. Factors affecting longevity of homograft valves use in right ventricular outflow tract reconstruction for congenital disease Circulation
2000;102(Suppl 3): 130-5.
Bielefeld M.R., Bishop D.A., Campbell D.N., Mitchell M.B.,
Grover F.L., Clarke D.R. Reoperative homograft right ventricular outflow tract reconstruction. Ann. Thorac. Surg. 2001; 71:
482?8.
Ruzmetov M., Shah J.J., Geiss D.M., Fortuna R.S.
Decellularized versus standard cryopreserved valve allografts
for right ventricular outflow tract reconstruction: A single-institution comparison. J. Thorac. Cardiovasc. Surg. 2012; 143:
543?9.
Corno A.F., Qanadli S.D., Sekarski N. et al. Bovine valved
xenograft in pulmonary position: Medium term follow-up with
excellent hemodynamics and freedom from calcification. Ann.
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Brown J.W., Ruzmetov M., Rodefeld M.D., Palaniswamy V.,
Darragh R.K. Valved bovine jugular vein conduits for right ventricular tract reconstruction in children: An attractive alternative to pulmonary homograft. Ann. Thorac. Surg. 2006; 82:
909?16.
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results for the Contegra conduit in the problematic right ventricle-to pulmonary artery connection. J. Thorac. Cardiovasc.
Surg. 2006; 132: 665?71.
Bove? T., Demanet H., Wauthy P. et al. Early results of valved
bovine jugular vein conduit versus bicusp homograft for right
ventricular outflow tract reconstruction. Ann. Thorac. Surg.
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Zavanella C., Portela F. Early failure of bovine jugular vein
conduits. J. Thorac. Cardiovasc. Surg. 2004; 127: 610.
Corno A.F., Mickaily-Huber E.S. Comparative computational
fluid dynamic study of two distal Contegra conduit anastomoses. Int. Cardiovasc. Thorac. Surg. 2008; 7: 1?5
Belli E., Saliholu E., Leobon B., Roubertie F., Ly M., Roussin R.,
Serraf A. The performance of hancock porcine-valved dacron
conduit for right ventricular outflow tract reconstruction. Ann.
Thorac. Surg. 2010; 89: 152?8.
Bockeria L.A., Podzolkov V.P., Kagramanov I.I., Kokshenev I.V.,
Astrakhantseva T.O., Yurlov I.A., Dontsova V.I., Kovalev D.V.,
Danilov T.Yu., Katsadze N.G., Askerova R.I. Comparative evaluation of the use of xenopericardial stentless three-valved
conduits in the surgical correction of complex congenital heart
disease. Grudnaya i serdechno-sosudistaya khirurgiya.
2010; 6: 4?10 (in Russian).
Bockeria L.A., Shatakhyan M.P., Shatalov K.V., Gorbachevskiy S.V., Kim A.I. et al. Outcomes of the grafting of extracardiac, xenopericardial three-valved small-diameter conduits
(?15 mm) in patients with congenital heart disease. Grudnaya
i serdechno-sosudistaya khirurgiya. 2009; 2: 4?10 (in
Russian).
Podzolkov V.P., Kokshenev I.V., Gadzhiev A.A. Pulmonary
atresia with ventricular septal defect . Moscow; 2003 (in
Russian).
Bockeria L.A., Shatakhyan M.P., Shatalov K.V., Gorbachevskiy S.V., Kim A.I. et al. Outcomes of the grafting of extracardiac xenopericardial three-valved conduits in patients with
congenital heart disease. Grudnaya i serdechno-sosudistaya
khirurgiya. 2009; 6: 29?37 (in Russian).
????????? 29.09.2013
╘ ????????? ???????, 2013
??? [616.131-007.271:616.124.6-007.253]-053.36-089
??????? ????????????? ????????? ??????? ????????
??????? ? ???????? ??????????????? ???????????
? ????? ??????? ???? ?????
?.?. ???, ?.?. ???????, ?.?. ??????, ?.?. ??????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ?
???????? ??? ? ???? ?.?. ???????) ????; ?????????? ?????, 135, ??????,
?????????? ?????????, 121552
??? ??????? ????????, ?. ?. ?., ?????????, ???. ??????????; e-mail: orhn@yandex.ru;
??????? ?????? ??????????, ?. ?. ?.;
?????? ??????? ????????????, ?. ?. ?.;
?????????? ?????? ?????????, ?. ?. ?.
? 2003 ?? 2013 ?. ?????????????? 26 ????? (9 ????????? ? 17 ???????) ? ?????????? ?????????? ????? ?????? ?????????? ? ???????? ???????. ??????????? ??????? ?????? ?????? ?????????????? ??????? ??? ??????? ???????????????? ???-
45
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
?????-???????? ????????? ?? Blalock?Taussig, 4 ? ??????????? ???????? ???????????? ??????. ???? ????????? ?????????
????????????? ????? ?????? ?? ??????? ????????? ??? ???????? ??????? ??????????????? ???????????. ?? ?????? ???????
?? ?????????? ????????? ? ???????????? ????? ????????? 93,2 ╠ 5,7 %, ?????????? ??????????? ? ?????????? ?????????? ?
???????? ?????. ??????????? ? ?????? ?????? ????????? ????????? ?????? 7,7 %. ?????? ???????? ????? ???? ????????????? ????? ? ???????? ???????? ??????? ??? ?????????? ??????? ???????? ??????? ? ??????????? ??????? ?????? ?????????.
???????? ?????: ???????; ?????????????; ???????????? ????????.
STAGED REPAIR OF PULMONARY ATRESIA WITH VENTRICULAR SEPTAL
DEFECT IN INFANTS IN THE FIRST YEAR OF LIFE
A.I.Kim, R.R.Khamitov, T.V.Rogova, T.R.Grigor'yants
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of Medical
Sciences; Roublevskoe shosse, 135, Moscow, Russian Federation, 121552
Kim Aleksey Ivanovich, MD, DM, Professor, Chief of Department; e-mail: orhn@yandex.ru;
Khamitov Rustam Ravil'evich, MD, PhD;
Rogova Tat?yana Vladimirovna, MD, PhD;
Grigor'yants Tigran Rachikovich, MD, PhD.
26 children (9 boys and 17 girls) with impaired communication between right ventricle and pulmonary trunk were operated
from 2003 to 2013. Modified Blalock-Taussig systemic-pulmonary anastomosis was performed in 11 patients in the first stage
of surgical treatment, in 4 ? stenting of patent arterial duct. All patients underwent right ventricular outflow tract reconstruction
without closure of ventricular septal defect. At the time of hospital discharge oxygen saturation was 93,2 ╠ 5,7 %, hemoglobin
content and hematocrit were within normal values. The mortality rate for this group of patients was 7,7 %. This type of operation can be recommended for children with pulmonary artery atresia in hypoplasia of pulmonary arterial system and reduced
left ventricular size.
Key words: atresia; reconstruction; palliative operations.
??????????? ?????????? ??????????? ????????? ??? ??????? ???????? ??????? ? ???????? ??????????????? ??????????? (????) ? ???????????? ???????? ??????? ??? ?? ????? ????????? ??????,
??? ? ?? ?????????????? ???????-???????????????
???????????? ???????? [1?3]. ????? ?? ????????
????? ????????????? ?????????, ??? ??????? ???????? ?????????? ????????, ???????????? ??
???????? ????????? ?????, ???????? ??????????
?????? ? ?????? ???????? ??????? (??). ?? ??????
????????? ???????, ??????? ????????? ????? ????????????????? ???????? ??????? ??? ??????? ???????? ??????? ? ???????? ??????????????? ??????????? ?????????? ???????? 15 % [4, 5], ?????????????, ?????? ??????????? ?????? ?????????
????????? ????????? ????????? ????????? ???????
??????????? ? ????????????? ????? ???????????
????????? ? ?????????????????? ??????? ? ?????? ????????? ?????????. ??????? ???????? ??????? ? ?? ?????? ? ??? ???????? ???????? ??????????? ?????????? ??????????? ???????? ? ????????? ? ???????? ????????????. ??????????
?????????? ?????????? ??????????? ???????????
??????????? ????????? ?? ??????? ???????? ????????? ?????. ????????????? ??????????? ??????????? ?????? ?????????? ??????? ?? ???? ??????????? ????????? ??????? ???? ?????????? ???????????? ????????????? ? ?????????????? ???
????????? [1, 6, 7]. ??????????????????? ?????????
? ?????????? ????????? ??????? ??????? ????????
??????? ???????? ??????? [1, 7].
? ????????? ????? ???????? ???????? ???????? ?????? ???????? ???????-???????????? ??????
46
(???), ???????????? ? 1984 ?. S.Y. Nakata ? ???????????? ?? ?????? ???????????????????. ????
?????? ?????????????? ????? ???????????? ??????? ??????????? ??????? ?????? ????? ????????
??????? ? ??????? ?????????? ?????? ??????? ????? ? ??????????? ??????? ?? ??????? ???????????
???? ????????.
??? ??????? ?????????? ?????????? ????????
?????????? 300 ╠ 30 ??2/?2. ??????????? ???????
?????????? ?????????? ?????????? ????????
??? ??? ??????????? ????????? 150 ??2/?2 [3, 5,
6]. ??? ??? ????? 150 ??2/?2 ???? ????????????
????????????? ?????????, ??? ?? ????? ??????????? ???? ???????? ?????????? ??????? ?????????.
?????????????? ??? ??? ???? ?????????? ???????? ????????? ?????? ???????????? ????????, ???????????? ?? ???????? ????????? ???????????
?????.
H. Oelert ? ?????. ?????????? ????????? ??????????? ??????????? ????????? ??????? ??????? ??? ????????? ???????? ?????????? ????? ??
?????? ????????? ? ????? ????????? ?????? ? ????? ???????? ???????. ??? ?????????? ??????????
????? 0,7 ??????????? ????????? ??????????.
?????? ??????? Nakata, ?????? ????????????
?????? ???????????????????????? ?????? ? ?????? McGoon. ?? ???????????? ??? ????????? ????? ????????? ?????? ?????? ?? ? ???????? ?????????? ?????. ???????????? ???????? ???????? ???
?????????? ????? 0,5.
????????? ???????????? ???????????, ?????????????? ??? ?????? ??????? ???????? ???????, ?????? ?????????? Z (Z-score). ??? ????????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
??? ????????, ??????? ???????????? ??? ?????
??????????? (??????????) ?????????? ?? ??????????? ???????? ??????? ??? ?????? ??????? ??????????? ????. ???????? Z-score ?????? -2 ????????
??? ?????? ? ????? ?? ??????????????? ? ?????????? ?????????? ?? ????? ? ???????? ????????????????? ? ??????????? ?????????.
? ????? ??. ?.?. ???????? ???? ???????? ????? ???????????? ???????????????????????? ??????? Nakata ? McGoon. ???????? ??????? ???????? ??????? ??????????? ??? ??????????????????
??? ??? ????? 300 ??2/?2 ? McGoon ????? 1,4;
????????? ?????????? ??????????????? ??? ???
200?250 ??2/?2 ? McGoon 1,2?1,4; ?????????? ?????????? ? ??? 100?200 ??2/?2 ? 0,8?1,2, ??????
?????????? ? ??? ????? 100 ??2/?2 ? ????? 0,8 ??????????????.
? ????????? ????? ?????????? ???????????
????????? ??????????????? ?????? ??????? ???????????? ??????? ? 90?96 % ?????????, ???????
????????? ? ?????????? ?????? ?? ????. ??? ????
????????? ??????? ? ?????????? ??????????? ??????? ???????? ???????, ?????????? ????, ?????????? ????????? ? ??????? ????????????? ??????? [1, 6, 8]. ????? ?? ????????, ?????????????
?????? ???????? ??????? ? ??? ????? ??????????
???????? ????????, ???????? ????????????? ?????
?????? ?? ??????? ????????? ??? ???????? ???????
??????????????? ???????????, ????????????????? ??????????????? ???????????? ???????????
???????? ?? ??????? ????????? (??) ? ??.
Е?зб?к?н к обзс??
?? ?????? ? 2003 ?? 2013 ?. ?? ???? ?????????
???????????????? ???????? ????????????? ? ????? ??????? ???? ????? ? ??????????? ????????
?????? (???) ????? ??. ?.?. ???????? ???? ???? ?????????????? 26 ????? (9 ????????? ? 17 ???????) ? ?????????? ?????????? ????? ??????
?????????? ? ???????? ???????. ???????????
?????? ???????? ?? ????????? ? ??????????????
????????? ╚??????? ???????? ???????╩. ????? ????????????????? ?? ?????? J. Somerville, ?????????
? ????? ??. ?.?. ???????? ????. ??????? 1-?? ???? ???????? ? 19 ??????? (73 %), ??????? 2-?? ???? ?
? 6 (23 %) ? ??????? 4-?? ???? ? ? 1 (4 %) ??????.
??????? ??????? ????????? ???????? 10,4 ╠ 2,4
(4,6?12,5) ???, ??????? ???? ? ????? ???? ?
68,6 ╠ 8 (49?78) ?? ? 7,3 ╠ 1,9 (2,7?9,8) ?? ??????????????.
?????????????? ????????? ??? ???????????
???????????? ????, n:
?? 2? ??. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
?? 1-? ??. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
?? 0 ??. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
?????? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
?????? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
?????????? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
???????????? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
?????????? ? ???????? . . . . . . . . . . . . . . . . . . . . . . 7
???????? ????????????? ? ??????????
???????? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
???????? ???????? . . . . . . . . . . . . . . . . . . . . . . . . 4
?????????? 1-? ??. . . . . . . . . . . . . . . . . . . . . . . . . . 1
?????????? 2-? ??. . . . . . . . . . . . . . . . . . . . . . . . . . 1
??? ???????? ?????????? ? ??????? ?????????.
??????????? ??????? ?????? ?????? ?????????????? ??????? ??????? ???????????????? ????????-???????? ????????? ?? Blalock?Taussig, 4 ?
??????????? ???, ??? ???? ? ???? ????????? ?? ?????? ??????????? ????????? ???????? ?? ?????????? ??? ????????? ???????.
??????? ??? ??????????? ????????????? ???
?????? ????????? ????????????????????? ???????????? ? ??????????? ???????????, ??????? ??????????? ???? ??????? ?? ????????. ??? ???????????????????? ???????????? ? ??????????? ????????? ???????? ?????????????? ????? ??????
????????? (??? ??) ??? ????????? ? ????????
?????????? ?????, ???????? ? ??????? 41,9 ╠ 2,5
(33?52) ??/?2. ???????? ????? ?????? ???????? ??????? ???????????? ? ???? ???????, ??? ???? ? ???
???????, ??????? ??????? ?????????? ??????? ?????????? ?????? ??????? ???????? ???????, ???
????????? ?????? ? 2 ? ????? ???? ?? ????????? ?
??????. ??????? ??????????????? ??????????? ?
?????? ????????? ?? ???? ????????????, ?? ??????? ??????? ???????? 12,7 ╠ 1,6 (10?16) ??.
? 5 ??????? ???????? ?????????? ????? ???????
????? ????, ????????? ? ?????????? ?????.
??? ???????????????? ???????????? ????????? ????? ?????? ?????????? ? ???????? ???????
????????????? ? ???? ?????????, ????? ????, ?????????? ??????????? ???????? ??????? ????????? ?
???????????? ?????? ????????? ??????? ????????????. ???????-???????????? ?????? ??? ?????? ?
209 ╠ 69 (44?311) ??2/?2. ?? ????? ??? ??????
???, ?????? 300 ╠ 30 ??2/?2. ????? ???????, ?
?????????? ??????????? ??? ??????????? ?????? ????????? ???????? 70 ╠ 22 % ?? ?????, ??? ????????? ?????????? ????????? ??????? ????????
??????? ? ?????? ????? ??? ?????????????????.
??????? ????????????? ?????????????? ??????? ????????? ? 7 (26,9 %) ???????: ? ?????? ??????? ? ? 3 (11,5 %), ? ????? ?????? ? ? 4 (15,4 %). ???????? ?? ????????-????????? ?????????? ??????????? ? 9 ???????, ??????? ?????????? ? ? 1 ??????,
??????? ?????? ???????????? ??????? ???? ?????????????? ????? ?????????? ? ? 1 ??????.
? 2 ??????? ?????????? ?????????? ? ??????? ????? ???????? ??????? ? ????? ????????? ??????????? ????? ??????????. ?? ?????? ??????????, ?????????? ???????? ??????? ? ????? ?????????
?????????? ? ?????????? ????? ?????????? ??????????? ???????? ????????????????? ? ?????????? ?????????? ??????????. ????? ? ??????? ???
?? ???? ??????? ??? ????????.
47
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
? ?????????? ????????? ?????????? ?????? ?
?????, ???????? ???????????, ??????????? ? ???????????????? ??????? ???????????? ? ???? ??????? ??????? ????????? ????????????? ????? ?????? ?? ??????? ????????? ??? ???????? ????.
??? ???? ??????? ??? ? ????????????? ?????????
??????? ???????? ??????? ??? ?? ?????????? ???????????, ??? ? ?? ????????? ???????? ?????????????? ??????? ?????? ????????? ? ????? ?????????.
Йбашн╦з?з?
??????????? ????????????? ??????????? ??
????????? ? ????? ?? ?.?. ???????? ???? ?????????, ????????????? ?????? ????????????? ?????
????????? ???????????. ??? ???????? ??????????? ? ?????????????? ?????????????? ?????????????? ? ???????? ????????? ?????????? ? ???????????? ????????? ╚?????????╩. ??????????????
?????????? ???????? ??????????? ? ??????? ?????????? ??????? ????????? ?????-??????? ???????. ?????????? ??????????? ?? ????? ?????????
????? ???????? ????????? ? ??????? 27,7 ╠ 2,36
(24?33) ╟?. ??????????? ????????????? ??????? ?
??????? 4,1 ╠ 1,5 (2,5?9) ?. ????????????? ?????????????? ???????????? 89 ╠ 48 (45?225) ???,
????????? ????? ? 40 ╠ 25 (0?115) ???. ? ?????
?????? ????????????? ?????????? ???? ???????????????? ?? ??-?? ?????????? ??????? ???????? ????????????????? ???????? ? ??????????? ??????
??? ?? ??? ?????.
???? ??????? ????????? ????????????? ?????
?????? ?? ??????? ????????? ??? ???????? ????
(??. ???????). ? ???????, ????? ???????? ??????
?????? ?????????????? ??????? ??? ??????? ????????-???????? ????????? ??? ??????????? ???,
?
????? ?????????? ????? ??????????? ?????????
?????????? ??? ????????? ??????? ?????????? ?????????. ? 17 (65,5 %) ??????? ??? ?????????????
????????? ?????? ?? ? ?????? ???????? ???????
?????????????? ??????? ?? ??????????????, ?? ???
? 5 (19,2 %) ??????? ? ????????????, ? 7 (26,9 %)
??????? ? ???????????????????? ??????? ? ???????? ????????? 11 ??, ??????? ?? ??????????? ??????? ? ???????????? ??????? ?? PTFE ?????????
6 ?? ?????????????? ?? ?????? ???? (3,8 %).
?????? ????????, ??????????? ????, ????????
??? ????????????? ???????????? ??????? ?? PTFE
????????? 8 ??, ?? ??-?? ?????? ??????? ???????? ?
????? ???????? ??????? ????? ????????? ?? ?? ???
??????? ?? ???????????????????? ??????? ? ???????? ????????? 11 ??. ??? ????????????????? ????????? ?????????????? ???????? ? ???????? ???????
??? ????????? 31 ╠ 17 (14?75) ?? ??. ??. ??? ?????????
???????????? ???????? ? 86,3 ╠ 12 (60?100) ?? ??. ??.
????? ???????, ??????? ???????? ????? ????????????? ????????? ? ???????? ??????? ? ????????? ???????????? ????????? ??? ??????
55,3 ╠ 26,7 (21?73) ?? ??. ??.
????????? ??????? ?? ????? ?????????? ???????? ?? ????, ??? ??????? ?????????? ? ?????????
?????????? ? ??????????? ??????? ?? ?????????
????????. ?????????????? ?????????? ??????????
????? ????? ?????????? ?? ? ???? ??????? ????????? ?????????, ? ?????? ???????? ??????????
????? ????????????? ?????? ?????? ??????????
??????? ? ???????????? ??????, ? ?????? ???????? ????? ?????????????? ??????????? ??????????????????? ??????? 1 ???????, ??????? ???? ?????????? ??????????????.
???????????? ????????????? ?????????? ?????? ? ????????????????? ??????? ?????????
52 ╠ 50 (7?144) ?. ??????? ?????????? ? ?????????
╥
?
г??к?лз? ??тснлблк? ?бмслрз?шм?кк тшзбх сззсм? т???с?с йбнш?с?м?:
? ? тн?рзкм? ???с?лс?с сз?бн? т???с?с йбнш?с?м? к рз?сн? нб?с?лсх ??зб?кк а?тн?зсх ка мрблстб?км????; ╥ ? ?бмслрз?шм?к? тшзбх сззсм? т???с?с
йбнш?с?м? рклзбзк?брмко ╥брмн?т?лл?о мсл?шкзсо; ? ? мрблстб?км???к?н╦л?о мн?т?лл?о мсл?шкзсо
48
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??????? ??????? ?????? ? ???????, ? 4, 2013
?????????? ? ??????????? ??????? ? ???????
2,5 ╠ 1,8 (1?6) ???. ???? ??????? ? ????????? ????????? ?????? ??????? ????????? ???????????????????? ???????? ???? ? ??????? ?????? ????? ?????
???????? ?????????? ?????? ????????? ???????????????; ??????, ? ???????????????? ??????????????
???????????????????? ????????? ? ?? 6-? ??? ????? ???????????? ????????????? ?????????? ???????-????????? ???????????????. ??????? ?????? ?
?????? ?????? ???????????????? ?????????????
??????, ?? ?????? ?????? ??????????????? ????????? ??????????????? ??????????? ????????????
???????????????? ? ???????????????? ?????????????? ????????? ? ??????. ????? ???????, ??????????? ? ?????? ?????? ????????? ?????????
?????? 7,7 %.
??? ???????????????????? ???????????? ? ??????? ?????? ????????????????? ????? ? ????
??????? ???? ??????????????? ?????????? ????????? ????? ?????? ?????????? ? ???????? ????????. ???????? ???????? ?? ???????? ?????? ??????? ?????????, ?????????? ? ??????? ?????????????? ??????????????, ???????? ?????????? ?
?????????? ??????????, ?????????????? ????????????????, ? ???????? 41,6 ╠ 18,2 (10?62) ?? ??. ??.
??? ?? ???????? ??? ??????? ??????? ???????????
?????????? ? 46,4 ╠ 14,68 (20?58) ?? ??. ??. ???????? ???????????? ?? ??????? ???????? ???????
??????????? ? ?????? ?????????, ??????? ????
????????? ??????????????? ???????? ?????????
?????? ??????? ????????? ????????????????????
????????, ? ?? ?? ????? ? ?????? ?????????, ??????? ???? ?????????????? ??????? ? ????????????,
???????????? ?????????? ? ??????? ???????. ??
?????? ??????? ?? ?????????? ????????? ? ???????????? ????? ? ????????????? ??????? ??????? ?
65,2 ╠ 12 ?? 93,2 ╠ 5,7 %, ?????????? ???????????
????????? ?? 159,2 ╠ 26,3 ?/? ?? 123,9 ╠ 14,5 ?/?, ?????????? ????? ???????? ? 47 ╠ 8,9 ?? 38,6 ╠ 5,4 %.
??????? ????? ??????????????? ?????? ????????? ????????? ??? ??????????? ????????? ?????? ? ??????? ???????????? ???? ?????. ?? ??????
??????????? ??? ? ?????? ??????? ??????? ?????????? ? ?? 430,6 ╠ 96,8 (387?526) ??2/?2, ?????
????, ???????? ?????????????? ????? ?????? ????????? ?????????? ?? 56 ╠ 4,2 (49?64) ??2/?2.
???????? ?????????? ???????? ??????? ?? ????????, ??? ????????? ????????? ?????? ?????????
??????????? ????????? ?????? ? ??????????????????? ????????????
И╥ршй?блкб
?????????? ????????? ???????? ? ?????? ??????? ????????????? ????? ?????? ?? ??????? ?????????.
C.W. Lillehei ? 1955 ?. ? J.W. Kirklin ? 1959 ?.
??????? ????????? ????????????? ?????? ?? ??????? ????????? ? ??????? ????????????????????
???????. ?????? ?????? ??????????? ? ?? ???
????, ?????? ?????? ??????? ????????????? ?????
?? ???????? ??????? ? ????????? ?????????? ???
???????? ??????? ?? ???????? ?????? ??????? ????????? [4, 6]. ? ???????? ??????????????? ?????????????? ????????????? ????????? ??? ????????
??????? ?? ???????? ?????? ??????? ????????? ?
?????? ???????? ??????? ????? ??????? ????????????, ?????????? ?? ????? ???????????????, ????
??????????? ?? ?????, ??? ????????? ??????? ?????????? ??????? ? ???????? ???????, ????????
??? ????? ?????????? ?????????? ? ????????? ????????. ????? ????, ???????? ?????????? ????????????? ??????, ? ????????? ????? ???????? ??????? ??????????????? ???????? ??????? ?? PTFE
???????? ????? ╚Gore-Tex╩.
??????????????? ?????????? ????????? ?????? ??????? ????????? ? ??????????? ??????????
??????? ??????? ???????? ??????? ????? ???????? ?????????? ?????? ??????? ?????? ? ??????
????????????????? ???????. ??? ???????? ??????????? ????????????? ??????? ?????????? ????
?????????? ??????????, ?????????? ???????????. ???????????????? ?? ?????????? ???????????
?? ?????? ???????. ???? ?????? ??????? ?? ????????????? ??????????? [2, 9], ?????? ????????,
??? ??? ?????????? ????? ??????? ????? ??????
?????????? ??-?? ???????? ??????? ????????????
????????? ? ??????? ????????? ??????? ???????????.
D. Ross ? J. Somerville ? 1966 ?. ??????????????
?????????? ????????? ? ???????? ???????, ???????
??? ???? ???????? ??????????. ? ??? ??? ???? ?????????? ????????? ??????????? ????????????????? ???????? ??? ?????????????, ??? ? ?????????????? ?????????????. ???????????? ?????????????
?????? ???????? ??????????? ? ?? ???????? ? ???????????? ? ??????????????? ????????????, ??????? ?????????????? ???????? ??????? ??????? ???????? ??????? ??????? ?????????? [5, 10]. ??? ?? ????? ???????? ?????? ????? ?? ?????????? ?
?????????????? ???????? ???? ?????? ???????????? ??-?? ????? ??????????? ??????????? ?????????? ???????? ? ????????????? ????????????? ???????? ??????????? ???????? ????????. ? ????????? ???? ????????????????? ??????? ????? ?????
????????. ???, ?? ??????? ?????? ???????????? ?????????? ╚Contegra╩, ? ??????????? ??????? ???????? ?? ???????? ? ????????????? ?????????????.
??? ???? ??????????????? ? ???, ??? ? ?????
??????? ???? ????? ? ???????? ???????? ???????
1 ???? ????????? ????????????? ? ???????? ????????????? ????????? ??????????????, ??? ??? ??
???????? ??????? ????????????, ?????? ??? ???
???????????, ??? ? ??? ??????????? ???????????
????????? ? ?????? ????????????? ?????????? ???????? ????????? ????? ?????? ?????????? ? ???????? ????????. ???????????????????? ??????? ?
???????????? ????????? ??????? ??????? ???????49
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???????? ??????? ???????? ??????? ??? ??????????????? ????????, ?? ??????? ??? ???? ???????? ?
?????????? ????????????????? ???????. ???????????????????? ????????? ??????? ?????????
???????? ?????????? ???????????? ? ????????????????? ???????, ?? ?? ?? ???????? ? ??????????
????? ??-?? ???????????? ??????????? ?????????
?????? ????????.
8.
9.
10.
А?мн??блкб
????????????? ????? ?????? ?? ??????? ????????? ???????? ??????? ?????? ??? ??????? ????
????????? ??????? ???????? ??????? ? ????? ??????? ???? ????? ? ??????????? ???? ??????? ???????? ???????. ? ?????? ????????????????? ?????????????? ??????????? ????????-????????? ?????????? ??? ??????????????? ??? ??????????
????????????? ????? ?????? ???????????????? ?????????? ????????? ??????????, ??? ??? ????? ??????? ??????????? ?????????? ???????? ???????
? ???????????????? ?? ?????.
References
1.
2.
3.
4.
??????????
1.
2.
3.
4.
5.
6.
7.
??????????? ?.?., ??????? ?.?. (???.) ????????-?????????? ????????: ???????????. ?.: ????????; 1996.
???????? ?.?., ?????? ?.?., ?????? ?.?. ???????????????? ????????????? ?? ?????? ? ?????? ???????? ???????
??? ??????? ?????????? ??????? ??????. ??????????? ?
????????-?????????? ????????. 2008; 5: 52?7.
Amar K.M., Karamlou T., O'Carroll A. et al. Independent factors associated with mortality, reintervention, and achievement of complete repair in children with pulmonary atresia
with ventricular septal defect. J. Am. Coll. Cardiol. 2006; 47:
1448?56.
????????? ?.?., ???????? ?.?., ??????? ?.?. ??????? ???????? ??????? ? ???????? ??????????????? ???????????. ?.: ????? ??. ?. ?. ???????? ????; 2003.
??????????? ?.?. ????????????? ????? ?????? ?? ???????
????????? ??? ???????? ??????? ??????????????? ??????????? ??? ??????? ?????????? ??????? ??????: ???????. ???. ? ?-?? ???. ????. ?.; 2010.
Kirklin J.W., Barratt-Boyes B.G. Cardiac surgery. 3rd ed. N.Y.:
Churchill Livingstone; 2005.
Nakata S.Y., Imai Y., Takanashi Y. et al. A new method for the
quantitative standartization of cross-sectional areas of the pulmonary arteries in congenital heart diseases with decreased
pulmonary blood flow. J. Thorac. Cardiovasc. Surg. 1984; 88:
610?9.
Ishikawa S., Takahashi T., Sato Y. et al. Growth of the
pulmonary arteries after systemic-pulmonary shunt.
Ann. Thorac. Cardiovasc. Surg. 2001; 7 (6): 337?40.
Gundry S.R., Razzouk A.J., Boskind J.F. et al. Fate of the pericardial monocusp pulmonary valve for right ventricular outflow
tract reconstruction. J. Thorac. Cardiovasc. Surg. 1994; 107:
908?13.
Christenson J.T., Sierra J., Colina Manzano N.E. Homografts
and xenografts for right ventricular outflow tract reconstruction: long-term results. Ann. Thorac. Surg. 2010; 90 (4):
1287?93.
5.
6.
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10.
Burakovskiy V.I., Bockeria L.A. (ed.) Cardiovascular surgery.
Moscow: Meditsina; 1996 (in Russian).
Glushenko I.A., Ivanov A.S., Baloyan G.M. Surgical reconstruction of pulmonary artery trunk and branches for complex
congenital heart defects. Kardiologiya i serdechno-sosudistaya khirurgiya. 2008; 5: 52?7 (in Russian).
Amar K.M., Karamlou T., O'Carroll A. et al. Independent factors associated with mortality, reintervention, and achievement
of complete repair in children with pulmonary atresia with ventricular septal defect. J. Am. Coll. Cardiol. 2006; 47: 1448?56.
Podzolkov V.P., Kokshenev I.V., Gadzhiev A.A. Pulmonary artery
atresia with ventricular septal defect. Moscow: A.N. Bakoulev
Scientific Center for Cardiovascular Surgery of the Russian
Academy of Medical Sciences; Moscow; 2003 (in Russian).
Chernogrivov A.E. Right ventricular outflow tract reconstruction without plasty of atrioventricular septal defect in complex
congenital heart diseases: Author's abstract of Ph.D. thesis in
Med.Sc. Moscow; 2010 (in Russian).
Kirklin J.W., Barratt-Boyes B.G. Cardiac surgery. 3rd ed. N.Y.:
Churchill Livingstone; 2005.
Nakata S.Y., Imai Y., Takanashi Y. et al. A new method for the
quantitative standartization of cross-sectional areas of the pulmonary arteries in congenital heart diseases with decreased
pulmonary blood flow. J. Thorac. Cardiovasc. Surg. 1984; 88:
610?9.
Ishikawa S., Takahashi T., Sato Y. et al. Growth of the pulmonary arteries after systemic-pulmonary shunt. Ann.
Thorac. Cardiovasc. Surg. 2001; 7 (6): 337?40.
Gundry S.R., Razzouk A.J., Boskind J.F. et al. Fate of the pericardial monocusp pulmonary valve for right ventricular outflow
tract reconstruction. J. Thorac. Cardiovasc. Surg. 1994; 107:
908?13.
Christenson J.T., Sierra J., Colina Manzano N.E. Homografts
and xenografts for right ventricular outflow tract reconstruction: long-term results. Ann. Thorac. Surg. 2010; 90 (4):
1287?93.
????????? 26.09.2013
50
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
╘ ????????? ???????, 2013
??? 616.126.42-053.36-089.8-77
?????????????? ??????????? ??????? ? ????? ???????
????????
?.?. ???????, ?.?. ???????, ?.?. ?????????, ?.?. ???????, ?.?. ???????????,
?.?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ?
???????? ??? ? ???? ?.?. ???????) ????; ?????????? ?????, 135, ??????,
?????????? ?????????, 121552
??????? ??? ?????????, ???????? ??? ? ????, ????????;
??????? ?????????? ????????????, ?.?.?., ?????????, ?????????? ??????????;
????????? ????? ????????????, ?.?.?., e-mail: arnautova74@mail.ru;
??????? ?????? ?????????, ?.?.?.;
??????????? ????? ????????????, ?.?.?.;
????????? ?????? ??????????, ?.?.?.
????. ??????????? ?????????? ???????? ?????????????? ??????????? ???????, ??????????? ? ?????? ??????? ???????? ?
????? ??. ?.?. ???????? ????.
???????? ? ??????. ???????? ?????????????? ??????????? ??????? ?? ?????? ? ?????? 2003 ?? ??????? 2012 ?. ???????????
89 ?????????. ??????? ????????? ????????? ?? 10 ??? ?? 5 ???, ????? ???? ? ?? 7,4 ??19,0 ??. ????????? ???? ????????? ????????????? ??? ??????? ??? ?????? ???????. ? ??????????? ??????? ??????????? ??????? ? ?????????? ??????? ?????????????? ??? ?????????? ?????????? ??????????????? (61,8 %).
???????? ???? ?????????????? ? ???????? ?? (87?309 ???), ?????????? (24 ╟?) ? ???????????????? ????????????.
???? ????? ???? ?????????????? ???????????? ???????: ╚St. Jude Medical╩ (n=68, ??? 76,4 %), ╚Carbomedics╩ (n=7, ??? 7,9 %),
╚??????╩ (n=2, ??? 2,2 %); ╚?????????╩ HALL (n=4, ??? 4,4 %), ╚ATS╩ (n=7, ??? 7,9 %), ╚Sorin╩ (1, ??? 1,1 %). ? 11 (12,4 %) ????? ?????????????? ???????? ???????????????? ??????????????.
? ?????????? ????? ????? ???????? (?? 3 ??????? ?? 9 ???) ??????????? 68 (88,3 %) ?????????. ??? ?????? ?????????? ? ?????????-???????????? ????????? ?????????????? ???????? ?? Somerville.
??????????. ??????????? ? ????????? ????????????????? ??????? ????????? 12 (13,5 %) ?????????. ??????????? ????????????????? ?????? ?????????? ? 34 (38,2 %) ?????; 44 ??????? (61,8 %) ?????????? ? 1 ???????? ?? Somerville ? ????????? ???? ????????? ??? ???????, ? 24 (35,3 %) ???????? ???????? ????????? ???????? ????????????? ? ?????????? ?????????
? ?????????????? ?????? ????????????? ?????????. ??? ??????? ????? ???????? ?????????? ????????? ???????????????.
????????????? ???????? ? ?????????? ????? ?????????? ?? ?????? ???????????????? ???????????? ?????????? ? ???? ?????. ????????? ???????? ????????? ??????????????? ???????? ?? ?????????? ??????? ????????? ?? 5 ?? 20 ?? ??. ??., ???????? ? ?? 7 ?? 14 ?? ??. ??. ?????????? ?????????? ??????????????? ???????? ?? ??????? ??? ??? ?????????? ???????? ? 6 (8,8 %)
?????????. ???????? ???????? ??????? ? ?????? ?????, ??????????? ??????? ??????????? ????. ?????? ????????? ???????
????????? ???????? ?? ?????? ??????????? ??????? ?? ?????? ???????? ????????.
? ?????????? ????? ?????????? ?????? 5 (7,3 %) ?????????, ?? ?????? ?? ??????? ? ??????????? ???????.
??????????. ???????? ?????????????? ??????????? ??????? ? ?????? ??????? ???????? ??????? ????????????? ??? ???????? ?????? ??? ????????????? ????????? ?????????????????? ????????. ??? ????, ?????????? ??????????? ?????????????? ??????? ? ?????? ????????, ???????? ??????????? ?? ????????? ??????????????. ????? ????????? ?????? ?? ????????
????????????????? ? ?????????? ??????????????, ??? ??? ????? ?????????????? ?????? ? ??????????????? ???????. ?????????? ???????????????? ??????? ???????? ????? ?? ???????? ???????? ??????????? ???????????????? ?????????????? ???????. ?????? ? ?????? ???????????????? ?????? ???????? ?????? ?????????????, ?????? ?? ?????? ???????????? ? ????????????????? ????????????.
???????? ?????: ?????????? ??????; ?????????? ???????????????; ????????????? ??????; ???? ??????? ????????; ??????????????; ????????????????.
MITRAL VALVE REPLACEMENT IN YOUNG CHILDREN
L.A. Bockeria, K.V. Shatalov. I.V. Arnautova, M.V. Makhalin. I.V. Vasilevskaya,
M.L. Ermolenko
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of Medical
Sciences; Roublevskoe shosse, 135, Moscow, Russian Federation, 121552
Bockeria Leo Antonovich, Academician of the Russian Academy of Sciences and Russian Academy
of Medical Sciences, Director;
Shatalov Konstantin Valentinovich, MD, DM, Professor, Chief of Department;
Arnautova Irina Vladimirovna, MD, DM, e-mail: arnautova74@mail.ru;
Makhalin Maksim Vadimovich, MD, PhD;
51
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
Vasilevskaya Irina Valentinovna, MD, PhD;
Ermolenko Marina Leonidovna, MD, DM.
Objective. To present the results of mitral valve replacement performed in early childhood at A.N.Bakoulev Scientific Center for
Cardiovascular Surgery of the Russian Academy of Medical Sciences.
Material and Methods. 89 patients underwent mitral valve replacement surgery for the period from January 2003 to December 2012. The
age of patients ranged from 10 months to 5 years, body mass ? from 7,4 to 19 kg. The condition of all patients was evaluated to be serious or critical. In most cases mitral valve replacement was performed in the presence of congenital mitral valve regurgitation (61,8 %).
All patients were operated under the conditions of cardiopulmonary bypass (87?309 min), hypothermia (24 ╟?) and hypothermic
chemical cardioplegia.
All children underwent implantation of mechanical valve prostheses: ╚St. Jude Medical╩ (n=68, or 76,4 %), ╚Carbomedics╩ (n=7, or 7,9 %),
╚MedIng╩ (n=2, or 2,2 %); ╚Medtronic?????????╩ HALL (n=4, or 4,4 %), ╚ATS╩ (n=7, or 7,9 %), ╚Sorin╩ (1, or 1,1 %). The method of
supra-annular mitral valve replacement was used in 11 (12,4 %) children.
68 (88,3%) patients were examined in a long-term follow-up after the surgery (from 3 months to 9 years). Somerville grading system
was used for developmental and adapted physical activity assessment.
Results. The mortality rate in the short-term postoperative period was 12 (13,5 %) deaths. Complicated postoperative period was
observed in 34 (38,2 %) children. 44 children (61,8 %) were classified as Somerville grade 1 and assessed their medical state as good,
in 24 (35,3 %) patients parents observed certain reduction in exercise tolerance and susceptibility to acute respiratory tract infections.
2 children had symptoms of severe heart failure. Clinical-instrumental assessment in the long-term follow-up studies showed positive
outcomes in all the children. Fluctuations of peak diastolic pressure gradient in prosthetic mitral valve ranged from 5 to 20 mm of mercury, of mean gradient ? from 7 to 14 mm of mercury. Augmentation of diastolic pressure gradients in prosthetic mitral valve without
its dysfunction was observed in 6 (8,8 %) patients. This phenomenon is related to children's growth, increase of body surface area.
These patients underwent successful surgery for replacement of mitral valve prosthesis with a one of a larger diameter.
In the long-term follow-up period 5 (7,3%) patients died and their death was not related to mitral valve prosthesis dysfunction.
Conclusion. Mitral valve replacement surgery in early childhood should be considered the operation of choice when there is no possibility to perform valve-sparing surgery. All children who underwent implantation of mechanical valve prosthesis at an early become the
candidates for reimplantation surgery. A narrow fibrous ring is not a contraindication for performing valve replacement surgery as it is
possible to implant prosthetic valves in the supra-annular position. Adequate anticoagulant therapy is one of the main factors of durable
valve prosthesis function. It is necessary to use individualized approach based on clinical assessment and instrumental examination to
determine timing of reimplantation.
Key words: mitral valve; mitral regurgitation; prosthetic valve; young children; anticoagulants; reimplantation.
?? ?????? ????? ???????? ?????????????? ??
???????? ???????? ????????????? ????????????
????????????? ??? ?????????? ????????? ??????????? ??????? (??) ? ????? ??????? ????????.
????????????? ????????????? ????????? ?????????? ?????????? ????????? ?????? ? ???? ?????????? ?????? ????????? ???, ??? ?????? ????????
???????????? ????? ??????? ?????????? ???????
? ??????? ????????? ????????? ???????????????,
???????????? ? ??????????????? ???????. ?? ????????? ?????????? ????????? ? ????????? ??????
????????? ? ????????? ???????? ????????? ???????? ??? ????????????? ?????????? ?????? ? ????
?????? ???????? ?????????? ??????????????.
? ????????? ?????????? ???????? ????? ??????? ???????? ? ??????????? ???????? ??????
????? ??. ?.?. ???????? ???? ???????? ???????
???? ?????????? ???????? ?????????????? ???????? ?????? ??? ?? ?????????? ????????? ? ????????? ?????????, ? ??? ????? ? ??? ????????? ??.
? ????? ? ???? ?? ????? ?????????? ???????????
?????????? ???????? ????????????, ???????????
? ?????? ??????? ????????.
Е?зб?к?н к обзс??
?? ?????? ? ?????? 2003 ?? ??????? 2012 ?. ???????? ?????????????? ?? ??????????? 89 ????????? ??????? ???????? ????????. ? ??????????? ??????? ??????????? ??????? ? ?????????? ???????
?????????????? ??? ????????????? ??????????
?????????? ??????????????? (??), ?????? ?????
?? ??????? ????????????? ???????? ?? ? ?????????
52
? ??????????? ????????? (???????? ????? ???????? ??????????????? ??????????? ? ????).
????? ????, ?????????????? ?? ??????????? ???
????????????? ????????? ?????? ???? ??????????
??????? ?????? (???), ?????? ??????? ??????????? ????, n (%):
?????????? ??????????
??????????????? * . . . . . . . . . . . . . . . . . . 55 (61,9)
?????????? ?????????? ???????????????
? ????????? ? ???? . . . . . . . . . . . . . . . . . . 8 (9,0)
?????????? ??????????????? ?????
??????????? ????????? ??? . . . . . . . . . . . . 4 (4,5)
????????? ????????? ??? . . . . . . . . . . . . . . 6 (6,7)
???? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 (7,9)
?????????? ??????????????? ? ?????????
? ??????????? ?? ? ??? . . . . . . . . . . . . . . . .1 (1,1)
?????? ?? . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 (5,6)
????????? ?? ? ????????? ? ???? . . . . . . . 2 (2,2)
????????????? ?????????? . . . . . . . . . . . . . .1 (1,1)
* ? 6 ??????? ??????????? ???????????????? ?? ????? ?????
??????????? ????????? ??.
????? ????????? (n=11) ????? ??????????????
????????????? ?? ?????? ? ??????? ?????????????
???????: 4 (4,5 %) ????? ????????? ???????????????? ???????? ?? ??????? ??? ???????????????????
???????????? ? ???????? ?????????????? ??????????????, 1 (1,1 %) ??????? ? ???????? ??????????
????? ? ????????? ????????? ????????????? ??????? (???), 6 ????????? (6,7 %) ? ?????? ????? ????????????????? ??????????? ??????? ? ????? ? ????????????? ????????? ??????? ???????.
??????? ????? ??? ????????? ? ????????? ???????? ?? 10 ??? ?? 5 ???, ????? ???? ? ?? 7,4 ?? 19,0 ??.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
????????? ??????? ??? ??????????? ? ???????
????????????? ??? ??????? ? ?????? ???????. ???????? ????????? ??????????? ?????? ?? ??????
??? ?????????? ?????????? ???????, ? ???? ??????? ?????? ?????????? ? ?????, ????? ????? ???????? ????????????? ? ?????????. ??????????? ??????? ????????? ? ?????????? ????????, ?????? ??
??? ????? ?????????? 2?3-? ???????, ????????
?????????? ?? ?????????? ? ???????? ????, ??????
?????????? ???????????. ? 3 (3,4 %) ????????? ????????? ????? ??? ?????????? ?????????? ????????? ???????????????. ??? (2,2 %) ??????? ???? ?
???????? ?? 1 ????. ??????????? ??????? ?????????? ?? ????? ????? ? 4 (4,5 %) ????????? ? ????
????????? ???????? ??? ???????????????? ?????????????? ???????. ???? ??????? ??????? ? ???????? 1 ???? ????????????? ??????????, ????????????? ????????? ?? 3-? ???????. ? ???? ???????
?????????????? ???????? ?? 2?3-? ??.
?????? ?? ????? ??????? ????????? (n=7, ???
7,9 %) ??? ??????????? ???? ???? ? ?????????
????????????????????? (????) ? ?????????? ??????????? ????? ?????????? ??????? ?? ????????
???????. ? ?????? ?????? ????????? ????? ????????? ???????? ???????? ? ???????? ????? ?????????? ??????? ? ??? ????????? ? ???????? ??????
??????????? ????????? ???????? ?????? ????????? (??) ? ??????????? ????????????? ???????? ???, ?????????? ????????????? ?????????
????? ???????, ? ?????? ? ????????? ??. ????????
?? ??? ?????????? ?????????? ????? ??????????
??????? ??????????? ??????????? ??????????
?????? ?? ? ?????????? ????????? ?? ? ??????????? ?????????? ??????????? ????. ???????? ?????? ?????? (????????????????) ? ?????? ?????????
?? ? ????????????? ??? ??????????????? ?????
???????????????? ????????? ???????? ???????
??????, ??????? ??????????? ? ???????? ╚?????????????╩ ?? ?????????? ???????? ?????? ??????????????? ??????????? ? ??????? ??????? ????????? [1]. ?????? ?????? ???????????? ???????? ??????????????, ???????????? ? ?????
??????.
? ???? ??????? ??? ??????????? ? ????? ??????????????? ?????????? ???? ?????????? ??????,
?????????, ?????????????? ??????????????. ?????????? ? ??????????? ?? ????? ?????????? ??????????????? ??????? ?????? ????????? ????????????
??????, ??? ?? ?????????? ????????? ??????????????? ????? ???????????? ? ??????????????? ??????? ????????.
???? ????? ??? ??????????? ?????? ??????? ?
???????????? ???????????? ???????? ??? ???????????????? ??????? ????????????, ????? ??? ???????????????????, ????- ? ?????????? ???????????????, ?????????????????? ???????????? ???????
??????? ?????? (3 ????????), ??? ?????????????
??????????? ???????????? ???????? ?????? ? ??????????????????.
Йкр. 1. Йблз?блс???оо? с???лс? ??ш?лсх мнбзмк (т??о?? т?сбм?к?) ╥сн╦лсх Ш., 2 ?. 4 обр. як??лса: ??сй?блл?? окз??н╦л?? лб?срз?зс?лсрз╦ р ?б?ш??кз??кбх 4 (+). Изоб??бзр?
шркнблкб нб?с?лс?с ?кршлм? тс ╚?блсалсош зктш╩. Д???ксоб??нк? а? р?бз ?рб? сз?бнс? рб????. ДМЮ ? 78 %
??????????? ? ???? ????????? ????????????????? ???????? ????????????? ?? ???? ??????????
???? ??????? ?????? (????????????????? ??????
????????? ?? 54 ?? 72 %), ? ????? ???????????? ?????? ????? ?????????????? ??????????????? ??
???? ????????? ?????? (???. 1). ?? ?????? ??????????????????? ?????????? ?????? ?????????? ????? ???????, ????????? ????????????, ? ? ????????? ?? ???? ? ???????? ?????? ? ???????????????? ????????? ???????? ??. ? ???????? ?????????
?????????? ?????????? ?????? ???????? ??????
????????? ? ??????????? ????.
???????? ?????? ??????????????? ???????,
??????????? ??????? ????????? ??, ??????? ???????? ??????, ? ????? ?????????????? ??????????? ????????, ??????? ????????????????????
????????????. ???????????? ?? ?? ??????????? ??
2,5 (+) ?? ????????? ??????????????? (???. 2). ???
??????????? ???????? ??????? ???????? ?? ??????????? ????????? ????????? ??????????????? ?
????????? ?????????????? ???????? ?????? ?????????. ??? ??????? ? ??????? ? ???????? ?????????
?????????? ???????? ????????????? ? ????????
?????????????? ??????. ??? ??? ?????????? ??????????? ????????? ? ??????????? ???????, ??????
? 15 (16,9 %) ?? ??? ??? ????????? ??????????
?????????? ? 2?2,5 ????. ? ??????? ???????? ????????????? ????? ????????? 3,3 ╠ 0,7 ??, ????????
????????????? ?????? ? 4,8 ╠ 0,6 ??, ????????
????????????? ????? ? 81,6 ╠ 58,4 ??, ????????
?????????????? ????? ? 142,2 ╠ 61,4 ??.
????????? ?????????????? ??????????? ???????? ?? ?????????? ?? ??? ??????? ???????.
? ???? ??????? ???? ??????? ??????????? ??????? ??????? ?? ?? ???? ?????????? ????????????
?? ??. ????? ????, ? ????? ? ?????????? ???????53
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
Йкр. 2. я?лл?б Ы?сДи-кррнб?с??лк? ╥сн╦лс?с Ц., 1 ?с? 2 обр.
як??лса: ??сй?блл?? окз??н╦л?? лб?срз?зс?лсрз╦ р ?б?ш??кз??кбх 4 (+). Х?к с?блмб окз??н╦лс?с мн?т?л? ????н??зр? 2 рз?шк ?б?ш??кз??кк, ?срзк????кб шрз╦б? нб?с?л?? ?бл
Йкр. 3. Юлз??стб???кслл?х о?зб?к?н ш??нбллс?с ЕД, т?б?рз??нблл?х ? ?к?б ╞к?смсх нст?зсс╥??алсх тб?б?лбх
рз?с?мк, шзсн?блл?? ?с?? к ык╥?салс каоблблл?? т?ткнн??л?? о?╞?
???? ????? ?????????? ??????? ?? ????????? ?????? ?????????? ???????? ?????????????? ???????
???????? ?????????? ?????????????? ?????????
??????: ?? ?? ? ???? ??????? ??????? ?????????? ?? 22 ?? 45 %. ??????? ???????? ? ??????? ???????? ??????? ? 12 (18 %) ????????? ???? ?????
50 ?? ??. ??., ?? ???? ????? ????? ???????? ????????? ???????? ???????????.
???? ????????? ????????? ? ??????????????
????????????? ?? ??:
? III?IV ?????????????? ????? ?? NYHA;
? ????????????? 2?3-? ???????;
? ??????? ???????????? ?? ??????? 2 + ? ?????;
? ????????? ?????????? ??????, ???????????
??????????????? ????? ??? ??????????? ????????
? 1,5 ????;
? ??????? ??????????????? ????????? ???? ??
? ????? ????????? ??????? (???????, ?????, ??????????? ?????);
? ?????????? ????????? ??????????????? ?????? ?????? ????????? ????? ??? ? 2 ???? ?? ????????? ? ?????????? ?????;
? ????? ???????? ?????????? ???????? ?? ??
?????? ?????.
????? ???????????? ???????????? ??? ???????
???? ??????????? ? ???????? ?????????????? ?????????????? (??), ?????????? ? ?????????? ???????????????? ????????????. ????? ?? ?????????
?? 87 ?? 309 ???, ??????????? ??????????? ? rectum ???? 24 ╟?.
?????? ?????? ??????????? ????????? ????????????? ???, ? ????? ? ?????????? ??????? ??
??? ??????????? ??????????? ?????????? ?????????????????? ????????. ?????????????????
?????? ?? ????????????? ?? ??????????? ?????????? ????????? ? ?????????????? ??????? ???????? ??????? ?? ??? ???????????. ??? ??????? ?????????? ?????? ??????? ???????? ???????? ?? ??-
????? ??? ?????????? ? ??????????. ?????????
?????????? ? ??????????? ????? ??????????
???????. ????? ?????????? ? ??????? ???????????? ????????: ????? ????????????? ?? ?????, ?????????????, ?????????, ??????????, ?????????,
??????? ? ??????. ????? ???? ???????? ??????
????????? ???? ?????? ?????????? ??????? ?? ????????? ? ????????? ????, ??? ??? ????????? ?? ?????? ?????? ???? ? ?????????? ? ???????????
???????, ??? ?? ????? ??????? ?????? ??? ?? ??????????????. ??????????? ????? ??????????? ??
?????, ??????????? ? ????????. ????? ????? ????
??????????? ?????? ? ?????????????? ?????????????? ?? ? ????????????????, ???????????, ???????????????????? ? ???????????????? ????????.
?? ???? ??????? ?????? ????????? ??????? ? ????,
? ????? ?????????? ?????? ? ???????????? ??????????? ???? ? ???????? ?? ?? ????????? ????????? ???????????????? ???????? ?? ???????
(???. 3). ?????????? ????? ???? ??????? ??????? ?
?????? ??????? ?? ?????????????.
??? ?????? ???? ??????????????? ???????
???????????? ???????? ????????????? ???????????? ????????. ? ????? ??????????? ????? ????
???????????? ????????? ???? ????????: ╚St. Jude
Medical╩ ? 68 (76,4 %), ╚Carbomedics╩ ? 7 (7,9 %),
╚??????╩ ? 2 (2,2 %); ╚?????????╩ HALL ? 4 (4,4 %),
╚ATS╩ ? 7 (7,9 %), ╚Sorin╩ ? 1 (1,1 %). ???????????
?????? ????????????????? ??????? ? 16, ???????????? ? 27 ??. ? ??????????? ??????? ???????
?????????? ?????? ?? ????????? ??????????????
?????? ??????????? ???????? ??????? (??? ??????? ??????????? ????????) ??????????????? ?
?????????? ???????. ? 11 (12,4 %) ????? ??? ???????? ????? ????????? ?????? ?? ?????????????? ???????? ???????????????? ??????????????,
??????????? ?????????????? ?????? ????????
????????.
54
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
????? ?????????????? ?? ??????????? ??????? ????????????? ????????? ???????. ????????
????????????? ??????? ?????????????? ??????????? ????????? ????????????????? ??????? ???????????????? ??????? ??????????????? ?????????????????. ?????? ??? ????????? ?????????????? ????????? ????????? ????? ??????????????
????????? ????????????. ????? ????, ??????????
???????? ??????? ??????? ? ??? ?????????? ??????? ?????????????? ????????????? ??????? ? ??????? ?????????? ???????? ?????????????? ??????????????.
Йбашн╦з?з?
????????? ????????????????? ??????. ??????????? ? ????????? ????????????????? ??????? ????????? 13,5 % (n=12). ??????????? ????????????????? ?????? ?????????? ? 38 (42,7 %)
?????????. ?? ?????? ????? ????? ?????????? ???? ????????? ??????????????? ? 18 (47,4 %) ?????,
?? ?????? ? ?????????? ?? ??????? ??????? ??????? ? 10 (26,3 %) ?????, ??? ????????? ???????????????? ????????????? ?????????? ?????? ? ?????
??????????? ?????????? ? ????????? ??????????.
? ?????????? ????????? ??????? ????????? ?????
? ???? ??????????????? ???????????? ??????????
??? ?????? ?????????? ???????, ??? ??????? ? ??????????? ?????????????? ???????? ????? ? 3 (7,9 %)
???????. ? 1 (2,6 %) ??????? ????? ????? ????????
?????????? ???????????? ? ??????????? ? ??????? ??????? ?? ???? ????????? ????????????
??????? ????? ? ???? ?????????????? ? ??????????????. ????? ??????????, ????????????? ?????????????? ????????????? (???????????????? ??) ?
?????? ????? ????? ????????, ??????? ????????
???????? ????????????? ??????? (n=1) ? ??????
??????? ????????????????? ??????? ? ??????? ?
????????? ????????????? ????????????.
? ???? ??????? ??? ???????? ??????? ???????????????? ????????? ??????????????? ? ?????????
????????????????? ??????? ???? ???? ???????????? ??????? ???????????????? ??????????????:
???????????????? ????????? ?????????????? (n=1)
? ?????????????????? ?????????? ???????????
(n=2). ?????? ???? ?????????? ?????????? ?????????????????? ??????? ??????????? ????, n (%):
?????? ????????? ??????????????? . . . . .18 (47,5)
??????????? ??????????????? . . . . . . . . .10 (26,3)
???????????? ??????????????? . . . . . . . . . 4 (10,5)
????????? ????? . . . . . . . . . . . . . . . . . . . . . 3 (7,9)
???????????? . . . . . . . . . . . . . . . . . . . . . . . .1 (2,6)
??????? ???????* . . . . . . . . . . . . . . . . . . . . . .1 (2,6)
????????????? ???????** . . . . . . . . . . . . . .1 (2,6)
* ?? 7-? ??? ????? ???????? ????????? ????????????????
?? ? ????? ? ????????? ???????? ???????; ** ?? 2-? ??? ?????
???????? ????????? ???????????????? ?? ? ????? ? ????????
??????????????? ???????? ????????????? ???????.
??? ???? ? ????????????????? ??????? ???????? ???????????????? ???????. ????? ?? ?????
???????? ????????? ??????? (200 ??/??/??? ?????? 6 ?) ? ??????????? ????????? ?? ????????
?????????????? (???????, ????????) ? ????
0,09 ??/??/???. ????????? ???????????????? ???????
??????????? ??? ????????? ??????????? ???????????? ??????? ????? ? ??????????????? ???????
(???) ? ?????????????? ???????????????? ????????? (???). ?? ????????? ???????????? ??? ?
???????? 45?55 %, ? ??? ? ? ???????? 1,8?2,2.
???????? ?????? ?????????? ????????????? ???
??????? ? ? ?????????? ?? ????? ??????????.
???? ????????? ??? ??????? ?? ?????????? ??????????? ??????????? ?????-????????????. ???
?????? ??????? ????????????????? ??????? ?????????? ???????? ?? ????????????? ???????
???????; ???????? ??????????????? ???????? ??
??????? (??????? ? ???????); ?? ??????? ????????????; ??????? ????????????? ??????. ?? ????
??????? ?????????? ?????????????????? ????????????? ??????? ???????, ?????? ?????????? ???????????? ?? ???, ?????????? ????????????? ?????? (?????????? ???????? ???????, ??????? ???
???????????? ?? 2-? ??? ????? ???????? ? ????? ?
???????? ??????????????? ???????? ????????????? ???????). ???????? ??????????????? ????????
?? ??????? ??? ?????????????? ? ???????? ? ??????? 6,3 ╠ 0,4 (???????) ? 3,7 ╠ 0,8 ?? ??. ??. (???????). ?????????? ???????? ?? ? ???? ??????????
??? ???????? ???????? (???, ???) ? ???????? ????????????? (???, ???) ???????? ??? ??????? ?
???? ?????.
?????????? ????????????????? ??????. ??????????? 68 ?????????, ??? ????????? 88,3 % ??
?????? ????? ?????????? ?????. ?????????? ?????? ?????????? ???????? ?? 3 ??? ?? 9 ??? (?
??????? 4,6 ????).
?????? ?????????? ??????????? ???????? ?????????????? ??????????? ??????? ?????????????
?? ????????? ????? ????????? ?????????, ??????
???????????????? ??????? ???????????? ? ?????????? ??????????????? ???????.
??? ?????? ?????????? ? ?????????-???????????? ???????????? ?? ???????????? ???????? ??
J. Somerville (1989 ?.), ??????? ???????? ????? ???????? ????????? ????????? ? ??? ??????????
????????? ????????.
?? ????????? ?????? ? ??????? 44 (64,7 %) ???????? ???? ???????? ? 1-? ???????? ?? ????????????? J. Somerville: ???????? ???????? ????????????? ???????? ? ????????? ????? ?????, ????????? ????????? ??? ╚???????╩, ?? ???????????
?????. ???? ? ???? ?????? ?????? ?????????? ?????????? ????????, ?? ????????? ????????? ????????? ? ?????????? ?????????. ?????? ?????? ??????? ?????????? ? ????, ?????? ??????????? ?????????. ???????? ?? ??? ??????? ?????????
????????????????? ????????????? ?????????. ??55
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
?????????? (20,6 %) ??????? ???????? ???????
???, ?????? (7,4 %) ? ?????.
? 24 (35,3 %) ????????????? ??????? ????????
???????? ????????? ???????? ????????????? ? ?????????? ????????, ?????????? ??????????????
?????? ????????????? ????????????.
? ???? (2,9 %) ????????? ?? ???? ?????? ??????????? ???????? ?????????? ????????? ??????????????? ? ???? ??????, ?????????? ????????????,
????????????? ? ?????????? ?????? ?? ?????? ???????????. ???????? ?????????? ???????????????
?????????????? ??????? ? ???????????? ???????? ??????? ?? ????? ?????????? ?/??? ????????????? ?????? ?????? ????????????? ??????????
?? ???? ?????????. ??? ???? ???? ???????? ? 3-? ?
4-? ???????? ?? ????????????? J. Somerville. ????? ??? ??? ???????? ????????? ?? ????????? ???????????? ? ?????? ??????????????? ??????? ?
????? ??. ?.?. ???????? ????. ????? ???????????? ???????????? ? ??????? ?????????? ???????????????? ??????? ???? ? ?????????????????? ????????? ???????? ?? ????? ??????????. ??? ????????? ???????????? ? ??????-???????????????
?????? ?????? ????? 1 ? 2 ???? ?????????????? ????????? ??????? ???? ????????? ??? ???????,
???????? ????????? ??????????????? ?????????????, ?? ???? ????????????? ? ?????? ?????????
?????????? ? ?????????? ??????????.
?? ?????? ???????????????? ??????? ???????????? ? ?????????? ????? ????? ????????, ? ????
????????? ?????????? ????????????? ????????.
???-???????????? ???? ????????? ???? ?????????. ? 100 % ??????? ??????????????? ?????????
???? ? ???????? ????????? ??????????, ??????????????? ?????????? ?????? ????????. ?????????
?????????????????? ???????????? ? ???? ???????? ??????? ?????? ????? ????? ???? ???????? ?
8 (11,8 %) ?????????. ? 6 (8,8 %) ??????? ??????????? ???????? ??????????? ??.
? ??????? ?????? ???? ??? ????? ???????? ???
?????????? ?????????????? ??????? ??????? ?????? ?????????? ?????????? ???????? ??????, ?????? ? ?????????? ??? ????????? ???????????, ?
??? ????? 3 ???? ????? ???????? ??????????? ????????????? ??????????? ?????????? ??? ? ??
63 ?? 51 % (p<0,05). ????? ????, ? 16 (23,5 %) ??-
??? ??????????? ???????????? ????????? ???????
?/??? ?? ?????????? ????????? ????????? ??????.
?????????? ???????????????? ????? ??????????? ???? ????????? ? ?????????? ???????, ??????
? ??????????? ????? ????????????. ?????? ?????
???????? ??????? ???????? ???????? ? ????????
????????????? ?? ? ?????????? ????? ????? ????????, ??? ???????? ???????, ? ????? ???????
????????????????? ???????. ?? ?????? ???????????? ???????????? ???????? ?????????? ????????
???????? ? ???????? ????????????? ?? (??. ???????). ??????? ???????? ???????, ???????? ????????????? ????????? ? ?????? ??????. ?????????
???????? ????????? ??????????????? ???????? ??
?????????? ??????? ????????? ?? 5 ?? 20 ?? ??. ??.,
???????? ? ?? 7 ?? 14 ?? ??. ??. ???????? ???????????? ?? ???????????????? ???????? ?? ??????????. ? ?? ?? ????? ??? ???? ????????? ??? ???????????? ??????????? ??? ????????? ?????????
?? ????????????????. ?????????? ?????????? ??????????????? ???????? ?? ??????? ??? ??? ?????????? ???????? ? 6 (8,8 %) ??????? ? ??????? ???????? ?? ??????? ???????? ? ??????? 19?24 ?? ??. ??.
??? ???????? ?????????? ?????? ???????? ??????????? ?????????? ????? ???????? ? ?? 3,5 ?? 7 ???.
???????? ???????? ??????? ? ?????? ?????, ??????????? ??????? ??????????? ?? ????, ??? ?????????? ????????????? ??????? ?????????????????
???????. ?????? ????????? ??????? ?????????
???????? ?? ?????? ??????????? ??????? ?? ??????
????????? ????????.
??? ???????? ? ?????????? ??????? ??????????
???????? ???????? ??????????????, ? ????????
????????. ????????????? ???? ? 0,09 ??/??/??? ???
????????? ??????????? ??? ? ???, ?????? ??????
?? ? ?????? ?????????? ?????? ????????????? ?????????????. ????? ????????? ????????? ???????.
??? ???? ????? ??????????? ?????????????, ?? ??????? ?????? 3 ???? ? ????.
? 2 ????????? ? ?????????? ????? ??????????
???????????? ?????????? ??????? ????????????,
????????? ? ??????? ???????????????, ???????
???????????? ????? ??????? ??????????? ???.
? ?????????? ????? ????? ???????? ??????
5 (7,3 %) ?????????, ??? ???? ?????? ????? ?? ????
??????? ? ??????????? ???????.
К???лкзбн╦л?? ????мзб?крзкм? т???обз?с? нб?с?с йбнш?с?м? ?с стб???кк
к ? сз??нбллсо тб?кс?б л?╥н??блк? ш т??кблзс? тсрнб т?сзбак?с??лк? ЕД
????????? ??
???, ??
???, ??
???, ??
???, ??
??, %
56
?? ???????? (n = 89)
?????????? ?????? (n = 68)
p
3,3 ╠ 0,7
4,8 ╠ 0,6
81,6 ╠ 58,4
142,2 ╠ 61,4
38,8 ╠ 5,3
2,9 ╠ 0,4
3,9 ╠ 0,1
46,3 ╠ 8,2
95,7 ╠ 11,6
62,3 ╠ 3,8
> 0,05
< 0,05
> 0,05
<0,05
< 0,05
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
И╥ршй?блкб
???????? ?????? I. Reyes ? ?????. [2], ??????????? ? ????????????? ?? ?? ? ????? ????????:
? III?IV ?? ?? NYHA;
? ????? ???????????????? ???????????????;
? ???????????????? ????????????? (??? ????? 60 %);
? ???????? ??????????? ?? ??????? ????????? ?
???????? ??????? ????? 50 ?? ??. ??.;
? ???????-??????????? ???????? ????? 20 ?? ??. ??.;
? ????????? ???????????????, ???????????? ?
??????????????? ???????;
? ???-?????? ?????????? ?????????? ??????????????? ? ?????????? ???????????? ???????
(? ??????????? ???????).
?? ?????? ?.?. ???????????? ? ?.?. ???????
[3], ??????????? ? ?????????????? ?? ????????
????????? ????????? ????????? ? ????????????
????????, ???????????? ??? ?????????????????
?????? ???????:
? ????????????? ???????????;
? ?????????? ???? ???????? ??????? ?? ??????? ??????????;
? ?????????? ??????????? ???? ? ???? ??????
??????;
? ?????????? ????????? ?????? ??? ????????
?????? ??????????? ???? ? ???????? ?????? ??,
????????? ?????? ?????;
? ?????????? ?????? ??????????? ???? ? ????????????? ??????????? ???????? ? ????????? ??;
? ????????????? ??????? ???????? ? ??????
???????;
? ?????????????? ? ???????????????? ??????;
? ???????????????? ???????????? ??????? ???????? ?????? ??????????? ???? ? ???? ????????
???????.
????????? ????????? ? ??? ?????????????? ????????????? ?? ??, ?? ????????? ?? ???????????
?????? (??????? ???????????? ???????????????
??????????????), ?????? ??????????????? (??????? ????????? ???????? ?? ? ???????????? ????????????), ? ????? ????????????? ????????? ??,
???????????? ??????????????? ? ????????????
??? ?????? ????????? ???????.
??? ???????? ?????? ???? ???????, ??????????????? ? ?????????? ???????, ?? ???????????
??????? ?????????????? ?????? ? ?????????????????? ????????????? ??????????????? ??????????????? ???????????? ???????? ? ?????????
?????. ???? ??? ????????????? ???????? ??????
????? ??? ??????????? ????? ?????????-????????? ????????? ? ???????? ?????????, ????????????? ??? ???????????? ???????? W. Roberat
??? ? 1976 ?.: ??????? ????????????, ??????????? ???????????, ?????????????, ???????? ???????????, ??????????? ???????, ????????????
?????????.
?? ???????? ???????????? ???????????? ???????? ???? ╚St. Jude╩, ??? ???, ?? ?????? ??????,
?????? ??? ? ????????? ?????? ???????? ???? ????????????? ???????????. ??????????????? ?????
???????? ??, ??? ? ????? ????? ?????????? ??????
??? ??????? ??????????? ? 68 (76,4 %) ????????? ?
???????? ????????????????? ???????????? ??? ?
?????????, ??? ? ? ?????????? ????????????????? ???????.
?? ?????? ??????? ??????????, ??????? ????????????? ??????? ?????? ?????????? ???????????????? ???????. ?? ?????? ???? ???????, ?? ?????? ?? ??, ??? ?????? ??????????????? ? ????? ??????? ???????? ????????? ??? ??????????,
?????????????? ?????????? ?? ?? ??????????
?????? ????????? [4].
??? ????? ????????? ??????????? ?????????????? ??????? ? ?????????? ??????? ? ?????????
????? ???????? ?????? ? ????????????????. ????????? ? ????????? ????? ??????????????? ? ????????????????? ? ????? ????????, ?????? ???????? ? ?????? ?????????? ?????? ? ????????????,
? ?????? ???????, ????????? ????????? ??????????? ? ???????? ????????????????? ??????? [5]. ??
?????? S. Friedman ? ?????. [6], ?????????? ?????
???? ? 2,5 ???? ???????? ?????????? ??? ?????? ???????. ?????? ?????? ??????????? ????????????????, ????? ??????? ??????????? ???? ??????? ????????????? ?????, ???????? ? ?????????, ?????????? ?????????????? ? ???????????? [7]. ??????
??? ??? ???????????? ?? ????? ???? ??????????
????????? ??? ???? ????????? ?????????, ? ??????
? ????????? ????????????? ?? ??????? ?????? ???????? ?????? ????????????? [5].
г??с??
1.?????????????? ?? ? ????? ??????? ????????
??????? ??? ??????????? ??????????, ????????? ?
?????????? ????????? ?????????? ??????. ??? ??
????? ????? ????????? ?????? ?? ?? ???????? ????????????????? ? ?????????? ??????????????,
??? ??? ???????? ?????????? ???????? ??????????????? ???????????.
2.?????????????? ???????? ?????? ? ??????
??????? ???????? ??????? ????????????? ??? ???????? ?????? ? ???????, ????? ?????????? ????????? ???????????????? ????????.
3.???????? ??????????? ???? ??????? ??? ?????????? ??????? ???????, ??? ????????, ????????????? ? ?????? ??????? ????????, ???????? ??????????? ?? ????????????????.
4.???????? ?? ?????????, ??????????? ???
??????? ? ?????? ???????? ??????????????? ? ?????, ?????????? ???????????????? ??????? ????????
??????? ??????????? ???????????????? ?????????????? ???????, ? ????? ????????? ? ??????????
????????????? ?? ???? ????? ? ???????? ? ?????
???? ???????.
57
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
5.?????? ? ?????? ?????? ??????? ????????
?????? ?????????????, ?????? ?? ?????? ???????????? ? ????????????????? ???????????? ?????????
??????????? ? ??????????????.
6.????????????? ?????? ???????????????? ?????????????? (????, ?????) ? ?????? ????????????????? ??????? ????????? ??????????????? ????????? ?????? ??????? ????????? ? ???????????
??????????????? ??????? ????????.
6.
7.
References
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2.
??????????
1.
2.
3.
4.
5.
??????? ?.?., ????????? ?.?. ????????????? ????????
???????? ???????. ?.; 2003.
Reyes I., Juff A., Pradas G., Burgos K. et al. // Ed. By
C. Gomez-Duran, G. J. Reui. 1989.
??????????? ?.?., ??????? ?.?. ????????-?????????? ????????: ???????????. ?.; 1996.
Fiane A.E., Lindberg H.L., Saatvedt K., Svennevig J.L.
Mechanical valve replacement in congenital heart disease.
J. Heart Valve Dis. 1996; 5 (3): 337?42.
Masuda M., Kado H., Tatewaki H. et al. Late results after mitral
valve replacement with bileaflet mechanical prosthesis in children: evaluation of prosthesis-patient mismatch. Ann. Thorac.
Surg. 2004; 77: 913?7.
Friedman S., Edmunds H., Cuasi C.C. Long-term mitral valve
replacement in young children. Influence of somatic growth on
prosthetic valve adequacy. Circulation. 1978; 57: 981?6.
Yoshimura N., Yamaguchi M., Oshima Y. et al. Surgery for
mitral valve disease in the pediatric age group. J. Thorac.
Cardiovasc. Surg. 1999; 118: 99?106.
3.
4.
5.
6.
7.
Bockeria L.A., Berishvili I.I. Surgical anatomy of coronary
arteries. Moscow; 2003 (in Russian).
Reyes I., Juff A., Pradas G., Burgos K. et al. // Ed. By
C. Gomez-Duran, G. J. Reui. 1989.
Burakovskiy V.I., Bockeria L.A. Cardiovascular surgery.
Moscow; 1996 (in Russian).
Fiane A.E., Lindberg H.L., Saatvedt K., Svennevig J.L.
Mechanical valve replacement in congenital heart disease. J.
Heart Valve Dis. 1996; 5 (3): 337-42.
Masuda M., Kado H., Tatewaki H. et al. Late results after mitral
valve replacement with bileaflet mechanical prosthesis in children: evaluation of prosthesis-patient mismatch. Ann. Thorac.
Surg. 2004; 77: 913?7.
Friedman S., Edmunds H., Cuasi C.C. Long-term mitral valve
replacement in young children. Influence of somatic growth on
prosthetic valve adequacy. Circulation. 1978; 57: 981?6.
Yoshimura N., Yamaguchi M., Oshima Y. et al. Surgery for
mitral valve disease in the pediatric age group. J. Thorac.
Cardiovasc. Surg. 1999; 118: 99?106.
????????? 26.09.2013
╘ ????????? ???????, 2013
??? 616.126.4-007.64:611.018.2-007.17
?????? ?????? ????????? ?????????????? ????? ?
????????? ?????????-??????????? ????????
?.?. ??????, ?.?. ????????, ?.?. ????????, ?.?. ????????
???? ╚??????????? ??????? ????? ???????????????? ? ????????????? ??????? ?????
????????? ?.?.????????╩ (???????? ? ???????? ???? ?.?. ?????) ????????????
??????????????? ??, ??. ?????????, ?. 1, ??????, ?????????? ?????????, 123182
?????? ??????? ?????????, ?. ?. ?., ?????????, e-mail: vpsivanov@gmail.com;
???????? ?????? ????????????, ?. ?. ?.;
???????? ????? ??????????, ?. ?. ?.;
???????? ????????? ?????????, ?. ?. ?.
??????????? ?????? ??????????? ?????? ????????? ?????????????? ????? ?????? ? ??????? 10 ??? ? ????????? ???????????????? ????????. ??????? ?????????? ??????????? ? ?????????? ????????? ? ?????????????? ???????.
???????? ?????: ????????? ?????????????? ????? ??????; ????????? ???????????????? ????????.
58
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
A RARE CASE OF CONNECTIVE TISSUE DYSPLASIA ? MITRAL-AORTIC
ANEURYSM
A.S. Ivanov, S.V. Glamazda, A.V. Lebedeva, A.S. Rodionov
Academician V.I.Shumakov Federal Scientific Center of Transplantology and Artificial Organs of
the Ministry of Healthcare of the Russian Federation, ul.Shchyukinskaya, 1, Moscow, Russian
Federation, 123182
Ivanov Aleksey Sergeevich, MD, DM, Professor, e-mail: vpsivanov@gmail.com;
Glamazda Sergey Vladimirovich, MD, PhD;
Lebedeva Alena Valerievna, MD, PhD;
Rodionov Aleksandr Sergeevich, MD, PhD.
The article presents a rare case of connective tissue dysplasia of the heart in a 10-year-old child ? mitral-aortic intervalvular fibrosa
aneurysm. It describes the difficulties in diagnosis and in assessment of indications for surgical treatment.
Key words: connective tissue dysplasia of the heart; mitral-aortic intervalvular fibrosa aneurysm.
? ????????? ???? ?????????? ?????????? ?????
?????????? ??????? ???????? ? ??????????????
???????????, ? ????? ?????????????????? ????????? ????????? ???????????????????? ?????????.
?? ??????????? ??????????????, ???????????????????? ????????? ?????????? ??? ??????????????? ??????? ?????????-???????????????????
???????, ????????????? ???????? ??????????????? ?????????? ? ????????? ? ????????????????
??????????? ?????????????? ????? ? ??????????
???????? ??????????? ?????? ??? ?????????? ?????????? ??????? [1, 2]. ??? ???????? ╚?????????
?????????????? ????? ??????╩ ???????????????
???????? ???????? ?????????, ? ?????? ???????
????? ??????????? ????????????????? ??????
??????? ????????? [3]. ??????? ????????? ?????????????? ????? ?????? (????) ??? ??????? ? ??????????????? ?????????????? ????? ?? ??????????, ??????????? ???????? ?????????? ?????????
?????????????? ????? (????, 1990 ?.), ? ? ????????????? ??????????? ????????-?????????? ??????? ???-???????? ?????????? ??????????? [1, 2].
?? ??????????? ?????????????? ? ???????? ????
??????? ???????? ???????? ??????, ?????????
?????????????? ??????????? ? ??????? ??????????, ? ????? ????????? ????????????? ?????
??????.
???????? ???????? ???? ?????????? ? ????
???????? ? ????? ? ??????? ?????? ???????? ?????
??????????, ??? ????????? ????? ? ????????????
??????, ???????????? ??????????, ????????????? ????????? ??????? ? ????????? ?????? [2, 4, 5].
? ????????? ?????, ???????? ?? ???????????? ??????????????? ???????? ???? ? ??????? ?????????, ?????? ??????? ??? ???????????????? ???????????, ??????? ??????? ? ???????? ???????? ????????????????. ?????????? ??????? ? ?????????
??????? ????? ? ????????? ????, ?????????? ??
??? ????????????, ?????????????, ? ????? ???????, ?????????? ??????? ?????????? ??? ??????
????????, ? ?????? ???????, ????????????? ????????? ????? ?????????? ??????????? [1, 6].
? ???????? ????????????? ????????????? ????
╚?????????-?????????????╩ ???? ??????????? ???????? ?????. ????? ??? ??????????? ????????
???????? (???? ???????????) ? ????????? ????????????? ????? ?????? ????????? (????? 90 %) [1,
6, 7]. ? ?????? ?????? ?? ?????? ?? ???????????
?????? ?????? ????????? ?????????????? ?????
??????, ????????????? ????????????????????
?????????????. ???????? ???????? ?????? ?? ??
?????? ????? ? ????????? ??? ??????????? ??????????, ?????? ????? ?? ???? ???????? ??????? ???
?????? ? ????, ??? ??? ?????? ??????????? ?????????? ?????????????? ??????????? ???????????????????? ???????? ?????? [8, 9].
?????????, ? ???????? ?? ??????????? ? ???????? ?????????? ????????, ???????, ?????? ?????,
? ??????????? ?????? ??????????????? ?????????,
??????? ??????????? ????????? ?? ??????? ???? ????????? ??? ? ?????????????? ???????, ??? ? ??
????? ????????. ??????????????? ??????????????
???????? ??? ????, ??? ?????? ??????? ??? ?????????? ?????? ????????????????.
???????, 10 ???, ???????? ? ????????? ????????
?????????? ??????? ?????? ? ????????? ╚cor triatriatum sinistrum╩. ??????? ??? ?????????? ? ??????? ????????? ???????????, ???? ?????????? ???????? ? ????? ? ???????? ??????? ?? ????????????. ??? ??????? ?????????????? ????? ???
???????? ?????? ?? ????????, ????????????? ?????????????? ?? ???????? ? ?????? ????? ?? ???????????????. ?? ?????????????? ?????????? ?????????? ?????? ? ?????? ?? ???? ?????? ??? ???????, ?? ??? - ??????? ?????? ????? ????? ????. ??
?????? ?????, ?????? ??????? ????????? (??) ???????? 2,0 ??, ???????????? ???????? ? ????????
??????? (Vmax ??) ? 1,4 ?/?. ? ????? ??????????
????????????????? ????????? ???????????, ??????? ????????? ? ????? ????????? ?? ?????? ?????????-??????????? ???????? ? ????????????? ?
?????? ?????????? ? ??????? ????????? ??????????? ? ?????????? ????????? ?????????? ??????
??????????? ??????? (???. 1).
59
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
RV
LV
TV
RA
MV
LA
Йкр.1. я?ш?об?л?? Ы?сДи, ?бз??б?м?об?л?? тсак?к?:
RV ? т????х йбнш?с?бм; LV ? нб??х йбнш?с?бм; RA ? т???сб т?б?рб??кб;
LA ? нб?сб т?б?рб??кб; MV ? окз??н╦л?х мн?т?л; TV ? з?кмшртк??н╦л?х
мн?т?л. И╥?болсб с╥??ас??лкб ? тснсрзк нб?с?с т?б?рб??к? шм?а?лс
рз?бнмсх
??? ????????? ???????? ? ?????? ???????????
??? ???????????? ???????? ???????? ???? ????????? ?????????? ???????????? ?????????? (???),
??? ? ??????? ?????? ?????????? ?? ?????? ???????? ??????? ??????????? ??????? ? ??????????? ??
???????? ?????? ???????????? ????????? ??????????? ????????? 3,5в3,6в3,2 ?? ? ???????????
??????? ???????? ?? 2,2 ??, ????????????? ? ??????? ??????? ?????????? ?? 1,5 ?? ????? ????????? ?????????????? ??????????? ????? 10 ?? ?
????????. ?????????? ????? ??????? (?? 18 ??)
????????? ????????? ???? ?????????????? ??????? ? ???????? ??????? ?????? ????????? (?????
?????????).
???????? ?? ??????? ???????? ? ?????????????, ?? ?????? ??? ?????????? ???? ????? ??????????????? ????? ??????? ???????????. ????
??????????? ??? ???? ??????? ??????????????
???????, ?? ???? ??? ??? ?????? ????????-??????????? ?????????? (???). ?????? ??? ???????????? ????????? ??????????? ?????? ???, ????? ??
???????? ????????, ??? ? ????? ????????????????,
??????????? ???????? ??????????????? ????????
????????.
????? ???????, ??????? ????????????? ? ????????? ???????????????? ??????????? ? ??? ?????????????, ???????? ?? ?????????? ????????????
????????, ?? ?? ????????. ???? ????, ??? ????????? ??????????????? ????????? ?? ???????? ?????????, ????????? ?? ??????? ????? ???????? ???.
? ?? ?? ????? ?????????????????? ???????????
??????? ? ??????? ????????? ??????????? ????????? ????????? ???????? ? ?????????? ??????? ???????????? ??????????????? ?????????. ????????
60
?????? ???????, ??????? ???????????? ??????
????? ?????????????? (?????? ?? ? 2,0 ??, Vmax
?? = 1,4 ?/?), ???? ?????????????, ? ????? ???????? ???????????????? ???????????, ???????????
??????? ????? ?????? ??????????, ?? ?????????,
??? ????????? ? ???????? ??????????.
?? ???????? ??? ???????? ??????? ???????
?????????? ???????????? ????????????????? ????????? ?????????????? ??????????? (???), ??
??????? ?????? ???????? ?????????? ????? ??????????? ?????? (??), ???, ????????, ???????? ????????? ????? ??????. ????? ?? ???? ????????
?????????? ???, ?? ???????? ???? ???????????
?????? ??? ????????? 9 ??, ?? 1,0 ?? ???? ?????
??????? ????? ???? (???). ????? ??????? ????????? ??? ?? ????? ?? ?? ??????? ??? ????????, ???
??? ??????? ?????? ?? ??????? ?????? ???????????? ??????????? ????????? 5,0в3,5 ??, ?????????????? ????????? ?????? ????????? 1,5в2,2 ?? ?
??????? ?????? ????????? ? ??????? ???????????????? ????????????. ??????? ?????? ????????? ?
3?5 ??. ????????? ???????? ????????? ? ??????????? ????????? ?? ????? ???????? ?? ?????????????? ???????? 2,0в2,0 ??, ????????????? ?????????? ?-????????? ????? ? ??????? ???????????????? ????????, ? ?? ?????????? ????????? ?
??????????? ????, ??? ????????? ????????? ??????? ???????? ??????? ??????????? ???????. ????????? ???????? ??? ???????? ?? ?????????????? ???????? 5,0в3,0 ??. ????? ?????? ?????? ?
????? ? ??????????????? ?????????????? ?????????? ????? ? ??-???????? I ??????? (PQ 0,26), ???????? ??????? ?????????????? ??????????????.
?? ??????????? ????????????????? ?????????????? ????? ????????????? ???????????????
??????????? ??????? 0?1 ???????, ?????????????? ???????? ?? ?????????? ??????? ???????? ? 8
?? 3 ?? ??. ??. ????????????????? ?????? ???????? ??? ????????????, ??????? ??? ??????? ??
??????? ?? 8-? ???. ?? ?????, ??????????? ?? 7-?
??? ????? ????????, ?????????? ?????????? ???????? ?????? ????????? ? 3,1 (???????) ?? 2,7 ??
(???. 2).
??? ??????????????????? ???????????? ????????? ???????????????? ?????????, ???????? ???
?????? ??????????, ? ????????? ???????? ? ? ?????????? ?????????? ????????? ? ?????????? ????????? ???? ????????????? ?????????????? ????? ? ??????? ??????????? ? ???????????? ???????
??? ????????? ??????????.
????????, ??????????????? ????????? ???????? ?? ??????? ??????????????????? ???????????,
???????????????? ????????. ????????, ??????????
??? ???? ????????? ???????, ?????????????? ? ?????????? ?????????????? ????????? ????????
??????? ??????????? ???????. ?? 10 ??? ????? ??????? ??????? ??????????? ??????????? ? ???????,
????????? ????? ??????? ??????? ???????????
????? ?????? ??????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
??????????
1.
2.
LV
RV
3.
4.
RA
LA
5.
6.
Йкр. 2. я?ш?об?л?? Ы?сДи, ?бз??б?м?об?л?? тсак?к?. А?о?м?збн╦л?? ышлм?к? мн?т?лс? лб л??ш╞бл?. И╥сал??блк? зб
йб, ?зс л? ?кр. 1
??? ???????? ????????????? ??????????????
??????, ?? ???? ????????????? ???? ?????? ???????, ? ??? ????? ? ? ??????? ??????? ?????????
?????? ??????????. ?????? ??? ?????? ???????????? ?? ?????????, ??? ?????? ????????? ????????. ?? ?? ????? ????????? ? ???????? ?????????????????? ?????????? ???????????, ??????? ?????
?????????????? ??????, ??? ?? ???????, ? ??????????? ????????? ??? ??????? ?????????, ???????? ??????? ??????? ???????????.
??????????????? ???????? ????? ????????? ?
????????, ????????? ??????????? ????????? ??????????? ????????????. ?????? ????????? ????? ??????????? ?????? ?? ?????? ????????????? ???????, ?? ? ????? ???????? ?????????? ??????????????, ???????? ????? ????? ?? ????????. ?????
????, ???????? ????????? ??????????????????
??????????, ? ????? ????????? ????? ? ???????????, ??????? ?????? ????????? ?? ??????????? ???????, ???????? ? ?????? ????? ??????? ?? ???????????? ? ????????, ????????? ? ???????? ???????? [2, 10].
?? ????????, ??? ???????????????????? ?????? ?????? ???????? ???? ??????? ??????????? ?
?????????????? ? ??????????? ? ??????? ?????
?????? ?????????, ??????? ????? ??????????? ? ??
????????. ??? ???? ??????????, ??? ?? ?????? ?????????? ????? ?????????? ??? ?????????? ??????????? ????????. ???????? ? ??????? ?????? ??????????????? ??????? ?? ????? ?????????????
????? ?????? ?????????????? ??????????? ?????
????????? ??????????????????? ?????????. ?????????? ??????????? ??? ?????????? ?????? ?,
?????????????? ??????????? ??????, ?????????
??????? ? ????????? ??????? ??????? ? ???????
????? ?????????.
7.
8.
9.
10.
?????????? ?.?. ???????????????????? ????????? ??????. ???: ????????; 1998.
??????????? ?.?., ????????? ?.?. ??????????? ????????? ????????-?????????? ??????????? ? ?????, ??????? ?
????????????. ?????????? ??????? ????????????? ? ?????????. 1997; 6: 14?20.
Bonnet D., Saygili A., Bonhoeffer P., Fermont L., Sidi D.,
Kachaner J. Atrio-ventricular valve dysplasia in 22 newborn
infants. Inter. J. Cardiol. 1997; 59 (2): 113?8.
??????????? ?.?., ????? ?.?., ?????????? ?.?. ? ??.
????????? ?????????????? ????? ? ??????? ??????????????? ??????? ? ????? ? ??????????? ????? ??????. ?????????. 1998; 6: 26?9.
Lin J.M., Hwang J.J., Chiu I.S. Cerebral embolism from the
thrombus in the atrioventricular septal aneurysm. Division of
Cardiology National Taiwan University, Taipei, Republic of
China. Cardiology. 1995; 86 (5): 441.
?????????? ?. ?., ?????? ?. ?., ???????? ?. ?. ?????????
?????????????? ????? ?????? ? ?????? ?????????????????
????????? ? ?????. ??????? ???????????. 2001; 19: 54?6.
???????????? ?.?., ???????? ?.?., ???????? ?.?., ??????? ?.?.
??????? ????????? ?????????????? ????? ? ???????? ???????????????. ??????????? ????????. 2003; 81 (4): 67?9.
Cengiz Bolcal, Oben Baysan, Suat Doganci, Mehmet Uzun,
Ufuk Demirkilic, Harun Tatar. A mitral-aortic intervalvular
fibrosa false aneurysm in a patient without overt heart disease.
Can. J. Cardiol. 2007; 23 (5): 389?90.
Imren Y., Halit V., Kula S., Olgunturk R. Giant right atrial
aneurysm: case report. Int. J. Cardiol. 2006; 112 (3): 66?8.
Nagaraja Moorthy, Sudeep Kumar, Satyendra Tewari, Aditya
Kapoor, Nakul Sinha Mitral-aortic Intervalvular Fibrosa
Aneurysm with Rupture into Left Atrium: An Uncommon
Cause of Acute Dyspnea. Heart Views. 2012; 13 (1): 13?5.
References
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2.
3.
4.
5.
6.
7.
8.
9.
10.
Zemtsovskiy E.V. Connective tissue dysplasia of the heart.
StPetersburg: Politeks; 1998 (in Russian).
Shkol'nikova M.A., Leont'eva I.V. The current classification of
cardiovascular diseases in children, treatment and prevention.
Rossiyskiy vestnik perinatologii i pediatrii. 1997.; 6: 14?20
(in Russian).
Bonnet D., Saygili A., Bonhoeffer P., Fermont L., Sidi D.,
Kachaner J. Atrio-ventricular valve dysplasia in 22 newborn
infants. Inter. J. Cardiol. 1997; 59 (2): 113-8.
Kantemirova M.G., Tyurin M.A., Ibragimova G.F. et al.
Connective tissue dysplasia and anti-organ antibodies level in
children with arrhythmia. Pediatriya. 1998; 6: 26?9 (in Russian).
Lin J.M., Hwang J.J., Chiu I.S. Cerebral embolism from the
thrombus in the atrioventricular septal aneurysm. Division of
Cardiology National Taiwan University, Taipei, Republic of
China. Cardiology. 1995; 86 (5): 441.
Men'shikova L.I., Surova O.V., Makarova V.I. Connective tissue dysplasia of the heart in the genesis of cardiovascular
pathology in children. Vestnik aritmologii. 2001; 19: 54?6 (in
Russian).
Gorbatenkova S.V., Drapkina O.M., Kuznetsov N.E., Ivashkin V.T.
Connective tissue dysplasia syndrome in cardiological practice. Klin. Med. (Mosk). 2003; 81 (4): 67?9.
Cengiz Bolcal, Oben Baysan, Suat Doganci, Mehmet Uzun,
Ufuk Demirkilic, Harun Tatar A mitral-aortic intervalvular
fibrosa false aneurysm in a patient without overt heart disease.
Can. J. Cardiol. 2007; 23 (5): 389?90.
Imren Y., Halit V., Kula S., Olgunturk R. Giant right atrial
aneurysm: case report. Int. J. Cardiol. 2006; 112 (3): e66?8.
Nagaraja Moorthy, Sudeep Kumar, Satyendra Tewari, Aditya
Kapoor, Nakul Sinha Mitral-aortic Intervalvular Fibrosa
Aneurysm with Rupture into Left Atrium: An Uncommon
Cause of Acute Dyspnea. Heart Views. 2012; 13 (1): 13?5.
????????? 26.09.2013
61
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
╘ ????????? ???????, 2013
??? 616.12-008.318-053.4-06:616.132.2-089.843.168
??????? ????????? ????? ???????????? ??????
? ??????? 4 ??? ????? ???????? ????????????? ?????
?????????? ??????? ? ?????
?.?. ????????????, ?.?. ??????, ?.?. ??????, ?.?. ??????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ?
???????? ??? ? ???? ?.?. ???????) ????; ?????????? ?????, 135, ??????, ??????????
?????????, 121552
???????????? ??????? ????????, ?. ?. ?.;
?????? ??????? ????????????, ?. ?. ?.; e-mail: orhn@yandex.ru;
?????? ?????? ???????????, ?. ?. ?.;
?????????? ??????? ???????????, ?. ?. ?.
??? ?????????? ?????????? ????? ?? ????????? ?????? ?????????????? ?????? ?????????? ????? ???????????? ? ??????????? ?????????? ???????????. ???????????????? ???????? ??????? ??? ???????????? ???. ?????? ??????????? ? ????????????? ??????? ?????? ????????? ????????? ?? ????????????? ?????. ??????? ??????????? ????? ???? ??????????? ????????? ??????????? ?? ?????? ??? ????????????? ?????????????? ??? ????????? ?????????? ?????? ????????? ??????.
??????????????? ?????????? ??????????? ??????? ?? ??????????? ?????????????? ????????????? ????????. ???????????
???????????? ?? ????????? ??????? ?????????????? ??????? ?????? ????????? ?? ???? ???????????. ?????????? ??????,
??????? ???????? ????????, ?????????? ???????????????, ??????????? ?????????? ????? ????? ?????????? ??????? ??????? ????????????? ???????? ????????????? ?????????? ? ????????????????? ???????. ?????? ??????? ??????????? ??
??????????? ??????? ????????????? ??????????????? ????????? ????? ? ????????????????? ??????? ?? ???? ??????????? ?????????? ????? ????? ?????????? ???????. ?????????? ????????? ????? ????? ?????????? ???????, ???????? ??????
????????? ? ???????????? ????????????? ?????? ???????????????????, ????????????? ???????????????, ???????????????, ??????? ???????? ?????????????, ???????? ???????? ?????? ? ??????? ?????????. ??? ?????????? ?? ??????????????? ??????? ?????????????????? ??????? ??????????????? ???????? ?????????? ????????? ??????????? ????????-??????????? ??????????.
???????? ?????: ?????????? ?????????? ????? ?????????? ??????? ?? ????????? ??????; ????? ?????????? ???????; ?????????????? ??????; ????????? ?????; ???????? ????? ????? ?????????? ???????; ?????????? ?????????? ????????.
COMPLEX ARRHYTHMIAS ISHEMICSKI GENESIS OF THE CHILD, 4 YEARS
AFTER THE OPERATION OF AORTIC REIMPLANTATION THE LEFT CORONARY
ARTERY
T. O. Astrakhantseva, T.V. Rogova, N.A. Putyato, L.A. Yurpol?skaya
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of Medical
Sciences; Roublevskoe shosse, 135, Moscow, Russian Federation, 121552
Astrakhantseva Tat?yana Olegovna, MD, DM.;
Rogova Tat?yana Vladimirovna, MD, PhD; e-mail: orhn@yandex.ru;
Putyato Niiole Al?phonsovna, MD, PhD;
Yurpol?skaya Ludmila Anatol?evna, MD, DM.
In the case of anomalous origin of the left coronary artery from the pulmonary trunk, myocardial ischemia determine the date
of manifestation and clinical manifestations of the disease. Arrhythmias or cardiogenic shock are life-threatening in this case.
Early diagnosis and surgical treatment increase the probability of the positive outcome. Late diagnosis may happen when the
dysfunction of the left ventricle of the heart is identification lead to carditis or dilated cardiomyopathy diagnosis. Long-term
prognosis depends on if the damaged myocardium could be recovered. The studies do not demonstrate the full recovery of the
left ventricular function. Fibrosis, myocardial perfusion deficit, mitral insufficiency, the possibility of restriction of the left coronary artery determine that rigorous dynamic monitoring in the period after the surgery. These are discussed on the clinical case
of occurrence of malignant arrhythmias in the postoperative period amid increasing restriction of the ostium of the left main
coronary artery. Monitoring of the left coronary artery, the left ventricular myocardium function with mandatory documentation of data electrocardiography, Holter monitoring, echocardiography, including tissue Doppler, will help to avoid the possible treatment mistakes. Diagnostic protocol should be supported by MRI studies in case of adverse postoperative period is
prognosed.
Key words: anomalous origin of the left coronary artery from the pulmonary artery; the left coronary artery; myocardial ischemia;
arrhythmias; closure of the left coronary artery ostium; long-term results of repair.
62
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
?????????? ?????????? ????? ?????????? ??????? (?????) ?? ????????? ?????? ???????? ?????????? ??????? ??? ???????? ??????? ???????????????? ?????? ???????? ?? ??????? ??????
????????? (??). ??????????????? ??????? ?????????????? ???????? ??????? ????? ????????? ?????? ????? ???????? ???????? ? ??????????? ?????????? ????? ?????????? ??????? ?? ?????????
??????. ??????????? ???????? ?? ???? ????????
??????????????? ????????? ????? ????????? ?????? ? ????? ?????????? ???????, ??????? ???????????? ???????? ????????? ????????? ??? ????????? ????? ??????? ???????????. ??? ???????????? ???? ????????????? ??????????????
???????? ????????????? ???????????? ????????.
?????????? ???????? ???????????? ??? ????????
???? ??????????? ????????? ???????????????
?????, ??? ???????? ? ??????????? ????????????
? ?????????? ???????? ???????? ?? ????? ????????? [1]. ??????????? ?????????? ??????????? ?
????? ??? ???????????? ????????????? ?????????????? ???????, ? ???????????????? ??? ???????????? ??????? ??????????? ???????? ???????
??? ???????????? ??? [1, 2]. ???????? ??? ????????? ?????????? ?????? ????????? ???????? ???????????? ??????? ??????? ??? ?????????????
??????????????. Sh.S. Karr ? ?????. [3] ????????,
??? ????? ????? ??????????????? ?????????????
?? ????? ?????? ????????? ??? ?????????? ?????????????. ??????? ??????? ? ????????????? ??????? ?????? ???????? ??????? ???????? ????????.
???? ???????? ? ?????????????? ???????? ?? ???
?? ?????. ??? ?????, ?? ?????? ??????????? ????????, ????????????? ??? ? ????? (????????????
????, ??????????? ??? ???????? Switch) ????????
???????? ?????????? ???????, ??? ??? ???????????? ?????? ??????? ? ?????????? ???????? [4]. ??????? ???????? ???????? ??????? ? ??????????
?.?. ??????? ? ?????. [4]. ????????????????? ?????????????? ???????? ????????? ????????? ?? ????????????? ????? ???????????. ?????? ??????????
??????, ??????? ???????? ????????, ??????????
???????????????, ??????????? ?????????? ?????
????? ?????????? ??????? ??????? ?????????????
???????? ????????????? ?????????? ? ????????????????? ???????. ??? ?????????? ?????? ???????? ?? ???????????? ??????????? ???? ?????????????? ??????? ????? ? ????????? ?., 4 ???.
???? ??????? ??????? ??????? ??? ? ????????
4,5 ???, ????? ??????? ????? ????? ?????????? ? ????, ????????? ? ?????????? ????????. ??? ???????????? ? ?????????? ?? ????? ?????????? ???????
??? ???????? ??? ??? ???????? ??????, ????????
???????? ????????? ???????????????, ??????????
???????? ?????????????? ??????????? ????????
?????? ????????? (?? ?? ? 31 %). ??????? ???????????? ????????????? ? ???????? ? ?????????
???????????, ??????????????? ??????? ????????????, ? ??? ????? ????????? ?????????????. ???-
???????????? ??????????? ??????????? ????? ????????????? ??????????????? ?? ???? ??????????? ??????? ? ????????????? ????????????????
??????????? ???????. ??????????????? ???????
????????? ??????????????? (????????, ??????????
?????????, ?????????????, ????????, ???????)
????????? ?? ????????. ? ???????? 3,5 ???? ??? ????????? ?????? ? ??????????? ???????????? ????????? ?????? (??????????? ?????????????? ?????? ?????????) ??? ?????????????? ??????. ???
???????????? ????????????, ????????? ????????,
??????????? ??????? ??????? ? ???????? ??????????????? ??????? ??????? ???????????????? ?
??????? ????? ???????? ????? ????, ??? ???????
??????????? ???????? ?????????? ?????????? ???????. ?????????? ?? ???????????? ? ?????
??. ?.?. ???????? ? ????? ???????????????? ??????????? ?????????? ????? ?????????? ???????
?? ????????? ?????? ?????????? ??? ??????????????
???????.
??????? ????????? ??? ??????????? ???? ??????????? ?????????? ??????????? ????????????
???????? ?????? ?????????. ????????? ????????
???????? ???????????? ?? ???????? ? ????? ?????????. ?? ??? ????????? ?????????? ?????????
???? ? ???????? ????????? ?????????? 90 ??/???,
?????????????? ???????????? ????????????? ???
??????, ??????????? ????? ???????, ??????????
????????? ????????????? ??????????, ?????????
???????? ST ? I, AVL ??????????.
?? ?????? ?????, ??????? ?????? ?????????
????????? (??? ?? = 4,7 ??, Z-score ? 0,6), ?????????????? ??????????? ???????? ?????? ?????????
??????? (?? ? 42 %, ?? ? 0,21), ????????? ?????? ??????????? ??????? ????????? (D ? 2,9 ??,
Z-score ? 2,57), ??????????? ???????????? 2-? ???????. ??????????? ?????????? ???????? ? ???????
???????? ?????? ?????????. ????? ?????????? ??????? ??????? ?? ????????????? ?????? ????????
???????, ??????? ????? ????? ?????????? ??????? ?
2,6 ??.
???????????? ???????? ?????? ? ????????????????? ??????????? ??????? ??????????? ?????????? ????? ?????????? ??????? ?? ????????? ??????,
??????????????? ??????????? ??????? 3-? ???????.
??? ????????-??????????? ?????????? ? ????????????????? ??????? ???????????? (????? ????????? 25?30 % ?? ????? ????? ????????). ??????? ???????? ?????? ????????? ?? ?????? ??????? ????????? ? ???????? ?????????: ????????
?????? ? 3 ??, ?????????????? ? 4, ???????????? ?
4, ?????? ? 4?5, ??????????????????? ? ?? 5, ????????????????????? ? 4 ??. ????????? ??,
???????????? ?? ??????? ????????????? ??????, ?????????: ??? ? 191 ??/?2, ??? ? 126 ??/?2,
?? ?? ? 34 %. ? ??????? ?????????? ??????????????? ???????????????? ????? ? ??????? ??????
?????????? (?????????? ????????????), ? ??????????? ???? ???????????????? ? ??????? ???????63
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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??? ???????????? ???????? ?? ???? ???????????
???? ??.
?????????????? ???????????? ??????? ??????
???????? ???????? 35 % ?? ??????? ?????? ?????????. ????? ??????? ???????? ????????? ????????? 10?12 %, ?? ??? 7 % ? ???????? ???????? ????????? ? ??????? ????????, ????????? ????? ?????????? ???????? ??????????? ???????????????
?????????.
??????? ????????? ????????: ?????????????
????? ?????????? ??????? ? ?????????? ????? ?
????????? ?????? ???????? ??????? ???????????????????? ????????; ?????? ???????? ???????????
??????? ? ???????? ?????????????? ??????????????, ?????????? ? ?????????? ????????????.
?????? ????????????????? ?????? ????????
??? ??????????, ??????? ???? ???????? ? ?????????????????? ????????? ?? 18-? ??? ????? ???????? ? ??????????????? ????????, ??????????
???????????? ??? ????????? ???????????? ??????? ?????. ??? ??????? ?? ??? ???????????????
?????????, ?????????? ????, ????????? ????????? ????????????? ??????????, ??????????????
???????? ST. ????????? ????? ?? ?????????????.
??????????????????? ???????? ????????? ?????????????? ??????????? ???????? ?????? ????????? (?? ? 50 %), ?????????? ???????? ? ??????? ?????????, ???????????? ?????????? ??????????????? 2-? ???????.
????? ??????? ??????? ??????????? ???? ??????, ????? ?? ???????????. ????? ????? ? ???????
???????? ??????? ??????????? ?? ??????????
????, ????????????? ?????????? ????????, ????
???? ╚??????╩ ? ╚????????╩. ????????????????? ?
??????? ????? ???????? ????? ????, ??? ???????????? ??????? ?????????, ?????????. ?? ???? ????????????? ???????? ?????????? ??????? ??????????????? ???? ?? ???????? ??? ????????. ???????????? ? ???????? ??????????, ??????????
???????????????????? ????????????, ???, ???????????? ???????????????, ?? ???? ??????? ?????????, ???????????????? ??????????? ???????????
?? ???????? ?????????, ??? ??? ????? ?????? ????
?????????? ?? ???? ???????????. ????????? ???????????? ????????? ????????? ????????? ???????
??? ?????????? ? ????????? ??????????? ???????,
??? ???????? ??????? ??????? ? ??????? ????????,
??????????? ?? 140 ??/???, ????????? ??????????
???????? ST ?? ???. ??????? ????????? ?????????
??-??? ? ???????????. ?????????? ?????????? ????????????? ??????????????? ??????? ??????????
????????? (???. 1) ? ???? ????????? ?????????? ???????????????? ???????????? ?????????? (??).
?????? ????????? ????????????? ?????? ?????????? ????????? ?????????, ????????? ?? ?? ????????????? ?????????? ??????. ??????????? ??????? ????? ?????????????????? ????? ?????????? ???????. ??? ??????????? ? ???????????
??????? ??????? ??????? ???? ???????? ????????????????? ? ????? ??. ?.?. ???????? ????. ??
?????? ??????????????? ???????????? ?????? ??????????? ?????????? ???????? ?? ????????????-
?
╥
Йкр. 1. Оснзб?с?рмсб ослкзс?к?с??лкб ?б?ба обр?? тсрнб стб???кк ?бкотн?лз??кк ЦДд ? ?с?зш:
? ? л? ыслб л???шамк тс??н?бзр? ╥снб?сх ркл??со, ?б?крз?к?шбзр? ш???блкб СКК ?с 140 ш?/окл р ?бт?брркбх рб?облз? ST, ?салкмлс?блкб йбнш?с?мс?сх з??км???кк; ╥ ? ?б?бзблсс╥??ал?? эМ
64
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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Йкр. 2. Юррнб?с??лкб тсрнб
стб???кк. ЙДМ р ?лшз?к?блл?о ╥сн?рл?о мслз??рзк?с??лкбо. Йблз?блс?рм?? мсот╦?зб?л?? зсос???ык? т?с?б?бл? р ркл??слка??кбх тс ЫДи,
?лшз?к?блл?о ╥сн?рл?о ??б?блкбо лбксллс?с мслз??рзлс?с т?бт???з?, ? шрнс?к?? ЮгЦ,
об?км?облзсалс?с ш?бйблк?
?кзо?. Юррнб?с??лкб ??тснлблс т?к СКК 90 ш?/окл. Д?к?снклбхл?б ?бмслрз?шм?кк:
?
╥
?????? ????? ?????????? ??????? ?? ??????? ???
??????????? ?? ?????? ????????? (61 %). ???????????? ?? ?????????? ??????? ??????????? ??
2?3-? ???????. ?? ?????????? ????????? ?????????? ??????????????? ????????? (????????-T ?
0,037 ??/??; ????????-I ? 0 ??/??; ??-??? ?
3,54 ??/??; ????????? ? 68,7 ??/??). ?????????
????????????? ???????????? ?????????? ? ???????????? ???????? ?????????????????. ????????
????????? ???????, ???????????? ?? ????????????? ?????????? ??????, ??????? ?????? 130 ??/???,
?????? ???????? ???????????? ? ???????? ???????????????? ??? ? ??????????????? ?????????
????? ??? ??????????? ?????????????-????????????? (???. 2). ????????, ??? ????? ?????????? ??????? ????? ??????????? ?????? ??????. ????????????? ? ?????????? ?????????????? ??????????????? ?????????????? ?? ????. ??????? ?????????
????????????? ???? ??????? ? ????????????? ????????.
? ????????????????? ??????? ???????????
??????? ????????? ????, ????????? ?? ?????????????. ????????? ??????????????????. ?????????????? ??????????? ?????? ????????? ?????????
(?? ? 51?60 %), ?????????? ???????????????, ??
?????? ???????????????, 2-? ???????. ???????
??????? ??? ?????????? ?????????? ?? ????? ?????????? ? ?????????????? ?????????? ????? ?????????? ??? ????????? ??? ? ???, ????????, ???????? ? ??????? 6 ???, ????????-?????? ? ???????
6 ??? ??? ????????? ???????????? ??????? ?????,
?????????? ???????????.
?????????? ??????? ??? ????????? ????? ???????? ????????? ??????????? ?????????? ?????
?????????? ??????? ?? ????????? ?????? ?? ?????
?? ????. ????????????????? ??????? ???????????
??????? ?? ??????????? ?????????????? ????????.
? ? т????? мс?сл??л?? ??зб?к?
╥ба каоблблкх; ╥ ? нб??? мс?сл??л?? ??зб?к? коббз м?кзк?брмкх
рзблса рз?сн?
???????????? ????????? ??? ?????????? ????????? ?????????? ? ??????????? ? ????????????
??????? ?????? ????????? ??? ???????????? ??????????? ????????. R. Bagur ? ?????. [5] ?????????? ???????? ??? ??????????? ?????????? ?????
?????????? ??????? ?? ????????? ?????? ??? ??????????????, ????????????????? ?????????????????? ????????. ?????????????? ????????????,
????????-??????????? ??????????, ??????????? ?
?????????? ????????????????? ??????? ????????
???? ?????????? ???????? ?? ?????????????????? ? ?????????????????????? ??????????? ?????? ????????? [6, 7]. ??????? ????????? ? ???????????? ???????? ???????? ??????????????
????????? ?????????? ?????????? ??????????????
?????????? ?????? ????????? ? ????????? ?
??????????? ???????? ??????????? [8]. ??????????? ???????????? ?? ????????? ??????? ?????????????? ??????? ?????? ????????? ?? ???? ???????????. ?????????? ????? ??????????? ?????????
?????????? ?????????? ???????? ?????? ????????? ? ???????? ?????? ??????????? ??????? ? ?????????? ????????????????? ??????? [9]. ???????? ???? ??????????????????? ??????? ? ?????????? ????????????????? ????????? ???????
?????? ????????? ??? ????????????? ??????????
?????? ????????? (? ?????????, ?????????? ?????)
[10]. ????? ????????????? ???????? ???????????? ??????, ??? ????????????? ???????? ?????
????? ???????? ?????? ????????????? ???????, ?
???????????? ?????????? ?????????? ??????? ????? ???????? ????????? ? ???????????????? ?????????? ??????????????? [2, 5].
?????? ?????????? ?????????????? ????????????? ?????????? ??????????? ?????????? ?????
?????????? ??????? ?? ????????? ?????? ??? ??????????? ????????????? ??????????????, ??? ????65
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
???? ???????? ?????? ? ???????? ?????????????????? ??????????????????? ???????. ????? ???????? ????????????? ????????? ??????? ??????
? ???? ????????? ?????????? ????????? ?????????? ????????? ????? ????? ?????????? ??????? ?
???????? ??, ???????????? ???????????? ???????? ???????????????????, ????????????? ???????????????, ???????????????, ?????????? ???????? ??????????????. ??? ?????????? ?? ??????????????? ??????? ?????????????????? ???????
??????????????? ???????? ?????????? ?????????
??????????? ???????-??????????? ??????????.
10.
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??????????? ??????????? ?????????? ????? ??????????
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????????. ??????????? ? ????????-?????????? ????????.
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?????? ?.?., ??????????? ?.? ???????????? ?.?., ??????? ?.?. ??????? ?????? ????????? ? ?????????? ????????????????? ??????? ? ????????? ? ?????????? ??????????? ????? ?????????? ??????? ?? ????????? ??????.
??????????? ? ????????-?????????? ????????. 2013;
3 (6): 64?7.
?????? ?.?., ??????? ?.?., ??????? ?.?., ???????? ?.?.,
???????????? ?.?., ??????????? ?.?. ?????????????? ????????? ???????? ?????? ????????? ? ????? ?????
???????????? ??????? ?????????? ????? ? ??????? ????????. ??????? ??????? ?????? ? ???????. 2010; 2: 31?4.
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Particular methods of computer tomography in the diagnosis of
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????????? 04.12.2013
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????????? ????????? ???????.
1. ???????????? ?????. ?????? ?????? ????? ???? ???????????? ? ?????????????? ??????????? ???????????? ?? ??????????, ?? ???????? ??????? ?????? (? ??????? ???????), ? ??????????? ??????? ?????????? ???????????. ? ??????????? ??????? ???????, ???????? ?? ?????? ???????????????.
?????? ?????? ???? ????????? ????? ????????.
?????? ?????????? ? ???????? ??????, ???????????? ? ???? ???????? ??? ???????????? ?
???? ???????.
???????? ????????? ?? ????? ????? ????????? ? ????????????? ???????? ??????. ????? ??????????? ?????? ????????? ????? ??????????? ?????????????? (???????????????) ???????? ??????.
2. ?????? ??????????? ? ???????? ? ?????????? ? ???????????? ??????????? ??????????? ??????. ?? ??????????? ????? ?????? ?? ???????????.
3. ?????? ?????? ???? ?????????? ??????? Times New Roman ??? Arial, ?????? ?????? 12, ?
??????? ?????????? ????? ????????, ???? ??????? 3 ??.
4. ????? ?????????, ???????? ? ????????????? ?????? ?? ?????? ????????? 15 ???????
(??????? ???????????, ??????? ? ?????? ??????????), ???????????? ???????????? ? 12, ???????? ? 3 ???????.
5. ????????? ???? ?????? ?????????: 1) ??????? ? ???????? ??????; 2) ???????? ??????;
3) ?????? ???????????? ??????????, ? ??????? ???????? ?????, ? ???????????? ?????? ? ???????????? ????????? ????????????? ??????????????; 4) ???????? ?????? ??????????, ?????, ??????.
???? ??????? ?????????, ? ?????? ??????? ? ???????????????? ?????????? ????????????? ???????? ??????. ???? ??? ?????? ?????? ???????? ? ????? ??????????, ????????? ????? ?????? ??????? ?????? ???????? ?? ?????.
?????? ???? ?????????? ?????? ???? ??????????? ??? ?? ???????, ??? ? ?? ?????????? ??????. ??????? ??????? ????????????? ????????????????? ??? ??, ??? ? ?????????? ???????????
??? ?? ??????? BGN (Board of Geographic Names), ??. ???? http://www.translit.ru. ? ????????? ???????????(??) ?????, ????? ??? ?????? ?????????? ???????? ?????????? ??????? ?????????????.
???? ??????????? ?????????????? ???????? ? ?????? ??????, ??????????? ??? ?????????
??????? ? ?????????? ??????? ???????? ???????????: ?.?.?. ????????? ?? ??????? ????? ? ?
??????????????, ?-mail, ???????? ????? ??????????? ??? ????????? ? ???????? ?????? (????? ????
?? ???? ???????).
??????? ?????????? ?????:
?. ?. ????? 1, ?. ?. ??????????? 2*
иИКХЮМдЦЗГдЭ ЦжМдЦЗГИКМЗ Ю ИМядЦжГГдЭ гУэЮгджЕИКМЗ ХИКЦж
ДИЙИГдЙГИиИ РЛГМЮЙИгдГЮЭ г АдгЮКЮЕИКМЮ ИМ ЮКХИЦЗАИгдГЮЭ
ЙдАГУО МЮХИг РЛГМИг Ад ХжЙЮИя К 2000 ХИ 2009 ?.
1???? ??? ╚??????????? ????????? ??????????? ????????╩ ????????? ??????; 2???? ╚??????? ?????
????????-????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ??? ? ???? ?. ?. ???????) ????,
??????
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L. A. Efros1, I. V. Samorodskaya2
Hospital mortality and long-term survival after coronary artery bypass grafting
depending on application on different types of grafts between 2000 and 2009
1Chelyabinsk
State Medical Academy Ministry of Health of the Russian Federation;
N. Bakoulev Scientific Center for Cardiovascular Surgery of Russian Academy of
Medical Sciences, Moscow
2A.
????? ????? ????????????? (Efros Lidia Alexandrovna),
??????????? ????? ???????????? (Samorodskaya Irina Vladimirovna);
samor2000@yandex.ru.
6. ?????????? ???? ?????????? ???????????? ?????? ?????? ???? ?????????: ??????; ???????? ?????; ??????? ????????, ?????????? ????????? ??????? ? ??????? ????????? ?????? ? ?????? ?????????? ????????????; ???????? ? ??????; ?????????? ? ??????????; ?????? ??
??????? ??? ??????????; ?????? ???????????? ??????????.
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?????????? ????? ? ?????????????? ????????????????? ????????╩. ?????? ????, ???? ? ?????????? ?????????????? ????????, ?????? ??????????? ?????? ????????? ????????????? ??? ?????????? ??????????? ???????? ?????? ????????????? ? ?????? ??????????? ????????.
????????? ?????? ?????? ???? ?????, ??????, ??? ??????? ???????????? ???????? ? ??????????. ???????????? ??????? ???????? ????? ? ??????????? ??????, ??????????? ?????????? ????????????, ?????? ??? ??????? ???????????? ????????.
????? ???????, ???????? ?? ?????????? ???????? ???????? ?????????? ??? ????????????,
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???????? ???????? ??? ??????????? ????????.
7. ?????????. ??? ??????? ? ??????????? ?????? ???? ?????? ??????????, ?? ?????????
(??? ???????, ??? ? ?????????) ?????? ??????????????? ╚?????????????????? ??????? ??????????? ????????╩ (? 3 ?????, ??? ???. ????. ?.?. ???????????).
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???????? ???????? ??????????, ?????????????????? ? ?????? (? ???????????? ? ?????????????????????? ???????? ╚??????-?????????╩ [??????????????? ?????? ????????????? ???????]).
??????????, ????? ????????? ????????? ??????????????? ????????? Enzyme Classification, ??????????? ??? ???????? ??????????? ? ????????????? ????????????? ??????????? ????????? ? ???????? (Mendelian Inheritance in M?n [http://ncbi.nlm.nih.gov/Omim]).
???????? ??????????????? ?????? ???? ???????? ? ???????????? ? ╚?????????????????
???????? ??????????? ????????╩ (? 3 ?????, ??? ???. ????. ?.?. ???????????) ??? ?? ??????? ╚??????????? ?????????????╩ (??? ???. ?.?. ???????????).
?.?.?. ???????, ??????????? ? ??????, ?????? ??????????????? ?????? ??????????.
???????? ????? ???????????? ??????? ???????? (???????, ????????? ??????? ? ???????? ??????????? ??? ?????????).
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?????????? ?????????????? ???????? ? ????? ??????, ????????????? ??????. ????????? ?????? ???????? ?? ????????? ???????????? ?? ?????? ????? ??. ?. ?. ???????? ???? ? ???????????? ╚????????╩ ??? ????????? ????????? ? ???? ???????? ? ????????????? ???????? ?????????? ?????????. ????????? ?????? ?????????????? ?? ??????? ? ??????????
??????.
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? ?????? ?????????? ?????? ?? ?????? ??????????? ????????, ???????????? ? ????????. ??????? ????????? ???????? ????? ?? ?????? ??????, ????? ?????????? ?????? ?????? ???? ????????? ?
?????, ???????? ?? ?????????????? ??????????, ?????? ??????? ????, ????? ? ?????????? ????????????.
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?? ??????? ????????? ?/??? ???????????? ?????????), ?? ?? ?????? ???? ????? 100?250 ????.
???????? ????? ?????? ????? ????? ? ??????? ? ?? ?????? ??????????? ????? ??????, ??????? ?????????????? ???????????? ??? ?????? ?????? ? ????.
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?????); ?????????? 600 dpi (??????? ?? ????); ??????? ?????? ???? ??????? ?? ????? ??????????? ? ?????? ?? ╚????╩ ? ╚???????╩; ?????? ??????? ? ?? ????? 180 ??; ?????? ??????? ? ?? ????? 230 ?? (? ?????? ?????? ?? ????????????? ???????); ?????? ?????? ????????
?? ??????? ? ?? ????? 7 pt (7 ???????); ???????? ????????????? ?????? LZW ??? ???????;
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??????.
10. ??????? ? ???????? ? ??????????? ?????? ?? ????????? ?????. ?????? ??????? ?????? ????? ????? ????????? ? ??????????? ???? ??????????. ? ???????? ? ???????? ??????????? ??????????? ?? ???? ??????? ? ??????? ? ??????? ?????????, ?????????? ????????? ??
?????? ??????. ? ???????? ? ???????????????? ??????????? ????? ??????? ? ??????????.
11. ?????????? ??????: ?????? ?????? ?????????? ?????????? ????? ???????, ???? ?????? ?? ????????. ?????????? ???? ? ???????? ?? ???????????. ??? ????? ? ???????? ?????? ??????????????? ?????? ? ?????? ? ??????????? ?????? ???? ?????????? ?????????????.
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12. ????????????????? ?????? ???????????? ? ?????? ╚?????? ?????????? ? ?????????, ?????????????? ? ?????????????? ???????╩ ?????????????? ???????? ?????????? ??????????? ???????? (Uniform Requirements for Manuscripts Submitted to Biomedical Journals). ?????????? ???????? ???????????? ?????????? ? ??????? ?????????? ???????? ??????? ????, ??? ?????????? ?????????? ????? ?????? ??? ?????? ??????? ???????????? ?? ??????? ? ???????????, ???
??? ????????.
? ???????????? ??????? ??????????? ?????????? ?? ????? 25 ??????????, ? ??????? ?????????? ?
?? ????? 50, ? ??????? ? ?????? ?????????? ? ?? 15. ???????????? ?????? ?????????, ?????? ???????????????? ?????, ?????????? ?? ????????? 5 ???.
? ?????? ?????????? ??? ?????? ????????????? ? ??????? ???????????. ?????????????????
?????? ? ?????? ?????? ?????????? ? ?????????? ??????? ????????? ???????.
?????? ?? ???????????????? ?????? ?? ???????????.
????????????????? ???????? ?????: ?????(?), ????????, ????? (??? ??????), ????? ????????? ?
???????? ????????????; ????? ????? ? ??????? ? ??? ???????. ???? ?????? ?????? ?? ????? ?? ?????:
??????, ???????? ?????, ????? ????? ???????? ╚? ??.:╩ ??? ╚In:╩ ? ???????(?) ??????(??) ??? ?????????(??), ????? ???????? ????? ? ???????? ??????.
????????????????? ???????? ?????? ?? ???????: ?????(?); ???????? ??????; ???????? ???????;
???; ???, ? ??????? ????? ???????, ????? ????????? ????? ?????? ? ????????? ???????.
??? ????????? ?????????? ?? 6 ??????? ???????????? ??????????? ???, ??? ??????? ????????? ??????????? 6 ?????? ??????? ╚? ??.╩, ? ??????????? ╚et al.╩); ???? ? ???????? ??????? ???? ????????? ?????????, ????? ??????? ??????? ??????? ╚???.╩, ? ??????????? ╚ed.╩.
?? ????? ????????, ??????????? ?????????? ????? ????????????? ?????? ???????????, ???
Web of Science ? Scopus, ????????????????? ?????? (References) ?????? ? ???????????? ???? ?????? ?
?????????????? ?????? ???????? ?? ?????? ?? ????? ?????????, ?? ? ? ???????? (????????? ?????????). ??????? ?????? ?????? ?????? ?????? ?????? ?????????? ? ???? ?????????: ???? ?? ?????
????????? (????????????? ????????? ??????????, ???????????? ?????????), ??? ???? ???????
?????, ? ????????? ?????? ??? ?? ?????? ?????????? (References) ? ????????? ???????? ??? Scopus
? ?????? ?????????? ??? ??????, ???????? ? ??? ??? ????????? ??????????, ?????????? ?? ????,
??????? ?? ????? ??? ???????????. ???? ? ?????? ???? ?????? ?? ??????????? ??????????, ???
????????? ??????????? ? ??????, ??????????? ? ????????? ????????.
? ????????? ???????? ??? ????????????? ?????????? ????????? ????????? ????????? ????????????????? ??????: ?????(?) (??????????????), ??????? ???????? ????? ??? ?????? ?? ?????????? ????, ???????? ????????? (??????????????), ???????? ?????? ? ???????? ???????, ???????? ?? ???? ?????? ? ??????? (in Russian).
?????????? ?????????? ?????? ? ?????????????? ??????? ?????????????? ?????????????? ? ???????????
?? ????? http://www.translit.ru ????? ????????? ??????????????? ?????????? ??????????????
???????? ?????? ? ????????. ????????? ????? ???????.
1. ?????? ? ????????? Translit.ru. ???????? ??????? ?????????????? BGN (Board of Geographic
Names). ????????? ? ??????????? ???? ???? ????? ????????????, ????? ???????? ????? ??? ??????,
?? ??????? ????? ? ???????? ?????? ╚? ????????╩.
2. ???????? ??????????????????? ????? ? ??????????? ?????? References.
3. ????????? ? ??????? ??????????? Google ??? ???????? ?????????, ????? ??????? (???????? ?????, ??????, ????????????? ? ?. ?.) ?? ?????????? ????, ????????? ??? ? ??????????? ??????. ???????, ??????????, ??????? ??????????????, ??????? ?????? ????? ?????????? ???????? ????????, ??????????? ?????????? ????.
4. ?????????? ???????? ? ????????? ? ??????????, ???????? ? ???????????? ? ?????????
?????????. ??? ???? ?????????? ???????? ????? ??????? (Moscow) ?, ????????, ?????? ????????? ??????????? ????????.
5. ? ????? ?????? ? ??????? ??????? ??????????? (in Russian). ?????? ??????.
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????????? ??????? ???????????, ???????????:
?????????? ??????? ??????????? ? ???????????????: ????????? ??????-???????????? ???????????. 8 ???? 2009 ?. ?????-?????????. ???.; 2009.
????? ?.?., ?????????? ?.?. ?????????? ??????? ??? ?????????????? ?????? ?????. ? ??.: ????????? IV ??????????? ?????? ╚???? ? ????╩. ?.; 2000; ?. 1: 516?9.
European meeting on hypertension. Milan, Jine 15?19, 2007. Milan; 2007.
Harnden P., Joffe J.K., Jones W.G., eds. Germ cell tumours V: Proceedings of the 5th Germ cell tumour
conference. 2001, sept. 13?15; Leeds; UK. New York: Springer; 2001.
?????????? ?.?. ???????-????????????? ? ??????????????? ????????? ?????? ? ??????? ?
??????????? ?????????????: ???????. ???. ... ?-?? ???. ????. ?.; 2008.
Borkowski MM. Infant sleep and feeding: a telephone survey of Hispanic Americans: diss. Mount
Pleasant (MI): Central Michigan University; 2002.
??????????? ????????:
??????????????? ?????? ╚? ????????? ???????? ????????? ?????????? ???? ? 2009 ????╩.
Available at: http://www.minzdrav.rkomi.ru/left/doc/docminzdr
Abood S. Quality improvement initiative in nursing homes: the ANA acts in an advisory role. Am. J.
Nurs. 2002; 102 (6). Available at: http.Vwww psvedu.ru/joumal/201l/4/2560.phtml
????? ????? ??????????????? ?? ???????????? ????????????????? ??????.
13. ?????? ?????? ???? ????????? ????? ????????.
14. ???????? ????????? ?? ????? ????? ????????? ? ????????????? ???????? ??????. ????? ??????????? ?????? ????????? ????? ??????????? ?????????????? (???????????????) ???????? ??????.
19. ?????? ?????????? ? ???????? ??????, ???????????? ? ???? ???????? ??? ???????????? ?
???? ???????.
20. ?????? ???????????? ???????? ??????? ?? ??????: 119049, ??????, ????????? ?????.,
?. 8, ????. 18, ???????????? ????? ??. ?. ?. ???????? ????, ???????? ??????? ╚??????? ???????
?????? ? ???????╩.
??? ????????? ????????? ?????? ?????? ??????????????? ?? ?????.
????? ?? ?????????? ????????? ?? ?????????.
72
Long-term
prognosis depends on if the damaged myocardium could be recovered. The studies do not demonstrate the full recovery of the
left ventricular function. Fibrosis, myocardial perfusion deficit, mitral insufficiency, the possibility of restriction of the left coronary artery determine that rigorous dynamic monitoring in the period after the surgery. These are discussed on the clinical case
of occurrence of malignant arrhythmias in the postoperative period amid increasing restriction of the ostium of the left main
coronary artery. Monitoring of the left coronary artery, the left ventricular myocardium function with mandatory documentation of data electrocardiography, Holter monitoring, echocardiography, including tissue Doppler, will help to avoid the possible treatment mistakes. Diagnostic protocol should be supported by MRI studies in case of adverse postoperative period is
prognosed.
Key words: anomalous origin of the left coronary artery from the pulmonary artery; the left coronary artery; myocardial ischemia;
arrhythmias; closure of the left coronary artery ostium; long-term results of repair.
62
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?????????? ?????????? ????? ?????????? ??????? (?????) ?? ????????? ?????? ???????? ?????????? ??????? ??? ???????? ??????? ???????????????? ?????? ???????? ?? ??????? ??????
????????? (??). ??????????????? ??????? ?????????????? ???????? ??????? ????? ????????? ?????? ????? ???????? ???????? ? ??????????? ?????????? ????? ?????????? ??????? ?? ?????????
??????. ??????????? ???????? ?? ???? ????????
??????????????? ????????? ????? ????????? ?????? ? ????? ?????????? ???????, ??????? ???????????? ???????? ????????? ????????? ??? ????????? ????? ??????? ???????????. ??? ???????????? ???? ????????????? ??????????????
???????? ????????????? ???????????? ????????.
?????????? ???????? ???????????? ??? ????????
???? ??????????? ????????? ???????????????
?????, ??? ???????? ? ??????????? ????????????
? ?????????? ???????? ???????? ?? ????? ????????? [1]. ??????????? ?????????? ??????????? ?
????? ??? ???????????? ????????????? ?????????????? ???????, ? ???????????????? ??? ???????????? ??????? ??????????? ???????? ???????
??? ???????????? ??? [1, 2]. ???????? ??? ????????? ?????????? ?????? ????????? ???????? ???????????? ??????? ??????? ??? ?????????????
??????????????. Sh.S. Karr ? ?????. [3] ????????,
??? ????? ????? ??????????????? ?????????????
?? ????? ?????? ????????? ??? ?????????? ?????????????. ??????? ??????? ? ????????????? ??????? ?????? ???????? ??????? ???????? ????????.
???? ???????? ? ?????????????? ???????? ?? ???
?? ?????. ??? ?????, ?? ?????? ??????????? ????????, ????????????? ??? ? ????? (????????????
????, ??????????? ??? ???????? Switch) ????????
???????? ?????????? ???????, ??? ??? ???????????? ?????? ??????? ? ?????????? ???????? [4]. ??????? ???????? ???????? ??????? ? ??????????
?.?. ??????? ? ?????. [4]. ????????????????? ?????????????? ???????? ????????? ????????? ?? ????????????? ????? ???????????. ?????? ??????????
??????, ??????? ???????? ????????, ??????????
???????????????, ??????????? ?????????? ?????
????? ?????????? ??????? ??????? ?????????????
???????? ????????????? ?????????? ? ????????????????? ???????. ??? ?????????? ?????? ???????? ?? ???????????? ??????????? ???? ?????????????? ??????? ????? ? ????????? ?., 4 ???.
???? ??????? ??????? ??????? ??? ? ????????
4,5 ???, ????? ??????? ????? ????? ?????????? ? ????, ????????? ? ?????????? ????????. ??? ???????????? ? ?????????? ?? ????? ?????????? ???????
??? ???????? ??? ??? ???????? ??????, ????????
???????? ????????? ???????????????, ??????????
???????? ?????????????? ??????????? ????????
?????? ????????? (?? ?? ? 31 %). ??????? ???????????? ????????????? ? ???????? ? ?????????
???????????, ??????????????? ??????? ????????????, ? ??? ????? ????????? ?????????????. ???-
???????????? ??????????? ??????????? ????? ????????????? ??????????????? ?? ???? ??????????? ??????? ? ????????????? ????????????????
??????????? ???????. ??????????????? ???????
????????? ??????????????? (????????, ??????????
?????????, ?????????????, ????????, ???????)
????????? ?? ????????. ? ???????? 3,5 ???? ??? ????????? ?????? ? ??????????? ???????????? ????????? ?????? (??????????? ?????????????? ?????? ?????????) ??? ?????????????? ??????. ???
???????????? ????????????, ????????? ????????,
??????????? ??????? ??????? ? ???????? ??????????????? ??????? ??????? ???????????????? ?
??????? ????? ???????? ????? ????, ??? ???????
??????????? ???????? ?????????? ?????????? ???????. ?????????? ?? ???????????? ? ?????
??. ?.?. ???????? ? ????? ???????????????? ??????????? ?????????? ????? ?????????? ???????
?? ????????? ?????? ?????????? ??? ??????????????
???????.
??????? ????????? ??? ??????????? ???? ??????????? ?????????? ??????????? ????????????
???????? ?????? ?????????. ????????? ????????
???????? ???????????? ?? ???????? ? ????? ?????????. ?? ??? ????????? ?????????? ?????????
???? ? ???????? ????????? ?????????? 90 ??/???,
?????????????? ???????????? ????????????? ???
??????, ??????????? ????? ???????, ??????????
????????? ????????????? ??????????, ?????????
???????? ST ? I, AVL ??????????.
?? ?????? ?????, ??????? ?????? ?????????
????????? (??? ?? = 4,7 ??, Z-score ? 0,6), ?????????????? ??????????? ???????? ?????? ?????????
??????? (?? ? 42 %, ?? ? 0,21), ????????? ?????? ??????????? ??????? ????????? (D ? 2,9 ??,
Z-score ? 2,57), ??????????? ???????????? 2-? ???????. ??????????? ?????????? ???????? ? ???????
???????? ?????? ?????????. ????? ?????????? ??????? ??????? ?? ????????????? ?????? ????????
???????, ??????? ????? ????? ?????????? ??????? ?
2,6 ??.
???????????? ???????? ?????? ? ????????????????? ??????????? ??????? ??????????? ?????????? ????? ?????????? ??????? ?? ????????? ??????,
??????????????? ??????????? ??????? 3-? ???????.
??? ????????-??????????? ?????????? ? ????????????????? ??????? ???????????? (????? ????????? 25?30 % ?? ????? ????? ????????). ??????? ???????? ?????? ????????? ?? ?????? ??????? ????????? ? ???????? ?????????: ????????
?????? ? 3 ??, ?????????????? ? 4, ???????????? ?
4, ?????? ? 4?5, ??????????????????? ? ?? 5, ????????????????????? ? 4 ??. ????????? ??,
???????????? ?? ??????? ????????????? ??????, ?????????: ??? ? 191 ??/?2, ??? ? 126 ??/?2,
?? ?? ? 34 %. ? ??????? ?????????? ??????????????? ???????????????? ????? ? ??????? ??????
?????????? (?????????? ????????????), ? ??????????? ???? ???????????????? ? ??????? ???????63
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??? ???????????? ???????? ?? ???? ???????????
???? ??.
?????????????? ???????????? ??????? ??????
???????? ???????? 35 % ?? ??????? ?????? ?????????. ????? ??????? ???????? ????????? ????????? 10?12 %, ?? ??? 7 % ? ???????? ???????? ????????? ? ??????? ????????, ????????? ????? ?????????? ???????? ??????????? ???????????????
?????????.
??????? ????????? ????????: ?????????????
????? ?????????? ??????? ? ?????????? ????? ?
????????? ?????? ???????? ??????? ???????????????????? ????????; ?????? ???????? ???????????
??????? ? ???????? ?????????????? ??????????????, ?????????? ? ?????????? ????????????.
?????? ????????????????? ?????? ????????
??? ??????????, ??????? ???? ???????? ? ?????????????????? ????????? ?? 18-? ??? ????? ???????? ? ??????????????? ????????, ??????????
???????????? ??? ????????? ???????????? ??????? ?????. ??? ??????? ?? ??? ???????????????
?????????, ?????????? ????, ????????? ????????? ????????????? ??????????, ??????????????
???????? ST. ????????? ????? ?? ?????????????.
??????????????????? ???????? ????????? ?????????????? ??????????? ???????? ?????? ????????? (?? ? 50 %), ?????????? ???????? ? ??????? ?????????, ???????????? ?????????? ??????????????? 2-? ???????.
????? ??????? ??????? ??????????? ???? ??????, ????? ?? ???????????. ????? ????? ? ???????
???????? ??????? ??????????? ?? ??????????
????, ????????????? ?????????? ????????, ????
???? ╚??????╩ ? ╚????????╩. ????????????????? ?
??????? ????? ???????? ????? ????, ??? ???????????? ??????? ?????????, ?????????. ?? ???? ????????????? ???????? ?????????? ??????? ??????????????? ???? ?? ???????? ??? ????????. ???????????? ? ???????? ??????????, ??????????
???????????????????? ????????????, ???, ???????????? ???????????????, ?? ???? ??????? ?????????, ???????????????? ??????????? ???????????
?? ???????? ?????????, ??? ??? ????? ?????? ????
?????????? ?? ???? ???????????. ????????? ???????????? ????????? ????????? ????????? ???????
??? ?????????? ? ????????? ??????????? ???????,
??? ???????? ??????? ??????? ? ??????? ????????,
??????????? ?? 140 ??/???, ????????? ??????????
???????? ST ?? ???. ??????? ????????? ?????????
??-??? ? ???????????. ?????????? ?????????? ????????????? ??????????????? ??????? ??????????
????????? (???. 1) ? ???? ????????? ?????????? ???????????????? ???????????? ?????????? (??).
?????? ????????? ????????????? ?????? ?????????? ????????? ?????????, ????????? ?? ?? ????????????? ?????????? ??????. ??????????? ??????? ????? ?????????????????? ????? ?????????? ???????. ??? ??????????? ? ???????????
??????? ??????? ??????? ???? ???????? ????????????????? ? ????? ??. ?.?. ???????? ????. ??
?????? ??????????????? ???????????? ?????? ??????????? ?????????? ???????? ?? ????????????-
?
╥
Йкр. 1. Оснзб?с?рмсб ослкзс?к?с??лкб ?б?ба обр?? тсрнб стб???кк ?бкотн?лз??кк ЦДд ? ?с?зш:
? ? л? ыслб л???шамк тс??н?бзр? ╥снб?сх ркл??со, ?б?крз?к?шбзр? ш???блкб СКК ?с 140 ш?/окл р ?бт?брркбх рб?облз? ST, ?салкмлс?блкб йбнш?с?мс?сх з??км???кк; ╥ ? ?б?бзблсс╥??ал?? эМ
64
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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Йкр. 2. Юррнб?с??лкб тсрнб
стб???кк. ЙДМ р ?лшз?к?блл?о ╥сн?рл?о мслз??рзк?с??лкбо. Йблз?блс?рм?? мсот╦?зб?л?? зсос???ык? т?с?б?бл? р ркл??слка??кбх тс ЫДи,
?лшз?к?блл?о ╥сн?рл?о ??б?блкбо лбксллс?с мслз??рзлс?с т?бт???з?, ? шрнс?к?? ЮгЦ,
об?км?облзсалс?с ш?бйблк?
?кзо?. Юррнб?с??лкб ??тснлблс т?к СКК 90 ш?/окл. Д?к?снклбхл?б ?бмслрз?шм?кк:
?
╥
?????? ????? ?????????? ??????? ?? ??????? ???
??????????? ?? ?????? ????????? (61 %). ???????????? ?? ?????????? ??????? ??????????? ??
2?3-? ???????. ?? ?????????? ????????? ?????????? ??????????????? ????????? (????????-T ?
0,037 ??/??; ????????-I ? 0 ??/??; ??-??? ?
3,54 ??/??; ????????? ? 68,7 ??/??). ?????????
????????????? ???????????? ?????????? ? ???????????? ???????? ?????????????????. ????????
????????? ???????, ???????????? ?? ????????????? ?????????? ??????, ??????? ?????? 130 ??/???,
?????? ???????? ???????????? ? ???????? ???????????????? ??? ? ??????????????? ?????????
????? ??? ??????????? ?????????????-????????????? (???. 2). ????????, ??? ????? ?????????? ??????? ????? ??????????? ?????? ??????. ????????????? ? ?????????? ?????????????? ??????????????? ?????????????? ?? ????. ??????? ?????????
????????????? ???? ??????? ? ????????????? ????????.
? ????????????????? ??????? ???????????
??????? ????????? ????, ????????? ?? ?????????????. ????????? ??????????????????. ?????????????? ??????????? ?????? ????????? ?????????
(?? ? 51?60 %), ?????????? ???????????????, ??
?????? ???????????????, 2-? ???????. ???????
??????? ??? ?????????? ?????????? ?? ????? ?????????? ? ?????????????? ?????????? ????? ?????????? ??? ????????? ??? ? ???, ????????, ???????? ? ??????? 6 ???, ????????-?????? ? ???????
6 ??? ??? ????????? ???????????? ??????? ?????,
?????????? ???????????.
?????????? ??????? ??? ????????? ????? ???????? ????????? ??????????? ?????????? ?????
?????????? ??????? ?? ????????? ?????? ?? ?????
?? ????. ????????????????? ??????? ???????????
??????? ?? ??????????? ?????????????? ????????.
? ? т????? мс?сл??л?? ??зб?к?
╥ба каоблблкх; ╥ ? нб??? мс?сл??л?? ??зб?к? коббз м?кзк?брмкх
рзблса рз?сн?
???????????? ????????? ??? ?????????? ????????? ?????????? ? ??????????? ? ????????????
??????? ?????? ????????? ??? ???????????? ??????????? ????????. R. Bagur ? ?????. [5] ?????????? ???????? ??? ??????????? ?????????? ?????
?????????? ??????? ?? ????????? ?????? ??? ??????????????, ????????????????? ?????????????????? ????????. ?????????????? ????????????,
????????-??????????? ??????????, ??????????? ?
?????????? ????????????????? ??????? ????????
???? ?????????? ???????? ?? ?????????????????? ? ?????????????????????? ??????????? ?????? ????????? [6, 7]. ??????? ????????? ? ???????????? ???????? ???????? ??????????????
????????? ?????????? ?????????? ??????????????
?????????? ?????? ????????? ? ????????? ?
??????????? ???????? ??????????? [8]. ??????????? ???????????? ?? ????????? ??????? ?????????????? ??????? ?????? ????????? ?? ???? ???????????. ?????????? ????? ??????????? ?????????
?????????? ?????????? ???????? ?????? ????????? ? ???????? ?????? ??????????? ??????? ? ?????????? ????????????????? ??????? [9]. ???????? ???? ??????????????????? ??????? ? ?????????? ????????????????? ????????? ???????
?????? ????????? ??? ????????????? ??????????
?????? ????????? (? ?????????, ?????????? ?????)
[10]. ????? ????????????? ???????? ???????????? ??????, ??? ????????????? ???????? ?????
????? ???????? ?????? ????????????? ???????, ?
???????????? ?????????? ?????????? ??????? ????? ???????? ????????? ? ???????????????? ?????????? ??????????????? [2, 5].
?????? ?????????? ?????????????? ????????????? ?????????? ??????????? ?????????? ?????
?????????? ??????? ?? ????????? ?????? ??? ??????????? ????????????? ??????????????, ??? ????65
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??????? ?????? ? ???????, ? 4, 2013
???? ???????? ?????? ? ???????? ?????????????????? ??????????????????? ???????. ????? ???????? ????????????? ????????? ??????? ??????
? ???? ????????? ?????????? ????????? ?????????? ????????? ????? ????? ?????????? ??????? ?
???????? ??, ???????????? ???????????? ???????? ???????????????????, ????????????? ???????????????, ???????????????, ?????????? ???????? ??????????????. ??? ?????????? ?? ??????????????? ??????? ?????????????????? ???????
??????????????? ???????? ?????????? ?????????
??????????? ???????-??????????? ??????????.
10.
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??. ?.?.???????? ????; 2010: 200?23.
????????? ?.?., ?????????? ?.?., ?????? ?.?., ??? ?.?.,
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??????????? ??????????? ?????????? ????? ??????????
??????? ?? ?????? ???????? ??????? ? ????????? ???????
????????. ??????????? ? ????????-?????????? ????????.
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?????? ?.?., ??????????? ?.? ???????????? ?.?., ??????? ?.?. ??????? ?????? ????????? ? ?????????? ????????????????? ??????? ? ????????? ? ?????????? ??????????? ????? ?????????? ??????? ?? ????????? ??????.
??????????? ? ????????-?????????? ????????. 2013;
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?????? ?.?., ??????? ?.?., ??????? ?.?., ???????? ?.?.,
???????????? ?.?., ??????????? ?.?. ?????????????? ????????? ???????? ?????? ????????? ? ????? ?????
???????????? ??????? ?????????? ????? ? ??????? ????????. ??????? ??????? ?????? ? ???????. 2010; 2: 31?4.
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(Bland-White-Garland syndrome) with systemic collateral
supply to LCA. Med. Sci. Monit. 2001; 7: 755?8.
Frapier J.M., Leclercq F., Bodino M., Chaptal P.A. Malignant
ventricular arrhythmias revealing anomalous origin of the left
coronary artery from the pulmonary artery in two adults. Eur.
J. Cardiothorac. Surg. 1999; 15: 539?41.
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????????? 04.12.2013
66
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??? ???????
????? ??????? ??? ???????
????????? ??????!
???????? ???? ???????? ?? ??, ??? ?????? ?????? ? ??????????????? ??? ???????? ??????? ????????????? ??????? ???????? ? ???????, ? ??????? ?????? ???? ???????????? ???????? ?????????? ??????????? ?? ????????? ?????? ??????? ??????? ? ????????? ????, ? ????? ? ????????????? ?????????????? ??????? ? ???? ??????, ??? ???????????? ??????????? ??????? ?????? ?????? ??????
????????? ????????? ???????.
1. ???????????? ?????. ?????? ?????? ????? ???? ???????????? ? ?????????????? ??????????? ???????????? ?? ??????????, ?? ???????? ??????? ?????? (? ??????? ???????), ? ??????????? ??????? ?????????? ???????????. ? ??????????? ??????? ???????, ???????? ?? ?????? ???????????????.
?????? ?????? ???? ????????? ????? ????????.
?????? ?????????? ? ???????? ??????, ???????????? ? ???? ???????? ??? ???????????? ?
???? ???????.
???????? ????????? ?? ????? ????? ????????? ? ????????????? ???????? ??????. ????? ??????????? ?????? ????????? ????? ??????????? ?????????????? (???????????????) ???????? ??????.
2. ?????? ??????????? ? ???????? ? ?????????? ? ???????????? ??????????? ??????????? ??????. ?? ??????????? ????? ?????? ?? ???????????.
3. ?????? ?????? ???? ?????????? ??????? Times New Roman ??? Arial, ?????? ?????? 12, ?
??????? ?????????? ????? ????????, ???? ??????? 3 ??.
4. ????? ?????????, ???????? ? ????????????? ?????? ?? ?????? ????????? 15 ???????
(??????? ???????????, ??????? ? ?????? ??????????), ???????????? ???????????? ? 12, ???????? ? 3 ???????.
5. ????????? ???? ?????? ?????????: 1) ??????? ? ???????? ??????; 2) ???????? ??????;
3) ?????? ???????????? ??????????, ? ??????? ???????? ?????, ? ???????????? ?????? ? ???????????? ????????? ????????????? ??????????????; 4) ???????? ?????? ??????????, ?????, ??????.
???? ??????? ?????????, ? ?????? ??????? ? ???????????????? ?????????? ????????????? ???????? ??????. ???? ??? ?????? ?????? ???????? ? ????? ??????????, ????????? ????? ?????? ??????? ?????? ???????? ?? ?????.
?????? ???? ?????????? ?????? ???? ??????????? ??? ?? ???????, ??? ? ?? ?????????? ??????. ??????? ??????? ????????????? ????????????????? ??? ??, ??? ? ?????????? ???????????
??? ?? ??????? BGN (Board of Geographic Names), ??. ???? http://www.translit.ru. ? ????????? ???????????(??) ?????, ????? ??? ?????? ?????????? ???????? ?????????? ??????? ??
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