close

Вход

Забыли?

вход по аккаунту

?

149.Клиническая физиология кровообращения №4 2013

код для вставкиСкачать
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????????
??????????
??????????????
Klinicheskaya Fiziologiya Krovoobrashcheniya
?????????????
??????-???????????? ??????
??????? ???? ??? ? ???????
??????? ? 2004 ?.
Clinical Physiology
of Circulation
Peer Reviewed Scientific Practical Journal
Published once in three months
Founded in 2004
4 ?2013
?????? ?????? ? ???????? ????????????? ?????????????
??????-??????????? ???????, ??????????? ? ?????????? ?????????
? ????????????? ??? ????????????? ???????? ??????????? ???????????
?? ????????? ?????? ??????? ??????? ? ????????? ????
?? ???????? ? ????????????? ??????
?????? ??????? ? ?????????? ?????? ???????? ???????????
????? ??. ?.?. ???????? ????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
Л??б?кзбн╦ к ка??збн╦ НиеЛ
╚ГЯККО ко. д.Г. е?мшнб??╩ ЙдЕГ
Цк?блак? л? ка??збн╦рмш? ?б?збн╦лсрз╦
Юя ? 03847 сз 25.01.2001 ?.
грб т???? а??к?бл?. Гк с?л?
??рз╦ ?зс?с ка??лк? лб осйбз ╥?з╦
а?лбрбл? ? т?о?з╦ мсот╦?зб??
нк╥с ?срт?ска?б?бл? н?╥?о
ртсрс╥со ╥ба т?б????кзбн╦лс?с
ткр╦обллс?с ??а?б╞блк? ка??збн?
Из?бзрз?бллсрз╦ а? ?срзс?б?лсрз╦
клыс?о??кк, рс?б?й??бхр?
? ?бмн?ол?? о?зб?к?н??,
лбршз ?бмн?ос??збнк
д??бр ?б??м?кк
119049, Есрм??, Цблклрмкх т?., 8
ГЯККО ко. д.Г. е?мшнб?? ЙдЕГ,
Из?бн клзбннбмзш?н╦лсх
рс╥рз?бллсрзк
Мбнбысл ?б??м?кк (499) 236-92-87
Н?мр (499) 236-99-76, 236-92-87
E-mail: izdinsob@yandex.ru
http: //www.bakulev.ru
К?к?бзбн╦рз?с с ?б?крз???кк р?б?рз??
о?ррс?сх клыс?о??кк ХЮ ? 77-16885
сз 24.11.2003 ?.
??????? ???????? ?.?. ???????
???????????? ????????
?.?. ???????, ?.?. ??????????,
?.?. ????????, ?.?. ????????????,
?.?. ??????????,
?.?. ???????? (???. ???????? ?????????),
?.?. ??????? (???. ???????? ?????????),
?.?. ???????, ?.?. ??????????,
?.?. ???????? (???. ???????? ?????????)
???????????? ?????
?.?. ?????, ?.?. ?????,
?.?. ???????, ?.?. ???????
А??. ?б??м?кбх Й??кслс?? г.Ш.
Мбн. (499) 236-92-87
Цкзб??зш?л?х ?б??мзс?,
мс??бмзс?
длзслс?? Ю.г.
Editor-in-Chief L.A. BOCKERIA
Дсот╦?зб?л?? ?б?рзм?
к ???ык?брм?? с╥??╥сзм?
о?зб?к?н?
Кн?╞ И.г., Осо?мс?? ж.М.
Editorial Board
Гсоб? тс?ткр?л ? тб??з╦ 20.12.2013
Нс?о?з 60в88 1/8
Хб?. н. 9,00
Л?.-ка?. н. 8,82
Лрн. тб?. н. 7,26
Изтб??з?лс
? ГЯККО ко. д.Г. е?мшнб?? ЙдЕГ
119049, Есрм??, Цблклрмкх т?., 8
збн. (499) 236-92-87
Днклк?брм?? ыкакснс?к?
м?с?сс╥???блк?
2013. ? 4. 1?72
ISSN 1814?6910
Мк??й 500 ?ма.
Хс?ткрлсх кл?бмр 84549
T.B. Averina, A.V. Gavrilenko,
D.Sh. Gazizova, S.V. Gorbachevskiy,
M.V. Zatevakhina,
G.V. Lobacheva (Assistant Editor),
R.M. Muratov (Assistant Editor),
E.S. Nikitin, N.O. Sokol?skaya,
M.V. Shumilina (Assistant Editor)
Editorial Council
V.A. Bykov, V.A. Lishchuk,
L.A. Piruzyan, K.V. Sudakov
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????
??????????
CONTENTS
??????
Reviews
5
Physiology of the Heart
?????????? ??????
??????? ?.?., ??????? ?.?., ???????? ?.?., ?????? ?.?., ?????????? ?.?., ?????? ?.?. ????????????? ???????? ???????? ?????? ? ????? ? ?????
10
????????? ?.?., ??????? ?.?. ???????????? ???????????? ? ????????? ???????????? ?? ???????? ? ?????? ? ???????????? ????????????
??????? ?.?., ??????? ?.?., ?????????? ?.?.
??????????? ??????????????? ? ????????? ????????????????? ???????, ????????????? ??????????? ??????? ?????????????? ?????? ?
???????, ?????????? ????????????? ?? ???????? ??????
20
Yunusov V.M., Plechev V.V., Izhbul'din R.I.,
Ostakhov S.S., Kislitsyn A.N. Studies on the interaction of heparin with de-endothelialized arterial
surface
28
Kuznetsova D.V., Kulikov V.P. Reactivity of cerebral
and systemic hemodynamics to orthostasis in young
men with arterial hypertension
Bockeria L.A., Nikitin E.S., Kiryushchenkov G.P.
Respiratory failure in immediate postoperative period caused by lung recruitment maneuver in patients
who underwent open heart surgery
35
Artificial Circulation
????????????? ??????????????
??????? ?.?., ????????? ?.?., ????????? ?.?.,
????????? ?.?., ??????? ?.?., ?????? ?.?.,
?????? ?.?., ?????? ?.?. ?????????? ??????? ?:
????? ?? ??????????????? ? ???????????????
???????? ??? ?????????? ?????????????
Bockeria L.A., Makhachev O.A., Golubkov V.V.,
Panova M.S., Filippkina T.Yu., Narsiya B.E.
Modeling of normal heart valve development in
children
Clinical Physiology
of Regional Circulation
??????????? ??????????
???????????? ??????????????
?????? ?.?., ?????? ?.?., ????????? ?.?., ??????? ?.?., ???????? ?.?. ? ??????? ????????
?????????????? ???????? ? ???????????????????? ???????????? ???????
Samuilova D.Sh., Borovkova U.L. Lipopolysaccharide-binding protein: main functions and clinical value
39
Bockeria L.A., Merzlyakov V.Yu., Samuilova D.Sh.,
Klyuchnikov I.V., Selimyan L.S., Sigaev I.Yu.,
Darvish N.A., Skopin A.I. Plasma protein ?: is there
diagnostic and prognostic value in coronary artery
bypass surgery?
??????????? ?????????? ??????????????, ? 4, 2013
????????? ?.?., ????????? ?.?. ???????????????-??????????? ?????: ???????? ??????? ?
??????????? ????????
3
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
4
??????????
?????? ?.?., ?????????? ?.?., ????????? ?.?.
??????? ?????????? ??????????? ??????????
????? ?? ??????? ?????????? ???????????????
?????? ? ?????????????? ????????????? ? ????? ??????? ???? ?????
???????? ?.?., ?????? ?.?., ???????? ?.?., ????? ?.?., ?????? ?.?. ???????????? ?????????? ??? ?????? ????????? ?????????????? ?????????? ????? ???????? ????????????????
???????? ? ???????? ?????????????? ??????????????
48
Semenova A.S., Agapov V.V., Prelatov V.A., Zhukov A.V.,
Shigaev M.Yu. Neural network technologies as a basis
for strategy for preventing the complications after
myocardial revascularization with cardiopulmonary
bypass
55
??????????? ???????????????
??????????? ?????????? ??????????????, ? 4, 2013
Osilov K.K., Grigor'yants R.G., Samsonova N.N.
Influence of transfusions of allogeneic blood components on the level of systemic inflammatory
response in neonates and infants of the first year of
life
Public Health Organization
??????? ?.?., ??????? ?.?., ?????????? ?.?.,
??????? ?.?., ???????? ?.?. ????????? ?????????????? ??????????? ? ???????????????????
??????? ? ????????? ?????????? ? ??????????? ???????
Bockeria L.A., Alshibaya M.M., Sokol'skaya N.O.,
Rakhimov A.A., Kopylova N.S. Diagnostic ultrasound standards for management of patients in the
division of resuscitation and intensive care
61
??????? ??? ???????
68
Rules for authers
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
5
??????
╘ ?.?. ?????????, ?.?. ?????????, 2013
??? 577.15.579.62:577.112
???????????????-??????????? ?????: ???????? ???????
? ??????????? ????????
?.?. ?????????, ?.?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ? ???????? ???
? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????, 121552, ??????
????????? ????? ??????????, ?????? ????. ????, ?????????? ???????-????????????? ????????????;
?-mail: d.samuilova@gmail.com;
????????? ?????? ??????????, ???? ??????????? ???????????? ???????????
???????????????-??????????? ????? ????????????? ???????????? ? ????? ? ????????? ????????, ????????????? ? ???????? ????????????. ???????? ??????? ???????????????-???????????? ????? ??????? ? ?????????????, ?????????? ? ???????????????? ??????????? ?????????????? ??????????? ????????????? ?????????????? ??????????, ?????????????? ?? ?????????? ? ?????? ???????, ???
???????????? ????????? ???????????????? ?????????? ? ???????? ? ???????? ??????? ????????? ?????????????. ???????????????-??????????? ????? ???????? ???????????? ???????????? ?????????
?????????????????, ????????????????? ??????????????? ? ???????????? ????????? ????????. ??????????? ???????????? ?????? ??????????????? ? ??????????? ????????????? ??????????????????????????? ????? ? ???????? ???????????????? ?????????? ???????????? ????????? ? ??????? ???????? ? ??????????????????? ???????. ???????? ??? ???????????? ?? ????????? ? ?????
????????????? ????????? ????????. ?????? ?? ??????????? ???? ? ?????????? ???????????? ???????????? ?????????? ???????????? ? ??????????? ?????????? ???????????????-???????????? ?????.
???????? ?????: ???????????????-??????????? ?????; ?????????? ?????????; ????????????
??????????.
D.Sh. Samuilova, U.L. Borovkova
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Sciences;
Rublevskoe shosse, 135, Moscow, 121552, Russia
Samuilova Daniya Shavketovna, Dr. of Biol., Chief of clinical biochemistry laboratory;
Borovkova Ul'yana Leonidovna, physician clinical laboratory diagnostics
Lipopolysaccharide-binding protein is constitutively present in blood of a healthy person, it is synthesized chiefly by hepatocytes. The key function of lipopolysaccharide-binding protein is to detect, bind and sequentially present bacterial endotoxin to geneticallyencoded receptors which are present on leukocytes and other cells, and that provide increased sensitivity of receptors to pathogen and amplification of signal of infection risk. Lipopolysaccharide-binding protein is able to
detect molecular structures of gram-negative and gram-positive microorganisms and fungal pathogens. Current literature
data provide evidence on the use of lipopolysaccharide-binding protein as a diagnostic biomarker of endotoxemia associated with local and severe infections in cardiac surgery patients. The article emphasizes its advantage compared to more
commonly used markers of infection. However, the existing literature provides limited amount of research data on the clinical value of lipopolysaccharide-binding protein.
Key words: lipopolysaccharide-binding protein; congenital immunity; infectious complications.
???????? ?? ???????? ?????????? ? ??????? ??????????????????? ???????, ??????????? ????????????????? ??????? ?????????????? ??????????????, ??????????????,
????????????? ??????????? ?????????? ??????????? ??????? ? ??????????? ????????????????? ??????????, ??????-???????????
?????????? ??-???????? ???????? ????????? ????????? ?????????????? ? ????? ? ??????????? ????????????????? ??????? ? ????????? ??????? ???????????? ???????. ??-
??? ??????? ????????????????? ???????????? ??????????, ???????????? ?? ???????
?????????? ?? ?????? ??????? ?? ??????????? ?????? ??????????? ? ??????? ?????? ???????.
╚??????? ??????????╩ ???????? ???????????? ??????????????????? ???????? ????????????? ????????. ?????? ??????? ?????????????????? ??????????? ??????? ???????????? ????? ??????? ?????? ? ????? ?
?????????? ???????? ????????? ? ??????-
??????????? ?????????? ??????????????, ? 4, 2013
LIPOPOLYSACCHARIDE-BINDING PROTEIN: MAIN FUNCTIONS AND CLINICAL VALUE
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
6
??????
??????? ???????????, ???????????? ????????? ?????????????????? ???????????. ???
??????????? ????????????? ???????? ? ????????? ????? ???????????? ????????? ???????????? ????????????? ????????. ?????????????? ???????????? ???? ??????????
?? ???????? ?? ??????????????? ? ??????????????? ????????????? ? ??????? ? ????????? ???????? ??????? ????????????? ????????. ?????????? ?????????? ????????????
????????? ?????? ??????????? ??????????
??????????? ?????? ?-??????????? ?????,
?????????? ?????????? ? ????? ? ??????? ?
????????????? ???????, ?????? ?????????,
???????????????. ????????? ?????? ???????? ???? ??????? ???????????????-???????????? ?????. ?? ??? ??? ??? ??????? ??????
? ?????????? ???????????? ??????????? ?
???????????????? ??????????? ???????????? ?????????? ? ???????????????????
???????, ????????????????? ?????? ??????? ????????? ? ???????? ???????????? ????????? ?????????????? ??????? ? ????? ??
???????? ??????????? ??? ?????????????
??????? ????????-?????????? ?????????.
???????????? ??????????? ? ????????????
????????? ???????? ????????? ?????????????? ??????? ??????????????? ? ????????????? ????????????? ?????????????
????????? ?? ???????????????? ???????????. ????? ????, ??????? ?????????, ??? ??????????? ???????, ?????????? ????????????????????? ?????????, ????? ??????????? ???????? ??????????? ? ????????????
???????? ?????????????? ??? ???????? ????????????? ??????????.
???????????????-??????????? ?????
??????? ???? ???????? ? ????? ?? ???????????? ???????????? ???????? ? ?????????????????. ??????????????? ???????? ??????????? ????????? ?????? ?????????????????
???????????????. ???????? ??? ??????? ??
???? ??????, ????? ?? ??????? ???????? ????? ?,
??????????? ??????????? ???????? ?? ???????? ????????. ?????? ??????? ????? ? ?
?????????? ??? ???????????????? ???????
????????????? [1]. ???????????????? ? ????? ?????????? ???????????? ? ?????????
????????? ?????????, ??? ???????????? ??????????? ? ?????? ???????? ??????????
??????????? ??????????. ???????????? ???????????????? ? ????? ????????????? ? ????????? ? ????? ? ?????????? ?????????????
????????? ??????? [2]. ? ????????? ?????????? ????? 60% ?????????? ????????? ??-
??????, ????????? ???????? ?? 1014 ????????? ?????? [3]. ???????????? ????? ?????????? ????????? ?????????? ????????????????? ??????????????. ??????? ??????????? ? ????????????? ????? ??????????
????? ???????? ?? ?????? [4, 5], ??? ??????????? ??????????? ???? ?????????????????
???????????? ?????????? [6]. ??????????
???????????? ???????????????? ????? ???????? ?? ?????? ????????? ? ?????????????
????????????????? ???????? ??? ??????????
???????????????? ? ????????? ??????????
? ?????????? ????????? ????????????? ????????? ???????? ????????? ? ????? ?? ??????????, ????????????, ??????-??????????. ?????????? ?????, ??? ???????????????? ??????? ????? ???????? ? ?????????
???????? ??????????????? ? ???????????
????????????? ?????? [7], ? ???????? ??
?????? ? ????????????? ???????????????,
??? ????????, ????? ?????????????? ??????????? ??????????? ? ?????????????? ??
??? ?????????? ???????????.
??????????????? ???????? ????? ?????? ??????????? ?????????????? ???????
[8]. ???????????? ?????????????? ??????????? ???????????? ??????????? ?? ??? ??????? ?????????. ????????? ???????????? ??????????? ?? ????????? ????? ???????? ?
???????????? ???? [9, 10].
????? ?????? ???????? ???????? ?????? ???????????? ???????????? ????????
??????? ??????????? ??????????, ?????????? ????????????? ??????????? ?????????????? ????? ???????-??????????????? ???????????? ????????, ??????????? ??? ??????? ????? ????????? ???????????????,
????????????? ??????????????? ???????????, ??????????????? ?? ?????????? ??????? [11].
????????? ??????????? ??????????, ???????????? ?????????? ??? ??????? ???????????? ????? ???????????????, ????????????? ??????? ?????????????? ? ???????????
?????????? ???????????? ? ???????????? ??????? ?????????? ??????????? ?????????
?????? ??? ?? ??????????. ??????????????? ? ???? ?? ????? ????????? ? ????????? ???????-??????????????? ???????????? ????????? ????? ???? ?????????????????
???????????????.
???????? ????????, ???????????? ??????????????? ????????????? ????????
???????, ???????? ????-???????? ???????? 4
(TLR-4), ????????????????? ?? ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ????????? ????? ?????????? ?
??????????. ?????? TLR-4 ?? ???????? ???????????? ??????????????? ? ???????? ??????????? ? ??? [12]. ??? ????????????? ? ????????????? ????? ??????????? ???????
TLR-4 ????????? ? ????????????? ??? ????????????????. ??????????? ???? ? ??????????? ?????????????? ?????????????? ???????????????? ? ???????-??????????? ??????
??????????? ?????????? ??????????? ???????????????-???????????? ?????.
???????????????-??????????? ?????
????????? ? ??????? ???????? ??????? ???????????? ???????????? ????????? ? ?????????????????, ?????????????? ? ?????????????, ??????????, ??????????????? ???????????????? ? ???????? ??????? ?????????
????????????? [13]. ???????????????-??????????? ?????, ?????????? ?? ?????????
??? ??????????? ???????????? ?? ???????
????????????????? ?????????, ?????????? ???
????????? ?????????? ?????????? ?
mCD14 ??? ??????????? ??? ????? ? sCD14
[14]. ??????????????, ??? ???? ???? ?????????????? ??????????? ??????????? ? ????????? ????????? ????????? ??????? ???????????????? [15], ????????? ????????????? ?????????? ??????????? ? ???????????????? ?
???? ?????? ??????????? ?????????? [16].
????????? ?????? ???????? ??????????? ???????????????? ??????????? ??????? ?????????????? ? MD2, ?????????? ? TLR-4 ?? ??????????? ??????, ??? ???????????? ?????????
???????? ????-???????? ?????????? 4, ???????????? ?? ?????????????? ? ?????? ?????????????? ??????? ? ?????????? ???????????? ?
???????????????? ??????? ?????? ??????
[17?19]. ???????? ???????????????? ?????????????? ???????????????? ? ???????????????-??????????? ?????? ? ????????????
???????????, ????????????? ???????-??????????????? ??????, ?????????? ??????????????? ?????????? ??????, ?????????????
?????????? ???????? ??????? ???????????? ?
NF-kB ? ???????? ??????? ?????????????????
??????????, ??????????? ???????? ???????,
???????????? ?? ??????? ?????????? ??????????? ???????? ?? ????????? [20].
???????????????-??????????? ?????
????????????? ??????? ??????? ? ?????? ?
?????????????? ? ????? ????? ???????????????? ? ???????????? ?????? 58?60 ??? [16].
???????????? ???????????????-???????????? ????? ? ????? ?????????? ? ?????????,
???????? ??? ?????????? ????, ????????,
7
?????????????? ????????. ?????????? ????????????? ?????????? ??? ?????? ? ?????????????? ??????? ????????? [21].
????????? ???????????????-??????????? ????? ???????? ????? ?? ??????? ?????????? ? ??????? ??????????? ????????? ?????? ?? ??????????? ??????????? (?????????????, ??????????, ??????????????? ?
????????? ??????????, ????????????? ?? ?????????? ???????? ??????????), ? ?????
????? ??????????? ? ???????????? ????????????????? ???????? ? ???????????? ????????? ????????, ?? ????????? ? ????????
??????? ???????????? [22, 23] ? ??????? ???????? [13, 16, 24]. ???????? ???????????
??? ????????????? ??? ??????????? ????????????? ??????????? ? ??????????? ??????
?? ?????????? ??????? [25].
??????? ???????????????-????????????
????? ??????????? ?????????? ? ??????????????????? ??????? ? ?????? ????? ?????
???????? ? ????????? ????????? ?? 3-? ???.
?????????? ??????? ???????????????-???????????? ????? ??????????? ?? 7 ??? ?????
???????? [4].
? ?????????????? ????????????? ?????????????? ????????????, ??????????
180 ????????? ? ??????? ????????, ????????, ??? ???????? ????????? ???????????????-???????????? ????? ???????? ?????
???????????? ????? ??????? ?? ????????? ?
???????????? ?? ?????? II, ?????????????-6, ?-?????????? ?????? ? ???????????? ?????????????? ? ??????????? ??????
??????? [26].
?????? ?????? ??????????????????, ???
???????????????-??????????? ????? ???????? ?????? ???????? ??????? [27] ? ?????
????? ?????????? ??????? ??????? ????????, ??? ?????????????? [28]. ??? ? ?????
???????????? ???????????????-??????????? ????? ? ????????? ?????????? ????????
??? ????? ???????? ??????????????? ??????? ????????????? ??????? ?? ????? ??????
?????? ? ????? ?????? ? ???????? ?????????? ? ?????? ?? ????????? ? ?-??????????
?????? ? ???????????????? [29].
?????? ??????? ?????? ? ???, ??? ???????????????-??????????? ????? ?? ????????? ???? ??? ????? ?????? ???????????????
?????? ? ?????????????? ??????? ?? ???????? ?????????? ??????????????? ?????? ?????????????? ??????? ? ??? ??????????????? ?????? ??????? ?? ????????? ? ???????????????? [30, 31].
??????????? ?????????? ??????????????, ? 4, 2013
??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
8
??????
????? ???????, ?? ???????????? ??????
???????????????-??????????? ????? ????????????? ???????????? ? ????????? ????????? ????????, ???????? ???????? ???? ?
?????????????, ?????????? ? ?????????????
???????????????? ? ?????? ???????-??????????????? ???????????? ???????, ??????????? ??? ????????????????? ??????????????? ? ???????????? ????????? ????????,
????????????? ?????????????? ?????????
?????????? ??????????? ??????????, ??????????? ?????? ????? ???????????????????? ???????. ??????? ??????????????????????????? ????? ?????? ?????????? ???
??????? ????????, ??? ?? ????????? ??????????????? ????????????? ????? ????? ???
?????????????? ?????? ???????????? ? ?
???????? ??????? ?????????????? ???
???????? ???????? ?????????????????? ????????????? ?????????? ? ??????????????????? ???????. ??? ????????? ????????
???????????????-???????????? ????? ? ??????????? ? ???????? ??????-???????????
?????????? ?????????? ??????????????
????????????.
??????????
1.
??????????? ?????????? ??????????????, ? 4, 2013
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
???????? ?., ????? ?., ??????? ?. (???.). C?????????? ?????????????. ??????????. ???. ? ????. ?.?. ?????????,
?.?. ????????????, ?.?. ????????. ???????? ?.?. (???.).
?. 2. ?.: ???; 2005.
Ma T.Y., Hollander D., Dadufalza V., Krugliac P. Effect of
aging and caloric restriction on intestinal permeability. Exp.
Gerontol. 1992: 27: 321?33.
?????? ?.?., ??????? ?.?., ????? ?.?. ?????????????????? ? ???????????????? ?????? ?????????????. ?.: ????????; 1982.
Kudlova M., Kunes P., Kolackova M. et al. LipopolysaccharideBinding Protein and sCD14 are Not Produced as Acute Phase
Proteins in Cardiac Surgery. Mediators Inflamm. 2007; 2007.
72356: 1?6.
Yaroustovsky M., Plyushch M., Popov D. et al. Prognostic value
of endotoxin activity assay in patients with severe sepsis after
cardiac surgery. J. Inflamm. (Lond). 2013; 10 (1): 8.
Klein D.J., Briet F., Nisenbaum R. et al. Endotoxemia related to
cardiopulmonary bypass is asso?iated with increased risk of
infection after cardiac surgery: a prospective observational
study. Crit. Care. 2011; 15 (1): R69.
Hanssen S.J., Libbers N., Hodin C.V. et al. Hemolysis results in
impaired intestinal microcirculation and intestinal epithelial
cell inyury. World J. Gastroenterol. 2011;17 (2): 213?8.
Beutler B.A. TLRS and innate immunity. Blood. 2009; 113:
1399?1407.
Matot I., Sprung C.C. Definition of sepsis. Intensive Care Med.
2001; 27 (1): S 3?9.
Opal S.M. Endotoxins and other sepsis triggers. Contrib.
Nephrol. 2010; 167: 14?24.
Medzhitov R., Janeway C. Innate immunity. Engl. J. Med. 2000;
343: 338?44.
Prohinar P., Re F., Widstrom R. et al. Specific high affinity
interactions of monomeric endotoxin protein complexes with
Toll-like receptor 4 ectodomain. J. Biol. Chem. 2007; 282:
1010?7.
Schumann R.R. Old and new on lipopolysaccharide-binding
protein: a soluble pattern-recognition molecule. Biochem. Soc.
Trans. 2011; 39 (4): 989?93.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Lu Y.C., Yen W.C., Ohashi P.S. LPS/TLR4 signal transduction
patway. Cytokine. 2008; 42: 145?51.
Post D.M., Zhang D., Eastvold J.S. et al. Biochemical and functional characterization of membrane, lebs purifield from
Neisseria meningitides serogroup B. J. Biol. Chem. 2005; 280
(46): 38383?94.
Zweigner J., Schumann R.R., Weber J.R. The role of
lipopolysaccharide-binding protein in modulating the innate
immune response. Microbes and Infection. 2006; 8 (3):
946?52.
Fitzgerald K.A., Rowe D.C., Golenbock D.T. Endotoxin recognition and signal transduction by the TLR4/MD2-c?mplex.
Microbes. Infect. 2004; 6: 1361?7.
Kato A., Ogasawara T., Homma T. et al. Lipopolysaccharidebinding protein critically regulates lipipolysaccharide induced
INF-beta signaling pathway in human monocytes. J. Immunol.
2004; 172: 6185?94.
Triantafilou M., Triantafilou K. Lipipolysaccharide recognition: CD14, TLRs and the LPS activation cluster. Trends
Immunol. 2002; 23: 301?4.
Takeuchi O., Akira S. Pattern recognition receptors and
inflammation. Cell. 2010; 140: 805?20.
Gonzalez-Quintela A., Alonso M., Campos J. et al. Determinants
of serum concentrations of Lipopolysaccharide-Binding
Protein (LBP) in the adult population: the role obesity. PLOS
ONE. 2013; 8 (1): e54600.
SchrЖder N.W.J., Morath S., Alexander C. et al. Lipoteichoic
acid (LTA) of Streptococcus pneumonia and Staphylococcus
aureus cctivates immune cells via Toll-like receptor (TLR)-2,
lipopolysaccharide-binding protein (LBP) and CD14, whereas TLR-4 and MD-2 are not involved. J. Biol. Chem. 2003;
278: 15578?94.
Stehle J.R., Leng X., Kitzman D.W. et al. Lipopolysaccharidebinding protein, a surrogate marker of microbial translocation,
in assotiated with physical function in healtly oder adults. J.
Gerontol. A Biol. Sci. Med. Sci. 2012; 67 (11): 1212?8.
Pavare J., Grope I., Kalnins I., Gardovska D. High-mobility
group box-1 protein, lipopolysaccharide-binding protein,
interleukin-6 and C-reactive protein in children with community acquired infections and bacteraemia: a prospective study.
BMC Infect. Dis. 2010; 10: 28.
Volmer T., Piper C., Kleesiek K., Dreier J. Lipopolysaccharidebinding protein: a new biomarker for infectious Endocarditis?
Clinical Chemistry. 2009; 55 (2): 295?304.
Villar J., PИrez-MИndez L. et al. Serum lipopolysaccharidebinding protein levels predict severety og lung injury and mortality in patients with severe sepsis. PLOS ONE. 2009; 4 (8):
e6818.
Gaini S., Koldkjaer O.G., Pedersen C., Pedersen S.S.
Procalcitonin, lipopoplysaccharide-binding protein, interleukin-6 and C-reactive protein in community-acquired infection
and sepsis: a prospective study. Crit. Care. 2006; 10 (2): R53.
Mierzchala M., Krzystek-Korpacka M., Gamian A., Durek G.
Quantitative indeces of dynamics in concentrations of
lipopolysaccharide-binding protein (LBP) as prognostic factors
in severe sepsis/septic shpck patients-comparison with CRP
and procalcitonin. Clin. Biochem. 2011; 44 (5?6): 357?63.
Mussap M., Noto A., Fravega M., Fanos J. Soluble CD14 subtype presepsin (sCD14-ST) and lipopolysaccharide-binding
protein (LBP) in n??natal sepsis: new clinical and analytical
perspective for two biomarkers. J. Matern. Fetal Neonatal Med.
2011: 24 (2): 12?4.
???????????? ?.?., ??????? ?.?., ?????????? ?.?., ????? ?.?.
? ??. ??????????? ?????????? ???????? ? ?????????????? ?????????????. ??????? ??????? ?????? ? ???????.
2009; 1: 48?56.
Meynaar I.A., Droog W., Batstra M. et al. In critically ill
patients, serum procalcitonin is more useful in differentiating
between sepsis and SIRS than CRP, IL-6 or LBP. Crit. Care
Res. Pract. 2011; 2011: 594645.
References
1.
Lengeler J., Drevs G., Shlegel G. (ed.). Modern microbiology.
Prokaryotes. Translated from English by I.V. Alferova,
A.V. Lebedinskiy, K.L. Tarasov, A.I. Netrusov (ed.). Vol.2.
Moscow: Mir; 2005 (in Russian).
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Ma T.Y., Hollander D., Dadufalza V., Krugliac P. Effect of
aging and caloric restriction on intestinal permeability. Exp.
Gerontol. 1992: 27: 321?33.
Chakhava O.V., Gorskaya E.M., Ruban S.Z. Microbiological
and immunological concepts of gnotobiology. Moscow:
Meditsina; 1982 (in Russian).
Kudlova M., Kunes P., Kolackova M. et al. LipopolysaccharideBinding Protein and sCD14 are Not Produced as Acute Phase
Proteins in Cardiac Surgery. Mediators Inflamm. 2007; 2007.
72356: 1?6.
Yaroustovsky M., Plyushch M., Popov D. et al. Prognostic value
of endotoxin activity assay in patients with severe sepsis after
cardiac surgery. J. Inflamm. (Lond). 2013; 10 (1): 8.
Klein D.J., Briet F., Nisenbaum R. et al. Endotoxemia related to
cardiopulmonary bypass is asso?iated with increased risk of
infection after cardiac surgery: a prospective observational
study. Crit. Care. 2011; 15 (1): R69.
Hanssen S.J., Libbers N., Hodin C.V. et al. Hemolysis results in
impaired intestinal microcirculation and intestinal epithelial
cell inyury. World J. Gastroenterol. 2011;17 (2): 213?8.
Beutler B.A. TLRS and innate immunity. Blood. 2009; 113:
1399?1407.
Matot I., Sprung C.C. Definition of sepsis. Intensive Care Med.
2001; 27 (1): S 3?9.
Opal S.M. Endotoxins and other sepsis triggers. Contrib.
Nephrol. 2010; 167: 14?24.
Medzhitov R., Janeway C. Innate immunity. Engl. J. Med. 2000;
343: 338?44.
Prohinar P., Re F., Widstrom R. et al. Specific high affinity interactions of monomeric endotoxin protein complexes with Tolllike receptor 4 ectodomain. J. Biol. Chem. 2007; 282: 1010?7.
Schumann R.R. Old and new on lipopolysaccharide-binding
protein: a soluble pattern-recognition molecule. Biochem. Soc.
Trans. 2011; 39 (4): 989?93.
Lu Y.C., Yen W.C., Ohashi P.S. LPS/TLR4 signal transduction
patway. Cytokine. 2008; 42: 145?51.
Post D.M., Zhang D., Eastvold J.S. et al. Biochemical and functional characterization of membrane, lebs purifield from
Neisseria meningitides serogroup B. J. Biol. Chem. 2005; 280
(46): 38383?94.
Zweigner J., Schumann R.R., Weber J.R. The role of
lipopolysaccharide-binding protein in modulating the innate
immune response. Microbes and Infection. 2006; 8 (3): 946?52.
Fitzgerald K.A., Rowe D.C., Golenbock D.T. Endotoxin recognition and signal transduction by the TLR4/MD2-c?mplex.
Microbes. Infect. 2004; 6: 1361?7.
Kato A., Ogasawara T., Homma T. et al. Lipopolysaccharidebinding protein critically regulates lipipolysaccharide induced
INF-beta signaling pathway in human monocytes. J. Immunol.
2004; 172: 6185?94.
Triantafilou M., Triantafilou K. Lipipolysaccharide recognition: CD14, TLRs and the LPS activation cluster. Trends
Immunol. 2002; 23: 301?4.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
9
Takeuchi O., Akira S. Pattern recognition receptors and
inflammation. Cell. 2010; 140: 805?20.
Gonzalez-Quintela A., Alonso M., Campos J. et al. Determinants
of serum concentrations of Lipopolysaccharide-Binding
Protein (LBP) in the adult population: the role obesity. PLOS
ONE. 2013; 8 (1): e54600.
SchrЖder N.W.J., Morath S., Alexander C. et al. Lipoteichoic
acid (LTA) of Streptococcus pneumonia and Staphylococcus
aureus cctivates immune cells via Toll-like receptor (TLR)-2,
lipopolysaccharide-binding protein (LBP) and CD14, whereas TLR-4 and MD-2 are not involved. J. Biol. Chem. 2003;
278: 15578?94.
Stehle J.R., Leng X., Kitzman D.W. et al. Lipopolysaccharidebinding protein, a surrogate marker of microbial translocation, in assotiated with physical function in healtly oder
adults. J. Gerontol. A Biol. Sci. Med. Sci. 2012; 67 (11):
1212?8.
Pavare J., Grope I., Kalnins I., Gardovska D. High-mobility
group box-1 protein, lipopolysaccharide-binding protein,
interleukin-6 and C-reactive protein in children with community acquired infections and bacteraemia: a prospective study.
BMC Infect. Dis. 2010; 10: 28.
Volmer T., Piper C., Kleesiek K., Dreier J. Lipopolysaccharidebinding protein: a new biomarker for infectious endocarditis?
Clinical Chemistry. 2009; 55 (2): 295?304.
Villar J., PИrez-MИndez L. et al. Serum lipopolysaccharidebinding protein levels predict severety og lung injury and mortality in patients with severe sepsis. PLOS ONE. 2009; 4 (8):
e6818.
Gaini S., Koldkjaer O.G., Pedersen C., Pedersen S.S.
Procalcitonin, lipopoplysaccharide-binding protein, interleukin-6 and C-reactive protein in community-acquired infection and sepsis: a prospective study. Crit. Care. 2006; 10 (2):
R53.
Mierzchala M., Krzystek-Korpacka M., Gamian A., Durek G.
Quantitative indeces of dynamics in concentrations of
lipopolysaccharide-binding protein (LBP) as prognostic factors
in severe sepsis/septic shpck patients-comparison with CRP
and procalcitonin. Clin. Biochem. 2011; 44 (5?6): 357?63.
Mussap M., Noto A., Fravega M., Fanos J. Soluble CD14 subtype presepsin (sCD14-ST) and lipopolysaccharide-binding
protein (LBP) in n??natal sepsis: new clinical and analytical
perspective for two biomarkers. J. Matern. Fetal Neonatal Med.
2011: 24 (2): 12?4.
Beloborodova N.V., Tumanyan M.R., Chernevskaya E.A.,
Popov D.A. et al. Novel biomarkers of infection in neonatal
cardiac surgery. Detskie bolezni serdtsa i sosudov. 2009; 1:
48?56 (in Russian).
Meynaar I.A., Droog W., Batstra M. et al. In Critically III
Patients, Serum Procalcitonin is More Useful in
Differentiating between Sepsis and SIRS than CRP, IL-6 or
LBP. Crit. Care Res. Pract. 2011; 2011: 594645.
????????? 25.06.2013
??????????? ?????????? ??????????????, ? 4, 2013
??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
10
?????????? ??????
?????????? ??????
╘ ????????? ???????, 2013
??? 611.126-053.2-092.9
????????????? ???????? ???????? ?????? ? ????? ? ?????
?.?. ???????1, ?.?. ???????1, ?.?. ????????2, ?.?. ??????1, ?.?. ??????????1,
?.?. ??????1
1????
??????????? ?????????? ??????????????, ? 4, 2013
╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ? ???????? ???
? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????, 121552, ??????;
2????? ╚???????? ?????????? ???????╩ ???, ??. 60-????? ???????, 9, ??????, 117312, ??????
??????? ??? ?????????, ?????? ???. ????, ?????????, ???????? ??? ? ????, ????????;
??????? ????? ??????????????, ?????? ???. ????, ?????????, ??. ????. ????.;
???????? ?????? ????????????, ???????? ???.-???. ????, ???. ????. ????.;
?????? ?????? ?????????????, ???????? ????. ????, ?????????? ???????????? ?? ????????????
?????????? ??????????? ? ??????????????? ?????? ?????? ??????????? ??????????? ? ???????
??????????? ????????-?????????? ???????; e-mail: marina_panova53@mail.ru;
?????????? ??????? ???????, ???????? ???.-???. ????, ??. ????. ????.;
?????? ????? ???????????, ?????? ???. ????, ?????????, ?????????? ??????? ?????????? ????????????
? ???????????? ???????????
???? ???????????? ? ??????? ??????? ???????? ???????? ?????? ? ???????? ??????? ????????? ??????????? ??????????????? ?????????????.
???????? ? ??????. ?????????? ??? ???????? ????????? ?????? ????????????????? ????????????
1447 ??????????????? ?????????? ?????????? ?????? ????? ? ???????? ?? ???????? ?? 15 ???. ??????????? ???????????? ????????? ???????? ???? ?? ?????????, ? ???????????? ???????? ????????? ? ??? ????
(????? ????) ? ???????. ? ?????????????? ?????? ????????????? ?????? ????????? ?????????????? ?????? ???????????? ?????????? ????????? ???????? ?? ???????? ? ?????, ? ????? ????? ?? ???????? ??? ?????
?????? ????. ?? ?????? ??????????? ??????? ???????? ?????? ???????? ???????? ????????? ????????.
??????????. ????????, ??? ??????????? ?????????? ?????? ?????????? ????????? ???????? ? ????? ???
?????? ???? ?????? ????????? ?????????????? ?????? (??? ??? ???????? ???????????? R2 ????? ???????? ?????? ??? 0,98). ???????????, ??? ? ???????? ~20 ??? (????? ??????????), ?????????? ?? ???? ??????? ? ???? ???????, ?????????? ???????????? ????????? ????????? ???????????? ?????????? ????????
? ????? ?? ????????: ?? ?????????? ????????? ?? 0 ?? ???????? ?????????? ??????? ????????????? ?
??????? ? 3,5 ????, ? ???? ? ? 4,5 ???? ???????????, ??? ? ????? ??????? ????????. ? ???????? ????????
? ????? ??????????? ??? ?????????? ???????. ? ?????? ???????, ?? 0 ?? tmax, ???? ???????? ????????? ???????????? ????, ? ???????????? ????????? ???????????????? ????????? ? ???????? tmax. ?? ?????? ???????, ?? tmax ?? tpr (tmax < tpr), ????????, ???????????? ???? ????????????? ???????, ??? ???? ????????.
? ??????? ??????? (t > tpr) ???????? ???????? ???????? ? ????????????? ????? ????? ????????????????
????????. ????????????????? ??????? ??????? ?? ??????? ?? ???? ? ?????? ??? ??????????? ??????? ??
????????? ? ????? ?????????? ????????? ?????? (??????? ???????? ??? ????????? ? ??????? ? 7,12 ???
?? ????????? ? 4,87; 5,16 ? 4,94 ???). ????????????????? ??????? ??????? ??? ????? ??????? ??????
??????, ??? ??? ?????? ??????? ?????? (111,70; 122,53 ?????? 83,20; 80,73 ? ????????? ? 93,24; 117,31
?????? 65,77; 71,86 ? ???????). ?????? ?????? ??? ???????? ?????? ??????? ?????? ????????????? ? ??????? ? 6 ?????, ??? ??????????? ? ??????????? ? ? 8?10 ????? ??????????????.
??????????. ??????? ????????????? ?????????? ?????? ? ??????? ???????? ???????????? ??? ???????? ???????? ????? ? ?????????? ???????? ??????. ??????????? ??? ??????? ????????? ????????
???????? ? ????? ???? ? ???????????? ???????? ????????, ???????????? ????????????? ????? ?
????????????????? ?????????? ???????? ? ?????. ? ?????? ??????? ??????? ????? ???????????????
???? ??????????? ???????. ?????? ?????? ??????????????? ????? ??????????????? ?????????
???????? ????? ??????? ?????? ?? ????????? ? ????????? ?????? ???????, ??? ????? ???????????????
?????, ????????? ? ?????????????? ??????????? ????? ??????? ?????? ? ???????? ?????? ?????????.
???????? ?????: ??????????????? ???????????; ?????? ???????? ??????; ????; ?????????????;
?????????????? ??????.
MODELING OF NORMAL HEART VALVE DEVELOPMENT IN CHILDREN
L.A. Bockeria1, O.A. Makhachev1, V.V. Golubkov2, M.S. Panova1, T.Yu. Filippkina1, B.E. Narsiya1
1A.N. Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Sciences,
Rublevskoe shosse, 135, Moscow, 121552, Russia;
2Institute of Systemic Analysis of the Russian Academy of Sciences, pr. 60-letiya Oktyabrya, 9, Moscow, 117312, Russia
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????????? ??????
11
Bockeria Leo Antonovich, MD, DM, Professor, Academician of the Russian Academy of Sciences and Russian Academy
of Medical Sciences, Director;
Makhachev Osman Abdulmalikovich, MD, DM, Professor, Chief Research Scientist;
Golubkov Viktor Vladimirovich, PhD in Phys. and Math. Sci., Leading Research Scientist;
Panova Marina Stanislavovna, PhD in Biol. Sci., Chief of laboratory of the research of parameters of normal heart and heart
pathology of the department of the optimization of diagnosis and treatment of cardiovascular diseases;
Filippkina Tat'yana Yur'evna, PhD in Phys. and Math. Sci., Senior Research Associate;
Narsiya Boris Evstaf'evich, MD, DM, Professor, Chief of Department of Professional and Continuing Education
????????
???????? ?? ??????? ???????????? ????
????? ???????, ??????????? ?????????,
???????????? ?????? ???, ????????? ? ???????????????? ??????????? ?? ?? ???????.
??????????????? ???? ???????????????
???????????? ????????????? ????????????? ????????? ??????????? ????? ??????? [1].
???????? ?????????????? ???????? ?????
?????? (relative growth), ?? ?????? J. Gaiton
[2], ?????? ??????? ? ????? XVIII ? ??????
XIX ???????? ? ??????? ? ???????? Fre?de?ric
Cuvier ?? ????????? ???????? ???? ? ????? ?
?????????????. ?? ?????? XIX ? XX ???????? ???????? ?????????????? ????? ????????
??????? ???????? ? ????????????? ????????
??????????? Euge?ne Dubois (1858?1940) ?
???????????? ????????? Louis Lapicque
(1866?1952), ? ????? ??????????? ?????????????? Albert Pe?zard (1914) ? Christian Champy
(1924). ? 1924 ?. ?????????? J. Huxley [3] ????????? ??????, ? ??????? ????????? ? ??????
????????????????? ???????? ? ???????? ???
????????: y = bxk, ??? y ? ?????? ????????-
??????? ????????? ??????, x ? ?????? ????, b
? k ? ?????????.
??????????? ??????? ╚??????????╩ ?
╚??????????????? ????????╩ ????????? ? 1936 ?.,
?? ???????? ????????? ??? ??????????
Julian Huxley ? ??????????? ?????? Georges
Teissier. ??? ?? ?????? ? ?????????? ???????????? ??????????????? ????????? ?????????????? ?????? ????????????????? ?????: y = bx?.
??????????????? ???????? ???????? ?????? ??? ??????? ?????? ???????? ?????????
????????????? ???????????? ????? ???????????? ????? ????????? ???????? ?????? ?
????????? ???? ? ????? ?????? ????????????
??????? ?????????? ???????? ??????????????? ???????? ???: 1) ???????? ??????????
????? ??????? ??? ?????? ????? ? ?????????;
2) ??????????? ????????? ?????? ????? ????????? [4?7]; 3) ??????????????? ?????
????????-?????????? ??????? [4, 8]; 4) ??????????????? ??????? ???????????? ?????
????????? ???? ? ????????? ??????????????? ???????? [9].
? ????????????? ?????????????? ?????
????? ???????? ??? ???????????. ?????? ?
??????????? ?????????? ??????????????, ? 4, 2013
Objective of the research is to study the process of heart valves development in growing children's bodies using mathematical modeling.
Material and methods. The data obtained from morphometric study of 1447 unfixed preparations of normal hearts of the
children in the age group between birth and 15 years was used as research material. Circumferences were taken as measurable indicators of the development of heart valves, and body growth and development were assessed using height
(body length measurements) and age. Based on developmental systems theory mathematical models showing the correlation between the circumferences of heart valves, age and height, as well as between height and age of children of both
genders were constructed. The constructed models were used to perform analysis of heart valve development.
Results. It was shown that the established age-related models of the correlation between the dynamics of development of
cardiac valve circumferences and body growth for both genders were very effective in describing the statistical data (in them
the adequacy criterion R2 value is higher than 0.98). It was determined that at the age of ~20 months (bifurcation point),
regardless of the type of the heart valve and child's gender, qualitative changes in the pattern of correlation between the circumferences of heart valves and body growth and age occur: in the age range from 0 to the age of bifurcation the rate of the
average valve growth in size was 3.5 times, and of the height ? 4.5 times more intensive than in older children. Three agerelated time periods in heart valve development and growth were established. In the first period, from 0 to tmax the valve growth
outpaces somatic growth with indexed circumference reaching its maximum value at tmax age. In the second period, from
tmax to tpr values (tmax < tpr), on the contrary, somatic growth outpaces valve growth. In the third period (t > tpr) valve development and somatic growth are proportional. The duration of the first period doesn't depend on gender and it is longer for aortic valve compared to three other heart valves (an average value for boys and girls is 7.12 months compared to 4.87; 5.16 and
4.94 months). The duration of the second period for left side of the heart is longer than for the right side of the heart (111.70;
122.53 versus 83.20; 80.73 in boys and 93.24; 117.31 versus 65.77; 71.86 in girls). The second period in the right-sided
valves ends around 6 years of age on the average, and in aortic and mitral valves ? by 8?10 years of age respectively.
Conclusion. Universal age-related models that are able to describe the dynamics of body growth and development of the
circumferences of heart valves with a high degree of adequacy were created. Three time periods in the concurrent processes of the development of heart valves and body growth are outlined ? when development of valves outpaces the body
growth, somatic growth outpaces valve growth and the period when valves and body growth is proportional. The growth of
aortic valve was more continuous in the first period. The second period was characterized by more continuous development
of valves of the left side of the heart in comparison with the valves of the right side of the heart, it has physiological significance related to the function of the left side of the heart and of the left ventricle in particular.
Key words: allometric relationships; size of heart valves; children; modeling; 4-dimensional mathematical models.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
12
?????????? ??????
??????????? ?????????? ??????????????, ? 4, 2013
???????????? ?????????? ???????????? ???
╚scaling╩ ??? ╚normalization╩ ? ?????????????
????????????? ???????? ??????????? ?????
???????? ???? ? ???????? ?????-???? ?????????. ? ???? ?????? ╚????????????╩ ??????????? ? ??????? ???????? ???????????
????????? ?? ???????? ?????????? ????? ????????? ? ?????. ? ???????? ?????????? ????????????? ????? ?????? ?????? ??????????:
??????? ??????????? ???? [5, 9?14], ??? ????
[15, 16], ????? ???? ??? ????, ??? ╚fat free
mass╩ [5, 13, 17], ???? [8, 14, 17, 18]. ??????
?? ???? ??????????? ????? ???? ???????????? ? ??????????? ? ?? ???????? ?????????????. ?????? ???????????? ? ????????????
??????????????? ???????? ????? ?????????? ???????? ?????????? ?????????, ??????
?????????? ??? ????????? ??????? ??????????: ? = ??b, ??? ? ? ???????? ????????? ??????, ? ? ?????????? ????????????? ?????, ? ? b ?
?????????. ??? ?????????, ? ????? ???????
????? ????????? ????? ????????????????
????? ??? ?????? (log y = log b + a log x) ?????? ??????????? ??? ???????? ?????????????? ????? ???????? ?????? [5, 6, 8, 17, 19, 20].
?????????????? ???? ???????????? ? ???
?????????? ???????? ???????? ???????? ???????? ?????? ? ???????? ??????? ????????? ??????????? ??????????????? ?????????????.
???????? ? ??????
?????????? ??? ??????? ????????? ?????? ????????????????? ???????????? 1447
??????????????? ?????????? ??????????
?????? ????? ? ???????? ?? ???????? ??
15 ???, ??????? ?? ???????????, ?? ???????
??????? ?? ???????????? ??????????
???????? ??????, ???????????? D.M. Schulz
? D.A. Giordano [21]. ?????????? ??????????? ???????????, ???????????????, ??????????? ? ????????? ???????? ???? ????? ?? ?????????? (????????), ???????????? ????????
????????? ? ???? (????? ????) ? ???????.
???? ????????? ?????????????? ??????
???????????? ?????????? ????????? ???????? ?? ???????? ? ????? ????? ?????? ????.
??????? ??? ??????? ??????? ???? ???????
?????????????? ??????, ??????????? ????????? X=P/L ? ????????? ??????? P ? ????? L
? ??????????? ?? ?????. ????? ???? ???????
?????? ????? L ??? ??????? ????????. ?? ?????? ??????????? ??????? ??? ???? ????????
???? ???????? ?????? ????????? ?????????? ???????? ? ????? ? ?????????? ????????
??? ??????? ???????? ????? ??????????? ?
??????????????? ??????????? ?????? ??
????? ?????? ????? ??? ?????????? ??????.
??????????????? ???????????? ??????
?????????????? ?????? ???????, ??? ??????????? ?? ????? ????????? ?????????? ???????? ? ????? ??? ??? ?????????, ??? ? ??? ??????? ????? ???? ? ??? ?? ???????????? ???.
??????? ? ??????????? ????? ????????? ????????? ??????? ? ????? ?????????????, ????????? ????????????? ????????, ????? ????????? ??????????? ? ?????? ????????
??????????? ?????????? (???, ??????,
?????????????? ????????? ? ???????????
????????). ?? ?????? ???????????? ????????????? ??????? ??? ???????? ? ???????????
?? ????? ????????? ????????? ??????? ? ????? ??? ???? ???????? ? ????? ????? ???? ????? ????????? ?????????????????????? ?????????????? ??????:
P/L=X (L)=X (L, q1, q2, q3, q4)=
= [q1+q2 (L?L0)] eq (L?L )+q4, L?L0, (1)
3
0
??? L0 ? ????????? ???????? ?????, q1, q2, q3, q4 ?
????????? ??????, ?????????? ??????????
?? ?????????????? ??????. ?????? ??? ?????? ???????? ?????????? ???? ?? ????? ??????
?????????? ??????????. ???????? ?????????
L0 ? ?????? (1) ?????????? ?????? ???????
(???????????) ??????????????? ????????
????? ??????? ??? ??????? ????. ??????? ??????? ???????????? ??????????? ??????? ????
(1) ???? ???????????? ??? ??????????? ????????? ?????????????? ??????.
??????? ????????, ??? ???? ????????????
??? ?????????? ?????? ????????? ????????? ??????? ? ????? ?????? ???????????????? ????????? ?????? (Huxley J.S., 1924),
??????????? ???????? ?????? ? ????????
???? ?, ? ????? ??????, ????????????? ? ????????? ??????? ??????? ??? P=bLa (b>0),
?? ??????????? ? ???? ?????? ??????
P/L=bLa?1 ????? ????? ?????????? ?? ????????? ? ???????????? ???????? ??????? (1),
????????? ???????? ??????????? ?????? ?
??????????? ????? ???? ????????? ??????
(??? a>1), ???? ????????? ???????????
(??? a<1), ???? ?? ?????????? (??? a=1).
??????, ??? ?????????? ?????????????? ??????, ??? ????? ????????? ????? ??? ????
???????? ????? ????? ????? ?? ???????????,
?? ???? ?????? P/L=bLa?1 ??? ????? ????????? ????? ??????????? ????????? ?????????
????????? ????????? ??????? ? ????? P/L.
?? ?????????? ???????, ??? ?????? (1) ??????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????????? ??????
L(t)=L (t, p1, p2, p3)=p1 (1?ep
2
(t?t0))+p ,
3
(2)
??? p1, p2, p3 ? ????????? ??????, ? t0 ? ????????? ???????? ???????? ?? ?????? ?????????? ????????????. ?????? ??????????????
?????? ??? ????? ? ??????????? ?? ????????,
??? ??? ?????????, ??? ? ??? ???????, ???????, ??? ????????? ????? ? ????????? ??????????? ???????? ??????? ? ?????????? ???????? t1. ?????? ?? ????? ? ?????????? ????, ???
????? ?? ??????? ????????? [t0, t1] ???? ?????
?????? ???? (2) ? ?????? ?????????? ??????????, ? ??? ????????? t>t1 ? ?????? ???? (2),
?? ? ??????? ?????????? ??????????. ???????????? ?????? ????? ? ??????????? ?? ????????, ??????? ?????????????? ? ??????, ? ?????? ?????????? ????? ????????? ??? (??-
??????? ???????? ???????? t0 ???? ????? ?????? ????, ?? ???? t0=0):
,
(3)
??? p1, p2, p3, p4, t1 ? ??????????? ?????????
??????, ?????????? ?????????? ?? ?????????? ????????? ????? ? ????????.
?????? ????????? ?????????? ????????
??? ??????? ????? ?????????? ????????????
???????, ????? ????????? ?????? (1) ?? ????
L, ?? ????:
P (L) =LX (L, q1, q2, q3, q4) =
= L [q1 + q2 (L?L0)] eq3 (L?L0) + q4, L?L0.
(4)
? ???? ???????, ?????? ????????? ?????????? ???????? ? ????? ? ?????? ?????????? ???????? ??? ??????? ???????? ?????????? ? ?????????? ??????????? ?????????????? ? ?????? (1) ? (4) ?????? ????? L ???????
????????, ?????????? ??????? (3).
?????????? ? ??????????
?????? ?????????? ??????? (1)?(4) ???
????? ?????? ???? ???????? ?? ??????????
?????????? ????????? ????????, ????? ? ????????. ????????? ????????? ??????????? ??
??????????? ??????? ????? ? ???????????
??????? ??? ?????? ??????????? ? ?????? ?????, ?????????, ??? ?????? ????????? ?????
??????????? ?????????????. ????? ????,
??????????????, ??? ?????? ????????? ????? ?????????? ????????????? ? ????????
??????????????? ??????????. ??? ????
?????????????? ?????? ?????????? ???????
?????????? ?????????? ??????? ?????????? ?????????. ?????? ?????? ??????????,
???? ????????? ?? ?????????? ?????????????? (??????????? ??????????), ? ?????
?????? ??????????? (?????, ?????????? ????????, ?? ????????? ? ?????) ? ?? 95% ????????????? ?????????. ?????????? ?????????? ????????????? ??????????? ? ????????
??????????? ?? ??????? ?????????, ???
?????? ?????????? ??? ?? ?????????? ?????
????????? [22]. ????? ????, ??? ?????? ?????? ??? ????????? ???????? R2 [23], ??????????????? ??????? ?? ????????????. ??? ????? ???????? ????? ???????? ? 1, ??? ?????????? ??????. ?????????? ???????? R2 ???
??????????? ?????????? ??????? (0,98?0,99)
??????????? ?????????? ??????????????, ? 4, 2013
???? ????? ?????? ???????, ??? ??????
P/L=bLa?1.
??? ?????????? ??????????????? ??????
????? L ? ??????????? ?? ???????? t ???? ???????????? ????????? ?????? ?????????????
??????. ???????? ???? ??????, ? ??????? ????
??????????????? ?? ?????????, ??????? ?
???????? ???????? ??????? ?? ??????????
??????? ??????? t1 (????? ??????????) ???????? ??????????? ???????????, ? ????? ??
????? ????? ????????? ????????? (t1, t1+?t)
?? ???????? ?????? (??????????? ?????????????) ??????????. ????? ??????? ????????
??????? ???? ? ?????? ?????????? ?????????? ?? ??? ???, ???? ????? ????????????? ??
?????????? ????????? ?? ???????? ? ?. ?.
?????? ???? ?????????, ??? ?????????? ??????????????? ?????? ????? ? ???????????
?? ???????? ???? ?????????? ???????? ?????????? ?? ???????????????? ????????????,
?? ??????? ???? ?????????? ????? ? ??? ??
??????????????? ???????, ?? ? ??????? ?????????? ?? ??????????. ??? ???? ? ??????
????????? ??????????? ????????? (?????? ??????????) ????????????? ??????? ????????????? ????? ? ??? ?????? ??????????? ?? ????????. ??????????? ????? ??????? ??????
????? ???????? ? ????? ????? ??????????
????? ? ???????? ?????????, ?????????? ?????? ????????? ??????????? ?????????. ????????, ??? ?? ????????? ?????????? ?????????? ????????? ????????????? ????????? ?
????????? ??????? ??????????? ???????????????? ????????. ??????? ?? ?????? ?????????? ???????????? ? ???????? ??????????????? ?????? ????? ? ??????????? ?? ????????
???? ????? ?????? ????????????????? ????:
13
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
14
?????????? ??????
180
150
????, ??
120
90
60
30
0
30
60
90
120
150
180
???????, ???
???. 1. ??????????? ????? ????????? ?? ????????:
,?
?????????????? ?????????????? ? ????????? ???????? ????? ? 95% ????????????? ?????????
180
150
????, ??
120
??????????? ?????????? ??????????????, ? 4, 2013
90
60
30
0
30
60
90
120
150
180
???????, ???
???. 2. ??????????? ????? ??????? ?? ????????:
,
?
?????????????? ?????????????? ? ????????? ???????? ????? ? 95% ????????????? ?????????
??????????????? ? ??????? ??????? ?? ????????????.
?? ???????? 1 ? 2 ? ??????????? ???? ?????????????? ??? ????? ???????? ? ????????
???? ???????????? ?????????????? ? ????????? ???????? ?????, ? ????? 95% ?????? ?
??????? ??????? ????????????? ??????????
? ??????????? ?? ???????? ?? ?????????? ????????? ?? 7 ???? ?? 180 ???. ?? ???? ???????? ?????, ??? ??????????? ?????????? ?????? ????? ????? ?????? ????????? ?????????????? ?????? ? ? ???????? t1~20 ??? (?????
??????????) ????????? ??????????? ????? ??
???????? ??????????? ???????? ??? ????? ?????. ??? ???????? ???? ??????? ? ????? ?????????? ???????? 20,8 (SD 1,9) ???, ???
???????? ???? ? 23,9 (SD 1,9) ???. ???? ????????? ???????? ???????? ? ????????? ???????? ?????????? ??? ???????? ? ???????? ????. ???????? ??????????? ??????????????
???? ????????. ????????? ??????? ??? ????? ????? ??????? ?????????? ? ??? ??????????? ??????????, ??????? ????????? ???????
?????????????? 21,5 ? 1,7 ???.
?? ???????? 3 ? 4 ? ??????????? ???? ???????? ?????????? ????????????? ??????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????????? ??????
15
110
???????? ???????, ??
90
70
50
30
10
0
30
60
90
120
150
180
???????, ???
???. 3. ??????????? ?????????? ????????? ???????? ????????? ?? ????????:
,
?????????? ?????? (?????????? ? ??????); ,
???????? ?????? (?????????? ? ??????);
??????????????? ?????? (?????????? ? ??????)
+,
?????????? ?????? (?????????? ? ??????); в,
110
70
50
30
10
0
30
60
90
120
150
180
???????, ???
???. 4. ??????????? ?????????? ????????? ???????? ??????? ?? ????????:
,
?????????? ?????? (?????????? ? ??????); ,
???????? ?????? (?????????? ? ??????);
??????????????? ?????? (?????????? ? ??????)
+,
?????????? ?????? (?????????? ? ??????); в,
??? ?????????? ???????? ? ????????? ?????????????? ??? ???????? ? ???????? ????.
??? ???? ????? ?? ???????????? ?????????
???????, ?? ??? ?? ?????????? ?????? ?
??????? ??????? ????????????? ??????????.
? ???? ????, ??? ?????????? ?????? ?????????? ???????? ????????? ? ??????????????
?????????? ?????? ?????, ?? ???????????, ???
???????? ????????? ? ????????? ???? ?????????? ???????? ??? ???????? ? ????????
???? ??????????? ???????? ? ????????, ???-
??? ???????? ?????????? t1 ?????????? ?????? ????? (??? ???????? ???? t1 = 20,8 ???,
??? ???????? ???? t1 = 23,9 ???). ?????????,
??? ?????????? ?????, ???????? ????? ??????? ?????????? ??? ???????? ? ???????? ???? ????????????? ?????????, ?? ????? ???????, ??? ???????????? ????????? ?????????
?????????? ?????????? ???? ???????? ? ????? ??? ????? ????? ?????????? ????????????, ? ???????? ??????????, ?????? ? ???????
21,5 ???.
??????????? ?????????? ??????????????, ? 4, 2013
???????? ???????, ??
90
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
16
?????????? ??????
1,0
0,8
0,6
0,4
0,2
0,0
0
30
60
90
120
150
180
???????, ???
??????????? ?????????? ??????????????, ? 4, 2013
???. 5. ????????? ????????????? ?????????????? ?????????? ????????? ???????? ? ????? ????????? ? ??????? ?
??????????? ?? ????????. ?? ??????? ?????? ? ????? ????? ? ??? ????????????? ???????? (?????? ?????) ? ????? (?????
??????? ?????) ?????????????? ??? ????????? ? ???????
??????? ????????, ??? ??????? ???????
???????????? ?????????? ??????? ?????????? ???????? ? ????? (???????? ????????????
R2 ??? ???? ??????? ???????? ?? ????? 0,995)
???????? ?????????????? ????, ??? ? ????? ?
??? ?? ???????? ?????????? ???????????? ????????? ? ???????? ???????? ? ????????, ?
?????, ???, ????????, ???????? ??????????
???????????? ??????????? ????????? ??????? ? ???? ????????.
?? ??????????? ?? ???????? 1?4 ???????? ???????, ??? ????????????? ??????????
?????????? ???????? ? ????? ?? ??????????
????????? ?? ???????? ??????? ?? ????????
?????????? (~20 ???) ??????????? ??????,
??? ?? ????????? ?????????? ?????????. ???
???? ???????? ? ?????, ??? ??? ????????, ???
? ??? ???????? ????, ???? ????????? ?? ????????????? ?????????????, ??????? ???????????? ??? ????????? ?????????????? ?
?????? ???????? ? ??????????????? ?????????????? ? ????????? ????????. ??? ????
????????????? ????????? ?????? ??????????
? ???????? ???????? ???????????? ??????????? ???????, ??? ????????? ???????? ????????? ?????????? ? ?????? ?????????? ? ????
????????.
?? ??????? 5 ???????????? ??????? ????????? ? ????????? ????????????? ?????????????? ????? ? ?????????? ????????? ????????
??? ????????? ? ???????. ?????, ??? ????????????? ????????????? ??? ???? ??????????
????? ????? ??????????? ???? ? ?? ??, ?????
??? ????????????? ????????????? ????????? ????? ??? ???????? ? ???????? ????, ?????? ??????????? ???????????, ??????????
?? ??????????????? ?????????????? ??? ????????. ????? ????, ?? ?????????? ?????????
?? 0 ?? 20 ??? (??????? ??????????) ????????????? ????? ???? ??????????? ???????????
??????? ??????? ? ????? ??????????? ??????? ??????? ????????, ??? ?? ????????? ?????????? ?????????. ??? ???????? ???????,
????????????? ?????????? ???????? ? ?????
??? ????? ????? ?? ?????? ?????????? ????????? (?? 0 ?? 20 ???) ? ??????? ???????????
?????????????? ? 3,5 ? 4,5 ????, ? ?? ??????
?????????? ????????? ??? ?? ????????????????? (?? 20 ?? 40 ???) ? ?????????????? ?
1,25 ? 1,4 ????. ??? ???????? ??????? ?? ???????? ???????? ????????????? ??????????????
?? ?????????? ?????????? ?? 0 ?? 20 ??? ? ??
20 ?? 180 ???, ?? ??? ?? ?????? ? ?????? ?????????? ????? ??????????? ??????????
???????? ??? ???? ?????????? ? ?????, ?????? ?????????????? 0,47 ?? ?????? ?????????
? 0,13 ?? ?????? ?????????. ??????? ?? ???????? ?? ????????? ?????????? ???????? ????????????? ?????????????? ??? ????? ????????? ? ??????? ????? ??????? ????????,
?????? ?????????????? 0,45 ?? ?????? ????????? ? 0,10 ?? ?????? ?????????. ?? ????? ???????, ??? ?? ????????? ?? 0 ?? ???????? ??????????, ?????? ?????????????? 20 ???, ??????? ????????????? ? ??????? ? 3,5 ????, ? ????
? 4,5 ???? ???????????, ??? ? ????? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????????? ??????
17
0,08
0,07
0,06
0,05
0,04
0,03
0
30
60
90
120
150
180
???????, ???
???. 6. ??????????? ?? ???????? ????????? ?????????? ????????? ???????? ????????? ? ?????. ??????????????, ????????? ???????? ????????? ? 95% ?????? ? ??????? ??????? ????????????? ?????????? ?????????? ??????????????
?????????:
,
,
??? ????????? ???????; ,
,
??? ??????????? ???????;
,
,
??? ???????????????? ??????? ? ,
,
??? ??????????? ???????
0,08
0,07
0,05
0,04
0,03
0
30
60
90
120
150
180
???????, ???
???. 7. ??????????? ?? ???????? ????????? ?????????? ????????? ???????? ??????? ? ?????. ??????????????, ????????? ???????? ????????? ? 95% ?????? ? ??????? ??????? ????????????? ?????????? ?????????? ?????????????? ?????????:
,
,
??? ????????? ???????; ,
,
??? ??????????? ???????;
,
,
??? ???????????????? ??????? ? ,
,
??? ??????????? ???????
????????. ????? ??????? ???????????? ????????? ? ????????? ???????? ???????? ? ?????,
????????, ???????? ?????????? ???????????? ??????????? ????? ?????????.
?? ?????? ?????????? ??????????? ????????????? ??? ???????? ????? ?????? ????????? ????????? ?????????? ???????? ?
????? ? ??????????? ?? ????????. ?? ???????? 6
? 7 ???????????? ??????????? ???? ????????? ?? ????????, ?? ?????????????? ? ????????? ????????, ? ????? ??????? 95% ????????????? ?????????? ?????????????? ???
????????? ? ???????. ???????? ???????????
?? ???????? ????????, ????????? ????????? ?????????? ???????? ? ????? ??? ????
????????, ??? ??? ?????????, ??? ? ??? ????-
??????????? ?????????? ??????????????, ? 4, 2013
0,06
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
18
?????????? ??????
??????? ? ?? ??????????? ?????????? ??? ?????????? ???????? ???????? ????????
??????
tmax
StDev(tmax)
P/L(tmax) StDev(P/L(tmax))
tpr
StDev(tpr)
P/L(tpr)
StDev(P/L(tpr))
111,70
83,20
80,73
122,53
3,36
3,90
3,63
5,43
0,036
0,040
0,067
0,052
0,00031
0,00047
0,00047
0,00041
93,24
65,77
71,86
117,31
3,31
5,81
4,74
5,67
0,037
0,040
0,068
0,054
0,00035
0,00057
0,00081
0,00042
??????? ???
??????????
????????
???????????????
??????????
7,00
5,39
4,40
4,16
0,85
0,99
0,86
1,07
??????????
????????
???????????????
??????????
7,25
4,35
5,48
6,15
0,93
1,56
1,33
1,34
0,0450
0,00044
0,0473
0,00067
0,0776
0,00062
0,0648
0,00052
??????? ???
0,0445
0,00051
0,0459
0,00065
0,0767
0,00089
0,0638
0,00058
??????????? ?????????? ??????????????, ? 4, 2013
? ? ? ? ? ? ? ? ? ?. StDev(tmax) ? StDev(tpr) ? ?????????????? ??????????? ?????????? ????????? tmax ? tpr; P/L(tmax), P/L(tpr),
StDev(P/L(tmax)) ? StDev(P/L(tpr)) ? ?????????????? ???????? ????????? ????????? ??????? ? ????? ? ?? ??????????? ?????????? ? ????????? tmax ? tpr.
???, ????? ???? ? ??? ?? ????????. ???? ?????????????? ??? ??????? ? ???????? ???????? ? ?????. ? ?????? ??????? (?? 0 ?? tmax) ????????? ???????? ????????????? ???????,
??? ????, ? ????????? ????????? ? ????? ????????? ????????????? ???????? ? ????????
tmax. ?? ?????? ??????? (?? tmax ?? tpr (tmax<tpr)),
????????, ???? ????????????? ???????, ???
????????? ????????. ? ??????? ??????? (???
t>tpr) ?????????? ?????????? ? ????? ?????
??????????? ???????????????? ????????.
??? ???? ???????? ???? ????????? ?????? ????????? tmax ? tpr, ???????? ?????????
?????????? ? ????? ? ???? ?????????, ? ?????
??????????????? ??????????? ??????????.
???????? ???????? tpr ?????????? ?? ???????,
??? ??????? ???????? ????? ????????? ????????? ????????? ? ????? ? ???????? tpr ? ???
?????????? ?????????, ??????????? ?? ??????, ?? ??????????? ???????? ????? ?????????? 0,05 ?? ??????????? ????????. ?????????? ??????????????? ?????????? ?????????
? ???????.
?????? ??????????? ? ??????? ?????? ???????, ??? ???????????? ???????????????
???????? ????????? (????????? ?????????
??????? ? ?????) ??? ??? ??????????, ??? ?
??? ??????????????????? ???????? ??????????? ????????? ? ?? ??????? ?? ???? ???????. ????????????????? ??????? ??????? ????? ?? ??????? ?? ???? ??????? ? ??? ??????????? ??????? ??? ??????, ??? ??? ????
????????? ???????? ?????? (7,12 ??? ? ??????? ???????? ??? ????????? ? ??????? ???
??????????? ???????, ?? ????????? ? 4,87;
5,16 ? 4,94 ??? ? ??? ?????????, ???????????
? ???????????????? ????????).
?????? ?????? ???????? ???????? ??????????????? ???? ??? ?????? ???????????? ???-
????? ????????? ?? ????????? ? ????? ???????? ? ??????????????? ???????? ??????????
??????????? ?? ????????? ? ????????????
??????. ??? ? ? ?????? ???????, ??????????????? ???????? ?????????? ? ??????????,
? ??????????????????? ???????? ?? ???????
?? ???? (?????????? ?????? ? 0,036; 0,037;
???????? ?????? ? 0,040; 0,040; ??????????
?????? ? 0,052; 0,054; ?????????????? ?????? ?
0,067; 0,068 ??? ????????? ? ??????? ??????????????). ????????????????? ??????? ??????? ? ????????? ? ??????? ??? ????? ? ??? ??
???????? ?????????? ?? ??????????. ???????? ?? ???? ????????, ??? ?????????????????
???????? ???????? ????? ??????? ??????
?????? ?? ????????? ? ??????????????????
???????? ???????? ?????? ??????? ??????,
??? ? ?????????, ??? ? ? ??????? (111,70;
122,53 ?????? 83,20; 80,73 ? ????????? ?
93,24; 117,31 ?????? 65,77; 71,86 ? ???????).
?????? ?????? ???????? ???????? ??????????????? ???????????????? ?????? ???????? ???????????? ????????????? ?????. ???
???????? ?????? ??????? ?????? ?? ????????????? ? ??????? ? 6 ?????, ??? ??????????? ?
??????????? ? ? 8 ? 10 ????? ??????????????.
??????????
? ?????????????? ???? ???????????? ???????? ??????? ???????? ???????? ?????? ?
???????? ??????? ????????? ???????????
??????????????? ?????????????. ?????????
??? ????????????? ??????????????? ??????,
???? ?? ??????? ????????? ??? ???????? ????????? ????????? ????????? ???????? ?
????? ??? ??????? ????? ???????, ? ??????
??????, ?????????? ?? ?????? ????????????? ??????, ????????? ??? ???????? ???????? ????????? ????? ??????? ? ??????????? ??
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????????? ??????
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
West G.B., Brown J.H. The origin of allometric scaling laws in
biology from genoms to ecosystems: towards a quantitative
unifying theory of biological structure and organization.
Journal of Experimental Biology. 2005; 208: 1575?92.
Gaiton J. Hystory of the Concept of Allometry. Amer. Zool.
2000; 40: 748?58.
Huxley J.S. Constant differential growth-ratios and their significance. Nature. 1924; 11(4): 895?6.
Malcolm D.D., Burns T.L., Mahoney L.T., Lauer R.M. Factors
affecting left ventricular mass in childhood: the muscatine
study. Pediatrics. 1993; 92: 703?9.
Batterham A.M., George K.P., Mullineaux D.R. Allometric scaling of left ventricular mass by body dimensions in males and
females. Med. Sci. Sports Exerc. 1997; 29 (2): 181?6.
Batterham A.M., George K.P. Modeling the influence of body
size and composition on M-mode echocardiographic dimensions. Am. J. Physiol. Heart Circ. Physiol. 1998; 274:
H701?H708.
George K., Sharma S., Batterham A., Whyte G., McKenna W.
Allometric analysis of the association between cardiac dimensions and body size variables in 464 junior athletes. Clinical
Science. 2001; 100: 47?54.
De Simone G., Devereux R.B., Daniels S.R., Koren M.J.,
Meyer R.A., Laragh J.H. Effect of growth on variability of left
ventricular mass: assessment of allometric signals in adults and
children and their capacity to predict cardiovascular risk.
JACC. 1995; 25 (5): 1056?62.
Sluysmans Th., Colan S.D. Theoretical and empirical derivation of cardiovascular allometric relationships in children. J.
Appl. Physiol. 2005; 99: 445?57.
Devereux R.B., Lutas E.M., Casale P.N., Kligfield P., Eisenberg R.R., Hammond I.W. et al. Standardization of M-mode
echocardiographic left ventricular anatomic measurements.
JACC. 1984; 4 (6): 1222?30.
Ichida F., Aubert A., Denef B., Dumoulin M., Van der Hauwaert L.G. Cross sectional echocardiographic assessment of
great artery diameters in infants and children. Br. Heart J.
1987; 58: 627?34.
Lappen Rh.S., Riggs Th.W., Lapin G.D., Paul M.H., Muster A.J.
Two-dimensional echocardiographic measurement of right
pulmonary artery diameneter in infants and children. JACC.
1983; 2 (1): 121?6.
Batterham A.M., George K.P., Whyte G., Sharma S., McKenna W.
Scaling cardiac structural data by body dimensions: a review of
theory, practice, and problems. Int. J. Sports Med. 1999; 20 (8):
495?502.
Liao Y., Cooper R.S., Durazo-Arvizu R., Mensah G.A., Ghali J.K.
Prediction of mortality risk by different methods of indexation
for left ventricular mass. JACC. 1997; 29 (3): 641?7.
Gutgesell H.P., Paquet M., Duff D.F., McNamara D.G.
Evaluation of left ventricular size and function by echocardiography. Results in normal children. Circulation. 1977; 56 (3):
457?62.
Nielan T.G., Pradhan A.D., King M.E., Weyman A.E.
Derivation of a size-independent variable for scaling of cardiac
dimensions in a normal paediatric population. Eur. J.
Echocardiography. 2009; 10: 50?5.
Daniels S.R., Kimball Th.R., Morrison J.A., Khoury Ph., Meyer R.A.
Indexing left ventricular mass to account for differences in
body size in children and adolescents without cardiovascular
disease. Am. J. Cardiol. 1995; 76: 699?701.
Nidorf S.M., Picard M.H., Triulzi M.O., Thomas J.D., Newell J.,
King M.E., Weyman A.E. New perspectives in the assessment of
cardiac chamber dimensions during development and adulhood. JACC. 1992; 19 (5): 983?8.
Gutgesell H.P., Rembold Ch.M. Growth of the human heart relative to body surface area. Am. J. Cardiol. 1990; 65: 662?8.
Lauer M.S., Anderson K.M., Larson M.G., Levy D. A new
method for indexing left ventricular mass for differences in
body size. Am. J. Cardiol. 1994; 74: 487?49.
Schulz D.M., Giordano D.A. Hearts in infants and children.
Arch. Pathol. 1962; 74: 464?71.
???????? ?.?. ?????? ????????????. ?.: ???????????????
???????????? ??????-?????????????? ??????????; 1962.
???????? ?.?., ?????? ?.?. ?????????????? ??????. ?.:
??????; 1998.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
West G.B., Brown J.H. The origin of allometric scaling laws in
biology from genoms to ecosystems: towards a quantitative
unifying theory of biological structure and organization.
Journal of Experimental Biology. 2005; 208: 1575?92.
Gaiton J. Hystory of the Concept of Allometry. Amer. Zool.
2000; 40: 748?58.
Huxley J.S. Constant differential growth-ratios and their significance. Nature. 1924; 11(4): 895?6.
Malcolm D.D., Burns T.L., Mahoney L.T., Lauer R.M. Factors
affecting left ventricular mass in childhood: the muscatine
study. Pediatrics. 1993; 92: 703?9.
Batterham A.M., George K.P., Mullineaux D.R. Allometric scaling of left ventricular mass by body dimensions in males and
females. Med. Sci. Sports Exerc. 1997; 29 (2): 181?6.
Batterham A.M., George K.P. Modeling the influence of body size
and composition on M-mode echocardiographic dimensions.
Am. J. Physiol. Heart Circ. Physiol. 1998; 274: H701?H708.
George K., Sharma S., Batterham A., Whyte G., McKenna W.
Allometric analysis of the association between cardiac dimensions and body size variables in 464 junior athletes. Clinical
Science. 2001; 100:47?54.
De Simone G., Devereux R.B., Daniels S.R., Koren M.J.,
Meyer R.A., Laragh J.H. Effect of growth on variability of left
ventricular mass: assessment of allometric signals in adults and
children and their capacity to predict cardiovascular risk.
JACC. 1995; 25 (5): 1056?62.
Sluysmans Th., Colan S.D. Theoretical and empirical derivation of cardiovascular allometric relationships in children. J.
Appl. Physiol. 2005; 99: 445?57.
Devereux R.B., Lutas E.M., Casale P.N., Kligfield P., Eisenberg R.R.,
Hammond I.W. et al. Standardization of M-mode echocardiographic left ventricular anatomic measurements. JACC. 1984; 4
(6): 1222?30.
Ichida F., Aubert A., Denef B., Dumoulin M., Van der Hauwaert L.G.
Cross sectional echocardiographic assessment of great artery
??????????? ?????????? ??????????????, ? 4, 2013
????????. ?? ???? ???? ??????? ??????? ?????????? ?????? ??? ???????? ???????? ????? ?????????? ????????. ??????????? ?????? ????? ??????? ??????? ????????????.
???? ???????? ?????????? ???????? ? ????????? ????? ???????? ?????? (?? ???????? ??
??????????) ???????????? ????????????? ????? ????? (?? ???????? ?? ?????): ?????????, ???
? ???? ???????? ????? ???????? ??? ???????:
???????????? ???????? ????????, ???????????? ????????????? ????? ? ????????????????? ???????? ???????? ? ????. ?????????, ???
? ?????? ??????? ??????? ????? ??????????????? ???? ??????????? ??????? ?? ????????? ? ?????????? ????????? ??????, ??? ??????????? ??? ? ?????????, ??? ? ? ???????; ??
???? ???????? ????? ?????????? ?? ??????????.
?????? ?????? ???????? ??????????????? ?????
??????????????? ????????? ???????? ?????
??????? ?????? ? ??????????? ? ???????????,
??? ? ?????????, ??? ? ? ???????, ?? ????????? ? ????????? ?????? ???????, ??? ?????
??????????????? ?????, ????????? ? ?????????????? ??????????? ????? ??????? ?????? ? ???????? ?????? ?????????.
19
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
20
12.
13.
14.
15.
16.
??????????? ?????????? ???????????? ??????????????
diameters in infants and children. Br. Heart J. 1987; 58:
627?34.
Lappen Rh.S., Riggs Th.W., Lapin G.D., Paul M.H., Muster A.J.
Two-dimensional echocardiographic measurement of right
pulmonary artery diameneter in infants and children. JACC.
1983; 2 (1): 121?6.
Batterham A.M., George K.P., Whyte G., Sharma S., McKenna W.
Scaling cardiac structural data by body dimensions: a review of
theory, practice, and problems. Int. J. Sports Med. 1999; 20 (8):
495?502.
Liao Y., Cooper R.S., Durazo-Arvizu R., Mensah G.A., Ghali J.K.
Prediction of mortality risk by different methods of indexation
for left ventricular mass. JACC. 1997; 29 (3): 641?7.
Gutgesell H.P., Paquet M., Duff D.F., McNamara D.G. Evaluation
of left ventricular size and function by echocardiography. Results
in normal children. Circulation. 1977; 56 (3): 457?62.
Nielan T.G., Pradhan A.D., King M.E., Weyman A.E.
Derivation of a size-independent variable for scaling of cardiac
dimensions in a normal paediatric population. Eur. J.
Echocardiography. 2009; 10: 50?5.
17.
18.
19.
20.
21.
22.
23.
Daniels S.R., Kimball Th.R., Morrison J.A., Khoury Ph., Meyer R.A.
Indexing left ventricular mass to account for differences in
body size in children and adolescents without cardiovascular
disease. Am. J. Cardiol. 1995; 76: 699?701.
Nidorf S.M., Picard M.H., Triulzi M.O., Thomas J.D., Newell J.,
King M.E., Weyman A.E. New perspectives in the assessment of
cardiac chamber dimensions during development and adulhood. JACC. 1992; 19 (5): 983?8.
Gutgesell H.P., Rembold Ch.M. Growth of the human heart relative to body surface area. Am. J. Cardiol. 1990; 65: 662?8.
Lauer M.S., Anderson K.M., Larson M.G., Levy D. A new
method for indexing left ventricular mass for differences in
body size. Am. J. Cardiol. 1994; 74: 487?49.
Schulz D.M., Giordano D.A. Hearts in infants and children.
Arch. Pathol. 1962; 74: 464?71.
Venttsel? E.S. Probability theory. Moscow: Gosudarstvennoe
izdatel'stvo fiziko-matematicheskoy literatury; 1962 (in
Russian).
Glinskiy V.V., Igonin V.G. Statistical analysis. Moscow: Filin;
1998 (in Russian).
????????? 21.11.2013
??????????? ?????????? ??????????????, ? 4, 2013
??????????? ?????????? ????????????
??????????????
╘ ????????? ???????, 2013
??? 612.115.35:616.13
? ??????? ???????? ?????????????? ????????
? ???????????????????? ???????????? ???????
?.?. ??????1, ?.?. ??????2, ?.?. ?????????1, ?.?. ???????3, ?.?. ????????1
1????
╚??????????????? ???????????????? ?????????╩,
??. ??. ????????, 96, ???, 450106, ??????;
2??????? ???????????? ???????? ???? ??? ╚?????????? ??????????????? ??????????? ???????????╩,
??. ??????, 3, ???, 450000, ??????;
3????? ╚???????? ???????????? ?????╩ ????????? ???????? ?????? ???,
??. ???????, 71, ???, 450054, ??????
?????? ???? ?????????, ???????? ???. ????, ????????-?????????? ??????; e-mail: vyunusov@yandex.ru;
?????? ???????? ????????????, ?????? ???. ????, ?????????, ?????????? ???????? ????????????
????????;
????????? ?????? ??????????, ?????? ???. ????, ?????????? ?????????? ?????????? ????????;
??????? ?????? ?????????????, ???????? ???. ????, ??. ????. ????.;
???????? ??????? ??????????, ????-??????
???? ???????????? ? ???????? ???????????? ???????????????? ?????????? ???????? ????? ????????? ??????????????? ?? ???????? ???????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
21
???????? ? ??????. ???????????-?????????????? ??????? ????????? ???????? ??????? ????????
?????? ?????. ???????????????? ?????????? ???????? ??????????? ?? ???????????? ╚Act plus╩
(Medtronic, ???).
??????????. ?????? ????? ??????? ????????????? ?????????? ????????? ? ?????????? ?????????
???????????? ??? ?????????? ? ??????????????. ?????????? ?????????????? ??????? ???????? ?????? ????? ? ?????????? ? ??? ????????? ? ????????? ????????. ??????? ???????????????? ????????
????????? ???????-????????????? ????????????. ???????? ??????? ???????????????? ?????????? ???????? ? ????????? ????????? ? ??????????????.
??????????. ???????????????? ???????? ??????????? ???????????????? ???????? ???????? ?????
??????????????? ?? ???????? ???????. ??? ???? ???????????????? ?????????? ????????? ?? ?????????.
???????? ?????: ???????; ?????????; ?????????????; ???????; ???????????????; ???????????????? ????????.
STUDIES ON THE INTERACTION OF HEPARIN WITH DE-ENDOTHELIALIZED ARTERIAL SURFACE
V.M. Yunusov1, V.V. Plechev2, R.I. Izhbul'din1, S.S. Ostakhov3, A.N. Kislitsyn1
1Republican Cardiologic Dispensary, ul. St. Kuvykina, 96, Ufa, 450106, Russia;
2Chair of Hospital Surgery of Bashkirsky State Medical University, ul. Lenina, 3, Ufa, 450000, Russia;
3Institute of Organic Chemistry of the Ufa Scientific Center of the Russian Academy of Sciences, pr. Oktyabrya, 71, Ufa,
450054, Russia
Yunusov Vali Maratovich, MD, PhD, Cardiovascular Surgeon;
Plechev Vladimir Vyacheslavovich, MD, DM, Professor, Head of Chair of Hospital Surgery;
Izhbul'din Ramil' Il'dusovich, MD, DM, Chief of Department of Cardiovascular Surgery;
Ostakhov Sergey Stanislavovich, PhD in Chem. Sci., Senior Research Associate;
Kislitsyn Aleksey Nikolaevich, Surgeon
Objective of the research ? is to study the possibilities of intracoronary heparin delivery after coronary artery endarterectomy procedure.
Material and methods. The processes of adsorption of heparin by the tissue of aorta were studied using the spectral
luminescence method. The anticoagulant activity of heparin was estimated on coagulometer ╚Act plus╩ (Medtronic, USA).
Results. The method of quenching of tryptophan fluorescence by heparin was studied and the stability constant of its
complexes with amino acids was determined. Consistent patterns of adsorption of heparin by the tissue of aorta with and
without endothelium under multiple conditions were detected. Anticoagulant properties of the complex heparin ? aromatic
amino acids were examined. It was proved that heparin has high anticoagulant activity in the state bound to amino acids.
Conclusion. The possibility of intracoronary heparin delivery after coronary artery endarterectomy was proved experimentally whereas anticoagulant activity of this therapeutic agent is not reduced.
????????
?????? ???????????? ?????????????? ?????????? ? ?????????? ???????? ??-????????
???????? ??????????. ????????? ??????????????? ?? ???????? ??????? ??? ?? ????????? ????????????-???????????? ?????????
????????? ? ??????? ?????? ???????? ????
????????????? ? ?????? ?????????????????
???????, ??? ?????????????? ??????? ??????
???????? ???????? ? ?????????? ??????. ????????? ? ????????? ??????????????? ? ????????? ????? ?????????????, ??? ??????????????
???????? ?? ?????????? ?? ?????? ?????????? (3,7?42,0%). ?????????? ???????? ???????
???????????? ?????????????? ??????????
????? ???? ????????? ????????? ?? ???????? ?????????? ??????? ?????? ?????????
???????. ? ????????? ?????????? ???????
???????? ?????? ? ????????? ??????????
??????????????? ??????? ???????? (??????????????????? ??????? ? ????????????????? ????????) ? ?????? ?????????????????
??????? ????? ?????????? ??????????? ??
???????? ???????? ???????????.
??????? ? ????????? ?????????????????, ?????????? ??????????????? ???????
????????. ?? ?????? ??????????? ? ??????????? ???????? ??? ???????????? ? ??????? ?????????????????? ???????????, ???
????????? ?? ?????? ? ??????????? ???????,
??? ??????????? ??????? ????????? ?????
? ????????? ?????????????? ??????????????, ? ????? ??? ?????????????? ??????????? ????? ??? ???????????? ?????????????
[1?3].
? ????????? ?????? ??????????? ????????????????? ??????????? ????????????????
?????????? ???????? ????? ????????? ??????????????? ?? ???????? ???????. ? ????
????? ???????? ????? ??????? ???????????
????????????? (??) ????? ??? ???????????? ????????? ??????? ???????? ?????? ?????, ????? ??????? ???????????????? ???????? ???????? ? ?????????? ? ??????????????
??????????? ?????????? ??????????????, ? 4, 2013
Key words: heparin; tryptophan; fluorescence; adsorption; endarterectomy; anticoagulant properties.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
22
??????????? ?????????? ???????????? ??????????????
?
?
500
35 000
30 000
400
25 000
1
300
20 000
15 000
200
2
10 000
100
5000
0
0
220
240
260
280
300
320
?, ??
???. 1. ?????? ?????????? ?????????? (1) ? ???????? (2) (0,9% ??????? NaCl, 300 ?)
?????????????? ? ???????????, ?????????
? ?????????????.
??????????? ?????????? ??????????????, ? 4, 2013
???????? ? ??????
? ???????? ?????? ???????????? ????? ???????? ????? (??? ? ??????????, ??? ? ??? ????), ????????? ? ????????? ????? ?? ??????????????. ??????? ?????????? ?????????????? ?? ???????????????? ╚Specord M-40╩,
????????????????? ??????? ?? ? ?? ?????????????????? ╚??-2203╩. ????????????? ???????? ????? ????? ?????????????? ??? ????? 45╟, ???????????? ?????????
????????? ? ????????? ?? ??????????
(340 ??), ????????????? ????????? ???????????? ? ??????? ????????? ???????.
????????? (99,5%) ????? Aldrich, ???????
?????? (??????: ???????? ????????: ??????? ?
50 ??/??; ??????????????? ????????: ?????
??????????, ?????? ??????, ???? ??? ???????? ? ?? 1 ?? (??? ╚??????╩, ??????)) ???????????? ??? ??????????????? ???????.
???????? ???????????????? ??????????
????????????????? ???????? ????????? ??
?????????????? ???????????? ╚Act plus╩
(Medtronic, ???) ????? ??????????? ??????????????? ??????? ??????????? (???).
???????????? ????????? ?? ?????????? HRACT ? ?????????: 12% ??????, 0,005 ? CaCl2,
Hepes-?????, Sodium azide. ?????? ???????????? ????????? ??????? ??????????????????? ??????????. ? ????????? ?????????????
??????????? (10?5 ?) ????????? ??????? ??
??????? ???????????? ?????????????????
???????????. ?????????? ?? ????????, ??? ???
???????????? ??????? ? ????????????????? ???????? ? ?????????. ????? ???????,
???? ???????????? ?? 5 ?? ?????? ????????????? ?????????? ???????? ? ?????????????
??? ? ??????????????? ????????, ??????
50 ??/??, ??? ????????? ????????????? ???????????? ????????????? ????????. ????
????? ?????? ??????????? ? ????? ? ??? ??
???????? ?????.
? ????? ??????????? ??????????? ?????????? ?????? ??????????? ?????????????
????? ? ???????????? ??????? ???????? ?????????? ?????? ???? ??????? ??????? ?????????????? ???????? ?? ?? ??????????. ??????????????? ?????????? ????????? ?? ?????
????? ????? (?????) 290 ??, ??? ??????? ??????? ????????? ????????? (???. 1). ?????????? ???????? ???????? ? ??????? ?? ?????????? (??. ??????? 1, ?????? 1), ??? ????????? ???????????? ????? ???????????
????????????? ????? ? ???????????? ????????? ??????? ?????????????? ??????????
??????.
????????? ????????????????? ????????? ?? ???????? ????? ????? ? ?????????? ?
??? ?????????, ??? ? ??????????? ????????,
??? ? ??? ??????????? ?????????????,
??????????? ?????????? ?????. ???????
???????? ? ??????? ????????? ???????? ?
????????? ?????? ? ????????? ???????????
?? ????? ????? ??? ????? 45╟. ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
I, ???. ??.
0
I0/I-1
[Hep]в10-2 M
2
4
6
23
8
10
6
5
2
1,5
4
1,0
3
2
0,5
1
1
0,0
0
350
400
450
?, ??
????????????? ?? ????? ????? ?? ????????,
????????????? ???????? ????????, ?????????? ? ????????? ????????? ?? ??????????
(????) ??? 340 ??.
????????????????? ???????? ???????????????? ??????? ?????????? ???????? ? ???????????????? ?????????????? ??????????? ? ???????????? ????????. ????????
???????? ???????? ???????? (????????????????????) ????? ?????????, ? ??????? ????????? ??????????? ??????? ????????.
??????????
????? ??????? ?? ??????????, ??????????? ?? ???????????? ????????? ??????????
??????????????????? ???????? ?????????,
??????????? ? ?????????? ?????????? ? Eu
(III) [4?6] ? ??????-????? [5], ??? ?????????
??????? ?? ????????? ????????????. ??????? ?? ?????????? ????????? ???????????
?????????? ??????????????? [7]:
I0/I ? 1 = ? [???????],
??? ? ? ????????? ??????? ???????????????, I0, I ? ????????????? ?? ?????????? ?
?????????? ? ??? ??????? ????????-????????
??????????????, [???????] ? ????????????
????????, ???????????? ??? ?????????????
????? ????????. ????????? ?????????????-
??, ???????????? ?? ??????????? ????????????? ?? ?????????? ?? ???????????? ???????? (???. 2, ??????????? 2), ????? K = 19╠2 ?-1
? ??? ??????????? ????????? ??????? ???????? ???????????? ????????? ?????????-??????? [8].
?? ??????? 3 ????????? ???????????? ??????????? ????????????? ?? ???????, ?????????? ??????? ??????? ???????? ??????
????? ? ?????????? ??? ??????????? ????????????? (??????????? 1) ? ? ???????????
???????? (??????????? 2). ? ??????????? ???????? ??????? ???????? ?????? ??????? ????????? ????? ??????????, ??????? ? ???????? ??? ??????????? ?? ?????????????? ??
90%, ????? ??? ??? ????????????? ?? ??? ??
?????????? ??????? ??????????? 60% ??????? ????????????? ?????????????. ????????, ??? ???????? ??????????? ???, ??? ???
????????????? ????????????? ?? ??????????? ?????? ??????? ?????????? ? ???????.
???????????? ??????? ???????????? ??????? ????????? ??????? ?? ??????? ?? ????????? ????????. ?? ??????? 4 ????????? ??????????? ????????????? ?? ????? ????? ?
?????????? (??????????? 1) ? ??? ???? (??????????? 2) ?? ??????? ? ???????? ???????? ???
?????????????. ??? ? ????????? ???????, ??
????????? ????? (~40 ???) ????? ??????????
???? ??????? ???????? ?????? ??????? ???
????????? ? ????? ? ??????????? ???????????
??????????? ?????????? ??????????????, ? 4, 2013
???. 2. ??????? ????????? ????????????? ?????????? ? ??????????? ?? ???????????? ???????? (???????? ?????? ????
???????????? ????????) (1). ??????????? ????????????? ?? ?????????? ?? ???????????? ???????? ? ???????????
????????? ??????????????? (2). ????????? = 10?5 ?, ????? = 290 ??, 0,9% ??????? NaCl, 300 K
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
24
??????????? ?????????? ???????????? ??????????????
I, ???. ??.
1,0
1
0,8
0,6
2
0,4
0,2
0,0
0
50
100
150
200
t, ???
???. 3. ????????????? ????????????? ????? ????? ? ???????? ???????? ? ??????????? ?? ???????: 1 ? ? ??????????????; 2 ? ??? ????????????? (????? = 225 ??, ???? = 340 ??, 300 ?)
I, ???. ??.
1,2
1,0
1
0,8
2
??????????? ?????????? ??????????????, ? 4, 2013
0,6
0,4
0,2
0,0
0
10
20
30
40
50
60
t, ???
???. 4. ??????????? ????????????? ????????????? ????????? ???????? ????? ????? ?? ??????? ? ???????? ????????:
1 ? ? ??????????; 2 ? ??? ????????? (????? = 225 ??, ???? = 340 ??, ??? ?????????????, 300 ?)
???????? ???????? ? ???????. ??? ????? ?????????? ???????? ??? ???????? ??????? ???????? ???????, ?????????? ?? ??????? ?????????, ?????????? ??????????? ??????????.
?? ??????? 5 ????????? ??????? ?? ????? ????? ? ??????????????? ???????? ? ???????? ???????? ? ????????? ??????? ???????. ?? ????????? ???????? 1 ? 2 ???????, ???
??????? ??????? ?? ???????????????? ???????? (?????? 1) ? ??????? ???????? ???????? ?
??????? ??????? ?? ????? ????? (?????? 2),
??? ???????? ??????? ??????? ?????????
????????? ?? ??????????? ????? ?????.
??? ???????????????? ????? ?? ???????
???????? ???????????????? ??????? ??????????? ???????? ?? ????????? ?????:
1) ???????? ??? ??????????? ????????
?????;
2) ???????? ??? ????? ? ??????????? ????????? ???? ????????????? ????????;
3) ???????? ??? ????? ? ??????????? ????????? ???? ?????????? ???????-????????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
25
I, ???. ??.
0,6
0,5
0,4
1
0,3
0,2
3
0,1
2
4
0,0
300
350
400
?, ??
450
500
???????? ??? (150?170 ?) ? ???????? ???????? ????? ??????????????? ? ?????? ??????????????, ????????? ? ??????? ?????????? ????????????? (??. ???????). ?????????? ?
????? ????????? ???? ???????????? ????????
??????? ? ???????? ?????????? ?????????????? (800?999 ?). ???????? ??? ? ????????
?????, ???? ??????????? ????????? ??????????????????? ?? ?????? 700?900 ?, ?????
???????????? ?? ??????? ????????????????
??????????.
??????????
??????? ???????? ???????????? ?????????? ?????????? ? ????????????? ?????? ?
???????????? ????? ??????? ????????? ?????????, ???????? ? ??????????? ?????????? ?? ??????? ????????? ????????????
????????????? ??????? [2, 9]. ??? ????????
?????????????? ????????? ? ??????? ??????? ???????????? ????????? ?????? ????-
??? ?? ??????????? ????????????? [10?13].
?????????????? ?? ???????????????? ??
?????? ???????? ???????? ? ?? ?????? ????????????? ???????????? ? ?????????, ??????? ? ??????????? [8, 14]. ?????? ?? ??????????????, ??? ????????? ????? ????????????? ?????????? ??????? ????, ??? ?
???????? ? ????????????, ?????? ????????
? ???????????? ?????? ????????? ?????????? (???. 6, ?????? 1) ? ????????? ???????
?? ?????? [6, 13]. ?????????????, ??? ?????
?????? ?? ??????? 6, ?????? ?? ????? ?????
(?????? 2) ????????????????? ??????????? ??
???????? ????????????? ??????????.
????????????, ??? ????????? ????? ??
?????????? ??????? ?? ??????? ?????????
????????? [10, 12, 13], ? ???????????-?????????????? ???????????? ????? ??????? ??????? ??? ?????????? ??????? ???????? ??
??????????????? ???????? ??????? ????? ?
?????????? ??????????? [8, 15?18]. ?????
???????? ??????????????? ??????? ??????????? (?) ? ??????????? ???????? ????????
??????????
???????? ????? (????????)
????? 1 (n=2)
????? 2 (n=2)
????? 3 (n=2)
150
173
159
????? ?? ???????????
????????? (????????)
927
999
816
?????+???????-?????????
953
963
999
?????+???????-???????????
734
809
833
?????+???????-???????
824
769
816
??????????? ?????????? ??????????????, ? 4, 2013
???. 5. ??????? ????????????? ??????? ??????? ? ??????????????? ???????? ?? ??????? (1), ??????? ??????? ?
???????? ???????? ? ????? ??????? (2), ??????? ??????? ? ??????????????? ???????? ? ?????? ????????? (3), ???????
??????? ? 0,9% ???????? NaCl ? ????? ????????? (4) (?ex = 228 ??)
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
26
??????????? ?????????? ???????????? ??????????????
I, ???. ??.
2,0
1,5
1
1,0
2
0,5
0,0
300
350
400
450
500
?, ??
??????????? ?????????? ??????????????, ? 4, 2013
???. 6. ??????? ????????????? ?????????? (1) ? ????? ????? (2) (????? = 225 ??, 0,9% ??????? NaCl, 300 ?)
????????????, ??? ??????? ?? ???????????
???????-???? ?????????? ????????? ?????????????? ?? ?????? ?? ?????????????, ?? ?
?? ???????????? ????????? ? ?????????? ??????????? ?????????????????? ?????????
?????????-???????. ???????????? ?????????????? ????? ???????? ??????? ???????? ?
????????????? ????? ??????? ?? ??? ?????,
??? ???????? ????????, ???????????????
???????????? ????????? ??????????, ?? ???? ???????? ?? ?????????? ????? ????? ?????
????????? ? ?????????? ????????????? ??
??????????? ?????????????. ???????????
???????????????? ?????? ????????? ????????? ???????????? ??????????? ???? ?????????.
?????????? ?????????? ?????????? ??????????????? ? ??????? ??????? ????????
?????? ???????????? ??????. ???????? ?? ??
??? ??????, ?????????? ?? ????????? ???????? ?????, ?????????????, ??? ?? ????? ???????? ????????? ??????? ???????? ??????
?????, ? ?????? ??????????????? ????????, ??????????? ? ????????????? ???????????????
?????? ??????????? ?????????????????
????? ??? ???????? ?????????????? ? ?????????? ?? ??????? ??????? ?????-????????????.
?????????????? ???????? ? ?????????????? ?????? ???????????????????? ??????????? ???????????? ?????? ??????? ????????????? ???????? ??? ????????????? ??????????. ? ???? ????? ?? ???????? ?????????
???????? ? ????? ?????????????? ?????????????? ?????????????? (??? ??????????
╚????????????????╩ ???????). ???????
????????????? ???????????????? ??????????
???? ?????????? ???????????? ??? ????, ???
???????, ?????????? ?? ???????????????????? ??????????? ???????????? ??????, ??
?????? ????? ???????????????? ?????????? ?
????? ????????? ?????????? ??????? ????????????? ??????.
??????????
????? ??????????? ?????????????????
????? ???????? ??? ???????? ??????????????
? ?????????? ?? ??????? ??????? ?????-????????????. ????? ?? ????????? ?????????? ??????????? ???????? ?? ??????????? ??????????
?????? ???????? ??? ???????-??????????? ?????????????? ? ?????????????? ?????? ???????????????????? ??????????? ???????. ???????
???????? ??????????? ? ????????? ??????????? ???????????????????? ???????????? ??????, ??? ???? ?? ????? ????? ????????????????
??????????, ? ??? ????? ???????????? ??????????? ??????? ???????????? ?????? ????????? ???? ???????????? ?????????????.
??????????
1.
2.
????????? ?.?., ????? A.M. ???????????????????? ???????? ? ????????????? ?????????. ????????. 1987; 36 (1):
80?5.
?????? ?.?., ?????????? ?.?., ????????? ?.?. ??????
????????????????? ?????????? ????????? ????????.
??????????????? ?????. 2011; 17: 745?79.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
??????? A.M., ?????? ?.?. ??????????? ?????? ? ???????? ? ??? ????????????? ?????????. ?????? ??????????? ????????. 1977; 83 (???. 1): 69?85.
??????? ?.?., ??????? ?.?., ????? ?.?. ? ??. ????????
?????????? UO22+ ? ???????????. I. ??????? ??????? ?
??????????? ?? ????????????????? ???????????? ???????????? ????????? UO22+ ? ??????????. ??????????.
2006; 48 (5): 399?402.
??????? ?.?., ??????? ?.?., ??????? ?.?., ????? ?.?. ??????? ????????????? ???? ??????? ???????????????????????? ? ?????????? ??? ????????????????????????
?????????. ????? ??????? ???????. 2006; 40 (1): 291?4.
?????? ?. ????????. ?????????? ??????? ? ????? ??????. ?. 1: ???. ? ????. ?.: ???; 1980.
??????? ?.?., ??????? ?.?., ????? ?.?. ??-?????????????????????? ??????????? ???????? ? ??????????? ?????? ? ????????????????. ??????-???????????????? ??????. 1982; 16 (3): 115?7.
Deyl Z., Macek K., Adam M. et al. Studies on the chemical
nature of elastin fluorescence. Biochimica et Biophysica Acta
(BBA) ? Protein Structure. 1980; 625: 248?54.
????? ?.?., ?????? ?. ????????????, ???????, ?????:
???. ? ???. ?.: ???; 1985.
???????? ?.?. ????????????? ? ???????? ?????????
??????. ????: ??????? ?????; 1988.
??????? ??. ?????? ?????????????? ?????????????:
???. ? ????. ?.: ???; 1986.
?????? ?. ????????????????? ?????????: ???. ? ????.
?.: ???; 1972.
???????? ?.?. ????? ??????????? ????????????? ?????.
?.: ?????; 2003.
????? ?., ?????? ?. ?????? ????????????? ?????: ???. ?
????. ?.: ???; 1970.
Aksamit R., Koshland D.E. Jr. Identification of the ribose binding protein as the receptor for ribose Chemotaxis in
Salmonella typhymurium. Biochemistry. 1974; 13: 4473?8.
Feng L., Jia X.B., Shi F., Chen Y. Identification of two polysaccharides from Prunella vulgaris L. and evaluation on their antilung adenocarcinoma activity. Molecules. 2010; 15: 5093?103.
McLean J. The thromboplastin action of cephalin. Am. J.
Physiol. 1916; 41: 250?7.
Zellweger M. Fluorescence spectroscopy of exogenous, exogenously-induced and endogenous fluorofores for the photodetection and photodynamic therapy of cancer. Thesis. ? D. Ph.
Lausanne: Swiss Federal Institute of Technology; 2000: 119.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
References
1.
Alekperov A.F., Aliev A.M. Complex formation of heparin with
organic cations. Farmatsiya. 1987; 36 (1): 80?5 (in Russian).
18.
27
Krylov V.B., Ustyuzhanina N.E., Nifant'ev N.E. The synthesis
of low- molecular-weight carbohydrate-based heparin mimetics. Bioorganicheskaya khimiya. 2011; 17: 745?79 (in
Russian).
Ul'yanov A.M., Lyapina L.A. Current evidence on heparin and
its biochemical properties. Uspekhi sovremennoy biologii. 1977;
83 (1): 69?85 (in Russian).
Kazakov V.P., Ostakhov S.S., Osina I.O. et al. Photonics of
UO22+ complexes with tryptophan. I. Influence of anions
and temperature on the inter-complex deactivation of excited
states of UO22+ and tryptophan. Radiokhimiya. 2006; 48 (5):
399?402 (in Russian).
Kazakov V.P., Ostakhov S.S., Alyab'ev A.S., Osina I.O.
Quenching of fluorescence of uranyl ion by adamantylideneadamantane and the products of its photosensitized oxidation. Khimiya vysokikh energiy. 2006; 40 (1): 291?4 (in
Russian).
Metsler D. Biochemistry. The chemical reactions of living cells.
Vol. 1: Translation from English. Moscow: Mir; 1980 (in
Russian).
Kobyakov V.V., Ovsepyan A.M., Panov V.P. UV-spectrophotometric methods of the determination of nipagin and benzyl
alcohol in organic compounds. Khimiko-farmatsevticheskiy
zhurnal. 1982; 16 (3): 115?7 (in Russian).
Deyl Z., Macek K., Adam M. et al. Studies on the chemical
nature of elastin fluorescence. Biochimica et Biophysica Acta
(BBA) ? Protein Structure. 1980; 625: 248?54.
Yakube Kh.D., Eshkayt Kh. Amino acids, peptides, proteins.
Translation from German. Moscow: Mir; 1985 (in Russian).
Demchenko A.P. Luminescence and the structural dynamics of
proteins. Kiev: Naukova dumka; 1988 (in Russian).
Lakovich J. The basic concepts of fluorescence spectroscopy.
Translation from English. Moscow: Mir; 1986 (in Russian).
Parker S. Photoluminescence of solutions. Translation from
English. Moscow: Mir; 1972 (in Russian).
Permyakov E.A. Method of intrinsic luminescence of proteins.
Moscow: Nauka; 2003 (in Russian).
Maler G., Kordes Yu. Basic concepts of biological chemistry.
Translation from English. Moscow: Mir; 1970 (in Russian).
Aksamit R., Koshland D.E., Jr. Identification of the ribose
binding protein as the receptor for ribose Chemotaxis in
Salmonella typhymurium. Biochemistry. 1974; 13: 4473?8.
Feng L., Jia X.B., Shi F., Chen Y. Identification of two polysaccharides from Prunella vulgaris L. and evaluation on their antilung adenocarcinoma activity. Molecules. 2010; 15: 5093?103.
McLean J. The thromboplastin action of cephalin. Am. J.
Physiol. 1916; 41: 250?7.
Zellweger M. Fluorescence spectroscopy of exogenous, exogenously-induced and endogenous fluorofores for the photodetection and photodynamic therapy of cancer. Thesis. ? D. Ph.
Lausanne: Swiss Federal Institute of Technology; 2000: 119.
????????? 04.07.2013
??????????? ?????????? ??????????????, ? 4, 2013
??????????? ?????????? ???????????? ??????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
28
??????????? ?????????? ???????????? ??????????????
╘ ?.?. ?????????, ?.?. ???????, 2013
??? 612.824:616.12-053.7-008.331.1
???????????? ???????????? ? ????????? ???????????? ?? ????????
? ?????? ? ???????????? ????????????
?.?. ?????????, ?.?. ???????
??????????? ?????????? ??????????????, ? 4, 2013
???? ??? ╚????????? ??????????????? ??????????? ???????????╩ ???????????? ???????????????
?????????? ?????????, ??. ??????, 40, ???????, 656038, ??????
????????? ????? ????????????, ?????????; e-mail: kdvl17@gmail.com;
??????? ???????? ????????, ?????? ???. ????, ?????????, ?????????? ???????? ??????????????,
?????????????? ? ?????????????? ???????????
???? ???????????? ? ?????????? ??????????? ??????? ????????? ????????? ? ????????? ???????????? ?? ???????? ? ?????? ? ???????????? ???????????? (??).
???????? ? ??????. ? 14 ????????? ? ?? ? 13 ???????? ?????? ???? ????????? ???????? ??????????????? ?????. ?????????? ???????? ????????? ? ??????? ???????? ???????? ? ????? ?????? ???????
???????????????? ??????????????, ????????????? ? ?????????????? ???????????? ???????? ? ????? ?
??????? ???????????? ????????????? ????????? ╚?? ?????????? ? ??????????╩. ????????????? ???????????????? ????????. ????????? ?????? ????????? (?????? 30 ? ?????????) ? ?????????? (? ??????? 10 ??? ?????????) ??????????????? ???????. ?????????? ????????? ??????????????? ??????????
??????? ???????? ??????????????? ????????????? ???????? ????? ??? ?? 20 ?? ??. ??. ?/??? ?????????????? ????????????? ???????? ????? ??? ?? 40 ?? ??. ??.
??????????. ??? ???????????? ????????? ??????????????? ??????? ???????? ???????? ???????? ??????????????? ????????????? ???????? ? ?????? ? ?? ?? ????????? ?? ????????? (?? 26 (22,3; 32,3) ?
19,1 (15,9; 25,3) ?? ??. ??. ??????????????, ?=0,0082). ????????? ??????????????? ?????????? ??? ??
??????????? ??????? ????, ??? ? ???????? (79 ? 31% ??????? ??????????????, ?=0,021). ???????? ????????? ???????? ????????? ????????? ? ????????? ? ?? ? ???????? ???? ??????????. ??? ???????????? ?????????? ??????????????? ??????? ? ?????? ? ?? ???????? ????? ?????????? ???????? ??????????????? ????????????? ???????? ? ???????? ????????? ????????? ?? ????????? ?? ?????????.
? ????? ??????? ??????????? ?????????? ??? ?????????.
??????????. ???????????? ??????? ????????? ???????????? ?? ???????? ???????????????
???????? ? ????????? ? ???????????? ???????????? ???????? ?????????????? ?????????? ? ?????
?????? ????????????? ????????? ??????????????? ??????????. ??? ?????????? ????????? ???????? ????????? ????????? ????????? ? ????? ???????, ????? ?? ?????? ????? ????? ???? ??????????. ? ????????? ? ?? ?????????? ??????????? ???????????? ????????????? ??? ???????????? ????????? ??????????????? ???????, ??? ?????????? ?? ????????? ?????????????
????????????? ?????????.
???????? ?????: ????????; ??????????????? ??????????; ???????????? ?????????????; ???????????? ???????????; ???????????????? ??????????????.
REACTIVITY OF CEREBRAL AND SYSTEMIC HEMODYNAMICS TO ORTHOSTASIS
IN YOUNG MEN WITH ARTERIAL HYPERTENSION
D.V. Kuznetsova, V.P. Kulikov
Altayskiy State Medical University of the Ministry of Health of the Russian Federation,
pr. Lenina, 40, Barnaul, 656038, Russia
Kuznetsova Dar'ya Vladimirovna, Assistant;
Kulikov Vladimir Pavlovich, MD, DM, Professor, Head of the Chair of Pathophysiology, Functional Diagnosis and Diagnostic
Ultrasonography
Objective of the study ? is to determine the characteristics of the response of cerebral blood flow and systemic hemodynamics to orthostasis in young men with arterial hypertension.
Material and methods. Active orthostatic test was performed in 14 patients with arterial hypertension and 13 healthy
young men. We used the method of transcranial Doppler ultrasound to measure blood flow velocity in middle cerebral
arteries on both sides, and systolic and diastolic blood pressure and pulse rate were measured using the method of continuous non-invasive ?beat-to-beat? blood pressure measurement. Capnographic monitoring was performed during the
experiment. The initial (for the first 30 seconds) and prolonged (for 10 min of orthostasis) orthostatic reactions were
assessed. The criteria for initial orthostatic hypotension were defined as a fall of at least 20 mmHg in diastolic blood pressure and/or 40 mmHg in systolic blood pressure.
Results. The study of initial orthostatic reactions has shown the considerable reduction of diastolic blood pressure in young
men with hypertension in comparison with healthy young men (fall of 26 (22.3; 32.3) and 19,1 (15.9; 25.3) mmHg respectively, ?=0,0082). Initial orthostatic hypotension in patients with arterial hypertension is observed significantly more often than
in healthy young men (in 79 and 31% of cases respectively, ?=0.021). The dynamics of cerebral blood flow changes was similar in patients with arterial hypertension and in healthy people. More prolonged reduction of diastolic blood pressure and
cerebral blood flow velocity in young men with arterial hypertension in comparison with healthy men was revealed in the study
of enduring orthostatic reactions. Hypocapnia throughout orthostasis was observed in both groups.
Conclusion. The reaction of systemic hemodynamics to active orthostatic load in patients with arterial hypertension is characterized by diastolic hypotension and increased incidence of initial orthostatic hypotension. During prolonged orthostasis
the cerebral blood flow velocity decreases in both groups, and we suppose that hypocapnia can be one of the causes of this
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
29
????????
???????????? ??????????? (??) ? ????????? ???????? ????? ?????????????? ??????????? ???????????? ??????? ??????? (???).
??? ???????????? ?????????????? ????????????? ???????????? ?????????? ????????? ???????????? ? ???????????? ?????????????? ??????? ????????????? ????????
(??) ???????? ????? ?????????? ????? ? ???????? ?????????? (???).
? ???? ????? ? ????????? ? ?? ? ???????,
??????? ? ??????? ???????? ???????? ????????? ???????????????? ??????? ?? ???????? ? ???? ??????????????? ???????????
?/??? ??????????, ??????? ????????? ? ?????????? ????????-?????????? ??????
[1?4].
??? ?????????? ?? ?????????? ????? ????????? ???????? ???????????? ????????????? ? ??????? ????? ??????? ???????? ? ??????????????? ?????????? ?????? ????????
??????? ? ???????????? ????? ? ????????
???????? [5]. ?????? ?????????? ???????? ???????????? ?? ??????????????? ????????
???????????? ??????? ? ????? ?????? ????????? ?????????????????? ????????? ?? ?????? ??????? ??.
????? ? ????????????? ??????? ???????
????????? ???????????? ? ????????? ????????? (??) ?? ???????? ????? ????, ? ??? ?? ?
????????? ???????? ? ???. ????? ????, ???
?????????? ??? ? ??????????? ??????????? ????? ???????? ?? ?? ????? 30-? ? ?????????, ??? ?????? ????????? ????????? ???????????? ? ????????? ????????????, ???
???????????? ?????? ??????? ??? ??.
????? ????????? ?????? ???? ???????????? ???????????? ??????? ?? ? ?????????
???????????? ?? ???????? ? ?????? ? ???????????? ????????????.
???????? ? ??????
? ???????????? ??????? ??????? 27 ??????. ? ?????? ?? ????? 14 ?????? ?? 19 ??
24 ???, ????????????? ? ???????????? ???????????, ? ?? 1 ??????? I ??????, ?? ??????????? ????????????? ????????????? ????????? ? ?????? ????????????. ??????? ????,
??? ? ?????? ????? ???? ????????? 180╠10 ??,
90,3 ╠ 15,8 ?? ? 26,9 ╠ 4,5 ??/?2 ????????????-
??. ??? ???? 21% ?????? ? ?? (n=3) ?????
???????????????? ???????. ? ?????? ???????? ???????? 13 ??????, ?? ?????????????
????? ?? ??????? ????????-?????????? ??????? ? ?? ?????????? ?? ???????????? ?????.
??????? ????, ??? ? ?????? ????? ???? ? ????
?????? ????????? 180 ╠ 10 ??, 73,8 ╠ 8,1 ?? ?
23 ╠ 1,9 ??/?2 ??????????????.
??? ?????????? ???? ??????????? ? ?????????? ???????????? ? ???? ?????????? ???????? ?? ??????? ? ???. ???????????? ??????????????? ????????????? ? ???????????? ?????????? ?????????? ? ???? ???????? ?????????
?? ?????????????? ????? ?????????? ???????????????? ???????????? ????????????.
???????????? ??????????? ? ????? ?????????????? ??????????? ?? ?????? ????????
???. ????? ???????????????? 10-?????????
?????? ?????????? ?????????? ? ?????????
???? ? ??????? 5 ???, ????? ??????????????
?????? ? ??? ???????? ????????? ???????????? ?????????. ? ????????? ?????????? ? ??????? 10 ???, ??? ???? ????? ???? ???????????, ???? ??????????? ?? ?????? ????.
????? ????????? ???????????? ???? ?????????? ?????????? ?? ??????? ????????????? ??? ????????? ????? ?????????, ??? ??????????????, ???????? ????, ?????????? ?
??????, ???????? (??? ?????????? ???????????? ????????????) [6].
?? ????? ??? ????????? ?????????????
???????????????? ??????????????????? ?????????? ? ???????????? (????????-?????????, ?????, ??????). ????????? ??????? ?? ??????? ???????????? ????????
????????? ? ???????? ?1 ????? ??????? ???????? ??????? (TAMX ????? ? ??????,
??/?) ? ??????????? ???????? CO2 ? ?????
?????? (PET??2, ?? ??. ??.). ????????????
2 ??? ?????????-???????? ??????????????
?????, ???????????? ? ??????? ??????? ???????????? ???????????? ???? ? ????? ??????
? ??????? ???????????? ????????? ?????.
??? ???????????? ????????? ???????????? ????????? ?????????? ?????????????? ?
??????????????? ?? (??? ? ???, ?? ??. ??.),
? ????? ?????? (??/???) ??????? ?????????
??????????????????, ????????? ??????????? ╚?? ?????????? ? ??????????╩ ???????????? ????????? (CNAP Monitor 500,
CNSystems, ???????).
??????????? ?????????? ??????????????, ? 4, 2013
response. Preservation of cerebral autoregulation was observed in patients with arterial hypertension in the studies of initial
orthostatic reactions, however the effectiveness of autoregulation during prolonged orthostasis is decreased.
Key words: orthostasis; orthostatic hypotension; cerebral autoregulation; arterial hypertension; transcranial Doppler
ultrasound.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
30
??????????? ?????????? ???????????? ??????????????
????????? ???????????? ????? ?????????? (?1) ? ?????? 30 ? ?? ?????? ???????????
(?????? 3 ?) ? ????????? ???????????????
?????????. ?? ???????? ???????? ?????????
??? ??????? ?1 ??????????? ??????? ????????
?? 15?30 ? ??????????????? ????? ????????????. ?????????? ????????? ???????????????
?????????? (???) ??????? ?????????? ???????? ??? ????? ??? ?? 40 ?? ??. ??. ?/???
??? ????? ??? ?? 20 ?? ??. ??. ? ????????? ?
?????????? ???????????? ???????????? [6].
????? ????????? ???????? ??????????? ???????????? ? ????????? ???????????? ?
PETCO2 ? ??????? 10 ??? ????????? ? ?????????? ??????????????? ?????????. ?????? ?????????? (?2) ????????? ??? ???????? ???????? ??? ???????? ????????? (??????? ??
????????? 2?3 ???) ? ?????? ?????? ? ?????????. ??????????????? ?????????? (??)
????????????? ??? ???????? ??? ????? ???
?? 20 ?? ??. ??. ?/??? ??? ????? ??? ??
10 ?? ??. ??. [7].
?????????????? ????????? ?????? ??????????? ? ?????????????? ?????? ?????????????? ???????? Statistica 6.0. ?????? ?????? ????????????? ???????? ?????????? ? ???????
?????????????????? ???????? ??????????.
???????? ????????? ????? ???????? ????????? ? ??????? U-???????? ???????????,
?????????????????? ???????? ????????????????, ??????? ????????????? ???????? ??????. ?????? ???????????? ? ???? ?????? (??)
? ????????? (25 ? 75 0/00). ??? ???? ?????? ????????????? ???????????? ????????? ????????, ?????????? ??????? ?<0,05.
??????????
??? ?????????? ?????? ???. ????????
?????? ?????????? ? ??????? 1.
????????? ??????????????? ?????????.
? ????? ??????? ??? ????????? ? 12-? ??
30-? ?, ??? ? ? 6-? ?? 30-? ?, ????? ? ??????
???????? ????????? ? 6-? ?? 30-? ?, ? ? ?????? ?? ? ? 3-? ?? 18-? ? (???. 1). ? ?????? ??
???????? ??? ??????????? ? 11 ??????, ?
?????? ???????? ? ? 4, ??? ???? ??????? ???
? ??????? ??????? ??????????? (79 ? 31% ??????????????, ?=0,021). ?????? ? ????? ??????? ????????? ??? ???? ???????? ??????
???. ?? ???? ??????????? ? ??? ????????
?/??? ?????????? ? ?????? ??? ????????? ???????? ???? ? ?????? ???????? ? ???? ? ?
?????? ??.
??????? ????????? ? ??? ???? ?????????? ? ????? ??????? (???. 2). ???????? ????????? ? ????? ? ?????? ??? ????????? ?? 6?9-? ?,
?? 15-? ? ? ???? ??????? ????. ? ??????? 2
???????? ????????? (?1) ?????????? ???????????? ? ????????? ????????????.
?????????? ??????????????? ?????????
?????????? ????????? ???????????? ???????????? ?? ??????? 3. ??? ??????? ????????? ? 1-? ?? 10-? ??? ????????? ? ?????
???????, ????? 8-? ??? ? ?????? ????????.
??? ????????? ??????? ?? 1?3-?, 6?7-? ?
9-? ??? ? ?????? ??, ???? ?? 3-? ??? ?
? ?????? ????????. ????? ??????? ???????????? ? 1-? ?? 10-? ??? ????????? ? ?????
???????. ??????????????? ?????????? ? ?????? ?? ???? ?????????? ? 6 ??????, ? ??????
???????? ? ? 2, ??? ???? 3 ?????? ?? ??????
?? ? 1 ?? ?????? ???????? ???????? ????????
??? ???????? ????. ??????? ?? ? ?????? ??
????????? 43% ?? ????????? ? 15% ? ??????
???????? (?=0,21).
???????? ?? ? ?????? ???????? ??????????? ?? 1?3-?, 7-?, 9?10-? ???, ? ??????
?? ? ?? 1?10-? ??? ?????????. PETCO2 ???? ??????? ??????? ? ??????? ???? 10 ??? ????????? ? ?????? ????????, ?? 3?4-?, 7?10-? ??? ?
? ?????? ?? (???. 4). ? ??????? 3 ????????
??????? ???????? ???????????? ? ??????????? ????????? (?2) ? ??????? ?? 10 ???
?????????. ?? ????? ??????, ?2 ???? ??????????? 1
??????? ???????? ?????????? ???????????? ? ????????? ????????????
??? ???????? ????????? ? ?????? ???????? ? ?????? ??
????????
???, ?? ??. ??.
???, ?? ??. ??.
?????, ??/???
TAMX ??????, ??/?
TAMX ?????, ??/?
PETCO2, ?? ??. ??.
?????? ????????
??
127,5
76,8
71,0
56,9
60,0
33,3
(25; 750/00)
(118,2; 128,4)
(71,8; 78,5)
(66,9; 73,2)
(49,6; 65,1)
(53,3; 63,3)
(31,3; 34)
?????? ??
??
(25; 750/00)
142,9
91,9
81,7
61,2
56,5
34,9
(134,2; 149)
(85,8; 94,6)
(74,5; 89,6)
(56,2; 68,0)
(52,9; 65,5)
(34; 36,2)
MW U-test
?
0,00005
0,00004
0,002
0,25
0,18
0,033
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
31
??????????? ?????????? ???????????? ??????????????
?????? ????????
?????? ??
150
150
140
140
130
130
120
120
110
110
100
100
90
90
80
80
70
70
60
60
50
50
????? 6
12
18
24
????? 6
30
?????, ?
12
18
24
30
?????, ?
???, ?? ??. ??.
???, ?? ??. ??.
?????, ??/???
???. 1. ????????? ??????????????? ????????? ????????? ????????????
10
5
5
0
0
-5
-5
-10
-10
-15
-15
-20
-20
-25
-25
-30
?????
6
12
18
24
-30
30
?????
?????, ?
6
12
18
24
30
?????, ?
???, ??? ??. ??.
TAMX ??????, ???/?
TAMX ?????, ???/?
???. 2. ????????? ??????????????? ????????? ???????? ????????? ????????? ? ????????????? ????????
??????? 2
????????? ??????????????? ????????? ?????????? ????????????
? ????????? ????????????
????????
???, ?? ??. ??.
???, ?? ??. ??.
?????, ??/???
TAMX ??????, ??/?
TAMX ?????, ??/?
?????? ????????, ?1
??
-16,3?
-19,1?
29,0?
-12,7?
-13,6?
?????? ??, ?1
(25; 75 /00)
0
(-22,1; -14,5)
(-25,3; -15,9)
(25,9; 32,3)
(-14,0; -9,2)
(-14,2; -8,0)
??
(25; 750/00)
-23,2??
-26,1??
26,1??
-11,4??
-12,1??
(-23,8; -10,8)
(-32,3; -22,3)
(22,5; 30,5)
(-12,7; -9,0)
(-12,5; -9,8)
?
0,38
0,008
0,44
0,35
0,29
? ? ? ? ? ? ? ? ? ?. ??<0,005 ?? ????????? ? ????????? ??????? ? ?????? ????????; ???<0,001 ?? ????????? ? ????????? ??????? ?
?????? ??.
??????????? ?????????? ??????????????, ? 4, 2013
?????? ??
?????? ????????
10
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
32
??????????? ?????????? ???????????? ??????????????
?????? ????????
?????? ??
25
25
20
20
15
15
10
10
5
5
0
0
-5
-5
-10
-10
-15
-15
?????
2
4
6
8
?????
10
2
?????, ???
4
6
8
10
?????, ???
???, ??? ??. ??.
???, ??? ??. ??.
?????, ???/???
???. 3. ?????????? ??????????????? ????????? ?????????? ????????? ????????????
?????? ??
??????????? ?????????? ??????????????, ? 4, 2013
?????? ????????
1
1
0
0
-1
-1
-2
-2
-3
-3
-4
-4
-5
-5
-6
-6
-7
-7
?????
2
4
6
8
?????
10
?????, ???
2
4
6
8
10
?????, ???
???? ??????, ???/?
???? ?????, ???/?
?????2, ??? ??. ??.
???. 4. ?????????? ??????????????? ????????? ???????? ?? ? PETCO2
??????? 3
?????????? ??????????????? ????????? ?????????? ????????????
? ????????? ????????????, ?? (25; 750/00)
????????
???, ?? ??. ??.
???, ?? ??. ??.
?????, ??/???
TAMX ??????, ??/?
TAMX ?????, ??/?
PETCO2, ?? ??. ??.
?????? ????????
?????? ??
?2 min
?2 max
?2 min
-12,4 (-14,5; -9,9)*
-5,5 (-6,8; -4,8)*
6,8 (3,1; 11)*
-8,0 (-11,7; -6,0)*
-7,1 (-8,8; -5,9)*
-3,9 (-1,5; -2,9)*
0,0 (-1,9; 4,6)
4,6 (0,7; 7,1)*
23,3 (21,1; 26,4)*
1,4 (-1,2; 2,8)
3,2 (2,5; 3,9)*
-0,3 (-0,9; 0,7)
-12,8 (-19,4; -5,8)#
-8,7 (-11,6; -4,0)#
7,5 (3; 10,6)#
-8,9 (-12,7; -7,3)#
-8,9 (-10,9; -6,4)#
-3,8 (-5,6; -2,2)#
?2 max
-1,4 (-8,8; 2,8)
1,5 (-1,6; 4,8)
19,3 (16,0; 29,4)#
1,6 (-0,8; 2,1)
1,3 (0,9; 3,5)#
0,6 (-0,2; 1,4)
? ? ? ? ? ? ? ? ? ? . ?2 min (max) ? ??????? ????????? ??????????? (????????????) ???????? ? ?????? ?? 10 ??? ?????????; *?<0,05
?? ????????? ? ????????? ??????? ? ?????? ????????; #?<0,001 ?? ????????? ? ????????? ??????? ? ?????? ??.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????? ??????? ?? ??????????? ????? ????????.
??????????
? ????? ???????? ?? ? ?????? ???????? ?
?????? ?? ?? ???????????, ???????? ?? ??, ???
? ????????? ? ?? ??? ? ??? ???? ????.
??????????? ?????????? ???????? ? ? ??????
??????? ?? ???????????? ?? ??? ?? ??????? ???? [10, 11]. ????? ??????????? ?? ?
???????? ?? ??????????? ??????????? ???????????? ?????????????. ????? ? ????? ???
???? ? ?????? ??, ??? ????? ????????? ????????????? ?????? ????????????? ???. ??????? PETCO2 ? ????? ??? ???? ? ?????? ??, ??
????? ??????? ? 1?1,5 ?? ??. ??. ?????????????? ??? ??????????????.
? ???????? ??????????????? ???????? ??
??????? ???, ??? ? ?????? ?????? [8, 9].
???? ??? ????????? ??????? ??? [6], ????? ????, ??? ?? ?????????? ?? ????????? ???????????? ????????????. ???????????????
???????? ???????? ??????????? ????????
??????????? ?? ??????? ??????????????.
??? ????????? ? ????? ?????? ???????????
???????????? ?? 15% ?????? ????????????? ?????, ??? ?????? ?? ????? ???????? ????????? ????????, ?????????? ??????? ? ??.
????? ?? ????? ??????????? ?????????
?????????? ?????????????? ?????????????? ????????? ??? ??????????? ??: ???????????? ?????????? ????????????? ?
?????????? ?????????????????, ???????????? ??????????????? ??????, ???????
??????? ? ???????? ?????? [12].
???????????? ??????????? ????? ?????????????? ?????????? ???????????? ???????????????? ??????? ??? ?????????? ???.
??????? ??????, ??????????? ???????????? ??????? ????????? ???????????? ??
???????? ? ??? ? ?? ????????, ???????? ? ???????? ????????. ?? ??????????? ???? ?????
??? ?? ?????????????? ??????????????? ?????????? [3], ??????????? [1, 4] ??? ?????????? ? ??????????? [2], ????????????? ??????? ??????????? ? ?????????? ??????
???????? ????????? ??????????????? [4], ????? ?????? ?????????????? ???????? ???????? [1], ????????? ????????? ???????-??????? ? ????????? [2]. ?????? ?????? ? ???????????? ????????? ? ????????????
???????????? ?? ???????? ??? ?? ? ????????? ???????? ???.
?? ???? ????????????????? ??????? ????????? ????????? ????????? ????????????
33
?? ????? 1-? ??? ?????????. ? ?????????? ???????? ????????? ?? ╚beat-to-beat╩ ?????
????????? ???????????? ????????? ??????????????? ??????? [6]. ???, ??? ??????????? ???????? ??????????????? ????????????
??????? ? ????????? ???????? ???????? ? ??
[8]. ?? ??? ?? ? ????????? ???????? ????????? ??????????????? ??????? ????? ?? ???????????.
? ????????? ?????? ? ????? ??????? ? ?????? 30 ? ????????? ??????????? ????????????
???????? ??? ? ??? ? ?????????????? ???????? ?????? (??. ??????? 1). ?????? ? ?????? ? ?? ??? ????????? ? ??????? ???????,
??? ? ????????.
??? ??????????? ?????????? ???? ? ????????? ? ??, ?????? ?? ???? ???????? ???.
?????????????? ??? ??????????? ????????? ??????????????? ????? ???????? ??????? ?????? ? ?????????? ?????????????? ??
???? ???????? ?????????? ??????????? ???????????????????? ???????? [6].
??? ?????????? ??????????????? ????????
?? ?????????? ? ????? ??????? ???????????? ???????? ??? ? ???????? ??????, ??
????????? ???????? ???. ? ?????? ????????
??? ????????? ???? ?? 3-? ??? ?????????, ?
? ????? 10-????????? ????????? ???? ????????? ??????????, ??? ??????????? ?????????????? ?????????? ??????????? ?????????????, ? ? ?????? ?? ??? ???? ??????? ??????????? ?? ???? ??????????
??????????????? ????????.
??? ?? ??????????????????? ????????
?????????? ??? ????????? ???????? ????????? ??????? ??????????????, ????????? ?????????? ?????????, ????????? ? ??????????????, ??????? ??????????? ?????? ????????? ? ??????? ?????????????? [2]. ? ?????
????????????, ???????? ????????? ???????,
????????? ?????? ?? ? ?????????? ????????????? ??????????????, ????????? ????????? ? ?????????? ??????????????? ??????? ?
???? ?????????????? ?????????? ???????????, ????????, ?????????? ??????? ?????????????? ? ????????????? ????????? ????????????????.
??????? ????????, ??? ? ?????? ????????
?????? ????? ??????????? ??? ? ??, ????
??????????? ????, ??? ??????????????? ?? ??????????????? ??????? ╚????????╩.
??????? ?? ?? ????????, ?????? ? ???????? ??, ??????? ??????????? ????. ?? ??? ??
??? ???????????? ??????? ???????, ??? ???
?????????? ????? ??????? ??????????? ?????-
??????????? ?????????? ??????????????, ? 4, 2013
??????????? ?????????? ???????????? ??????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
34
??????????? ?????????? ???????????? ??????????????
??????? ????????????? ? ??????? ????? ??????? ???????? [5], ??? ????? ??????? ?? ?????
????????? ?? ????? ?? ?????????? ?????????? ?? ??? ?????????.
? ????????? ???????????? ????????? ??????????????? ???????? ?? ??????? ?? ???????? ?????????? ???????? ???????? ????????? ? ???. ?????? ??? ?????????????
???????? ?? ? ???????? ?? ????????? ???????????? ? ????????? ???????? ??????????? ??????. ?????????? ???????? ????????
?? ? ?????? 15 ? ????????? ???? ??????????
? ? ?????? ??????? [8]. ??????? ??????? ???????? ?? ?? ???? ??? ?? ????????????????
?????????? ?? ?????????? ?????????????
?????????? ???????????? ????????????
?????????????. ???????? ??????????? ???????? ???????? ?? ? ???????? ? ?????? ? ??,
????? ?????? ? ??????????? ?????????? ???????????? ????????????? ? ?????? ????????? ???.
??? ?????????? ????????? ???? ?????????? ???????? ???????? ????????? ? ??? ?
????? ???????, ??? ??????????? ? ???????
?????? ??????? [9]. ???????? ???????? PETCO2
??? ?????????, ???????? ???????? ?? ?????
???? ??????????? ?? ?????? ???????????????
??????????? ? ??????? ???????? ????, ?? ?
??????????? ? ?????????? ???????????? ???????????????. ?????? ???????? ????????
?? ? ??????? ???????????. ???, ? ?????? ???????? ???????? ?? ?????????? ?? ????????? ???????? ? ???????? ??????????????? ????????, ?? ???? ????????????? ??????????
? ???????? ???, ???? ?? ??????????? ? ?????? ? ??. ????? ????????? ??????????????
???????? ?? ? ?????? ???????? ???????????,
??????, ????????????? ????????????????
??????????, ???? ?? ??????????? ??? ??.
??????????
? ????????? ???????? ??? ?? ?? ??????
??? ?????????? ????????? ????????? ?
?????????? ??????????????? ??????? ????????? ???????????? ? ???? ??????????????
?????????? ? ????? ?????? ?????????????
???. ??? ?????????? ????????? ???????? ??
????????? ?????????? ?? ??????? ??, ???
???? ????? ?? ?????? ????? ???? ????????????? ?????????? ? ???????? ????????????
???????????????. ? ?????? ? ?? ??????????
??????????? ?????????? ???????????? ????????????? ??? ???????????? ????????? ??????????????? ???????, ?? ??? ??????????
??????????????? ???????? ?????????????
???????????????? ?????????? ????? ????
???????.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
?????????? ?.?., ???????? ?.?., ?????? ?.?., ???????? ?.?.
??????????????? ??????????? ??? ?????? ????????-??????????? ????? ? ??????? ???????????? ???????????. ??????? ????. 2009; 7: 40?2.
Fan X.H., Wang Y., Sun K., Zhang W., Wang H., Wu H. et al.
Disorders of orthostatic blood pressure response are associated
with cardiovascular disease and target organ damage in hypertensive patients. Am. J. Hypertens. 2010; 23 (8): 829?37.
Jones C.D., Loehr L., Franceschini N., Rosamond W.D.,
Chang P.P., Shahar E. et al. Orthostatic hypotension as a risk
factor for incident heart failure. The atherosclerosis risk in
communities study. Hypertension. 2012; 59 (5): 913?8.
Mark A.L. Regulation of the sympathetic nerve activity in mild
human hypertension. J. Hypertens. 1990; 8 (7): 67?75.
Strandgaard S., Paulson O.B. Cerebral blood flow in untreated
and treated hypertension. Neth. J. Med. 1995; 47 (4): 180?4.
Wieling W., Krediet C.T., van Dijk N., Linzer M.,
Tschakovsky M.E. Initial orthostatic hypotension: review of a
forgotten condition. Cli. Sci. J. 2007; 112 (3): 157?65.
Lanier J.B., Mote M.B., Clay E.C. Evaluation and management
of orthostatic hypotension. Am. Fam. Physician. 2011; 84 (5):
527?36.
?????? ?.?., ???????? ?.?., ???????? ?.?., ??????? ?.?.,
?????????? ?.?. ??????????????? ???? ??? ????????? ????????? ??????????????? ????????? ? ??????? ??????????????? ????????. ???????????????? ???????. 2008; 3
(1): 12?22.
???????? ?.?., ??????? ?.?. ???????????? ???????????
??????? ?? ??????????? ? ???????? ?? ?????? ????????????????? ????????? ??????????? ????????????. ??????????????? ????????????. 2012; 4: 274?7.
???????? ?.?., ??????? ?.?., ????????? ?.?., ????????? ?.?., ????????????? ?.?., ????????? ?.?. ?????????
???????? ???????????? ? ?????????????????? ???????????? ? ??????? ???????????? ???????????. ???????????? ???????????. 2005; 11 (4): 245?8.
??????? ?.?., ????????? ?.?. ?????????????????? ???????????? ? ?????? ? ???????????? ????????????. ??????????? ?????????? ??????????????. 2013; 1: 61?7.
Mathias C.J. Orthostatic hypotension: causes, mechanisms,
and influencing factors. Neurology. 1995; 45: 6?11.
References
1.
2.
3.
4.
5.
6.
7.
8.
Dzizinskiy A.A., Protasov K.V., Kuklin S.G., Sinkevich D.A.
Orthostatic hypertension as a marker of cardiovascular risk in
patients with arterial hypertension. Lechashchiy vrach. 2009;
7: 40?2 (in Russian).
Fan X.H., Wang Y., Sun K., Zhang W., Wang H., Wu H. et al.
Disorders of orthostatic blood pressure response are associated
with cardiovascular disease and target organ damage in hypertensive patients. Am. J. Hypertens. 2010; 23 (8): 829?37.
Jones C.D., Loehr L., Franceschini N., Rosamond W.D.,
Chang P.P., Shahar E. et al. Orthostatic hypotension as a risk
factor for incident heart failure. The atherosclerosis risk in
communities study. Hypertension. 2012; 59 (5): 913?8.
Mark A.L. Regulation of the sympathetic nerve activity in mild
human hypertension. J. Hypertens. 1990; 8 (7): 67?75.
Strandgaard S., Paulson O.B. Cerebral blood flow in untreated
and treated hypertension. Neth. J. Med. 1995; 47 (4): 180?4.
Wieling W., Krediet C.T., van Dijk N., Linzer M., Tschakovsky M.E. Initial orthostatic hypotension: review of a forgotten
condition. Cli. Sci. J. 2007; 112 (3): 157?65.
Lanier J.B., Mote M.B., Clay E.C. Evaluation and management
of orthostatic hypotension. Am. Fam. Physician. 2011; 84 (5):
527?36.
Rogoza A.N., Oshchepkova E.V., Kuz'mina Yu.V., Gorieva Sh.B.,
Balakhonova T.V. Diagnostic test for the detection of initial
orthostatic hypotension in patients with essential hypertension.
Kardiologicheskiy vestnik. 2008; 3 (1): 12?22 (in Russian).
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
9.
10.
Dicheskul M.L., Kulikov V.P. Vertebral artery reactivity to hypercapnia and orthostasis based on the data of transcranial colorcoded duplex ultrasonography. Fundamental'nye issledovaniya.
2012; 4: 274?7 (in Russian).
Logacheva I.V., Ivanova I.V., Pocheptsova L.V., Tsyplyashova I.V.,
Perevozchikova O.S., Krivileva S.P. The condition of cerebral
hemodynamics and cerebrovascular reactivity in patients with
11.
12.
35
arterial hypertension. Arterial'naya gipertenziya. 2005; 11 (4):
245?8 (in Russian).
Kulikov V.P., Kuznetsova D.V. Cerebrovascular reactivity in
young men with arterial hypertension. Klinicheskaya fiziologiya
krovoobrashcheniya. 2013; 1: 61?7 (in Russian).
Mathias C.J. Orthostatic hypotension: causes, mechanisms,
and influencing factors. Neurology. 1995; 45: 6?11.
????????? 17.09.2013
╘ ????????? ???????, 2013
??? 616.2-008.64-089.168.1:616.24-089:616.12-089
??????????? ??????????????? ? ????????? ?????????????????
???????, ????????????? ??????????? ??????? ??????????????
?????? ? ???????, ?????????? ????????????? ?? ???????? ??????
?.?. ???????1, ?.?. ???????1, ?.?. ??????????2
1????
??????? ??? ?????????, ?????? ???. ????, ?????????, ???????? ??? ? ????, ????????;
??????? ??????? ?????????????, ?????? ???. ????, ?????????? ?????????? ??????????;
e-mail: nikitines@yandex.ru;
?????????? ???????? ????????, ???? ????????????-????????????
??? ???????, ???????? ??????? ??????????? ? ????????? ????????????????? ???????
? ??????????????????? ??????? ??????? ? ?????????? ???????????? ??????????? ??????, ????
???????????? ?????????????? ???????????????? ????????? ??????. ??? ???????? ? ?????????????
???????? ?????????? ???????? ? ???????????????? ???????????? ??????. ??????? ???????
??????????????????? ???????? ????????? ???????? ????????? ?????????? ???????? ??
????????????????? ???????????? ? ??? ????? ?????????????? ???????????? ??????? ??????.
? ?????????, ????? ?????, ?? ???????????? ? ???????? ???????? ???????????? ?????????? ?????
??????????, ?????????????????? ????????? ????????? ?????????????? ?????? ? ????? ????????? ??
?????????????? ???????. ??? ???????, ??? ???????? ? ???????????????? ??????? ??? ????? ??
???????? ? ????? ??????? ???????????, ??? ??? ?????????? ????????? ???????????????? ????????
? ??????? ??????? ?????????????? ??????. ???????? ?????? ???????? ???????? ??????????????
??????? ?????? ?????? ? ??? ??????, ???? ????????????? ?? ????????????????? ???????????? ??????
???? ????? ??????????? ?????????? ????????, ? ?????? ?????? ?? ???????????? ???? ????????????
? ????? ??????? ???????? ??????????.
????? ????, ??? ?????????? ??????? ?????????????? ????? ???? ?????????? ????????? ??????????
?????? ?? ????? ??????????? ??????? ???????? ?????????????? ???????? ? ????? ??????.
? ?????????? ????? ????????? ??????????? ??????????? ???????????????, ?????????????
? ????????????? ???????? ╚?????╩ ??????? ??????????? ?????, ?????????? ???? ?????? ??????????
?????? ????????????? ?????????? ??????.
???????? ?????: ??????????? ???????????????; ????????? ??????? ??????; ????????? ?????????????? ??????? ??????; ?????? ?????????????? ??????; ??????????????; ????????????????? ??????????.
??????????? ?????????? ??????????????, ? 4, 2013
╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ? ???????? ???
? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????, 121552, ??????;
2???? ╚??????????? ??????-??????????? ?????╩ ???????????? ??????-?????????????? ????????? ??????,
???????? ?-?, 28, ??????, 115682, ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
36
??????????? ?????????? ???????????? ??????????????
RESPIRATORY FAILURE IN IMMEDIATE POSTOPERATIVE PERIOD CAUSED
BY LUNG RECRUITMENT MANEUVER IN PATIENTS WHO UNDERWENT OPEN HEART SURGERY
L.A. Bockeria1, E.S. Nikitin1, G.P. Kiryushchenkov2
1A.N.
Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Sciences,
Rublevskoe shosse, 135, Moscow, 121552, Russia;
2Federal Scientific-Clinical Center of the Federal Medical-Biological Agency of Russia,
Orekhovyy bul'var, 28, Moscow, 115682, Russia
Bockeria Leo Antonovich, MD, DM, Professor, Academician of the Russian Academy of Sciences and Russian Academy
of Medical Sciences, Director;
Nikitin Evgeniy Stanislavovich, MD, DM, Chief of Department of Intensive Care;
Kiryushchenkov Grigoriy Petrovich, Anesthesiologist-Intensivist
As a rule, decrease of oxygenation index in the immediate postoperative period in cardiac patients is related to the
impaired pulmonary diffusion capacity which can be the consequence of untimely or inadequate repair of cardiac
pathology. This can lead to the deposition of large amounts of fluid in the pulmonary interstitial space. Therefore, the
duty of an intensivist is to remove immediately excess fluid from interstitial space and thus to restore pulmonary diffusing capacity.
Regretfully, it often happens that intensivist performs lung recruitment procedure in order to improve function of the
lungs in oxygenizing the blood without having examined the reasons for the decline in the partial pressure of oxygen
in the blood. As a rule, it has a short-term effect or doesn't result in the increase of oxygenation index at all, as it is
impossible to remove interstitial fluid by performing lung recruitment maneuvers. This maneuver can improve function
of the lungs in oxygenizing the blood only in case if initially sufficient amount of fluid was removed from interstitial
space of the lungs and provided that the patency of bronchial tubes haven't been restored and some parts of alveoli
remain in a collapsed state.
Furthermore, pulmonary stretch receptors may be damaged during lung recruitment maneuver when high levels of
positive end-expiratory pressure are being maintained. As a result severe respiratory failure can develop which presents with inability of a patient to draw a proper tidal volume, as a consequence prolonged mechanical ventilation will
be performed.
Key words: respiratory failure; pulmonary function impairment; impaired function of the lungs in oxygenizing the blood;
lung recruitment maneuver; cardiac surgery; postoperative complications.
??????????? ?????????? ??????????????, ? 4, 2013
????????
??????????? ??????????????? ? ?????????
????????????????? ??????? ? ?????????, ?????????? ????????????? ?? ?????? ? ????????
?????????????? ??????????????, ???????? ????? ?? ???????? ?????? ?????????? [1, 2].
????????? ??????? ??????, ??? ???????,
????????? ??????? ?????????? ?????????????????? ??????? ? ???????????? ??????????
??????????? ? ???? ????????? ??????? [1, 3].
????? ?? ???????? ?????? ??????????
??????????? ??????????????? ?????? ????????? ?????????????? ??????? ?????? [1].
???? ?????? ?????? ? ?????????? ????????? ???????? ??????????? ??????????????? ? ????????? ????????????????? ???????
? ???????, ?????????? ????????? ?????????????? ??????? ??? ????????? ?????????????-???????????? ???????????.
???????? ??????
??????? 60 ??? ?? ?????? ???????????
??????? ? ??????????? ??????? ??????, ??????????? ?? ???? ???????????? ???????????, ????????? ?????????????? ???????????
??????? ???????? Sorin ? 21, ??????????????? ?????????????? ?????????? ?????, ????????-?????????? ???????????? ????????
??????????????? ????? ????? ??????????
???????.
??? ??????????? ? ???? ?????????????
???????????? ???????? (???) ? ???????? ????????? 140 ?? ??. ??., ??????????? ????????
???????? (???) ? 9 ?? ??. ??., ??????? ??????? ?????? ????????? (?? ??) ???? ?????
54%, ??????? ????? ?????? ?????????
(?? ??) ? 64 ??, ? ??? ???????? ?????????????? ????? (??? ??) ? 120 ??. ????????? ?????? (??) ??????????? ?? ??????
3,92 ?/???/?2, ????? ?????????????? ?????????? ????????????? (???) ?????????
556 ???/?/??-5. ?????? ??????????? ????????? 210. ??? ???? ???????? ????????? (??2)
??????????????? 484 ??/???/?2, ?v?2 ?
38 ?? ??. ??., SvO2 ? 76%. ??????????? ??????? ?????????? ? ???? 0,05 ???/??/???.
??? ????????? ?????????????? ???????
?????? ? ????????? ?????????????-???????????? ????????? ?????? ???????? ?????? ?????????????? ???????. ????????????? ?????????? ?????? ????????? ? ?????? Pressure
Control. ?????? ?????????????? ????????????
??????????? ?????????? ???????? ? ??????????? ?????. ???????? ??????? ??????????? ??
?????? PEEP 30 ?? ???. ??. ? ?insp40 ?? ???. ??.
????? ????? ??? ????????? 130 ?? ??. ??.,
??? ? 10 ?? ??. ??., ?? ?? ? 55%, ??? ?? ?
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
125 ??, ?? ?? ?????????? ?? 69 ??. ????????? ?????? ?????????????? 3,85 ?/???/?2,
??? ? 743 ???/?/??-5. ?????? ???????????
?????????? ????????????? ? ?? 253. ??? ????
??2 ????????? 485 ??/???/?2. ???? ??????????
??????? ?? 0,03 ???/??/???.
?????? ????????? ????????? ?? 3-? ???.
? ????? ? ???, ??? ?????? ?????????????? ??
?????? ? ????????????? ????? ??????? ???????????, ????????? ?????????????? ??????? ?????? ???? ??????? ? ?????????? ??
???????????? ???????????. ???? ?????????
???????????? ? ???????????? ???????? ?????, ???????????? ?????????. ?? ???? ?????
? ???????? ???????? 8 ? ????????.
????? ????? ??? ????????? 120?140 ?? ??. ??.,
??? ? 6?8 ?? ??. ??., ?? ?? ? 57%, ???
?? ? 138 ??, ?? ?? ? 75 ??. ?? ?????????????? 3,93 ?/???/?2, ??? ? 1010 ???/?/??-5.
?????? ??????????? ?????????? ?? 340.
??? ???? ??2 ????????? 590 ??/???/?2. ??????? ?????????? ??????????? ? ????
0,03 ???/??/???.
????? ???????, ?????? ?????????????? ???????????? ???????? ?? ??????? ??????. ?????????? ????? ?????? ?????????? ??????, ??????????? ????????? ?? ???. ? ???????
43 ???? ??????? ?? ??? ???????????? ??????????? ??????????? ????? (??? PSV
13?15 ?? ???. ??. ??????????? ????? ?????????
350?450 ??) ? ?????? ????? ??????????????
??????? ?????????? ??????, ?? 50-? ????, ?????? ??????? ╚???????????╩ ?????, ??? ? ????????? ???????? ???????? ?? ???????? ???.
??????????
??? ???????? ??????? ????? ?????????
? ???????? ????????? ???????????? ?????
?????????? ? ????????? ????????????????? ??????? ? ??? ????????? ??????????
??????, ?????????????-???????????? ??????????? ? ???????????? ??????????? ??????.
??? ?????? ??????? ?????? ????? ?? ????????? ???????? ??????????????. ?????
??? ??????? ????? ?????????? ????? ?????
? ????????????? ????????? ????????????
?????????, ??? ? ????? ? ????????????? ???????????? ?????????? [4].
????????????? ???????????? ??????????,
??? ???????, ????? ???? ??????? ????? ???????? ???????????: 1) ????????????? ???????? ??? ????? ??? ?????? (??-?? ???????????
??????); 2) ???????????? ???????????? ?????? ?????? ??????; 3) ???????????? ???????
37
????????? ???????????? ????????????
? ?????? ???????? ????????????? ??????.
????????? ?? ??? ???????? ? ??????????
????????? ??????????/???????? ? ????????? ???????? ??????, ???? ???????? ?? ????????????????? ?????????????? ??????????.
???? ?????????? ?????? ?? ???????? ??????????? ?????? ??????????? ??? ?????????? ?????, ? ??????????? ? ??????? ?????????
???????? ??????????? ????????? ??????????????? ?????????? [4].
?????????? ????? ?????????? ??? ????????? ????????? ????? ??????????? ? ??????????, ? ?????????? ????????? ???????? ????????? ?? ???????????-??????????? ?????? [4].
??????? ????????? ?? ??????? ? ????????
??????????? ?????????? ? ???????? ????????? ?????????? ????? ????????? ?????: ???????????? ????????, ???????????????? ????????, ???????? ?????????, ???? ??????,
???????? ??????????.
????? ??????????? ???, ????????? ?????
? ?????? ???????????? ???????, ??????????? ?? ???????????????? ?????? ?? ??????????? ???????? ?????????? ??????. ?????????????, ????????, ??????????? ?? ?????????? ??????, ???????????? ????? ?????
??????? ? ????? ?????? ?????? [5].
?????? ??? ????????? ????? ????? ? ?????? ??????? ???????? ????? ????????? ?????????? ??????, ??????? ?????????????
? ?????????? ????????? ??????. ?????????
?????????? ?????? ????????? ? ????????
? ?????????????? ???? ?????? ??????????????????? ?????? ? ????????????? ? ???????? ? ??????????. ?? ????? ?????, ?????
?????? ???????? ????????? ? ??????, ??? ?????????????, ? ?????????, ??????????????
? ??????????, ????????????. ???????? ??
??? ?? ???????? ??????????? ????? ????????? ? ????????? ?????????????? ?????
? ?????? ????????, ???????????? ??????????? ?????. ??? ???????? ????????????,
? ????????????? ?????, ? ??? ??????????
? ??????????? ?????, ???????????? ?????
????? ? ??????, ?????? ???????? ??????? ?????????? ??????????????, ???????? ??????????? ? ??????????? ?????, ????????????? ??????????? ????? [5]. ??????????
???? ???? ??? ?????? ??????????? ?????
??????? ??????, ?????? ?????????? ?????????
? ????????, ?????????? ??. ????? ?????????
? ??????????? ????? ?? ?????????? ??????
?????????????. ????? ???????, ???? ????????????? ?????? [5].
??????????? ?????????? ??????????????, ? 4, 2013
??????????? ?????????? ???????????? ??????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
38
??????????? ?????????? ???????????? ??????????????
??? ???????, ???????? ??????? ??????????? ? ????????? ????????????????? ??????? ? ??????????????????? ??????? ???????
? ?????????? ???????????? ???????????
??????, ??? ??????? ? ?????????????? ??????????????? ????????? ?????????? ??????
? (???) ????????? ???????????? ??????????????? ????????. ??? ??? ???????? ? ????????????? ???????? ?????????? ????????
? ???????????????? ???????????? ?????????,
? ????????? ? ??????????? ??????. ???????
??????? ??????????????????? ???????? ???
????? ????? ??????? ???????? ?????????
?????????? ???????? ?? ?????????????????
???????????? ? ??? ????? ??????????????
???????????? ??????? ??????.
? ?????????, ????? ?????, ?? ???????????? ? ???????? ???????? ???????????? ?????????? ????? ?????????? ? ?????????
????????????????? ???????, ?????????????????? ????????? ????????? ?????????????? ??????? ? ????? ????????? ?????????????? ??????? ??????. ??? ???????, ??? ???????? ? ???????????????? ??????? ??? ?????
?? ???????? ? ????? ??????? ???????????
(??? ??? ?????????? ????????? ???????????????? ???????? ? ??????? ??????? ?????????????? ???????). ???????? ?????? ???????? ???????? ?????????????? ???????
?????? ?????? ? ??? ??????, ???? ????????????? ?? ????????????????? ????????????
?????? ???? ????? ??????????? ??????????
????????, ? ?????? ?????? ?? ????????????
???? ???????????? ? ????? ??????? ????????
??????????. ? ????? ?????? ???? ??????
? ???????? ? ????????? ????????????????????????? ??????????? ?, ??? ?????????, ????? ??????? ???????????.
? ????? ?????? ??????? ??????? ???????
??????? ??????????? ? ????????? ????????????????? ??????? ???? ??????? ? ????????
??????????? ???????? ? ????????????????
???????????? ??????. ? ????? ? ??? ?????? ?????????????? ?????? ? ???????? ????? ?? ??????? ?? ???? ???????????? ???????????
??????. ?????? ????? 3 ???, ????? ???? ??? ???? ???????? 8 ? ???????? ? ????????, ???????
?????? ????? ?????????????. ?????? ??????????? ?????? ?????????????? ? ???????
???????? ???????????? ???????? ?? ???????
??? ?????? ? ???? ?????????? ?????????
?????????? ??????, ????????, ?? ????? ??????????? ??????? ???????? ??????????????
???????? ? ????? ??????. ?????????? ?????
?????? ?????????? ?????? ???. ? ???????
43 ???? ??????? ??? ?? ???????? ???????????? ??????? ??????????? ?????,
? ?????? ????? ???????????? ?????????????? ??????? ?????????? ??????? ?????????
??????????? ╚?????╩ ??????? ????? ??????? ??? ?????? ????????? PSV, ???????????? ??????????? ??????? ????? ?? ????????? ?? ?? ?????? ??????????? (? ????????????? ╚?????╩ ??????? ????? ?? ????? ???)
? ?????? ????? ?????, ?? 50-? ????, ??????
??????? ╚???????????╩ ?????, ??? ? ????????? ? ?????????? ???????? ???????? ?? ???????? ???.
??????????
? ???????? ????????? ????????????
????? ?????????? ? ????????? ????????????????? ??????? ????? ????????? ??? ???????? ???????: ????????? ??????????
??????, ????????? ?????????????-???????????? ???????????, ????????? ???????????? ??????????? ??????. ????? ?????
????????? ?????????? ╚?????? ?????╩ ? ????????? ?????????? ?????????. ??????????? ?????? ?????????????? ?????? ?????
???????? ? ???????? ??????????? ??????????????? ? ????????? ?????????????????
???????, ????????????? ? ?????????????
???????? ? ?????????? ╚?????╩ ??????? ??????????? ????? ?? ???? ????????? ???????
???????? ??????????.
??????????
1.
2.
3.
4.
5.
?????????? ?.?., ?????? ?.?., ??????? ?.?. ???????
????? ???????? ??????????? ??????????????? ????? ???????? ?? ?????? ? ???????? ?????????????? ??????????????. ??????? ??????????? ???????. 2004; 3: 41?3.
Weiss Y.G., Merin G., Koganov E. et al. Postcardiopulmonary
bypass hypoxemia: a prospective study on incidence, risk factors and clinical significance. J. Cardiothorac. Vascul. Anesth.
2000; 14 (5): 506?13.
Messent M., Sullivan K., Keogn B.E. et al. Adult respiratory distress syndrome following cardipulmonary bypass: insedence
and prediction. Anesthesia. 1992; 47: 267?8.
???????? ?., ?????? ?., ???? ?. ?????????????? ???????. ?.: ????????; 1967.
???? ??. ?????????? ???????. ??????. ?.: ???; 1988.
References
1.
2.
3.
4.
5.
Dement'eva I.I., Charnaya M.A., Morozov Yu.A. Risk factors for
respiratory failure after heart surgeries under cardiopulmonary
bypass. Vestnik intensivnoy terapii. 2004; 3: 41?3 (in Russian).
Weiss Y.G., Merin G., Koganov E. et al. Postcardiopulmonary
bypass hypoxemia: a prospective study on incidence, risk factors and clinical significance. J. Cardiothorac. Vascul. Anesth.
2000; 14 (5): 506?13.
Messent M., Sullivan K., Keogn B.E. et al. Adult respiratory distress syndrome following cardipulmonary bypass: insedence
and prediction. Anesthesia. 1992; 47: 267?8.
Navratil M., Kadlets K., Daum S. Respiratory pathophysiology.
Moscow: Meditsina; 1967 (in Russian).
West J. Respiratory physiology: the essentials. Moscow: Mir;
1988 (in Russian).
????????? 02.09.2013
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
39
????????????? ??????????????
╘ ????????? ???????, 2013
??? 611-018.54:547.96:616.132.2-089.819.5
?????????? ??????? ?: ????? ?? ???????????????
? ??????????????? ???????? ??? ?????????? ?????????????
?.?. ???????, ?.?. ?????????, ?.?. ?????????, ?.?. ?????????, ?.?. ???????,
?.?. ??????, ?.?. ??????, ?.?. ??????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ? ???????? ???
? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????, 121552, ??????
???? ???????????? ? ?????? ??????????? ?????? ??????????? ???????? ? ?? ??????? ???????????
?????????? ?????? ??? ?????????? ???????????? ? ??? ?????????? ???????????? ? ?????????
? ???????????????? ?? ??????????????? ???????, ? ????? ?? ??????? ???????????? ??????????
??????????????? ?????? ? ??????????? ????????????????? ??????????.
???????? ? ??????. ? ???????????? ????? 55 ????????? ? ??????? ???????????? ???????????
??????? ??????. ? ??????????? ?? ????????? ??????????? ???????? ???????? ???? ????????? ??
??? ??????. ????????? 1-? ?????? (n=22) ???? ????????? ?????????? ???????????? (??) ? ????????
?????????????? ?????????????? ? ???????????????? ????????????, 2-? ?????? (n=23) ? ?? ??
?????????? ??????, 3-? ?????? (n=10) ? ????????????? ???????? ?? ?? ?????????? ??????
? ?????????? ??????????????? ? ????????? ???????????????????? ????????.
?? ???????? ? ? ????????????????? ??????? ? ???????? ??? ??????????????? ????-? (pregnancyassociated plasma protein A ? ?????????? ??????? ?, ??????????????? ? ?????????????).
??? ???????? ?? ???????????????? ???????????? ???????? ??? ??????????? ??????????
????????? ???????? I (???I), ? ??? ?????? ?????????????????? ?????????? ??????????????? ??????
???????????????? ???????????? ???????? ??-6.
??????????. ???????? ????????? ?????? ????-? ? ?????? ????????????????? ??????? ?? ???????
???????? ????????? ?? ????????? ? ??????????????? ????????????.
??????????. ?? ???????? ???????????? ?????????? ?????? ???????????? ?????????? (????-?)
? ???????? ????? ???????? ?? ????????? ? ?????????????? ??????? ?? ????????? ???????,
? ????? ????? ????????. ?? ???????? ??????????? ?????? ????-? ? ???I, ? ????? ??-6, ????
? ??????? ?????????? ?????????? ?? ????? ???????? ???? ???????????, ???????????????
??????????? ???????? ? ????????? ?????????????? ?????. ? ?????? ????????????? ??????? ????
???????? ???????? ?? ?????? ?????????? ??????????????? ?????? (??-6) ? ??????????? ?? ???????
??????? ??????????? ????? (???) ? ????????? ????????????????? ???????. ?? ? ??? ??????????
????????? ?? ?????? ?? ???????? ??????? ??? ?????????? ??? ? ????????????????? ??????? ?????
?? ???? ???????? ??????????? ? ?????? ????-?.
????????, ?????? ?????? ????? ???????????? ??????? ??????? ? ????????? ? ???????? ??????
?????????? ?????????, ??????????? ?? ????????????? ???????????????? ????????.
???????? ?????: ?????????? ????????????; ????-?; ??-6; ???I; ??????????? ????????.
PLASMA PROTEIN A: IS THERE DIAGNOSTIC AND PROGNOSTIC VALUE IN CORONARY ARTERY
BYPASS SURGERY?
L.A. Bockeria, V.Yu. Merzlyakov, D.Sh. Samuilova, I.V. Klyuchnikov, L.S. Selimyan, I.Yu. Sigaev,
N.A. Darvish, A.I. Skopin
??????????? ?????????? ??????????????, ? 4, 2013
??????? ??? ?????????, ?????? ???. ????, ?????????, ???????? ??? ? ????, ????????;
????????? ????? ???????, ?????? ???. ????, ?????????? ?????????? ?????????????? ???????
??????????? ??????? ?????? ? ?????????????? ?????????? ???????? (????? ? ????);
????????? ????? ??????????, ?????? ????. ????, ?????????? ???????-????????????? ????????????;
????????? ???? ????????????, ?????? ???. ????, ?????????, ??. ????. ????.;
??????? ????? ??????????, ????????; e-mail: lianasel@mail.ru;
?????? ????? ???????, ?????? ???. ????, ?????????, ?????????? ?????????? ???????? ??????????
??????????? ?????????? ? ????????????? ???????;
?????? ????? ?????????, ???????? ???. ????, ?. ?. ??????????? ?????????? ?????????????? ???????
????????? ????????? ??????????????;
?????? ????? ????????, ???????? ???. ????, ???. ??????????? ?????????? ????? ? ????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
40
????????????? ??????????????
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Sciences;
Rublevskoe shosse, 135, Moscow, 121552, Russia
Bockeria Leo Antonovich, MD, DM, Professor, Academician of the Russian Academy of Sciences and Russian Academy
of Medical Sciences, Director;
Merzlyakov Vadim Yur'evich, MD, DM, Chief of Department of Surgical Treatment of Ischemic Heart Disease and Minimally
Invasive Coronary Surgery;
Samuilova Daniya Shavketovna, Dr. of Biol., Chief of clinical biochemistry laboratory;
Klyuchnikov Ivan Vyacheslavovich, MD, DM, Professor, Chief Researcher;
Selimyan Liana Samvelovna, Graduate Student;
Sigaev Igor' Yur'evich, MD, DM, Professor, Chief of Department of Surgery for Concomitant Occlusive Diseases of the Coronary
Arteries and Great Vessels;
Darvish Nidal Akhmedovich, MD, PhD, Acting Chief of Department of Surgical Procedures for Cerebrovascular Diseases;
Skopin Anton Ivanovich, MD, PhD, Deputy Chief of Department of Surgical Treatment of Ischemic Heart Disease and Minimally
Invasive Coronary Surgery
Objective of the study is to evaluate the relationship between plasma protein-A level and the severity of vessel wall damage in coronary artery bypass graft surgery (CABG) and in combined coronary artery bypass graft surgery and endarectomy for brachiocephalic arteries, as well as the severity of systemic inflammatory response and the presence of postoperative complications.
Material and methods. The study was conducted on 55 patients with a leading diagnosis of coronary artery disease.
Patients were divided into three groups on the basis of the type of surgical procedure performed. Group 1 patients (n=22)
underwent on-pump coronary artery bypass graft surgery (CABG with cardiopulmonary bypass) under conditions of
chemical hypothermic cardioplegia, group 2 patients (n=23) ? off-pump coronary artery bypass graft surgery, group 3
patients (n=10) ? simultaneous off-pump coronary artery bypass surgery and carotid endarectomy with xenopericardial
patch repair.
The dynamic changes in PAPP-A (Pregnancy-Associated Plasma Protein A) levels were analyzed before and after surgery.
The amount of cardiac troponin I (cTpI) was measured concurrently to control perioperative myocardial damage, and
serum IL-6 levels were tested in order to evaluate postoperative systemic inflammatory response.
Results. Serial measurement of PAPP-A levels in the early postoperative period didn't show any significant changes compared with preoperative values.
Conclusion. The study of dynamic changes in PAPP-A levels didn't reveal any significant increase in the postoperative
measurements of this indicator examined both within the groups and between the groups compared to those in preoperative period. There were no relationship determined between PAPP-A, ???I and IL-6 levels, even in cases of large degree
of discrepancy between the observed values and normal values of these indicators which characterize myocardial damage and systemic inflammatory response. The study found different levels of systemic inflammatory response (IL-6) in the
examined patients associated with the presence of acute kidney injury in the immediate postoperative period. However,
when patients were divided into study groups based on the presence or absence of acute kidney injury in the postoperative period there was no correlation with PAPP-A levels revealed either.
Perhaps, this marker will be more relevant in patients with pre-existing acute coronary syndrome admitted for myocardial
revascularization.
Key words: coronary artery bypass graft surgery; ????-?; IL-6; ???I; myocardial damage.
??????????? ?????????? ??????????????, ? 4, 2013
????????
??????????? ???????? ? ??? ??? ???? ??????? ??????????? ?????????? ????? ?????
???????? ???????? ?? ??????. ? ??????????????? ????? ?????? ??????? ???????? ?????
??????? ??????????? ????????, ???????, ???
???????, ????????? ?? ?????? ??????????????????? ??????????? ? ????? [1?4].
? ??????????? ????? ?????? ?????? ???????? ????? ????????? ???????? ?????????,
??????????? ? ??????????? ????????. ???????? ??? ????? ??? ?????????? ???????????? (??) ? ??? ?????????????? ?????????????? ????????? ??????????, ?????????
? ????????? ?????????? ??????? ??? ??????.
? ????????? ???? ?????????? ???????
? ????-? (pregnancy-associated plasma protein
A), ??????????? ???????? ?, ???????????????? ? ?????????????, ??? ??????? ?????????????? ??????????????????? ??????
? ??????????????? ?????? ? ????????? ? ?????? ?????????? ????????? (???) [5?8].
????-? ? ?????????????? ?????????? ??-
??????????????? [9], ??????????? ?? ???????????? ?????? ???????????? ? ????????????
????????? I ????????? ???????????? ??? ?????? ??????????? ???????? ? ?????. ???? ????? ????????????? ????????????????????,
?????????????, ???????????? ???????? ???????? ?????, ? ????? ??????????????? ???????? ???????. ????-? ????????? ???? ???????? ?? ???????????????? ?????? ????? (IGF)
????? ??????????? IGF-???????????? ?????-4 (IGFBP-4), ??????? ???????? ????? ??
????? ???????????? IGF. ?????????, ??? ??????????? IGFBP-4 ??? ???????????? ????-?
???????? ?????? ??? ??????? IGF [10].
??????? ??????????????? ???????? ?????
????? ???????? ???????? ?????? ? ?????????? ???????? ? ??????????? ????????????
????-? ? ?????. ? ?????????? ????? ???????
????????? ? ??????????????? ???????? ?????????? ?????? ????-? ? ????? ? ?????????
?? ?????????? ???????? ??????????? ??????? ?????? (???) ???????????? ????? ????????????? ????????? ????????-?????????? ??????? [11, 12].
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ?????????? ???????????? ???????
?????? ??????????? ?????? ???????????
???????? ? ?? ??????? ??????????? ?????????? ?????? ??? ?????????? ????????????
? ??? ?????????? ???????????? ? ????????? ? ???????????????? ?? ???????????????
???????, ? ????? ?? ??????? ????????????
?????????? ??????????????? ?????? ? ??????????? ????????????????? ??????????.
???????? ? ??????
? ???????????? ???? ???????? 55 ????????? ? ???. ? ??????????? ?? ????????? ??????????? ???????? ??? ??????? ???? ????????? ?? ??? ??????. ????????? 1-? ??????
(n=22) ???? ????????? ?? ? ???????? ??
? ???????????????? ????????????, 2-? ?????? (n=23) ? ?? ?? ?????????? ??????, 3-?
?????? (n=10) ? ?? ?? ?????????? ??????
? ?????????? ??????????????? (????) ? ????????? ???????????????????? ????????.
?????????? ?????????? ?? ????????????
???? ??????? ? ???????? ??????? ?????????
????????? ?????????????? ? ??????? ????????? 6 ???, ????????? ???????? ?? ??????,
??????? ???????? (??) ? ??????? ?????????
30 ????, ???????????? ???????????, ???????
??????? ?????? ????????? ????? 35%, ????????????????? ????????????? ? ??????? ????????? 3 ???, ????????? ?????? ?????????,
??????? ????????? ?????????, ?????????
????????????? ?????????.
????? ?????? ?????? PAPP-A ??? ???????? ?? ???????????????? ???????????? ???????? ??? ??????????? ?????????? ????????? ???????? I (???I), ? ??? ?????? ?????????????????? ?????????? ???????????????
?????? ???? ???????????????? ???????????? ???????? ??-6.
???????????? ??????????? ????-?, ???I
? ??-6 ??????????? ?? ?????????????? ???????????????????????? ??????????? IMMULITE 2000 (Siemens Healthcare
Diagnostics, ??? ? ????????). ?????? ??????? ???????????????? ?????? ??? ????-?
?????????? 0,03 ???/?, ??? ???I ? 0,2 ??/??,
??? ??-6 ? 2 ??/??.
???????????? ???????????? ?????? ?????????, ??????????, IgG ? ?????????????? ??????????? ??????????? ?? ??????????????
????????????? ??????????? AU-400 (Olympus,
??????).
????? ????? ? ????????? ????????????? ??
????????, ?? 1-?, 3-? ? 7-? ??? (? ?????????
? ?????????????????? ???????????? ? ??
41
14-? ???) ????? ????????, ? ????? ????? ???????? ? 8.30 ?? 9.30. ??? ??????? ???? ??????????? ? ??????? 3 ? ????? ?????? ?????.
??? ??????????? ???????????? ????????
???????????? ????????? ????????? ???????? ????????, ???????? ???????????? ??????????? ?????????.
???????? ?????????? ?????????? ????
??????????????? ???????????? ??????????? ? ?????????????? ????????? ???????
[13]: (????????????????? ????????) ?? = (??????????? ????????) ?? в IgG (??)/IgG (??).
???????????? ???????? ??????????? ?????????? (????) ?? ???????? ????????????
? ??????? ????????????????? 4?v MDRD
(Modification of Diet in Renal Disease Study)
????????? [14]: ???? [??/???/1,73 ?2] =175 в
в (???????????? ????????? [??????/?] в 88,4)?
?1,154 в (??????? [????]) ? 0,203 в (0,742 ???
??????) в (1,212 ??? ?????????????? ?????????? ????).
?????? ??????????? ????? (???) ????
??????????????? ??? ?????????? ????????????? ?????????? ? 50% ??? ?????
26,4 ??????/? ???????????? ???????? ???????? ? ??????? ?????? 48 ? ????? ????????.
????????????? ??? ? ??????????? ??
??????? ????????? ????????????? ?????????? ? ????????? ??????? ??????????????
????????? [15]:
? I ?????? ? ?????????? ?????????????
?????????? > 50?100% ??? ? ??????? ??????????? ?? 26,4 ??????/? ???????????? ???????? ????????, ?????? ? ????? 0,5 ?? /??/?
? ??????? 6 ?;
? II ?????? ? ?????????? ?????????????
?????????? > 101 ? 200% ???????????? ???????? ????????, ?????? ? ????? 0,5 ?? /??/?
? ??????? 12 ?;
? III ?????? ? ?????????? ?????????????
?????????? > 200%, ??? ???????? ????????????? ?????????? ? 354 ??????/? ? ???????
??????????? ?? ????? 44 ??????/? ???????????? ???????? ????????, ?????? ? ?????
0,3 ?? /??/? ? ??????? 24 ? ??? ?????? ? ??????? 12 ?.
?????????? ?????????? ???? ??????????
?? ?????????? ? ?????????????? ?????? ?????????????? ???????? ??????-?????????????? ??????? Statistica 6.0 (StatSoft Inc.,
???). ?????? ???????????? ? ???? ???????
???????? ?? ??????????? ???????????
(M╠?), ??????? ? ???????????????? ???????? (Me (IQR)) ??? ?????. ??? ?????????
????? ??????????? ?????? ????? ????????-
??????????? ?????????? ??????????????, ? 4, 2013
????????????? ??????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
42
????????????? ??????????????
???? ????????? ????????????? ???????? ?2.
?????? ?????????? ? ??????????? ??????????? ?????????????? ?????? ????? ?????
???????????? ????????? ????????????
? ?????????????? ???????? ????????????????, ????? ????? ? ? ?????????????? U???????? ???????????. ????????? ???????
???????? ????? ????? ???????? ?????????
? ??????? ANOVA, ????? ????? ? t-?????
??? ??????????? ???????. ???????????
?????????? ????????? ? ??????????????
???????? ?????????? ?? ????????. ?????????????? ???????? ????????? ????????? ???
?????? ?<0,05. ? ?????? ????????????? ????????? ???? ???????????? ????????? ?? ?????????? ???????? p ? 0,05/3 (0,02).
??????????? ?????????? ??????????????, ? 4, 2013
??????????
??????? ??????? ????????? ? 1-? ??????
???????? 58╠6 ???, ?? 2-? ? 55╠8 ???. ???????????? ???? ????????? ? 3-? ?????? ????????? ??????? ???? ? ???????? 66╠6 ???
(p<0,05 ??? ????????? ? 1-? ? 2-? ????????).
?? ???? ???? ??????? ??????????? ???????
???? ??????? (19/22, 19/23 ? 9/10 ??????????????, p>0,05). ? ????????????? ????? ????????? ???? ????? ???? II? ?????? ?? ????????????? ???????????????????, III ?? ??
NYHA, III ?? ??????????? ?????????? ??
CCS (p>0,05). ??? ???????? ???????? ?????
????????????? ???????????? ????????????
(p>0,05). ? ???? ??????? ??????? ?? ????????
??????????????? ????????? ???? (p>0,05).
????? ?????????, ?????????? ?? ??????
???????? ??????? ????????, ?????????
10/22, 13/23 ? 7/10 ? 1-?, 2-? ? 3-? ??????? ?????????????? (p>0,05). ? 4/22 ? 7/23 ???????
1-? ? 2-? ????? ?????????????? ? ? ???? ????????? 3-? ?????? ??????? ???????????????
???????? ??????????????????? ?????????
?????????? ?????????? ????????? (p<0,05 ???
????????? 3-? ?????? ? 1-? ? 2-? ????????).
???????????????? ????????? ?????????????
(?????) ?? ?????????????? ????????? 3, 4
? 2 ????????? 1-?, 2-? ? 3-? ????? ?????????????? (p>0,05). ?? ?????? ??????????????
??????????????? ???????? ??????????????
????????? ????? 12, 11 ? 7 (p>0,05) ???????, ????????? ?????? ??? ????? 50% ? 2, 4
? 1 ??????? ? 1-?, 2-? ? 3-? ??????? ?????????????? (p>0,05).
??????? ?????????????? ??????????? ??
???????? ? ???? ????????? ????????? ? ???????? ????? ? ????????????? ?????????????
????????? ????? ????????.
???????????? ???????? ???????????
?????????? ? ??????????? ????????? ??
???????? ? ???? ??????? ????????? ?????
60 ??/???/1,73 ?2 (p>0,05). ???????????
??????? ????? (???) III ?????? ????? 4 ???????? ?? 1-?, 3 ???????? ?? 2-? ? 2 ???????? ?? 3-? ?????.
??????? ???? ?? ????????, ??????????????? ????????????? ??????? ?????????
??? ??? ????? 2,5 ?????/?, ??? ? 3 ????????? 1-?, 3 ? 2-? ? 2 ? 3-? ?????. ? ?????????
????????? ?? ??? ??????? ? ????????
4,4╠1,0; 4,8╠1,1 ? 4,0╠0,5 ?????/? ?????????????? (p>0,05).
?????? ???????????????? ? 1-?, 2-? ? 3-?
??????? ???????? 2,9╠0,5; 3,1╠0,8 ? 2,8╠0,7
?????????????? (p>0,05). ??????? ????????????????? ???????? ??? ?? ?? ??????????
?????? (5,4╠1 ?) ???? ??????????? ??????,
??? ??? ?? ? ???????? ?? (6,1╠1,1 ?) ? ???
?? ?? ?????????? ?????? ? ?????????????
???? (6,3╠1 ?) (p<0,05). ?????????????????
?? ????????? 98╠25 ???, ????????? ????? ?
53╠15 ???. ? 8 ????????? ?? 1-? ?????? ????????? ???? ????????????? ????? ????????????? (p<0,05).
????????????????? ????????????? ?????????? ?????? (????) ???? ???????????
?????? ? 1-? (17 (10; 19)) ? 3-? (9,5 (9; 12,5))
??????? ?? ????????? ?? 2-? (7 (5; 9))
(p<0,001). ??????????? ? ????????????????
????????? (???) ????? ???? ???????????
???? ? 1-? ?????? (2 (1; 3)) ?? ????????? ??
2-? (1 (0,5; 1)) ? 3-? (1 (1; 1,5)) ????????
(p<0,001).
???????? ????????? ???????? ????-?
? ?????? ????????????????? ??????? ?? ???????? ???????? ????????? ?? ?????????
? ?????????????? ????????? (???. 1).
????????? ???????? ???I ? ???? ?????????
???? ????? 0,2 ??/??. ?? ???? ?????? ????????? ???????? ???I ???? ????????????? ??????? ???? ? 1-? ?????? ?? ????????? ?? 2-?
? 3-? ???????? (?<0,02) (???. 2).
???????? ??????????? ??????? ?????????? ???????? ???I, ? ???? ????????? ?? 1-?
?????? ?? 1-? ??? ??? ????????? 185 ??/??
? 162 ??/??, ??? ???? ??????????? ?????????
??????? ???????? ???????? ? ??? II ??????? ? ?????? ????????????????? ???????
(??????? ??? ????????? ?? ????????? ??????????????????? ? ???????? ????????? ??
???). ??????? ???????? ???? ?????????
?????????? ????????????? ????, ??????? ? ????????????? ? ??? ???. ???????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
43
0,035
0,03
0,025
0,02
0,015
0,01
0,005
0
?0
?1
?2
1-? ??????
2-? ??????
?3
3-? ??????
???. 1. ???????? PAPP-A (???/??): ?0 ? ?? ????????, ?1 ? ?????? ????? ????? ????????, ?2 ? ?????? ????? ?????
????????, ?3 ? ??????? ????? ????? ????????
25
20
15
10
*
5
*
*
?0
?1
1-? ??????
?2
2-? ??????
?3
3-? ??????
???. 2. ???????? ????????? I (??/??): ?0 ? ?? ????????, ?1 ? ?????? ????? ????? ????????, ?2 ? ?????? ????? ?????
????????, ?3 ? ??????? ????? ????? ????????.
* ? < 0,02 ??? ????????? 1-? ?????? ?? 2-? ? 3-? ????????
??? ???????? ?T?I ? ?????? ????????? ????
?????????: 47,9 ? 14,4 ??/??; 8,5 ? 0,75 ??/??;
0,69 ? <0,2 ??/?? ?? 3-?, 7-? ? 14-? ??? ?????
????????. ????????????????? ?????? ? ????
????????? ????????????? ?????????? ????????? ????????????? ????????? ? ???????
? ?????????????? ????????, ??????????
??????? ??????????? ???????, ? ? ???????
????????. ???????? ?? ????????? ??????
????????? ??????????, ? ???? ????????? ????? ???????????? ?????????????? ????????????? ?? ???????? ???????? ?????? ????-?
? ?????? ???????.
???????? ??????????? ??????? ??????????
???????? ???I, ? ????? ????????? ?? 2-? ?????? ??? ???????? ?? 1-? ??? ????????? 34,4 ??/??.
?????? ????????????????? ?????? ? ????
??????? ???????? ? ????????? ??? I ??????? ? ?????? ????????????? ????????? ???????????????, ????????? ????????????????
????????? ? ??????? 2 ???. ? 7-? ??? ????????
???I ???? <0,2 ??/??.
?????? ????????????????? ?????? ? ?????? ???????? ?? 2-? ?????? ?? 6-? ??? ?????
???????? ?????????? ????????? ??????
???????? ????????????? ??????????????,
???????????????? ?????????? ?????????????? ??????? ? ??? II ??????. ????
??????????? ????? ????????? ??????????
?T?I, ???????? ???????? ?? 7-? ??? ?????????
0,34 ??/??.
?? ??????????? ??????? ?????????? ???????? ???I ? ?????? ???????? 79 ??? ? ???
II ?????? ?? 3-? ?????? ??? ???????? ???????-
??????????? ?????????? ??????????????, ? 4, 2013
0
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
44
????????????? ??????????????
100
90
80
70
60
50
40
30
20
10
0
?0
?1
1-? ??????
?2
2-? ??????
?3
3-? ??????
???. 3. ???????? ??-6 (??/??): ?0 ? ?? ????????, ?1 ? ?????? ????? ????? ????????, ?2 ? ?????? ????? ????? ????????,
?3 ? ??????? ????? ????? ???????? (p>0,05)
?????????????? ?????????, ??????/?
280
260
240
220
200
180
160
140
120
100
80
??????????? ?????????? ??????????????, ? 4, 2013
60
0
20
40
60
80
100
120
140
160
??-6, ??/??
r=0,5; p<0,01
???. 4. ?????????????? ????? ????? ?????????? ????????????? ?????????? ? ??-6
?? 41,5, 10 ? 0,3 ??/?? ?? 1-?, 3-? ? 7-? ??? ????? ????????. ????????????????? ??????
? ????? ???????? ?????????? ??? II ??????
? ????????????? ?????????.
??? ??????? ???????? ??-6 ?? ???? ??????
????????? ?? ?? ??????? ????????????? ???????? ???????? ? ???? ??????? (???. 3). ?????
?? ??????? ????? ????? ??????? ??-6
? ????-? ?? ??????? ?????????.
?????? ???? ?????????? ?????????????
???????? ????????? ??????????? ????? ????????????? ?????????? ??-6 ? ????????????? ?????????? (r=0,5; p<0,01) (???. 4). ????? ???????? ??????? ????????????? ???????, ??????????? ? ????????? ??-6 ? ???I.
? ????? ? ???? ?? ????????? ?????????????? ????????? ????????? ?? ??? ?????? ?
? ???????? ????????????????? ????????
?????????? ? ??? ??? ? ???????????????? ?????????? ???????????? ?????????? ??????????????? ??????. ?????? ???????????? ? ???????.
??? ????? ?? ???????, ???????? ??-6
? c??I ????????????? ??????? ???? ? ????????? ? ???. ?? ???? ???????? ????? ?????
??????? ????-? ? ??-6 ?? ??????? ? ???????????? ??????? ????????? ???????????
? ???????? ???????????????. ??????? ????????, ??? ??????? ??????? ????????? ??? ???? ? ?????? ? ??? (p<0,03). ? ???? ????????? ? ????????? ??? ?????????????????
?????? ?????????? ???. ?????????????
?????? ???? ????? ????????? ???????, ???
??? ???? ??????????? ????? ?? ? ????????
?? ? ?? ?? ?????????? ?????? ? ????????????? ????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
45
????????????? ??????????????
????????????? ????????? ? ??????????? ?? ??????? ??????? ??????????? ?????
? ????????????????? ???????
??????? ???????, ??? (M╠SD) (min?max)
??? (n=31)
??? ??? (n=24)
?
61╠8 (49?79)
56╠9 (45?74)
0,03
???????? ??????
6 (19%)
2(8%)
0,25
??????????????? ????????????
16 (52%)
5 (21%)
0,02
??????????? ????????????? ??????? ??????
3 (10%)
2 (8%)
0,8
????????? ????? ?????
6 (19%)
3 (13%)
0,6
?????????????? ?????????????
20 (65%)
13 (54%)
0,4
??????????? ??????? ?????
10 (32%)
?
0,0035
?? ? ??
14 (45%)
8 (33%)
0,37
?? ?? ?????????? ??????
10 (32%)
13 (54%)
0,1
?? ?? ?????????? ?????? + ????
7 (23%)
3 (13%)
0,35
71 (46; 81)
33 (15; 58)
<0,01
9 (4; 20)
3 (2; 7)
<0,01
??-6, ??/?? (Me (IQR))
?T?I (??? ????? ???????? ??? ???), ??/?? (Me (IQR))
????????????????? ??
?????????? ? ????, ??? (Me (IQR)) (min; max)
?????????? ? ??????????, ??? (Me (IQR)) (min; max)
????????? ?? ????????, ??????/? (M╠SD)
2 (6%)
0
0,2
1 (1; 2) (1;9)
1 (1; 1) (1;2)
>0,05
8 (7; 15) (5; 35)
8 (7; 11) (6; 14)
>0,05
101╠16
85╠16
<0,001
???????????? ???????? ????????????? ??????????, ??????/?
(M╠SD)
199╠62
113╠16
<0,0001
???????????? ????????? ??? ???????, ??????/? (M╠SD)
129╠35
102╠14
<0,001
?????? ????????? ???????????????
5 (16%)
?
0,04
??????????? ???????????????
3 (10%)
?
0,1
?????????
3 (10%)
?
0,1
???????
11 (35%)
1 (4%)
0,01
??????? ?????????? ??????? ????
4 (13%)
1(4%)
0,25
????????? ????? ??????
3 (10%)
?
0,1
??????? ????????
6 (19%)
?
0,03
????????????????? ?????????????
2 (6%)
?
0,2
???????? ????????????? ??????????????
1 (3%)
?
0,4
??????????
?????? ?????? ??? ??????????? ???????? ????? ???????? ?? ????? ??????????? ??
???? ??????, ????????? ? ?????????? ?????????????? ?????????? ???????: ???????
??????, ???????? ???????????????? ????????, ????? ?????????? ???????, ??????????
??????, ??????????????? ?????? ???? ?????
?????????? ? ??????. ??????????? ??????
???????? ? ???? ?????? ????? ???? ?????? ????????????????, ? ????????? ?????? ????????? ??????????????? ? ???????????????
????????? ????? ??????. ???????????????
????? ???????? ?????? ???????? ? ????????? ????????????????? ??????? ????????
?????????? ???????.
????? ????????????, ??? ??????? ??????????? ?????????? ?????? ?? ????? ???????? ??????????? ???? ???????? ?????? ?????? ????????, ????????? ? ?????????? ???-
?????. ??????????? ??????? ??????????? ?????????? ?????? ?? ???? ??????????? ????????????? ????? ????????? ??????, ????????
? ????????? ???????????????? ???????
??? ?????????? ??????????? ????????????.
??????????? ??????????? ???????????????
???????, ? ??? ????? ????????????, ????????? ???????????. ? ????????????? ????????
??????????? ?????????? ?????? ????????????? ???????? ?????????????? ??????? ???????? ? ????????? ????????????????? ???????.
???????? ??????????? ??????????????,
?????????? ???????, ??????????????? ? ?????????????, ???????? ?????????? ??????????? ?????????? ?????? ???????????????????
?????????. ?????????? ??????? ???????? ??????????? ?????? ??????? ??????????? ?????????? ?????? ?? ????? ???????? ??? ? ??????????? ?? ????? ????????? ????? ????????
?????? ???????? ? ???????????? ???????????????? ????????????. ?????? ??????-
??????????? ?????????? ??????????????, ? 4, 2013
????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
46
????????????? ??????????????
??? ? ??????? ????? ??? ?????????? ?????????? ????????????.
??????????????????? ?????? ???????????? ????? ???????????? ?????????, ?????????????? ???????????? ???????????????.
?????????????? ??????? ? ???????????? ??????? ???????????? ?????? ????? ???????????? ? ??????????? ?????????, ??? ??????????
???????????? ? ??????? ???????????????????
??????. ???????? ? ?????????????? ??????
???????? ?????? ???? ????????? ? ?????????????? ?????? ? ????? ??????????, ???????,
??????? ???????? ??????????? ???????????? ????????? ???????????? ? ?????? ???????, ???????????? ?? ???????????? ????????
???? ?????? ???????????? ?????????????
???????? [17]. ? ???? ???????, ?????????????? ?????? ? ????????? ??? ????????????
????????????????? ????????? ? FAS-???????? ????? ???????????? ???????? ?????? ??????????????????? ??????. ???????? ?????
??????????? ????????? ????????? ???????????????? ???????????. ??? ???????? ???????? ?????????? ?????????, ??? ?????
?????????? ??????? ?????????? ??????????????????? ?????? ? ???????????? [18]. ??????????, ??????? ?????? ????? ?????????????????? ? ?????????????????? ??????????
?????????, ????? ????? ?????????????? ??????????? ????????. ????? ???????, ?????????????? ?????? ??? ???????????? ????????????????? ????????? ???????? ????????
??????, ?????????? ????????????????
??????????, ? ????? ?????????????? ?????????????? ??????????????????? ??????. ?????? ????????, ??????????? ???????? ?????????? ?????? ?????????? ????????????? ? ????? ???????? ? ???????? ??????? ???????????
????????, ?? ????? ??? ?? ??????. ????? ????, ??????? ??????????????????? ?????? ??
??????????? ????????? ? ???????????? ??
?????? ?????????????? ???????????? ?????????? [7].
????????? ????????????? ???????? ??????????????? ???????? ????-? ??? ????????? ╚????????╩ ?????? ? ????????? ?? ?????????? ???????? ??? [19], ??? ???? ??????????? ?????? ??????? ???????????????,
?? ????????????? ??? [11].
?? ????????? ???????????? ?????? ????
???? ??????????? ??????? ??????? ??????????? ??????? ??????????? ?????????? ?????? ?? ????? ????????, ??????? ??????????
??????????????? ?????? ? ??????????? ?????????? ? ??????? ????-?. ???????? ??-
?? ????????? ?? ?????? ? ??????????? ??
???????????? (? ?? ??? ??? ??) ? ?????????????????? (????????????? ???????? ??
??? ? ????????? ? ???????????????? ?? ?????? ???????) ?????????????. ?? ?? ???????? ???????????? ?????????? ?????? ???????????? ?????????? (????-?) ? ???????? ?????
???????? ?? ????????? ? ??????????????
??????? ?? ????????? ???????, ? ????? ????? ????????. ?????????? ????-? ??? ?????????? ????????? ??? ? ??????? ??????????
?????????????????? ??????? ? ?? ???? ??????????????? ??????????. ?? ???? ????????
??????????? ?????? ????-? ? ???I, ? ?????
??-6, ???? ??? ?????????? ??????????? ??
????? ???? ???????????, ???????????????
??????????? ???????? ? ????????? ?????????????? ?????. ? ?????? ????????????? ????
??????? ???? ???????? ???????? ?? ??????
?????????? ??????????????? ?????? (??-6)
? ??????????? ?? ??????? ??????? ??????????? ????? ? ????????? ?????????????????
???????. ? ???????????????? ??????? ?????
?????? ????????, ??? ???????????? ? ????????????????? ?????? ????????, ??????, ????? ???????? ? ?????????? ????????????????? ??????, ???, ? ???? ???????, ????????????
???????? ????????? ????????? ? ????????
??????????? ??????????. ?? ????? ????????
???????? ?? ?????? ???????? ????? ?????????????? ?????????? ??????? ??????? ?????,
???????????? ????? ???????? ???????? [19].
???? ????????, ??? ??? ???? ??????????? ????? ?? ? ???????? ?? ? ?? ?? ?????????? ?????? ? ????????????? ????.
?? ?????? ?????? ???, ????????, ???? ???????
? ????????? ???????. ??????????? ????????? 3-? ?????? ????????? ??????? ????,
? ???????, ??? ????????, ?????????? ?? ??????? MDRD ?? ?????? ?????. ????? ???????, ????????, ?????? ???????? ???????
????? ???????????? ???????? ??????, ? ?????????????? ??????????? ?????? ????????????? ???????? ? ??? ???.
?????? ??? ?????????? ????????? ?? ?????? ?? ???????? ??????? ??? ?????????? ???
? ????????????????? ??????? ????? ?? ????
???????? ??????????? ? ??????? ????-?.
??????????
? ???? ???????????? ???????????? ?? ??
???????? ?????? ? ?????? ???????????????
??????????????? ??????????? ?????? ????-?
????? ???????? ?? ??? ?????? ????? ???????? ??????????? ???????? ? ???????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
19.
References
1.
2.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Thygesen K., Alpert J.S., Jaffe A.S., Simoons M.L., Chaitman B.R.,
White H.D. Third universal definition of myocardial infarction.
Circul. 2012; 126 (16): 2020?35.
Jaffe A.S., Ravkilde J., Roberts R., Naslund U., Apple F.S.,
Galvani M. et al. It's time for a change to a troponin standard.
Circul. 2000; 102 (11): 1216?20.
Tuman K.J. Perioperative myocardial infarction. Semin.
Thorac. Cardiovasc. Surg. 1991; 3 (1): 47?52.
Libby P., Ridker P.M., Maseri A. Inflammation and atherosclerosis. Circul. 2002; 105 (9): 1135?43.
?????? ?.?., ?????????? ?.?., ??????? ?.?., ????????? ?.?. ??????????????????? ?????????? ? ??????????? ? ??????????????. ????? I. ????? ??????????????
???????????. ???????. ? ????.-?????. ???. 2010; 3: 26?33.
?????? ?.?., ?????????? ?.?., ??????? ?.?., ????????? ?.?., ????????? ?.?. ??????? ??????????? ????????
? ??????????? ? ??????????????. ????? II. ???????. ?
????.-?????. ???. 2010; 4: 10?6.
Bayes-Genis A., Conover C.A., Overgaard M.T., Bailey K.R.,
Christiansen M., Holmes D. et al. Pregnancy-associated plasma
protein A as a marker of acute coronary syndromes. N. Engl. J.
Med. 2001; 345 (14): 1022?9.
Blake G.J., Ridker P.M. Novel clinical markers of vascular wall
inflammation. Circ. Res. 2001; 89 (9): 763?71.
Lawrence J.B., Oxvig C., Overgaard M.T., Sottrup-Jensen L.,
Gleich G.J., Hays L.G. et al. The insulin-like growth factor
(IGF)-dependent IGF binding protein-4 protease secreted
by human fibroblasts is pregnancy-associated plasma protein-A. Proc. Natl. Acad. Sci. USA. 1999; 96 (6): 3149?53.
Overgaard M., Haaning J., Boldt H., Olsen I.M., Laursen L.S.,
Christiansen M. et al. Expression of recombinant human pregnancy-associated plasma protein-a and identification of the
proform of eosinophil major basic protein as its physiological
inhibitor. J. Biol. Chem. 2000; 275 (40): 31128?33.
Elesber A., Conover Ch., Denktas A., Lennon R.J., Holmes D.R. Jr,
Overgaard M.T. et al. Prognostic value of circulating pregnancy-associated plasma protein levels in patients with chronic
stable angina. Eur. Heart J. 2006; 27 (14): 1678?84.
Futterman L.G., Lemberg L. Novel markers in the acute coronary syndrome: BNP, IL-6, PAPP-A. Am. J. Crit. Care. 2002;
11 (2): 168?72.
Bruins P., de Velthuis H., Yazdanbakhsh A.P., Jansen P.G., van
Hardevelt F.W., de Beaumont E.M. et al. Activation of the
complement system during and after cardiopulmonary bypass
surgery. Circul. 1997; 96 (10): 3542?8.
Levey A.S., Coresh J., Greene T., Stevens L.A., Zhang Y.L.,
Hendriksen S. et al. Using standardized serum creatinine values
in the modification of diet in renal disease study equation for
estimating glomerular filtration rate. Ann. Intern. Med. 2006;
145 (4): 247?54.
Mehta R.L., Kellum J.A., Shah S.V., Molitoris B.A., Ronco C.,
Warnock D.G. et al. Acute kidney injury network: report of an
initiative to improve outcomes in acute kidney injury. Crit.
Care. 2007; 11 (2): R 31.
?????? ??. ?????????????? ?????: ???. ? ????. ?.: ?????; 2010.
Schwartz S.M., Virmani R., Rosenfeld M.E. The good smooth muscle cells in atherosclerosis. Curr. Athero. Rep. 2000; 2 (5): 422?9.
Loree H.M., Kamm R.D., Stringfellow R.G., Lee R.T. Effects
of fibrous cap thickness on peak circumferential stress in
model atherosclerotic vessels. Circ. Res. 1992; 71 (4):
850?8.
Schoenhagen P., Stone G.W., Nissen S.E., Grines C.L., Griffin J.,
Clemson B.S. et al. Coronary plaque morphology and frequency of ulceration distant from culprit lesions in patients with
unstable and stable presentation. Arterioscler. Thromb. Vasc.
Biol. 2003; 23 (10): 1895?900.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Thygesen K., Alpert J.S., Jaffe A.S., Simoons M.L., Chaitman B.R.,
White H.D. Third universal definition of myocardial infarction.
Circul. 2012; 126 (16): 2020?35.
Jaffe A.S., Ravkilde J., Roberts R., Naslund U., Apple F.S.,
Galvani M. et al. It's time for a change to a troponin standard.
Circul. 2000; 102 (11): 1216?20.
Tuman K.J. Perioperative myocardial infarction. Semin.
Thorac. Cardiovasc. Surg. 1991; 3 (1): 47?52.
Libby P., Ridker P.M., Maseri A. Inflammation and atherosclerosis. Circul. 2002; 105 (9): 1135?43.
Charnaya M.A., Dement'eva I.I., Morozov Yu.A., Gladysheva V.G.
Cardiac-specific biomarkers in cardiology and cardiac surgery.
Part I. General characteristics of biomarkers. Kardiologiya i
serdechno-sosudistaya khirurgiya. 2010; 3: 26?33 (in Russian).
Charnaya M.A., Dement?eva I.I., Morozov Yu.A., Gladysheva V.G.,
Uryuzhnikov V.V. Markers of myocardial damage in cardiology
and cardiac surgery. Part II. Kardiologiya i serdechno-sosudistaya khirurgiya. 2010; 4: 10?6 (in Russian).
Bayes-Genis A., Conover C.A., Overgaard M.T., Bailey K.R.,
Christiansen M., Holmes D. et al. Pregnancy-associated plasma
protein A as a marker of acute coronary syndromes. N. Engl. J.
Med. 2001; 345 (14): 1022?9.
Blake G.J., Ridker P.M. Novel clinical markers of vascular wall
inflammation. Circ. Res. 2001; 89 (9): 763?71.
Lawrence J.B., Oxvig C., Overgaard M.T., Sottrup-Jensen L.,
Gleich G.J., Hays L.G. et al. The insulin-like growth factor
(IGF)-dependent IGF binding protein-4 protease secreted by
human fibroblasts is pregnancy-associated plasma protein-A.
Proc. Natl. Acad. Sci. USA. 1999; 96 (6): 3149?53.
Overgaard M., Haaning J., Boldt H., Olsen I.M., Laursen L.S.,
Christiansen M. et al. Expression of recombinant human pregnancy-associated plasma protein-a and identification of the
proform of eosinophil major basic protein as its physiological
inhibitor. J. Biol. Chem. 2000; 275 (40): 31128?33.
Elesber A., Conover Ch., Denktas A., Lennon R.J., Holmes D.R. Jr,
Overgaard M.T. et al. Prognostic value of circulating pregnancy-associated plasma protein levels in patients with chronic
stable angina. Eur. Heart J. 2006; 27 (14): 1678?84.
Futterman L.G., Lemberg L. Novel markers in the acute coronary syndrome: BNP, IL-6, PAPP-A. Am. J. Crit. Care. 2002;
11 (2): 168?72.
Bruins P., de Velthuis H., Yazdanbakhsh A.P., Jansen P.G.,
van Hardevelt F.W., de Beaumont E.M. et al. Activation of the
complement system during and after cardiopulmonary bypass
surgery. Circul. 1997; 96 (10): 3542?8.
Levey A.S., Coresh J., Greene T., Stevens L.A., Zhang Y.L.,
Hendriksen S. et al. Using standardized serum creatinine values
in the modification of diet in renal disease study equation for
estimating glomerular filtration rate. Ann. Intern. Med. 2006;
145 (4): 247?54..
Mehta R.L., Kellum J.A., Shah S.V., Molitoris B.A., Ronco C.,
Warnock D.G. et al. Acute kidney injury network: report of an
initiative to improve outcomes in acute kidney injury. Crit.
Care. 2007; 11 (2): R 31.
Sheyman J. Renal pathophysiology: Translation from English.
Moscow: Binom; 2010 (in Russian).
Schwartz S.M., Virmani R., Rosenfeld M.E. The good smooth muscle cells in atherosclerosis. Curr. Athero. Rep. 2000; 2 (5): 422?9.
Loree H.M., Kamm R.D., Stringfellow R.G., Lee R.T. Effects of
fibrous cap thickness on peak circumferential stress in model
atherosclerotic vessels. Circ. Res. 1992; 71 (4): 850?8.
Schoenhagen P., Stone G.W., Nissen S.E., Grines C.L., Griffin J.,
Clemson B.S. et al. Coronary plaque morphology and frequency of ulceration distant from culprit lesions in patients with
unstable and stable presentation. Arterioscler. Thromb. Vasc.
Biol. 2003; 23 (10): 1895?900.
????????? 02.09.2013
??????????? ?????????? ??????????????, ? 4, 2013
??????????????? ??????????, ?????????
? ????????? ?????????????? ???????, ???????????? ? ?????????? ??????? ?????.
???, ????????, ??????? ? ???????????? ???????????? ???????, ?????????? ??????? ????????? ? ??????????? ???. ????????, ?????? ?????? ????? ???????????? ??????? ??????? ? ????????? ? ???????? ??????
?????????? ?????????, ??????????? ?? ????????????? ???????????????? ????????.
47
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
48
????????????? ??????????????
╘ ????????? ???????, 2013
??? 615.38:616.12-053.36-089
??????? ?????????? ??????????? ?????????? ????? ?? ???????
?????????? ??????????????? ?????? ? ??????????????
????????????? ? ????? ??????? ???? ?????
?.?. ??????, ?.?. ??????????, ?.?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ? ???????? ???
? ???? ?.?. ???????) ????; ?????????? ?????, 135, ??????, 121552, ??????
??????????? ?????????? ??????????????, ? 4, 2013
?????? ????? ??????????????, ??. ????. ????., e-mail: karen_osilov@yahoo.com
?????????? ????? ?????????, ?????? ???. ????;
????????? ??????? ??????????, ?????? ???. ????, ?????????, ?????????? ??????? ???????????
???????????? ???????????
???? ???????????? ? ???????????????? ??????? ??????????? ????? ?????? ???????, ???????????
??????? ? ?????????????? ??????????? ?????????????? ??????? ?????????? ??????? ?????? (???) ?
????????????? ? ????? ??????? ???? ?????, ? ??????? ?????????? ??????????????? ?????? ? ???? ????????? ?????????.
???????? ? ??????. ?????? ???????? ?? ??????? ??????? 234 ??????????????????? ?????????. ? ??????????? ?????? ???? ???????? 164 ????????, ? ??????? ??? ?????????? ??????? ??? ?????????????
?????????????? (??) ?????????????? ?????? ????????????????????? ????????????????? ??????
(???) ? ????????? ? ???????????? ??????? ?? ?????? ??????. ??????????? ?????? ????????? 70 ?????????, ? ??????? ??? ?? ?????????????? ??????????????????? ?????? ? ???????????? ?????? ?? ??????
???????. ???????????????? ?????? ????????? ?????????? ?? ?????? ????????????????? ?????????.
?????????? ????????????? ?????? ??????????? TNF-? (?????? ??????? ??????? ?), IL-8 (???????????-8)
? IL-10 (???????????-10) ?? ???? ?????? (?? ????????, 1-?, 3-?, 7-? ????? ????? ????????) ???????????? ?????????? ? ??????????? ? ??????????? ???????.
??????????. ?? I ????? ??????? TNF-? ???????? 8,3╠1,6 ??/?? ? ??????????? ?????? ? 8,6╠1,5 ??/?? ?
?????? ????????. ?? II ????? ??????????? ????????????? ??????????? ??????? ????? ?????????? ????
?????: ? ??????????? ?????? ??????? TNF-? ????????? ?? 26,2╠2,9 ??/??, ? ? ??????????? ?????? ? ??
47,7╠8,3 ??/??. ?? 7-? ???? ????? ???????? ??? ?? ?????????? ? ??????????? ?????? ????????
24,1╠4,2 ??/??, ? ? ??????????? ??????? ?? ??????? ?????? ? 41,1╠5,7 ??/??. ??????? IL-8 ?? IV ?????
????????? ? ??????? 70,9╠8,1 ??/?? ? ??????????? ?????? ? 104,7╠12,7 ??/?? ? ? ?????? ????????. ???? ?? ?????? ???? ?????? ???????????? ? ???? ??????? ??????? IL-10 ????????? ? ???????? ???????????
???????? (< 9,1 ??/??), ?? ?? IV ?????? ??? ??????? ? ??????????? ?????? ??????????? ????? ? ????????
?????????? ????? ? 1,5 ???? (14,3╠4,1 ??/??).
??????????. ?????? ??????????? ??????????? ?????????? ???????, ??? ?? ???? ?????????? ?????????? ??????????? ????? ???????????????? ?????? ???????? ?????? ? ??????????? ??????????? ????????? ?????? ? ??????????? ????????????????????? ??? ? ????????? ? ???????????? ??????? ?? ?????? ? ???? ?? ?????? ????????, ??????????, ???????????????? ????????????? ??????????? ????? ??
?????????? ??????? ?? ????? ????????????? ????????? ??????? ??? ? ???????? ?? ? ????????????? ?
????? ??????? ???? ?????.
???????? ?????: ????????????????????? ??????; ????????? ??????????; ?????????????; ????;
?????????? ??????????.
INFLUENCE OF TRANSFUSIONS OF ALLOGENEIC BLOOD COMPONENTS ON THE LEVEL
OF SYSTEMIC INFLAMMATORY RESPONSE IN NEONATES AND INFANTS OF THE FIRST YEAR OF LIFE
K.K. Osilov, R.G. Grigor'yants, N.N. Samsonova
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Sciences;
Rublevskoe shosse, 135, Moscow, 121552, Russia
Osilov Karen Konstantinovich, Junior Researcher;
Grigor'yants Rachik Gagikovich, MD, DM;
Samsonova Natal'ya Nikolaevna, MD, DM, Professor, Chief of Department of Clinical Laboratory Diagnostics
Objective of the study is to analyze the relationship between the number of donors who provided blood for transfusions
for surgical procedures for congenital heart disease in neonates and infants of the first year of life and the level of systemic inflammatory response in this category of patients.
Material and methods. The work was based on the study of the treatment of 234 cardiosurgical patients. The study group
included 164 patients, who received only virus-inactivated fresh frozen blood combined with erythrocyte suspension from
a single donor for the filling of circuit during extracorporeal circulation. The control group consisted of 70 patients who
received quarantined plasma and erythrocyte suspension from several donors during extracorporeal circulation.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
49
Immunological status of the patients was assessed by the level of anti-inflammatory cytokines. A comparative analysis of
the parameters TNF-? (tumor necrosis factor ?), IL-8 (interleukin-8) and IL-10 (interleukin-10) was conducted on all
stages (before surgery, on the 1-st, 3-d, 7-th post-operative days) of the clinical observation in the study group and control group.
Results. On the stage I TNF-? level was 8.3╠1.6 pg/ml in the study group and 8,6╠1,5 pg/ml in the control group. On
the stage II statistically significant difference was observed between two groups of patients: TNF-? level increased to
26.2╠2.9 pg/ml in the study group, and ? up to 47.7╠8.3 pg/ml in the control group. On the 7-th post-operative day the
same indicator was 24.1╠4.2 pg/ml in the study group, and it remained on the high level in the control group ?
41.1╠5.7 pg/ml. The mean IL-8 level on the stage IV was 70.9╠8.1 pg/ml in the study group and 104.7╠12.7 pg/ml in
the control group. If on the first three stages of the study the IL-10 level fluctuated within the reference range
(< 9.1 pg/ml), then on stage IV its level significantly increased in the control group and it exceeded 1.5 times the admissible norm (14.3╠4.1 pg/ml).
Conclusion. Analysis of our own clinical studies showed that in allogeneic blood transfusions immunological status of a
patient is related to the number of donated units of blood and the transfusion of virus-inactivated fresh frozen plasma
combined with erythrocyte suspension from a single donor is undoubtedly more preferable than the use of blood components from several donors during the surgical repair of complex congenital heart disease with extracorporeal circulation in
neonates and infants of the first year of life.
????????
????????-?????????? ???????? ????????
????? ?? ???????? ??????????????????? ???????? ???????? [1, 2]. ?? ?????? ??? ??????????? ???????? ?????????????? ?????????????????? ???????? ? ????????????????
??????? ??????????? ???????????????????
???????????? [3?7]. ???????????????? ?
???????????? ??????????, ????????? ? ??????????? ????????????, ?????????? ?????
4% ? ???????? ????? ?? ???????? ????????,
?????????? ??????????, ????????????????? ?????????????? ? ?????????? ? ?????????????? ????????????? ???????? [1, 2,
8?11]. ?????????? ??????????? ????? ??
?????????? ??????? ????? ??????????? ????
???????? ?????????????? ??????????. ???????? ????????????? ? ???????? ??????????
???????? ????????????? ? ???? ??????? ???? ????? [12?14]. ? ????? ? ???? ??????????
???????????????? ???????????, ???????????? ?? ?????????? ?????????? ??????????
?????????? ?? ?????? ???????, ???????? ????? ?? ????????? ????? ????????????????????? ??????????? ??????????????.
?????????? ??????????? ???????????????, ?????????? ?? ???????? ???????????
??????????? ???????????? ? ???????? ???????????? ????? ? ?? ???????????, ?????????
????????? ?????????????? ????? ?? ???????????? ????? ???????, ???, ? ???? ???????,
??????? ???????????? ????????????????? ?
??????????????? ??????? [15?19].
??????????? ??????? ? ????????? ??????
???????????????? ??????? ? ??????????? ???????????? ?????? ? ???? ?? ???????? ??????
???????????? ??????? ??????????? ???????????? ?????????? [13, 20, 21]. ???????????
????? ???????????? ????? ??????????????
?????????, ??????? ??????? ? ???????????
???????? ??? ??????????? Paul Ehrlich ? 1890 ?.
(??? ??????? ??? ?????????? ?????????), ? ?
1950 ?. ?? ??????????? ??? ???????????????
???????? [20].
? 2006 ?. ????????? ????????????????
?????? ????????????? ????? ?? ???????? ???????????? ??????????? ?????????? ??????
????? ? ????????????? ??????? ??????
╚???????????? ?? ?????????????, ????????????? ? ???????? ???????? ??????????? ?????╩ [13].
?????? ?? ???????????????, ?? ????????????, ??? ?????????? ???????????? ?????? ? ????????????????? ?????? (???) ??
?????? ??????, ??? ?????????? ?????????
??? ????????????? ?????????????????????
?????? ? ??????????? ??? ??????????????
?????? ? ??????? 6 ???, ???????? ?????????
??????? ?????????????? ??????? ? ????????????? ? ????? ??????? ???? ????? ? ????????????????? ???????.
???????? ? ??????
? ????????????? ?????????????? ????????????????? ???????????? ????????
234 ??????? ? ???????? ?? ?????? ????, ? ??????? ? ?????? c ??????? 2009 ?. ?? ??????
2011 ?. ??????????? ????????? ???????????
?????? ?????? ? ???????? ??????????????
?????????????? (??). ???????? ????? ????
???? ???????? ?? ??????? ? ????????????.
???????? ?????? ????????? 164 ????????
(96 ????????? ? 68 ???????), ? ??????? ???
?????????? ???????? ?? ??????????????
????????????????????? ??? (????) ? ???????????? ?????? ????????????? ?????? ??????. ? ????????????????? ??????? ???
????????????? ????? ???????????? ????????????????????? ??? ?? ???? ?? ??????.
??????? ????????? ???????? ?????? ?????-
??????????? ?????????? ??????????????, ? 4, 2013
Key words: virus-inactivated plasma; systemic inflammation; neonates; children; allogeneic blood transfusions.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
50
????????????? ??????????????
??? 5,4╠2,1 ???, ????? ???? ? 4,7╠1,8 ??. ?????????????? ?????? ?????? ??? ???????????
???????? ????? (55 (33,5%) ??????????),
????????????? ????????????? ??????? (47
(28,7%) ??????????) ? ????? ???????? ??????????????????? ??????? (62 (37,8%) ??????????).
??????????? ?????? ????????? 70 ??????? (42 ????????, 28 ???????), ? ??????? ??
????? ?? ?????????????? ??????????????????? ?????? ? ???????????? ?????? ?? ?????? ???????. ??????? ????????? ??? ?????
5,6╠2,4 ???, ????? ???? ? 4,9╠1,7 ??. ?????????????? ?????? ?????? ??????????? ????????
????? (22 (31,4%) ??????????), ????????????? ????????????? ??????? (25 (35,7%) ??????????) ? ????? ???????? ??????????????????? ??????? (23 (32,8%) ??????????).
????????????? ?????????? II?III ??. ??????????? ? 128 (78%) ????????? ? ??????????? ?????? ? ? 56 (80%) ? ? ???????????.
??????? ??????????? ? ??????????? ??????
?? ???????? ??? ????? 141,0╠2,5 ?/?, ? ??????????? ?????? ? 143,2╠2,3 ?/?. ????????
??????? ?????? ????? ????? ? ????????? ??????????? ?????? ???????? 61,5╠3,4 ?/?, ?
??????????? ?????? ? 62,7╠2,8 ?/?. ????? ???????, ?? ???????? ???????????????, ???????????, ???????????? ??????????? ?????? ?? ???????????.
???? ??????? ??????????? ???????????
????????? ?????? ? ?????????? ????????
?????????? ????????: ????? ????????? ????? ? ???????? ? ??????????? ??????? ????????? 57╠13 ? 59╠15 ??? ??????????????, ????? ?????????????? ?????????????? 112╠17 ?
115╠18 ???.
???????????????? ??? ??????????????
?? ???????? Macotronic ? ??????????????
????????? ??????? Theraflex-MB-Plasma
(MacoPharma, France).
?????????? ?????? ????????? TNF-?,
IL-8, IL-10 ? ?????? ??????????? ? ?????????????? ??????? ????????? ProCon TNF-? ?
ProCon IL-8, IL-10 (╚??????????? ??????╩,
??????). ???????????? ???????????? ??????????? ?? ???????? (I ????), ?? ??????
(II ????), ?????? (III ????) ? ??????? (IV ????)
????? ????? ????????.
???????? ????????????? ?????? ???????
???????????? ????????? ??????????????
???????, ???????? ??????????? ? ???????
?????????????? ? ???????????????? ???????, ???????????? ?????????? ????????? ?
???? ? ??????????.
????????? ??????????? ???????????? ????????? ? ??????? ?????? ???????????????
??????? ?????? Statistica v 6.1 (StatSoft). ???
???????? ???????????? ??????? ?????????????? ????????? ? ??????? ??????????? ???????? ????????????? ?????????? ? ???????????????????? ??????. ????????????? ????????
??????????? ? ??????? t-???????? ?????????. ?????????? ???????????? ? ???? ?╠?, ???????? ????????? ???????????? ??? p<0,05.
??????????
??????????? ? ?????? ??????????????.
????????????????????? ??? ? ????????? ?
???????????? ??????? ?? ?????? ?????? ?????????????? ??? ?????????? ??????? ??? ?
??????????? ?????? ? ?????? 185╠25 ?? ?,
??? ??????? ?????????, ? ????????????????? ???????. ? ??????????? ?????? ? ???????????????? ??????? ?????????????? ??????????????????? ??? ? ????????????
?????? ?? ?????? ??????? ? ?????? 180╠27 ??.
?????????????? ?????????? ??? ? ????
???????? 56 (34,1%) ????????? ???????????
?????? ? 23 (32,8%) ???????? ???????????
??????. ??????? ??????????? ??????????????
104╠26 ?? ? ??????????? ?????? ? 106╠26 ?? ?
?????? ????????. ????? ???????, ??????
??????????? ? ?????????????? ? ????? ??????? ?????????? ?????????????.
??????? ???? ?? ???????????? ??????????.
?? ?????? ????? ???????????? ??????? ??????????? ? ??????????? ?????? ????????
43,4╠1,6%, ? ???????? ?????? ? 44,2╠1,9%.
? ????????????????? ??????? ???????????
???????? ??????????? ?? II ????? ??????????, ????????? ???????????? ????????????
? ????????????, ? ?????????? ?????????????? ?? ?????????? ???? (III ? IV ?????),
?????????????, ??? ?????????????, ?????????????? ???????? ? ??????????????? ?????????????? ???????????????. ? IV ?????
??????? ??????????? ????????? ?????????????? 38,1╠1,3 ? 36,8╠1,2% ? ??????????? ? ??????????? ???????. ??????????? ???????? ?
?????? ??????????? ? ??????????? ? ??????????? ??????? ?? ???? ??????? ?????? ???????? ?? ????.
???????? ?????? ??????????? ?????????
???????? ????? ????????????? ??????? ?
??????????? ?????????????????? ??????? ?
???? ? ?????????. ????????????? ????????
???????? ? ???????? ?????????? ???????????
? ????????? ??????????? ? ??????????? ?????
?? ?????? ???????????? ???????? ?? ????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
51
??/??
70
60
50
40
??????????? ??????
??????????? ??????
30
20
10
0
I
II
III
IV
?????
???. 1. ???????? ?????? TNF-?
??/??
140
120
100
80
??????????? ??????
??????????? ??????
60
40
20
0
II
III
IV
?????
???. 2. ???????? ?????? IL-8
?????????? ????????? ? ?????? ????? ?
????????? ????? ? ????????? ???? ????? ??
???? ?????? ???????????? ????????????? ??
??????????.
?? ?????? ????? ??????? TNF-? ? ???????????? ??????? ?? ????????? (???. 1). ??????
??? ?? ?????? ?????, ? ?????? ????? ?????
???????????? ?????????????, ???????????
????????????? ??????????? ??????? ?????
?????????? ? ????????????? ???????. ??
??????? ? ????????? ?????? ??????? TNF-? ?
????? ??????? ???? ????????? ? ????????,
?????? ?? 7-? ???? ????? ???????? ? ??????????? ?????? ???????? 24,1╠4,2 ??/??, ?????
??? ? ??????????? ?????? ??? ??? ?????????
?? ??????? ?????? ? 41,1╠5,7 ??/??.
??????? IL-8 ?? ?????? ????? ? ????? ??????? ?? ????????? (???. 2) ? ?? ??????? ?? ??????? ??????????? ???????? (<62 ??/??). ????? ???????? ????????? ???? ????????????
????? ????????, ?????? ??? ?? III ????? ???
??????? ? ???????? ?????? ??? ??????????
??????, ??? ? ???????????, ? ? ??????????
??????????? ??? ???????????? ?? ?????????
? ???????? ??????, ???? ?? ???? ? ??????
????????.
???????????? ?????????? ?????? ????????????-10 ????????? ??????? ????????? ??????????????: ???? ?? ?????? ????
?????? ???????????? ? ????? ??????? ??????? IL-10 ????????? ? ???????? ??????????? ???????? (<9,1 ??/??), ?? ?? ?????????
?????? ??? ??????? ? ??????????? ??????
??????????? ????? ? ???????? ????? ? 1,5 ???? (???. 3).
??????????? ????????????? ????. ???????????????? ?????????? ? ??????????? ?
??????????? ??????? ?????????? ??????????? ? ??????? ????? ????????????????? ???????. ??? ??????????? ? ???? 83% (n=136)
??????????? ?????????? ??????????????, ? 4, 2013
I
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
52
????????????? ??????????????
??/??
25
20
15
??????????? ??????
??????????? ??????
10
5
0
I
II
III
IV
?????
???. 3. ???????? ?????? IL-10
?????
20
p<0,006
18,2
18
16
??????????? ??????
??????????? ??????
14
12
p<0,004
10
10,2
8,2
8
6
4,1
4
2
??????????? ?????????? ??????????????, ? 4, 2013
0
???????????? ??????????
? ????
???????????? ???????
? ??????????
???. 4. ????????? ??????? ?????????????????? ???????
??????? ? ??????????? ?????? ? 88% (n=62)
??????? ? ??????????? ?????? ????????? ?
?????????? ???????????????? ??????????.
? ??????????? ??????? ?????????????? ????????????????? ??????? ? ??????? ? ??????????? ??? ???????????.
??????????? ????????? ????? ????? ????????????? ? ?????? 8?12 ? ????? ????????.
???????? ??? (13%) ???????? ? ???????????
?????? ? 10 (14%) ? ?????? ???????? ????????????? ????? ??? ????? 12 ? ????? ???????????? ?????????????.
????? ????? ????????? ? ???????????
???????? ????????? 8 (4,88%) ??????? ? ??????????? ?????? ? 6 (8,57%) ? ? ??????????? (p<0,05). ??????? ??????????????????
??????? ? ????????? ??????????? ??????
??????????? ?????? ???????? ??????????-
?????? (3 (1,82%) ??????), ?????? ?????????-???????? ???????????????? (3 (1,82%)
??????) ? ????????????? ????????-????????? (2 (1,22%) ??????). ? ??????????? ??????, ??? ???????? ??????????? ????? ??????????, ? ?????????? ??????????? ???????? ????????????? ??????????? ???????:
2 (2,86%) ???????? ? ???, 2 (2,86%) ???????? ? ????, ? ? 2 (2,86%) ????????? ????????????????? ?????? ?????????? ???
(p<0,05).
??????????? ? ??????????? ?????? ????????? 2,43% (4 ????????), ? ??????????? ?????? ? 4,29% (3 ????????).
? ??????????? ?????? ???????????? ?????????? ? ???? ? ??????? ? ?????????? ???? ?????????? ??????, ??? ? ???????????
(???. 4).
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????
?? ????????? ??????? ??? ????????????
?????????? ?????????? ?????????? ?????????? ???????? ? ??? ??????? ????????? ??????????? ??????????? ?? ? ????????????
?????? ?? ????????. ????????????? ? ???????????? ? ???? ?????? ??? ????????????, ?
????????? ?????????? ????????????????
??????????????????? ??????? ???????? ??,
????????? ????????? ??????? ????????????
??????????????? ??????, ?????? ?? ??????
???????? ?????????. ????? ?? ?????? ?????
????? ???? ?????????? ?????????????? ????? ???????? ?????????? ??????????, ?????????, ????????, ? ???????????? ??????????
??????????? ????? [19, 22].
?????????? ??????????? ??????????? ??????????, ?? ??????????, ??? ?? ????
?????????? ?????????? ??????????? ?????
???????????????? ?????? ???????? ???????? ?????? ? ?? ???????????. ???????????
????????????????????? ??? ? ????????? ?
???????????? ??????? ?? ?????? ? ???? ?? ??????, ??????????, ???????? ????? ????????????????, ?????? ????????????? ??????????? ????? ?? ?????????? ???????. ??????
? ??? ??????????? ???????????? ????? ????????????????????? ?????? ???????? ?? ?????? ???????????? ????????????? ???????????, ????????????? ? ????????? ??????.
??? ?????????? ??????? ???????? ?????????????? ??????????????, ? ????? ??? ????????? ????????????????? ????????? ? ??????? ????? ?????? ???????? ???????? ?????????????? ???????????? ????????????
?????? ? ???. ????????????? ???????????
????? ?? ?????? ?????? ?? ??????????????
?????????, ??? ??? ???? ???????? ???????????? ?????? ????????? 42 ?????, ????? ???
??? ?????? ?????? ?????????????? ? ??????? 6 ??? ??? ?????????? ??????????? ????????? ??????????????????? ??????????. ?
?? ?? ????? ????????????? ??????????? ????? ?? n-?? ????? ??????? ??? ??????? ? n ???
???????? ???? ?????????????????????? ?????????? ? ? n ??? ????????? ????????? ?????????????? ?????.
? ???? ???????????? ?? ????????, ??? ??????? ?????????? ??????????????? ?????? ? ??????????? ?????? ??????? ????, ??? ? ???????????, ??? ?????????????? ?? ??????
????????????????? ?????????.
TNF-? ????????? ? ???????? ?????????
??????, ???????????? ???????????? ?- ?
53
?-??????????, ? ???????????? ????????????? ???????????????? ?????????????. ??
????? ???????? ??????-, ?????- ? ?????????. ?????? ? ?????????? ╚???????? ?????╩
????????? TNF-? ???????? ?????? ???????? ????????? ????????? ??????????? ????????????? [14, 22].
IL-8 ???????? ????? ?? ??????? ?????????? ?????? ???? ??????????. ????????? ???
?????? ????? ???????? ? ????????????
╚????????? ? ??????????? ?????? ??????????? ??????╩ (TRALI), ????? ?????????? ?
??????????? ??????, ???????? ??????? ???????? ?????????? ???????????? ?????? ? ???
?? ???? ? ????? ???????, ????? ??? ????????
??????????? ?????? ? ??????????? ???????
???????? ???????????? ?????? ? ????????????????????? ??? ?? ?????? ?????? [14, 22].
????????, ??? ??????????? ????? ??????????? ????????? ????????????-10. IL-10 ???????? ????? ?? ???????? ??????????? ??????? ????????????????? ?????????, ????????? ?????????? ?????????? ? ?????????? ????
?????????. ? ??????? ? ???????? ???????????????? ????????? ????????????-10 ????,
??? ? ?????? ???????? ???. ????????? ?????? IL-10 ? ??????????? ?????? ????????, ??
???? ?????????, ???????????? ???????? ????????? ?? ?????????? ????? ? ???? ?????????????? ???? ?? ?????????? ?????? ???????
?/??? ????????? ?????? ????????????????? ????????? IL-8 ? TNF-? [14, 22].
???????? ???????? ???? ? ?????????
??????????????????? ?????? ?????? ? ???????????? ?????????????, ??? ??????? ??????????? ?????? ???????? ??????????? ????????? ?????????????? ??????? ?????????,
?? ???? ????????????? ? ????????????? ????????? ????????? ? ?????? ?????????????
? ????????? ?????????? [10, 14].
?????? ? ??? ????????????? ???????????
???????? ????????????????, ?????????????
? ??????????? ??????????? ?? ???? ?????? ???????????? ? ????? ??????? ?? ??????????.
??????????
?????? ?? ?????????? ???? ???????????,
????? ??????? ?????, ??? ??? ?????? ??????
???????? ????????????? ??????????? ?????
(???????????? ?????? ? ?????????????????
??????) ?? ?????? ?????? ???????? ????????
???????????????? ???????? ??? ??????????? ??????? ??????? ?????????? ???????
?????? ? ????????????? ? ????? ??????? ????
?????.
??????????? ?????????? ??????????????, ? 4, 2013
????????????? ??????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
54
????????????? ??????????????
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
??????????? ?????????? ??????????????, ? 4, 2013
15.
16.
17.
18.
19.
20.
21.
22.
??????????? ?.?., ??????? ?.?. ????????-?????????? ????????: ???????????. ?.: ????????; 1989.
??????? ?.?., ??????? ?.?. ??????????? ?? ????????????????????. ?.; 2005: 198?209.
?????? ?. ????, ????????? ? ???????????? ?????. ?????????????? ? ??????????????. ??????????. ???????????? ??????????? ????? ? ????????: ????????? ??????????. 1999: 27?44.
???????? ?.?., ???????? ?.?. ??????????? ???????: ???????????? ???????????. ?. 2. ?.: ??????-?????; 2009:
250?5.
???????? ?.?., ?????? ?.?., ?????? ?.?. ?????????? ??????? ??????????? ???????????? ????????? ???????????????? ??????. ???????????????. 2007; 1?2: 59?60.
?????? ?.?., ????? ?.?., ?????????? ?.?. ?????????????
? ??????????????? ?????????????? ? ????????-?????????? ????????. ?.; 2004.
Dodd R.Y. The risk of transfusion-transmitted infection.
N. Engl. J. Med. 1992; 327: 419?21.
?????? ?.?., ??????? ?.?., ???????? ?.?. ? ??. ???????????????? ???????? ? ?????????????. ? ??.: ??????????
???????? ? ????? ? ??????????? ????????. ?.; 2002:
135?7.
Benson A.B., Moss M., Silliman C.C. Transfusion-related acute
lung injury (TRALI): a clinical review with emphasis on the
critically ill. Br. J. Haematol. 2009; 147: 431?43.
Clark S.C. Lung injury after cardiopulmonary bypass.
Perfusion. 2006; 21: 225?8.
Colleen E., Lang J.D., Vavilala M.S. et al. Early packed red
blood cell transfusion and acute respiratory distress syndrome
after trauma. Anesthesiology. 2009; 110: 351?60.
Ando M., Takahashi Y., Suzuki N. Open heart surgery for small
children without homologous blood transfusion by using
remote pump head system. Ann. Thorac. Surg. 2004; 78:
17?22.
Guide to the preparation, use and quality assurance of blood
components. 16th ed. Council of Europe; 2010: 268.
Meduri G.U., Kohler G., Headley S. et al. Inflammatory
cytokines in the BAL of patients with ARDS. Persistent elevation over time predicts poor outcome. Chest. 1995; 108:
1303?14.
?????? ?.?., ?????? ?.?., ???????? ?.?. ???????????????? ??????. ??????? ????????????? ??????-?????????????? ?????? ??. ?.?. ????????. 2007; 1: 105?10.
Cardigan R., Allford S., Williamson L. Levels of von Willebrand
factor-cleaving protease are normal in methylene blue-treated
fresh-frozen plasma. Br. J. Haematol. 2002; 117: 253?4.
Garwood M., Cardigan R.A., Drummond O. et al. The effect of
methylene blue photoinactivation and methylene blue removal
on the quality of fresh-frozen plasma. Transfusion. 2003; 43:
1238?47.
Mohr H., Knuver-Hopf J., Gravemann U. et al. West Nile virus
in plasma is highly sensitive to methylene blue-light treatment.
Transfusion. 2004; 44: 886?90.
Technical Manual. American Association of Blood Banks,
12th ed.; 1996: 830?9.
Paul-Ehrlich-Institut, BundesДrztekammer: Richtlinie zur
Gewinnung von Blut und Blutbestandteilen und zur
Anwenduung von Blutprodukten (Haemotherapie). KЖln:
Deutscher дrzte-Verlag; 2001.
Zhong R., Wang H., Yuan L., Liu J. Evaluation of quality of
fresh-frozen plasma after methylene blue photoinactivation and MB removal filtration. Vox. Sanguinis. 2008; 95
(Suppl. 1): 317.
Kleinman S., Caulfield T., Chan P. et al. Toward an understanding of transfusionrelated acute lung injury: statement of a
consensus panel. Transfusion. 2004; 44: 1774?89.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Burakovskiy V.I., Bockeria L.A. Cardiovascular surgery.
Guidelines. Moscow: Meditsina; 1989 (in Russian).
Bunatyan A.A., Trekova N.A. Guideline for cardiac anesthesiology. Moscow; 2005: 198?209 (in Russian).
Vin'on D. Risk associated with blood transfusions. Anesthesiology and intensive care medicine: blood transfusion alternatives. Proceedings of the symposium. 1999: 27?44 (in
Russian).
Gel'fand B.R., Saltanov A.I. Intensive therapy. National guidelines. Vol. 2. Moscow: GEOTAR-Media; 2009: 250?5 (in
Russian).
Gubanova M.N., Anishchik A.V., Zhiburt E.B. Developing standard operating procedure of viral inactivation of plasma.
Transfusiologiya. 2007; 1?2: 59?60 (in Russian).
Lokshin L.S., Lur'e G.O., Dement'eva I.I. Extracorporeal and
assisted circulation in cardiovascular surgery. Moscow; 2004
(in Russian).
Dodd R.Y. The risk of transfusion-transmitted infection.
N. Engl. J. Med. 1992; 327: 419?21.
Lubnin A.Yu., Gromova V.V., Gadzhieva O.A. et al. Methods of
blood preservation in neurosurgery. In: Bloodless surgery ? outcomes and prospects for the development. Moscow; 2002:
135?7 (in Russian).
Benson A.B., Moss M., Silliman C.C. Transfusion-related acute
lung injury (TRALI): a clinical review with emphasis on the
critically ill. Br. J. Haematol. 2009; 147: 431?43.
Clark S.C. Lung injury after cardiopulmonary bypass.
Perfusion. 2006; 21: 225?8.
Colleen E., Lang J.D., Vavilala M.S. et al. Early packed red
blood cell transfusion and acute respiratory distress syndrome
after trauma. Anesthesiology. 2009; 110: 351?60.
Ando M., Takahashi Y., Suzuki N. Open heart surgery for small
children without homologous blood transfusion by using
remote pump head system. Ann. Thorac. Surg. 2004; 78:
17?22.
Guide to the preparation, use and quality assurance of blood
components. 16th ed. Council of Europe; 2010: 268.
Meduri G.U., Kohler G., Headley S. et al. Inflammatory
cytokines in the BAL of patients with ARDS. Persistent elevation over time predicts poor outcome. Chest. 1995; 108:
1303?14.
Zhiburt E.B., Filina N.G., Gubanova M.N. Viral inactivation of
plasma. Vestnik Natsional'nogo mediko-khirurgicheskogo tsentra imeni N.I. Pirogova. 2007; 1: 105?10 (in Russian).
Cardigan R., Allford S., Williamson L. Levels of von Willebrand
factor-cleaving protease are normal in methylene blue-treated
fresh-frozen plasma. Br. J. Haematol. 2002; 117: 253?4.
Garwood M., Cardigan R.A., Drummond O. et al. The effect of
methylene blue photoinactivation and methylene blue removal
on the quality of fresh-frozen plasma. Transfusion. 2003; 43:
1238?47.
Mohr H., Knuver-Hopf J., Gravemann U. et al. West Nile virus
in plasma is highly sensitive to methylene blue-light treatment.
Transfusion. 2004; 44: 886?90.
Technical Manual. American Association of Blood Banks,
12th ed.; 1996: 830?9.
Paul-Ehrlich-Institut, BundesДrztekammer: Richtlinie zur
Gewinnung von Blut und Blutbestandteilen und zur
Anwenduung von Blutprodukten (Haemotherapie). KЖln:
Deutscher дrzte-Verlag; 2001.
Zhong R., Wang H., Yuan L., Liu J. Evaluation of quality of
fresh-frozen plasma after methylene blue photoinactivation
and MB removal filtration. Vox. Sanguinis. 2008; 95
(Suppl. 1): 317.
Kleinman S., Caulfield T., Chan P. et al. Toward an understanding of transfusionrelated acute lung injury: statement of a
consensus panel. Transfusion. 2004; 44: 1774?89.
????????? 27.05.2013
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
55
╘ ????????? ???????, 2013
??? 616.127-089.844.168-06:616.12-089.8-78:004.383.032.8
???????????? ?????????? ??? ?????? ????????? ??????????????
?????????? ????? ???????? ???????????????? ????????
? ???????? ?????????????? ??????????????
?.?. ????????1, ?.?. ??????1, ?.?. ????????1, ?.?. ?????1, ?.?. ??????2
1???
╚????????? ??????????????????? ?????╩, ??. ????????, 15, ???????, 410039, ??????;
??? ╚??????????? ??????????????? ??????????? ??????????? ??. ?.?. ????????????╩
???????????? ??????????????? ?????????? ?????????, ??. ?. ???????, 112, ???????, 410012, ??????
2????
???? ???????????? ? ?????? ??????????? ??????????????? ???????? ?????????? ? ?????? ???????
????? ???????? ???????????????? ???????? ?? ????????? ????????????????? ?????????? ? ?????????????? ?????????? ????????? ?????.
???????? ? ??????. ? ??????????????? ???????????? ?? ???????? ╚???????????????╩ ???? ???????? ?????? 107 ????????? (??????? ??????? 58,4╠8,5 ????), ??????? ???? ????????? ???????? ?????????????? ???????????? ?????????? ???????. ???????????? ??????? ???????? ???????? ??????????
(?????? ????????, ???????????, ????????-??????????, ??????????? ??????? ???????, ??????? ???????? ? ?????????? ??????????? ??????????) ? ?????? ????????????????? ??????? (0?6 ???). ? ???????? ??????????? ???????????? ??????? ?????????????? ?? ????? ?????????????? ????????????? ? ???????? ?????????????? ?????????????? ?????????? ???????????? ? ?????????? ????? ?????????. ???
??????????????? ???????????? ????? ????????? ?????, ???????? ? ???????????? ??????????, ? ?????
?????????????? ?????? ?????????? ? ?????????????? ???????????? ?????? Statistica 6.0 StatSoft Inc.
??????????. ? ???? ??????? ?? ????? ??? 3 ???. ????????????? ??????????? ? ?????????????? ????????????? ?????????? ????? ???? ???????? 2 ????????? ????, ?????????? ??????? ?????????????
????????????????. ????? ????? ???????? ??????????? ? ???????? ??????? ?????????? ????????? ?????????? ? ?????????????? ??????: ??????? ??? ?????????? ??????????. ???????? ??????? ??? ?????? ?? ??????????? ROC-??????? ?????????: ??? ?????? ?? EuroSCORE ? 0,611 (p=0,48), ??? ?????????
?????: 0,778 (p=0,027), 0,833 (p=0,034) ? 0,944 (p=0,005).
??????????. ???????? ??????????????? ?????? ? ????????? ???? ? ??????? ???????????????? ?????????, ????????? ??? ????????????? ? ??????????? ????????.
???????? ?????: ?????????? ????????????; ????????? ????; ????????????????? ??????????.
NEURAL NETWORK TECHNOLOGIES AS A BASIS FOR STRATEGY FOR PREVENTING
THE COMPLICATIONS AFTER MYOCARDIAL REVASCULARIZATION
WITH CARDIOPULMONARY BYPASS
A.S. Semenova1, V.V. Agapov1, V.A. Prelatov1, A.V. Zhukov1, M.Yu. Shigaev2
1Regional
Center for Cardiac Surgery, ul. Krymskaya, 15, Saratov, 410039, Russia;
Razumovskiy Saratov State Medical University, Ministry of Health of the Russian Federation,
ul. Bol'shaya Kazach'ya, 112, Saratov, 410012, Russia
2V.I.
Semenova Anna Sergeevna, MD, PhD, Deputy Physician-in-Chief;
Agapov Valeriy Vladimirovich, MD, DM, Physician-in-Chief;
Prelatov Vadim Alekseevich, MD, DM, Professor, Deputy Physician-in-Chief;
Zhukov Aleksey Valerievich, Chief of Department of Cardiac Surgery ? 2;
Shigaev Mikhail Yur'evich, MD, PhD, Assistant
Objective of the study ? is to evaluate the possibilities of predicting the development of complications in early post-operative period after myocardial revascularization based on intra-operational parameters using artificial neural network technologies.
Material and methods. The retrospective ?case-control? study included data on 107 patients (mean age 58.4╠8.5 years),
who underwent isolated coronary artery bypass graft surgery. Development of organ dysfunctions (acute kidney, respiratory, cardiovascular, central nervous system dysfunction, myocardial infarction and paroxysmal atrial fibrillation) was con-
??????????? ?????????? ??????????????, ? 4, 2013
???????? ???? ?????????, ???????? ???. ????, ??????????? ???????? ?????; e-mail: semannserg@yandex.ru;
?????? ??????? ????????????, ?????? ???. ????, ??????? ????;
???????? ????? ??????????, ?????? ???. ????, ?????????, ??????????? ???????? ?????;
????? ??????? ??????????, ?????????? ??????????????????? ?????????? ? 2;
?????? ?????? ???????, ???????? ???. ????, ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
56
????????????? ??????????????
sidered a complication in an early postoperative period (0?6 days). Hemodynamic indicators and internal milieu parameters routinely monitored during surgical procedure with cardiopulmonary bypass were used as predictors of complications.
Neural network method was applied for prediction, training and testing of artificial neural networks as well as the statistical analysis were performed using software package Statistica 6.0 StatSoft Inc.
Results. 2 artificial neural networks that showed the best operating characteristics were selected after analysis of more
than 3 thousand automatically constructed personal computer-based networks. After entering the values of predictors in
binary format neural network gives an output on perspective outcome: presence or absence of complications. The area
under the ROC curve was: for EuroSCORE ? 0.611 (p=0.48), for artificial neural networks: 0.778 (p=0.027), 0.833
(p=0.034) and 0.944 (p=0.005).
Conclusion. We obtained prognostic models ? artificial neural networks with high predictive accuracy, suitable for the use
in clinical practice.
Key words: coronary artery bypass graft surgery; neural networks; postoperative complications.
??????????? ?????????? ??????????????, ? 4, 2013
????????
? ?????????? ??????? ???????? ????????????? ???????, ????????????, ???????????????? ???????????? ????????? ???????
??????????? ??? ????????? ????????????
?????????? ??????? ?? 0,5?2,5% [1, 2]. ???????? ?? ????????? ???????? ?????????
?????????????? ?????????????? (??) ? ???????????? ?? ???????????, ??????? ????? ??
??????????? ??????? ???????? ? ????????????????? ??????? ?????????? ????????? ??????? ? ?????? ?? ???????. ?? ?????? ??????
???????, ??????? ???????? ????? ????????
???????????? ?????????? ??????? ??????
???????? ??????????????? ????? ?????????
30% [3, 4], ? ???????? ?????? ?????????? ?
??????????? ?????????? ? ??????????? ?
20?40% ????????? ????? ??? [5]. ???????
???????? ??????????? ????????????????????
????????? ????????? ????????????????? ???????? ?????????? ? ?????? ╚???????????╩
??????????, ?????? ? ????? ????????? ?????
????????????? ????? ?????????? ? ?????????? ? ????????? ??????????? ???????, ???
???????? ? ????????????? ?????????? ???????, ? ????? ????????????? ???????? ???????? ????? ? ???????????????? ???????.
???????? ?????????????? ? ?????????
????? ???????? ????????? ????????????? ????? ? ??????????????????? ???????, ?????????? ?? ?????? ?????????????? ??????????, ??????????????? ??????? ????????? ?
????????????? ???????????, ??????? ????????? ??????????? ?????, ????????? ??????? ?????? ????????? ? ?. ?. ????????????
???????? ????????????? ????? EuroSCORE ?
????????? ????????????, ????? ??????
??????????? ????????? ??????? STS,
QMMI. ??????? ???????????????? ??????????? ?????? ?????? ? ????????? ??????
????? ?????????? ?????? ? ???????? ?????????? ???????????? ??????????????? ?????????????? [6?8]. ????????????? ???? ????????? ????????? ??????? ????????? ?? ????-
?? ???????, ?????????? ? ???????? ?????,
???, ? ???? ???????, ?????????? ??????? ?????????????? ??????? ? ????????????????????, ? ??? ????? ???????????????????, ???????????. ?????? ??????? ???????, ??? ?????????????? ?????? ??? ?? ?? ????????? ?????
????????? ?????????????? ??????? ?????????? ???????????? ?????????????, ??????????? ????? ????????? ? ?????????????? ??????????????. ? ????? ? ???? ??????? ???????
???????????? ???????? ?????? ???????????
??????????????? ???????? ???????? ?????????? ? ?????? ??????? ????? ????????
???????????????? ???????? ?? ?????????
????????????????? ??????????.
???????? ? ??????
? ??????????????? ???????????? ?? ???????? ╚???????????????╩ ???? ???????? ??????
107 ????????? ? ???????? ?? 42 ?? 76 ??? (??????
???? 85 (79,4%), ?????? ? 22 (20,6%)), ?????????? ???????? ?????????????? ???????????? ?????????? ??????? ? ??? ╚?????????
??????????????????? ?????╩ ?. ????????, ??????? ? ?????????? ?????????????? ??? ???????? ? ???????? ????????????????? ????????? ?????.
??? ?????????????? ????????? ?????? ?
?????????? ????????? ????? ????????????
??????????? ????? Statistica 6.1 StatSoft., Inc.
??? ????????? ?????????????? ????????
????? ???????? ?????????? ????????????????? Mann?Whitney U test.
? ???????? ?????????? ?????????????
???????? ???? ?? ?????? ?? ????????? ?????????: ?????? ???????? ??????????????? (????????? ?????? ????????????? ??????????
????? 200 ??????/? ??? ????? ??? ?? 50% ??
??????????????? ??????); ??????????? ???????????????, ????????? ?????????? ?????????? ???; ????????? ???????????
??????????; ?????? ????????-?????????? ??????????????? ? ???? ?????????????? ???????????? (????????? ?????????? ??? ????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
57
??????? 1
????????? ????????????????? ??????????
????? ?????????, ? ??????? ???????? ???????? ???????
??????????, n (%)
??????????
?????? ??????? ????????
7 (13,0)
?????? ???????? ???????????????
22 (40,7)
??????????? ???????????????, ????????? ?????????? ???
13 (24,1)
????????? ??????????? ??????????
15 (27,8)
?????? ????????-?????????? ???????????????
15 (27,8)
???????? ????????????? ? ???????? ????
13 (24,1)
?????? 1 (n= 54)
?????? 0 (n= 53)
? (Mann?Whitney U test)
???????, ???
59,6╠7,9
58,4╠8,5
0,357
EuroSCORE, ?????
1,88╠1,1
2,55╠2,1
0,439
??????????? ??????????
?????? ?? EuroSCORE, %
1,37╠0,51
2,3╠1,8
0,174
0,952
?????????
??????? ???????,%
59,7╠11,9
58,8╠10,3
?????????? ??????????? ???????
2,42╠0,76
2,43╠0,57
0,774
????? ??, ???
147,4╠99,2
79,2╠24,2
0,0011
????? ????????? ?????, ???
64,7╠34,2
41,5╠15,0
0,0118
?????????? ????????? ?/??? ??????? ???????????????? ??????????????); ???????? ??????? ???????? ????????, ?????????????
??? ????????? ??????? ????????? ?????????
?????????????? (????). ?????????????
??????????, ????????? ? ?????? ????????????????? ??????? ? ? ?????? 6 ??? ?????
????????.
?? ???????? ???????/?????????? ????????? ?????????? ???????? ???? ????????? ??
??? ??????: ?????? 0 ? ??? ?????????? (53 ????????), ?????? 1 ? ? ???????????? (54 ????????). ????????? ???????? ?????????? ???????????? ? ??????? 1. ???????? ????????????
????????? ??????? ????? (40,7%), ??? ????
???????? ???????????? (? ????????? ?????????? 3 ? ????? ??????) ???????????????
???? ???????? ? 17 (31,5%) ????????? ??????
??????. ??????????? ? ?????? ? ???????????
???????? ?????????????????? ??????? ????????? 24,1% (?????? 13 ?????????).
?? ?????????????? ??????????????? ??????????? ???????? ????? ???????? ????????????? (????. 2).
??? ??????? ???????? ???????? ?????
???????? ?? ???????????? ?? ? ?????????
?????, ??? ??????????? ? ??????? ??????????
?? ?????????? ??????????? ???????? ???????? ??????????????? ? ??????? ?? ???????
??? ?????????? ??????? ?? ? ??????? ????????? ????? [9].
??? ?????? ??????????????? ???????? ???? ??????? ??????? ?????????????? ?? ????? ?????????????? ????????????? ? ????????
?????????????? ?????????????? ??????????
???????????? ? ?????????? ????? ?????????:
??????? ?? (?? ??. ??.), ??? (?? ??. ??.), ???????????? ??????? ? ????? (?????/?), ???????
??????????? (%), ??????????? ???????? ????????? ? ???????????? ? ???????? ????? (paO2
? pvO2, ?? ??. ??.), ????? ?????????? ???????
????????. ?????????????? ????????, ???????????? ????? 30 ??? ?? ?????? ??.
??? ??????? ?????? ??????????????? ???????? ?????????? ??? ?????? ????? ????????? ?????, ??????????? ???????????? ?????????? ??????, ?????????? ?????????????
???????????. ??????? ??????????? ????????? ????, ?????????????? ?? ??????? ?????????????? ???????? ????????, ???? ??????????? ? ??????? ???????????? ??????? ??????????? ????????????? ?????????, ???????
?? ????????? ???????? ????????? ?????????. ????? ????????? ????? ?????? ???????????? ??? ????????????? ????????? ? ??????
????????? ? ??????????. ? ?????????? ??????? ??????? ?????? ?? ?????????? ???????????? ?????????? ??? ??????????????? ??????? ? ?????? ????????????? ??????? ? ??????????? ????????, ? ??????? ????????
??????? ???????? ??????? ?????? [10?12].
?????? ? ????? ??? ???????? ??????? ? ??-
??????????? ?????????? ??????????????, ? 4, 2013
??????? 2
???????????????? ?????????????? ????? ? ????????? ????????????? ????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
58
????????????? ??????????????
???????????: ?? 9:9?40?33?1:1, N=20
?????????????????? ????. = 1,000000,
?????. ?????????????????? = 1,000000,
????. ?????????????????? = 0,555556
???. 1. ??????????? ????????? ???? snn20
???. 2. ??????????? ????????? ???? snn2119
?????? ????????? ???? ???????????? ?????,
??? ???????????, ????????? ?????, ?????????
?????????? ?? ???????? ? ??????????.
??? ???????? ????????? ????? ???? ?????????????? ??????????????? ?????? 70 ?????????, ????????? ??????? (????????? ????????? ?????) ?????????? ?? 107 ?????????
???? ????????? (?? 35 ?? ?????? ??????).
???: snn20 ? 87,5%, snn2119 ? 83,3%, ??? ??????????????? ? ??????? ????????????????
??????????? ????? ??????? ? ?????????? ???????? ??????????? ????????????????? ?????? ?? ????????? ???????????? ??????????????????? ???????.
????????????? ???? ???????????? ??????
? ????? ? ?????????????? ? ???????? ??????????? ??????? ??????? ?? ? ????????? ????? ??????????? ????? ??????????? ??? ??????????????? ???????? ?????????????????
?????????? ???? ?? ????????? ???????????? ?????????????. ????? ???????, ????????
?? ????????????? ??????????????? ????????, ?????? ?????? ?? ????????? ?????????????? ???????????? ???????????? ???????????? ????????????? ? ??????????????????? ??????? ??????????????? ?? ?????
??????????, ? ?????? online, ? ????????????
???????????? ???????? ??? ?? ?? ?????????.
? ????? ? ???? ?? ?????? ????? ???????????? ?? ????? ??????? ?????????? ???? ????????????? ????????? ???????????? ?? ?
????????? ?????. ??? ??????????????????
??????????? ???? ???????? ????????? ????
(????? ? ???????????? ????????????? ???????????) snn5.
??? ????????????? ?????? ??????????????? ???????? ??????? ?????????????? ????????? ROC-??????? ? ??????? ???????? ??????? ??? ?????? (AUC). ????????????? ??????? ? ????????? ???????????? ????????
?????????? ???????????? ? ???????????????
????????? ????? EuroSCORE. ??? ????????
?????????????? ???????? ??????? (n=37), ?????????? ?? ???????? ????????? ???????, ???
??????????
??????????? ?????????? ??????????????, ? 4, 2013
???????????: ?? 8:8?31?1:1, N=2119
?????????????????? ????. = 0,709091,
?????. ?????????????????? = 0,769231,
????. ?????????????????? = 0,807692
? ???? ??????? ?? ????? ??? 3 ???. ????????????? ??????????? ? ?????????????? ????????????? ?????????? ????? ???? ????????
2 ????????? ????, ?????????? ???????
????????????? ????????????????. ??????
???? ???????????? ????? ???????????? ???????????, ??????? 1 (snn20) ? 2 (snn2119)
????????????? ???? (???. 1 ? 2). ???? snn20
????? 9 ??????? ??????????: ???????, ???????????? ??, ???????????? ????????? ?????,
??????? ?? ? ???, ???????????? ??????? ?
?????, ??????????, ? ????? ?????????? paO2 ?
pvO2. ???? snn2119 ????? 8 ??????? ?????????? ? ?? ??, ??? snn20, ?? ??????????? ???????? ????????. ?? ?????? ? ???????? ???????
????????? ?????????? ? ?????????????? ?????? ? ??????? ??? ?????????? ??????????.
? ????? ???????? ????????????? ??????
?????? ??? ???????? ???????????? ???????
?? 40 ????????? ???????????? ?? ?????????????? ??????????????? ????????? ???????????? ?????? ? ???? ╚????????? ?????????
??????????? ???????????????? ?????????╩.
?? ??????????? ????????????? ???????????
??????? ?????????? ?????? ???? ????????
????????? ?????????? ???????? ??????????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????????????? ??????????????
??????????
?????????? ?????????? ??????????????? ?
????????? ??????????????? ?????????????
????? EuroSCORE, ??? ???????????? ???????? ???????????? ? ???????? ??????? ??????? ?? ????????? ???????? ????? ? ????????
?????????? ?? ????? ?????????. ??? ???? ?????? ? ??????????, ???????? ??, ??????????
?????????, ?????????????? ??????????? ???? ???????????? ?? ???????????? ?????????,
???????????. ?????????? ??? ROC-???????
?????????? ??????????????? ? ??????? ??????????????? ???????? ???? ??????????? ????????? ???????.
????????????? ??????????, ????? ???????, ????????? ???????? ???????? ??????????????? ??????? ? ????????, ????? ?? ????????? ?????????? ???????? ???????? ???????????????? ??????, ?????????? ? ????? ?
???????? ?????????? ???????? ?????????????? ?????????. ??? ???????? ?????, ?????
?????? ??????????, ?????????? ??? ???????????, ?? ??????? ?? ??????? ?????????? ??????????. ? ???????? ??????????? ????????
??? ??????????? ???????.
? ? ? ? ? ? 1. ????????? ?., 58 ???.
EuroSCORE = 3,83%. ????????? ?????????????????? ???????????? ???? + ???-3.
????? ?? ????????? 79 ???, ????????????
????????? ????? ? 30 ???, ?? 30-? ??? ??
?????????? ????????? ??????????: ?? =
= 49 ?? ??. ??., ??? = 7 ?? ??. ??., ???????????? ??????? ? ????? 2,3 ?????/?, paO2 =
= 204 ?? ??. ??., pvO2 =39 ?? ??. ??., ?????????? 25%. ??????? ????????? ?????: snn20 ?
??????????, snn5 ? ??????????. ? ????????????????? ??????? ???????? ?????????????? ????????????, ??? ??????????? ????????? ????????? ? ???? 12 ???/??/??? ?
??????? ????? ??? 8 ?.
? ? ? ? ? ? 2. ??????? ?., 49 ???.
EuroSCORE = 3,5%. ????????? ???-3. ????? ?? ????????? 57 ???, ???????????? ????????? ????? ? 30 ???, ?? 30-? ??? ?? ?????????? ????????? ??????????: ?? = 47 ?? ??. ??.,
??? = -1 ?? ??. ??., ???????????? ??????? ?
????? 2,20 ?????/?, paO2 = 103 ?? ??. ??., pvO2 =
= 36 ?? ??.??., ?????????? 34%. ??????? ????????? ?????: snn20 ? ??? ??????????, snn5 ?
??? ??????????. ? ????????????????? ??????? ? ??????? ???????.
? ????? ??????? ????????? ?????? ???????? ????? ?? EuroSCORE ??????????? ??????? ??????????? ?????????????, ??? ?????????? ?? ?????????????? ?????????? ??
??????? ?? ??????? ??????????, ?????? ? ????????????????? ??????? ? ?????? ??????
??????????? ??????????. ??? ?????? ??????????? ?????????? ???????????????? ╚??
????╩, ????? ??? ??????? ??????? ???? ???????
? ????????????????? ??????? ?, ????????,
?? ?????? ?? ?? ?????? ???? ?????????.
??????????? ??????? ???????? ????????????? ??????? ?????????? ???????????? ?????????? ? ???????????? ??????????? ????????.
??????????
?????????? ???????????? ????????????
??????????????? ? ??????? ???????????????
???????? ????????? ????? ? ????????? ???????? ???????? ?????????? ? ?????? ??????? ????? ???????? ???????????????? ???????? ? ???????? ??. ??????????? ??????????
????????? ????? ? ?????????????? ???????
???????????? ????????????????? ?????????? ?????? ????????? ? ????????????? ??
?????????? ? ?????? online ? ???????? ??????????????????? ????????????. ???????
?????????? ???????????? ???????? ?????????? ??????????? ?????????? ????????????? ?
???????????????????? ???????????, ?????????? ?? ??????????? ???????? ????????????
???????.
??????????
1.
2.
3.
4.
5.
6.
7.
??????? ?.?., ??????? ?.?. ????????-?????????? ???????? ?
2010. ?.: ????? ??. ?.?. ???????? ????; 2011.
Miyata H., Motomura N., Murakami A. et al. Effect of benchmarking projects on outcomes of coronary artery bypass graft
surgery: Challenges and prospects regarding the quality
improvement initiative. J. Thorac. Cardiovasc. Surg. 2012; 143
(6): 1364?9.
Mangos G.J., Brown M.A., Chan W.Y. et al. Acute renal failure
following cardiac surgery: incidence, outcomes and risk factors. Aust. N. Z. J. Med. 1995; 25: 284?9.
Stallwood M.I., Grayson A.D., Mills K. et al. Acute renal failure
in coronary artery bypass surgery: independent effect of cardiopulmonary bypass. Ann. Thorac. Surg. 2004; 77 (3):
968?72.
Zangrillo A., Landoni G., Sparicio D. et al. Predictors of atrial
fibrillation after off-pump coronary artery bypass graft surgery.
J. Cardiothorac. Vasc. Anesth. 2004; 18: 704?8.
Carnero-Alcazar M., Silva Guisasola J.A., Reguillo Lacruz F.J.
et al. Validation of EuroSCORE II on a single-centre 3800
patient cohort. Interact. Cardiovasc. Thorac. Surg. 2013; 16 (3):
293?300.
Noyez L., Kievit P.C., van Swieten H.A., de Boer M.J. Cardiac
operative risk evaluation: The EuroSCORE II, does it make a
real difference? Neth. Heart J. 2012; 20 (12): 494?8.
??????????? ?????????? ??????????????, ? 4, 2013
???? ??????? ????. ???????? ??????? ???
?????? (AUC) ?????????: ??? ?????? ??
EuroSCORE ? 0,611 (p=0,48), ??? ?????????
???? snn5 ? 0,778 (p=0,027), snn2119 ? 0,833
(p=0,034) ? snn20 ? 0,944 (p=0,005).
59
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
60
8.
9.
10.
11.
12.
????????????? ??????????????
Vanagas G., Kinduris S., Leveckyte A. Comparison of various
systems for fisk stratification in heart surgery. Medicina
(Kaunas). 2003; 39 (8): 739?44.
?????? ?.?. ??????? ???????????? ??????????????? ????? ????????-?????????? ???????? ? ???????? ?????????????? ??????????????: ???. ? ?-?? ???. ????. ?.;
2011.
Lette J., Colletti B.W., Cerino M. et al. Artificial intelligence
versus logistic regression statistical modeling to predict cardiac
complications after noncardiac surgery. Clin. Cardiol. 1994; 17
(11): 609?14.
Orr R.K. Use of a probabilistic neural network to estimate the
risk of mortality after cardiac surgery. Med. Desic. Making.
1997; 17 (2): 178?85.
Tu J.V., Gurriere M.R. Use of a neural network as a predictive
instrument for length of stay in the intensive care unit following cardiac surgery: Proceedings 16th Annual Symposium on
Computer Applications in Medical Care. Baltimore; 1992.
AMIA: 666?72.
References
1.
2.
3.
Bockeria L.A., Gudkova R.G. Cardiovascular surgery - 2010.
Moscow: A.N. Bakoulev Scientific Center for Cardiovascular
Surgery of the Russian Academy of Medical Sciences; 2011 (in
Russian).
Miyata H., Motomura N., Murakami A. et al. Effect of benchmarking projects on outcomes of coronary artery bypass graft surgery: Challenges and prospects regarding the quality improvement
initiative. J. Thorac. Cardiovasc. Surg. 2012; 143 (6): 1364?9.
Mangos G.J., Brown M.A., Chan W.Y. et al. Acute renal failure
following cardiac surgery: incidence, outcomes and risk factors. Aust. N. Z. J. Med. 1995; 25: 284?9.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Stallwood M.I., Grayson A.D., Mills K. et al. Acute renal failure
in coronary artery bypass surgery: independent effect of cardiopulmonary bypass. Ann. Thorac. Surg. 2004; 77 (3):
968?72.
Zangrillo A., Landoni G., Sparicio D. et al. Predictors of atrial
fibrillation after off-pump coronary artery bypass graft surgery.
J. Cardiothorac. Vasc. Anesth. 2004; 18: 704?8.
Carnero-Alcazar M., Silva Guisasola J.A., Reguillo Lacruz F.J.
et al. Validation of EuroSCORE II on a single-centre 3800
patient cohort. Interact. Cardiovasc. Thorac. Surg. 2013; 16 (3):
293?300.
Noyez L., Kievit P.C., van Swieten H.A., de Boer M.J. Cardiac
operative risk evaluation: The EuroSCORE II, does it make a
real difference? Neth. Heart J. 2012; 20 (12): 494?8.
Vanagas G., Kinduris S., Leveckyte A. Comparison of various
systems for fisk stratification in heart surgery. Medicina
(Kaunas). 2003; 39 (8): 739?44.
3Multiple organ dysfunction syndrome after cardiovascular
surgery with cardiopulmonary bypass. Dr. Med. Sc. Diss.
Moscow; 2011 (in Russian).
Lette J., Colletti B.W., Cerino M. et al. Artificial intelligence
versus logistic regression statistical modeling to predict cardiac
complications after noncardiac surgery. Clin. Cardiol. 1994; 17
(11): 609?14.
Orr R.K. Use of a probabilistic neural network to estimate the
risk of mortality after cardiac surgery. Med. Desic. Making.
1997; 17 (2): 178?85.
Tu J.V., Gurriere M.R. Use of a neural network as a predictive
instrument for length of stay in the intensive care unit following cardiac surgery: Proceedings 16th Annual Symposium on
Computer Applications in Medical Care. Baltimore; 1992.
AMIA: 666?72.
??????????? ?????????? ??????????????, ? 4, 2013
????????? 27.05.2013
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ???????????????
61
??????????? ???????????????
╘ ????????? ???????, 2013
??? 616.12-073.431.1
????????? ?????????????? ??????????? ? ???????????????????
??????? ? ????????? ?????????? ? ??????????? ???????
?.?. ???????, ?.?. ???????, ?.?. ??????????, ?.?. ???????, ?.?. ????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?.?. ????????╩ (???????? ? ???????? ???
? ???? ?.?. ???????) ????, ?????????? ?????, 135, ??????, 121552, ??????
???? ???????????? ? ??????????? ?????? ?????? ?????? ?????????? ?????????????? ??????????? ?
???????? ????????? ?????????? ? ??????????? ??????? (????) ??????????????????? ???????, ??????????? ??????????????????? ??????????? ??????, ? ?????????? ??????????? ????????????? ?????????? ??????????? ?????????????? ???????????? ?? ??????? ???????, ????????????? ?? ??????
??????????? ??????? ?????? (???) ? ?????????????? ????????? ?????? ?????????.
???????? ? ??????. ? ???????????? ???????? 102 ??????? ??? ? ?????????????? ?????????? ?????? ?????????, ??????? ???? ????????? ???????? ???????????????? ???????? ? ?????????????? ????????????? ?????? ????????? ? ??????? ?????????????????? ???????. ??????????? ??????? ?????
??????? ??????? ??????? ?????????????????? ??????? ? ??? ????????? 1-? ??????, ?? 2-? ?????? ????? 12 ????????? ? ??????????? ????????.
??????????. ? ??????? 1-? ?????? ??? ? ?????? ????????????????? ??????? ????????????????????
?????????? ??????????????? ????????? ???????? ?????? ????????? ????????????????? ?? ??????????
?????? ???????? ?? ??????????? ????????????? ????????? ? ???????? ?????????????? ???????????????? ??????????. ?? 2-? ?????? ??????? ? ?????? ????????????????? ??????? ?????????? ????
????????????? ????????? ? ?????????????? ???????????? ???????? ?????? ?????????, ??? ????????????????? ????? ???????????????????? ???????????.
???????? ? ??????? ???????? ??????? ?????????????????? ??????? ?????????? ? ???? ?? 24 ?? 48 ? ?
? ??????? ? ??????? ????? ?? ?????? ???????? ??????????? 2 ?????????????? ??????????????? ????????? ? ??????????????? (?????) ? ?????????????? ???????????? (???) ??????. ????????? ? ??????????? ???????? ? ???? ????????? ??????????? ????? 2 ?????????????? ????????????, ????? ?????????? ??? ?? ?????? ???????? ?????????? ?? 20 ?? 40. ??? ???????????? ?????????? ?? 3?9-? ?????,
??????? ??????????? ??????????????? ??????????? ?? ????????? 2 ???????????? ? ?????.
??????????. ????????? ??? ??? ??????? ? ??????? ???????? ??????? ?????????????????? ???????
?????? ???????? ??????????????? ????? ? ??? ??????????? ???????? ? ????? ???????? ? ????? ????????? ?? ????. ? ????????? ? ??????????? ???????? ??????? ?????????????????? ???????, ???????????? ???????????????? ?????????? ???????????? ?????????????? ????????? ??? ??????? ?
?????? ????????? ? ??????????? ?? ????????? ??????????? ?????????. ????????? ? ????????? ???????????????? ???????? ??????????? ? ???????????? ?????-????????????, ??????????? ????????
??????? ? ???????? ?????????????? ????????? ?????? ? ??????? ?????????????? ? ?????.
???????? ?????: ?????? ????????????????? ??????; ???????????????; ??????????????
????????? ?????? ?????????.
DIAGNOSTIC ULTRASOUND STANDARDS FOR MANAGEMENT OF PATIENTS
IN THE DIVISION OF RESUSCITATION AND INTENSIVE CARE
L.A. Bockeria, M.M. Alshibaya, N.O. Sokol'skaya, A.A. Rakhimov, N.S. Kopylova
A.N. Bakoulev Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Science,
Rublevskoe shosse, 135, Moscow, 121552, Russia
??????????? ?????????? ??????????????, ? 4, 2013
??????? ??? ?????????, ?????? ???. ????, ?????????, ???????? ??? ? ????, ????????;
??????? ?????? ??????????, ?????? ???. ????, ?????????, ?????????? ?????????? ??????????????
??????? ??????????? ??????? ??????;
?????????? ??????? ????????, ?????? ???. ????, ???????????? ?????? ?????????? ??????????????
? ?????????????? ???????????;
??????? ???????? ?????????????, ???????? ???. ????, ?????????? ?????????? ??????????????,
?????????? ? ??????????? ???????;
???????? ??????? ?????????, ???????? ???. ????, ??. ????. ????., e-mail: kopylova5@rambler.ru
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
62
??????????? ???????????????
Bockeria Leo Antonovich, MD, DM, Professor, Academician of the Russian Academy of Sciences and Russian Academy
of Medical Sciences, Director;
Alshibaya Mikhail Mikhaylovich, MD, DM, Professor, Chief of Department of Surgery for Ischemic Heart Disease;
Sokol'skaya Nadezhda Olegovna, MD, DM, Head of the Group of Emergency Ultrasound and Functional Diagnosis;
Rakhimov Abduvali Abdurozakovich, MD, PhD, Chief of Department of Anesthesiology, Resuscitation and Intensive Care;
Kopylova Natal'ya Sergeevna, MD, PhD, Senior Researcher
Objective of the study is to present the analysis of performance of emergency diagnostic ultrasound services in the division of resuscitation and intensive therapy of cardiovascular surgery clinic that provides technologically advanced care,
and to determine the possibilities to use the standards of diagnostic ultrasound examination in intensive care in patients
who underwent surgery for ischemic heart disease and post-infarction left ventricular aneurysm.
Material and methods. The study included 102 patients with coronary artery disease and post-infarction left ventricular
aneurysm who underwent myocardial revascularization and left ventricular geometry reconstruction by endoventricular
circular patch plasty repair. Majority of patients had a smooth post-operative course ? they were included in group I,
group II was composed of 12 patients with complicated course.
Results. Echocardiographic indices of the functional state of the left ventricular myocardium in an early post-operative
period in group I patients indicated an adequate myocardial response to the surgical correction performed and appeared
to be the favourable prognostic factors. Breakdown of adaptive processes and compensatory mechanisms of left ventricular myocardium was observed in group II patients in an early post-operative period, that was characterized by a number
of echocardiographic parameters.
Patients who had a smooth post-operative course stayed in Resuscitation and Intensive Care Unit within 24 to 48 hours and
two diagnostic ultrasound procedures on average ? echocardiography and ultrasound examination of the pleura were performed on each patient daily. Patients with complicated course in Resuscitation and Intensive Care Unit had more than two
ultrasound examinations, the total number of ultrasound scans performed per one patient ranged from 20 to 40. The
largest number of ultrasound examinations were performed on 3d?9th post-operative day, the rate of further ultrasound
monitoring didn't exceed 2 scans per day.
Conclusion. Diagnostic ultrasound standards for patients who have a smooth early post-operative course must include
focused echocardiography and ultrasound examination of pleural cavities ? before surgery and before transfer from the
Resuscitation and Intensive Care Unit. Additional ultrasound protocols of organs and body systems must be used for
patients who have complicated early post-operative course and multiple organ dysfunction syndrome depending on the
form of pathology developed. All patients with congestive heart failure must undergo clinically indicated extended and
repeated echocardiographic examination which enables a detailed dynamic assessment of the functional state of the heart
and circulatory system taken as a whole.
Key words: early post-operative period; echocardiography; post-infarction left ventricular aneurysm.
??????????? ?????????? ??????????????, ? 4, 2013
????????
???????????? ?????? ? ?????????? ?????????????? ?? ??????????? ????? ????????
??????????? ????? ?????????? ??????? ? ????????? ???????????? ???????????, ???????
???????????? ?? ???? ?????? ??????????????
??????? ??????? ? ????????????? ?????? ? ???????, ??????? ????????????????? ? ??????
????????????????? ???????. ? ???????? ????????? ?????????? ? ??????????? ???????
(????) ????? ????????? ??????????????? ??????? ???????????? ???????? ????? ?????????????? ??????, ??? ??????????? ?????????????? ?????????? ???????????, ???????????????, ????????????, ?????????????
????????? ?????????, ? ????? ?????????? ?
????????? ???? ??????????? ??????????????
?????? ? ??????? ????????? ???????????
[1?8]. ?? ?????? ?????????? ?????????????
???????????? ?? ????? ????????? ?????? ?????
? ?? ????????? 4% ??????? [9].
?????? ???????, ??????? ???????? ???????? ????????????? ??????????? ?????????????? ?????????? ? ???????????????????
??????? ? ???????? ????, ?????????? ?????? ??????????? ? ?????????????????, ?????? ????????? ??????? ??????? ???????????
???????? ? ????????.
???? ?????? ???????????? ? ???????????
?????? ?????? ?????? ?????????? ?????????????? ??????????? ? ???????? ????????? ?????????? ? ??????????? ??????? ??????????????????? ???????, ??????????? ??????????????????? ??????????? ??????, ? ??????????
??????????? ????????????? ?????????? ??????????? ?????????????? ???????????? (???) ??
??????? ???????, ????????????? ?? ??????
??????????? ??????? ?????? (???) ? ?????????????? ????????? ?????? ?????????.
???????? ? ??????
? ???????????? ???????? 102 ???????
??? ? ?????????????? ?????????? ??????
?????????, ??????? ???? ????????? ???????????????? ???????? ? ?????????????? ????????????? ?????? ????????? ? ???????
?????????????????? ???????. ????????
??????????? ? ???????? ?????????????? ??????????????, ?????????? ? ???????????????? ????????????. ??????????? ???????
????? ??????? ??????? ??????? ?????????????????? ??????? ? ??? ????????? 1-? ??????, ?? 2-? ?????? ????? 12 ????????? ? ??????????? ????????. ??????????? ?????????????? ??????? ? ??????? ????????????
????????????? ???????????? ? ??????? 1.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ???????????????
63
??????? 1
??????????? ?????????????? ??????? ? ??????? ????????
???????, ???
???
???????
???????
??????????? ??????????, %
II ??
III?IV ??
??????????????? ??????????????, %
I ??.
IIA ??.
IIB ??.
????? ??, ???
????? ????????? ?????, ???
1-? ?????? (n=90)
2-? ?????? (n=12)
56╠12
55╠9
21
69
3
9
12
88
0
100
8
80
12
116,2╠25,2
78,5╠15,4
0
92
8
134,7╠65,2
83,4╠13,8
????????? ? ??????? ???????? ???????
?????????????????? ??????? ? ????????
???? ?????????? ??????????? ????????
??????????? ?????????????? ????????????,
??????? ??????? ??????????????? (?????)
? ??? ??????????? ????????. ????????????
?????????????? ????? ???????? ? ????? ????????? ?? ???? ? ?????????? ?????????.
? ???????????? ? ???????? ? ?????
??. ?.?. ???????? ???? ?????????? ????????????????? ????????:
? ?????? ????????? ????????? ??? ??????????? ?????? ? ??? ??????? ?? ????????????;
? ?????? ???????? ? ???????? ????????????? ????? ??????;
? ?????? ???????? ??????? ????????;
? ?????? ????????? ?????? ? ??????????
???????;
? ?????? ????????? ?????????? ????????
??????;
? ???????? ???????? ????????.
? ?????? ???????? ??????? ????? ?????????? ???????????????????, ?????????? ??????? ????????? ?????????? ? ???????? ?????,
???? ?????????? ?????????. ??? ????????????? ??????????? ???????????? ?????????
??? ??????????? ????????.
? ??????? ? ??????????? ???????? ??????????? ???????? ??? ???????? ??????????
???????? ?????????????? ??????????? ? ??????????? ?? ????????? ??????????.
?????????????? ??????????? ??????????? ??
??????????? ???????? ╚Cypress╩ ????? Siemens
? ??????? ???????????? ?????? ????????.
??????????
? ??????? 1-? ?????? (? ??????? ????????
?????????????????? ???????) ??? ?????????? ????????????????????? ???????????? ??-
?????? ??????, ????????????????? ? ???????????? ???????-??????????????? ?????????
???????? ?????? ?????????. ???????? ?????????? ? ???? ?? 24 ?? 48 ?, ??????? ? ???????
????? ????????? ??? ?????????????? ??????????????? ????????? ? ????? ? ??? ??????.
???????????? ?????????? ? ????????? ?????????? ????????? 2-? ?????? ????????? ?
??????? 14 ??? (?? 4 ?? 25 ???), ?????????? ??????????? ?????????????? ???????????? ???????????? ?????????? ?????????? ? ?????????????????? ?????????? ??????? ? ?????????????? ?????? (????. 2). ???, ?????????????
?????? ????????? ??????????????? ??????????? ? 2 ???????. ? ??????????? ?????????
????????? ??????????????? ?????????? ? ???????????????? ????????????, ???????????
????????????????, ? 5 ?????????????????
?????? ?????????? ????????? ????????????
???????????????. ??????? ? ???????????
???????? ?? ???? ?????? ????????? ??????????????? ????? ? ??????? ????? ???????????
????????????, ?????? ?? ???????????? ?????????. ? 58% ?????????, ?????????? ?? 2-?
??????, ??? ?????????????? ????? ? ???????
????????? ? ??????.
? ?????????? ? ??????????????? ? ???
??????????? ???????? ??????? ? ???????????????? ???????????? ??????????? ?????????? ???????????? ??????????????? ???????. ?? ???? ??????????? ???????????????
? ????????? ????????????? ????????????
?????????? ??????, ??????????? ???????
????????????, ?????????, ??????? ?????????
???????? ?????. ? ??????? ??????? ??????????? ??????????? ??? ??????? ??????? ?
????? ?????? ????????? ? ???????? ????????????? ??????, ????????? ????????? ???????? ? ??????? ???????.
??????????? ?????????? ??????????????, ? 4, 2013
??????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
64
??????????? ???????????????
??????? 2
?????????? ??? ? ??????? 2-? ?????? ? ??????????? ?? ????????? ??????????
? ???????????? ?????????? ? ????
????? ???????
??????????
??????? ?????-????
??????????
??-????????????
?? 1 ????????
??????????
??-????????????
?? 1 ???????? ? ?????
???
2
5 (min 4, max 7)
20
4
??? + ??????????????? ??????????
3
10 (min 6, max 15)
24
2,4
??? + ??????????? ???????????????
1
12
28
2,3
??? + ??????????????? ?????????? +
?????? ??????????
1
9
26
2,9
???????????? ???????????????
5
15 (min 7, max 25)
40
2,7
??????????? ???????? ????????? ???????? ? ???????????? ????????????????, ???????
??????????? ???????????????, ??? ??????????? ???????? ? ????? ???????, ??? ???????
??????? ???????, ?????, ???????????? ???????.
????? ???????, ????????? ? ???????????
???????? ??????? ?????????????????? ???????
? ???? ????????? ??????????? ????? 2 ?????????????? ????????????, ????? ?????????? ???
?? ?????? ???????? ?????????? ?? 20 ?? 40. ???
???????????? ???????? ?? 3?9-? ???, ?????????? ?????????????? ?????????? ?? ???????? 2
???????????? ? ????? (??. ???????).
?? ????????? ?????? ??? ??????? ? ???????????? ? ?????? ????? ????? ????????
???????????? ??????????? ?????????? ??????????????? ???????, ???????????????? ????
?????????? ?????????, ???????????? ????????. ?????? ??????????????? ?????????
?????????? ????????? ????????? ???????????????, ???????????? ????????? ????????? ?
?????????? ????????????? ??????? ???????????????? ??????????????. ??? ?????????
??????????? ??????????? ????? ??????????
?????????????, ???????????????? ?????????????? ????????? ???????? ????????????.
??????????
???????? ???????, ??????? ?? ??????????
??????????? ? ?????? ?????? ? ??? ????????.
???????? (?? ????. standard ? ?????, ???????)
? ??????? ?????? ????? ? ??? ???????, ??????, ??????, ??????? ??????????? ??? ???????? ??? ????????????? ? ???? ?????? ???????? ????????. ???????? ??????????? ?????? (???) ? ??? ?????????? ??????, ???????
? ?????? ???? ?????? ??????????????? ???????? ???????? ???????? ??????????? ??????. ? ???? ???????, ???????? ???????????
?????? ?? ????????????? ??? ???????? ?????? ???????? ???????: ??????????? ??????????, ???? ??? ???????? ?? ??? ?????????????? ? ??????????? ??????????? (?????? ?
??.), ????????????? ????????????? ????????,
????????????????? ???????? ?? ?????????????? ? ??????????? ???????????.
??????? ?????????????? ? ?????????????? ?
? ?????????????, ??????? ????????? ? ???????
5
?????????? ??-???????????? ? ?????
??????????? ?????????? ??????????????, ? 4, 2013
? ? ? ? ? ? ? ? ? ?. ??? ? ?????? ????????? ???????????????.
??????????
?????-????
1
2
4
3
4
5
3
6
7
8
9
2
10
11
12
1
1
3
5
7
9
11
13
15
17
?????-????
19
21
23
25
27
???????? ??????? ??-???????????? ? 12 ????????? 2-? ?????? ? ?????? ????????????????? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????????????????????? ??????????, ??????????????? ??????????????? ? ???????? ??????? ?????? ???? ??????? ??????????? ?????,
??????? ? ????? ???????? ????????-?????????? ???????? (?????????????? ? ??????????????, ????????????? ??????????????, ??????
???????? ? ?. ?.) ? ?????????? ?????????? ????????????? ??????????????, ?????? ??????.
??????, ???????? ????????? ???????? ??????????????? ? ??????????? ????? ? ??????, ???????? ????? ??????????? ???????, ???????????? ?? ??????????? ??????? ?????????? ????????? ???????????? ? ????????? ???????????
???????, ? ??????? ???????????? ????? ????????? ???????? ??????????????, ???????? ?????????? ?????????? ? ?????????????? ?????????? ?????? ? ??????????.
???????? ??????? ????? ??. ?.?. ???????? ???? ???????? ???????? ??????????????????? ??????????? ?????? ????????? ?
????????????? ?????? ? ???????, ??????? ?????????? ?? ?????? ??????????????? ? ?????????? ??????? ????????????, ??????????????? ? ?????? ? 1956 ?. ??? ???? ??????
?????? ???? ???????? ???????? ? ? ???????????? ?????????. ?????????? ????????????
???? ????????? ? ??????????? ????? ???????????, ╚??????? ??????????╩ ???????? ??????????? ????? ??? ?????? ???????.
?????? ??? ?????-???? ??????? ?????????
? ?????????, ??? ?????? ?????? ??????????
???????? ?? ????????, ? ? ╚??????? ?????????╩
???????? ??????? ???? ?????????????? ?????????. ? ????? ??. ?.?. ???????? ????
????????? ??????? ?????????????? ??????????? ? ??????????? ???????? ???????? ? 80-? ???? ???????? ????????. ??? ???????????? ????????? ???? ?.?. ????????????, ?????????
???? ?.?. ????????, ?????-??????????????
???? ?.?. ??????????, ?????????? ?.?. ?????????? ?????? ?????? ?????? ??????? ? ?????? ????? ????????????? ????????? ???????
???????????????????? ??????????? [4, 10?16].
? 1998 ?. ???????????? ??????? ?? ???????????? ???????? ??????????? ?????? ??????
??????????? ?????????????? ???????????, ???
??????? ???? ??????????? ?????? ?????? [9,
17, 18]. ?????????????? ???????????? ?????????? ?????????????? ???????????? ? ???????????? ????????? ??? ????????? ???????
????????, ? ?????????, ??? ??????? ??? ????? ??????????? ????????? ????????? ? ???????????? ?????? ????????? ????????, ? ???
????? ? ?????????? ?????????? ? ??????????? ???????. ??? ?????? ????? ?????????? ?
65
????????????, ???????????? ???????? ????????, ??????? ???????? ????? ? ???????????????? ??????????? ???????? [19, 20]. ? ????????? ???? ?? ??????? ?????? ????????????? ???????? ????????????? ??-??????? ?
?????????? ??????????? ??????? [9]. ???? ?????? ?????????? ???????? ???????????????
???????????????????? ??????????? (focus
assessed transthoracic echo ? FATE), ?????? ?
??? ???????? ??????????????? ????????????
? ??????????? ??????????? ????????? ??????????? ????????? ??????????? ????????
????????????????????? ????????????. ??
?????? ??????? ????????????? ????????? ??
??????????? ?????????? ???????? ?????????????? ???????, ? ??? ????? ??????????
????????? ????????, ??? ???????? ?????????????? ??????? ???????? ? ??????? ????? ??????????????????? ???????????? [18, 21, 22].
??????? ????????? ?? ?????????????
??????? ???????????? ??????????? ? ?????????????? ??????? ????? ???? ???????
?????????? ? ???????? ???????? ?????
??. ?.?. ???????? ???? ? ? ????????? ?????
???????? ???????????? ?????? ?????????
??????? ??????? ? ?????? ????? ????? ????????? ??????????????????? ????????????.
? 2005 ?. ?? ?????????? ????????? ?????? ????????? ??? ? ???? ?.?. ??????? ???? ??????? ?????? ?????????? ?????????????? ? ?????????????? ???????????, ?????????? ???????
????????? ??????????????? ???????????? ?
?????????????? ??-??????? ? ??????????????????? ??????? ? ????, ? ???????????? ????? ? ?????????????? ?????? ??????.
? ????? ?????????? ??????????? ???????????? ?? ????????? ????????? ?????????
?????????????? ???????????. ? ?????????
??????? ? ??????? ???????? ??????? ?????????????????? ??????? ?????????????? ?????????? ?? ?? ? ????? ??. ?.?. ???????? ????,
??????? ???? ??????????? ? 2005?2006 ??. ???
????? ?? ??????? 3, ? ???????????? ?????????? ?????????????? ????????????? ?????? ???????????????, ?? ???????? ?????? ??????
?????????????? ??????????? ??? ?????? ???????? ?????? ??????? ?????????, ??????????? ?? ????????????????? ??????? ???????????? ???????, ??? ??????? ?????????? ?????????????? ???????????? ????? ???????????
????????? ???????????? ?????????.
?????????? ???????????? ????????????
??????????????? ? ???, ??? ????????? ?? ??????????? ???? ????????? ?? ????????????? ??-??????? ? ???? ? ???????????????-
??????????? ?????????? ??????????????, ? 4, 2013
??????????? ???????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
66
??????????? ???????????????
??????? 3
???????????????????? ????????? (?????????? ???????????? ? ?????),
????????????? ?? ? ?? ?? ? ????? ??. ?.?. ???????? ???? (2006 ?.)
?? ? ?? ??
?????
??????? ???????
1
1
??????????? ???????
?
1
??????? ???????
1
2
??????????? ???????
?
1
??????? ???????
1
1
??????????? ???????
?
1
?????????????? ???????
??????? ??????????? ???????? ?????? (? ??? ????? ? ?????? ????????? ????????)
??????? ? ?????????????? ???????? ?????? (????????? ???????????, ???????????
??? ??????????????? ????????)
??????? ? ???????????? ??????????
???? ??????? ?? ????????????? ???????????? ?????? ???????? ??????????????. ??????
???????? ??????? ??????????? ???????? ?
???????? ?????????????? ???????. ?????????? ?????????? ?? ?????? ???????????????
?????? ???????????? ?????????????? ???????????, ??????-??????????????, ??????????????, ???????? ??????????? ???????????? ??????? ??????????, ????? ?????????? ??????
???????, ????????? ? ????????? ??????? ????????, ????????? ??? ???????? ??????, ? ?
????? ????????????? ??????????? ?????? ?????? ???????? ????????.
??????????? ?????????? ??????????????, ? 4, 2013
??????????
??????????? ???? ?????? ?? ????????????? ??????? ?????????????? ??????????? ?
???? ???????????????????? ??????? ??????????????? ?? ?? ??????? ????????????? ?
??????????, ?????????? ??????????? ?????????????? ???????. ???, ????????? ??? ???
??????? ? ??????? ???????? ??????? ?????????????????? ??????? ?????? ????????
??????????????? ??????????????? ? ???
??????????? ???????? ? ????? ???????? ?
????? ????????? ?? ????.
? ????????? ? ??????????? ????????
??????? ?????????????????? ???????, ???????????? ???????????????? ???????????? ?????????????? ? ???????????????????
????????? ??? ??????? ? ?????? ?????????
? ??????????? ?? ????????? ??????????? ?????????. ????????? ???????????? ????-???????????? ? ???????????? ?????????????
?????????????? ???????????. ????????? ?
????????? ???????????????? ???????????
??????????????? ?? ???????????? ?????????, ? ?????????????? ???????? ??????????, ??? ????????? ???????? ??????? ?????????????? ????????? ?????? ? ??????? ???-
??????????? ? ?????. ??? ???????????? ???????????? ?? ???? ?????? ????????? ??????????????? ??????????? ?????????? ????????????? ????????????????????? ??????????? ?? ?????????? ?????. ?????? ? ???
?????????? ?????????????? ??????????????????? ??????? ??????????? ???????? ?
????????????? ?????????? ???????????
??????, ??????? ?????? ??????????? ??????
???????? ? ?????????, ??????? ???????? ???????????????????? ?????????? ????????????, ╚?? ?????? ??????╩, ???????? ??? ?????
? ????? ? ?????????? ????? ???? ?????????????? ???????????????.
??????? ????? ????????, ??? ????????? ??????????? ?????? ?? ????? ? ?? ?????? ?????????? ? ????????? ?????????, ????????,
??? ?? ??????????? ?????? ????????? ??????? ??????????? ????????????????? ? ??????????, ??????? ?????????? ?????? ? ????????? ? ???????????? ??????????? ?????.
? ???????? ????? ????????? ?????? ??????????????? ?? ?????? ?????? ?? ??????? ????????? ???????? ? ? ?????? ???? ??????
??????????? ???????? ? ??????????????? ?????????: ????? ???????? ? ??????? ?????.
??????????
1.
2.
3.
4.
5.
??????? ?.?., ???????? ?.?., ????????? ?.?. ?????????????? ??????????? ? ???????????. ?.: ?????
??. ?.?. ???????? ????; 2002.
??????? ?.?., ???????? ?.?. ??????????? ???????????. ?.:
????? ??. ?.?. ???????? ????; 2011.
??????? ?.?., ?????????? ?.?., ?????????? ?.?. ??????????? ? ???????? ????????? ??????? ??????????????? ?
??????? ? ?????????? ????? ?? ? ? ?????? ????? ?????
?????????????? ???????. ??????? ? ????????-??????????
????????. 2007; 5: 37?42.
??????????? ?.?., ??????? ?.?. (???.) ????????-?????????? ????????: ???????????. ?.: ????????; 1996.
?????????? ?.?., ??????? ?.?. ? ??. ???????? ???????????????????? ??????????? ? ?????? ?????????????????
??????? ? ??????? ????? ?????????? ????????????????
???????? ?? ????? ????????? ? ??????????? ????????????. ?????????????? ? ??????????????. 2006; 3: 64?7.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
?????? ?., ?????? ?.?. ??????????? ???????????????.
?.: ???; 1993.
Sokolskaya N.O., Malashenkov A.I., Rusanov N.I., Rychin S.V.,
Kopylova N.S. Geometric and functional characteristics of the
left ventricle in patients with aneurysm and dissecting aneurysm
of the ascending aorta before surgery and in the early postoperative period. Interactive CardioVascular and Thoracic Surgery.
60th ESCVS International Congress. Moscow; 2011: 166.
Walker D., West N., Ray S. et al. From coronary care unit to
acute cardiac care unit ? the evolving role of specialist cardiac
care. Recommendations of the British cardiovascular society
working group on acute cardiac care. 2011: 1?35.
Haji D.L., Royse A., Royse C.F. Clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia.
Emergency Medicine Australasia. 2013; 25: 4?12.
??????????? ?.?., ??????? ?.?., ????????? ?.?. ? ??. ???????????? ?????????? ???????????? ???????: ????????,
??????, ???????????, ???????, ????????. ?.: ?????
??. ?.?. ???????? ????; 1995.
??????? ?.?. ??????????????? ??? ?????????? ???????
?????? ? ??????? ?? ?????????????? ??????? ? ?????
????????? ????? ???????????? ?????????????: ???. ?
????. ???. ????. ?.; 1979.
????? ?.?. ??????? ?????? ? ????????????????? ??????? ? ????? ??????? ???????? ? ??? (?? ?????? ???????????????): ???. ? ????. ???. ????. ?.; 1989.
?????? ?.?. ???????????????????? ??????????? ?????????? ??????? ??????, ???????????????? ?????????? ??????????????????? ????????: ???. ? ????. ???. ????. ?.; 1982.
??????? ?.?., ????????? ?.?. ??????????? ???????????
?? ?????????????? ???????????. ?.: ?????; 1998; V.
?????????? ?.?. ??????????? ? ??????? ????????? ????? ?????? ? ???????????? ? ?????? ?????????????????
??????? ? ??????? ????? ?????????????? ???????? ??????: ???. ? ?-?? ???. ????. ?.; 1996.
???????? ?.?. ???????????? ???????????????? ??????
??????? ??????? ????? ? ?????????? ???????: ???. ?
????. ???. ????. ?.; 2001.
Ferrada P., Murthi S., Anand R. et al. Transthoracic focused
rapid echocardiographic examination: real-time evaluation of
fluid status in critically ill trauma patients. Journal of Traumainjury Inferction and Critical Care. 2011; 70 (1): 56?64.
Gottdiener J., Bednarz J., Devereux R. et al. American Society of
Echocardiography recommendations for use of echocardiography
in clinical trials. J. Am. Soc. Echocardiogr. 2004; 17: 1086?119.
Chambers J. Accreditation in echocardiography. SA Heart
Autumn. 2010; 7: 90?2.
Herbst P. Echocardiography: is there unseen risk in cardiac
ultrasound? SA Heart Autumn. 2010; 7 (8): 86?9.
Lang R., Bierig M., Devereux R. et al. Recommendations for
Chamber Quantification: A Report from the American Society of
Echocardiography's Guidelines and Standards Committee and the
Chamber Quantification Writing Group, Developed in
Conjunction with the European Association of Echocardiography,
a Branch of the European Society of Cardiology. J. Am. Soc.
Echo?ardiogr. 2005; 18: 1440?63.
Samad B., Alam M., Jensen-Urstad K. Prognostic impact of
right ventricular involvement as assessed by tricuspid annular
motion in patients with acute myocardial infarction. Am. J.
Cardiol. 2002; 90: 778?81.
??????? ?.?., ??????? ?.?., ??????????? ?.?., ?????????? ?.?., ??? ?.?., ??????? ?.?., ???????? ?.?. ????????? ??????????? ?????? ? ?????????? ??????? ???????? ? ????????? ? ????????-?????????? ????????:
???????? ? ??????????????? ???????. ??????? ? ????????-?????????? ????????. 2012; 4: 4?8.
References
1.
2.
3.
Bockeria L.A., Golukhova E.Z., Ivanitskiy A.V. Functional
diagnosis in cardiology. Moscow: A.N.Bakoulev Scientific
Center for Cardiovascular Surgery of the Russian Academy
of Medical Sciences; 2002 (in Russian).
Bockeria L.A., Golukhova E.Z. Clinical cardiology. Moscow:
A.N.Bakoulev Scientific Center for Cardiovascular Surgery of
the Russian Academy of Medical Sciences; 2011 (in Russian).
Bockeria L.A., Malashenkov A.I., Sokol'skaya N.O. Possibilities and significance of various echocardiographic methods
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14
15.
16.
17.
18.
19.
20.
21.
22.
23.
67
in patients with aortic aneurysm in preoperative and in early
post-operative period. Grudnaya i serdechno-sosudistaya
khirurgiya. 2007; 5: 37?42 (in Russian).
Burakovskiy V.I., Bockeria L.A. (eds). Cardiovascular surgery. Moscow: Meditsina; 1996 (in Russian).
Sokol'skaya N.O., Alshibaya M.M. et al. Dynamic changes of
echocardiographic indices in an early post-operative period
in patients who underwent left ventricular reconstructive
surgery and coronary artery bypass graft surgery.
Anestesiologiya i reanimatologiya. 2006; 3: 64?7 (in Russian).
Shiller N., Osipov I.A. Clinical echocardiography. Moscow:
Mir; 1993 (in Russian).
Sokolskaya N.O., Malashenkov A.I., Rusanov N.I., Rychin S.V.,
Kopylova N.S. Geometric and functional characteristics of the
left ventricle in patients with aneurysm and dissecting aneurysm
of the ascending aorta before surgery and in the early postoperative period. Interactive CardioVascular and Thoracic Surgery.
60th ESCVS International Congress. Moscow; 2011: 166.
Walker D., West N., Ray S. et al. From coronary care unit to
acute cardiac care unit ? the evolving role of specialist cardiac
care. Recommendations of the British cardiovascular society
working group on acute cardiac care. 2011: 1?35.
Haji D.L., Royse A., Royse C.F. Clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia.
Emergency Medicine Australasia. 2013; 25: 4?12.
Burakovskiy V.I., Bockeria L.A., Tskhovrebov S.V. et al. The
computer technology of intensive therapy: control, analysis,
diagnosis, treatment, training. Moscow: A.N. Bakoulev
Scientific Center for Cardiavascular Surgery of the Russian
Academy of Medical Sciences; 1995 (in Russian).
Zubkova G.A. Echocardiographic examination for mitral valve
disease in patients in preoperative period and after various
types of surgical procedures: PhD med. sci. Diss. Moscow;
1979 (in Russian).
Kapba I.V. Function of the heart in post-operative period in
young children with congenital heart defects (based on
echocardiographic data): PhD med. sci. Diss. Moscow; 1989
(in Russian).
Mitina I.N. Diagnostic echocardiography of congenital heart
defects accompanied by atrioventricular valvular disease: PhD
med. sci. Diss. Moscow; 1982 (in Russian).
Mit'kov V.V., Sandrikov V.A. Clinical guidelines for diagnostic
ultrasound. Moscow: Vidar; 1998; V (in Russian).
Poplavskaya L.M. Diagnosis and treatment of heart rhythm
and conduction disorders in an early post-operative period in
patients after heart valve replacement: Dr. med. sci. Diss.
Moscow; 1996 (in Russian).
Soboleva N.N. Non-invasive hemodynamic assessment of
prosthetic heart valve EMIKS function in the aortic position:
PhD med. sci. Diss. Moscow; 2001 (in Russian).
Ferrada P., Murthi S., Anand R. et al. Transthoracic focused
rapid echocardiographic examination: real-time evaluation of
fluid status in critically ill trauma patients. Journal of Traumainjury Inferction and Critical Care. 2011; 70 (1): 56?64.
Gottdiener J., Bednarz J., Devereux R. et al. American Society of
Echocardiography recommendations for use of echocardiography
in clinical trials. J. Am. Soc. Echocardiogr. 2004; 17: 1086?119.
Chambers J. Accreditation in echocardiography. SA Heart
Autumn. 2010; 7: 90?2.
Herbst P. Echocardiography: is there unseen risk in cardiac
ultrasound? SA Heart Autumn. 2010; 7 (8): 86?9.
Lang R., Bierig M., Devereux R. et al. Recommendations for
Chamber Quantification: A Report from the American Society of
Echocardiography's Guidelines and Standards Committee and the
Chamber Quantification Writing Group, Developed in
Conjunction with the European Association of Echocardiography,
a Branch of the European Society of Cardiology. J. Am. Soc.
Echo?ardiogr. 2005; 18: 1440?63.
Samad B., Alam M., Jensen-Urstad K. Prognostic impact of
right ventricular involvement as assessed by tricuspid annular
motion in patients with acute myocardial infarction. Am. J.
Cardiol. 2002; 90: 778?81.
Bockeria L.A., Salagay O.O., Samorodskaya I.V., Sokol'skaya N.O., Son I.M., Volkova I.I., Krupyanko S.M. Standards
of medical care in keeping balance of quality and cost in cardiovascular surgery: legal and organizational aspects.
Grudnaya i serdechno-sosudistaya khirurgiya. 2012; 4: 4?8 (in
Russian).
????????? 02.09.2013
??????????? ?????????? ??????????????, ? 4, 2013
??????????? ???????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
68
??????? ??? ???????
??????? ??? ???????
????????? ??????!
??????????? ?????????? ??????????????, ? 4, 2013
???????? ???? ???????? ?? ??, ??? ?????? ?????? ? ??????????????? ??? ???????? ??????? ????????????? ??????? ???????? ? ???????, ? ??????? ?????? ???? ???????????? ???????? ?????????? ??????????? ?? ????????? ?????? ??????? ??????? ? ????????? ????, ? ????? ? ????????????? ?????????????? ??????? ? ???? ??????, ??? ???????????? ??????????? ??????? ?????? ?????? ?????? ????????? ?????????
???????.
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. ? ????????? ???????????(??) ?????, ????? ??? ?????? ?????????? ???????? ?????????? ??????? ????????????.
5) ???? ??????????? ?????????????? ???????? ? ?????? ??????, ??????????? ??? ????????? ??????? ? ?????????? ??????? ???????? ???????????: ?.?.?. ????????? ?? ??????? ????? ? ? ??????????????,
??????? ???????, ??????, ?????????, ?-mail ??????????? ??????.
??????? ?????????? ?????:
?.?. ???????1, ?.?. ????????1, ?.?. ??????????2
??????????????? ??????????????????? ?????? ????????????
???????? ???????????? ??? ????????? ????????? ?????????
?????? ????? ?? ?????
1????
??? ╚????????? ??????????????? ??????????? ???????????╩
???????????? ??????????????? ??,
??. ??????, 40, ???????, 656038, ?????????? ?????????;
2???? ??? ╚???????????? ??????????????? ??????????? ???????????
??. ????. ?.?. ?????-??????????╩ ???????????? ??????????????? ??,
??. ????????? ?????????, 1, ??????????, 660022, ?????????? ?????????
??????? ???????? ????????, ?????? ???. ????, ?????????, ?????????? ???????? ??????????????,
?????????????? ? ?????????????? ???????????; e-mail: kulikov57@mail.ru;
???????? ????????? ??????????, ???????? ???. ????, ????????? ??????? ??????????????, ??????????????
? ?????????????? ???????????;
?????????? ???????? ????????, ?????? ???. ????, ?????????, ?????????? ???????? ??????? ???????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??? ???????
69
V.P. Kulikov1, M.L. Dicheskul1, S.I. Zhestovskaya2
INFORMATIVITY OF DOPPLEROGRAPHIC EVALUATION OF CEREBRAL VENOUS REACTIVITY
IN DIFFERENT TYPES OF DISTURBANCES OF VENOUS BLOOD OUTFLOW FROM THE BRAIN
1Altai
6. ?????????? ???? ?????????? ???????????? ?????? ?????? ???? ?????????: ??????,
???????? ?????, ??????? ????????, ?????????? ????????? ??????? ? ??????? ????????? ??????, ? ?????? ?????????? ????????????, ???????? ? ??????, ?????????? ? ??????????, ?????? ?? ??????? ??? ??????????, ?????? ???????????? ??????????.
???????? ???????????? ?????? ???? ??????? ????? ?????, ??? ????? ?? ????? ????? ???? ?????????????.
??? ?????????? ? ?????? ????????????????? ????? ??????? ????????????????? ╚????????? ?????????? ????? ? ?????????????? ????????????????? ????????╩. ?????? ????, ???? ? ?????????? ?????????????? ???????? ?????? ??????????? ?????? ????????? ??????????? ??? ?????????? ???????????
???????? ?????? ????????????? ? ?????? ??????????? ????????.
????????? ?????? ?????? ???? ?????, ??????, ??? ??????? ???????????? ???????? ? ??????????.
???????????? ??????? ???????? ????? ? ??????????? ??????, ??????????? ?????????? ????????????,
?????? ??? ??????? ???????????? ????????.
????? ???????, ???????? ?? ?????????? ???????? ???????? ?????????? ??? ????????????, ???????? ??????? ????????, ??????????, ????????? ?????????????, ??????, ????????????, ???????? ??? ??????????? ????????, ??????????? ? ??????.
7. ?????????. ??? ??????? ? ??????????? ?????? ???? ?????? ??????????, ?? ????????? (???
???????, ??? ? ?????????) ?????? ??????????????? ╚?????????????????? ??????? ??????????? ????????╩ (? 3-? ?., ??? ???. ????. ?.?. ???????????).
????????????? ????????? ?????? ???? ????????? ?????? ? ????????????? ??????????????? ?????????, ??????? ????????????? ???????, ????? ? ?????? ????????????? ?????????? ????????? ???????? ???????? ??????????, ?????????????????? ? ?????? (? ???????????? ? ?????????????-?????????
???????? ╚??????-?????????╩ ? ??????????????? ?????? ????????????? ???????).
??????????, ????? ????????? ????????? ??????????????? ????????? Enzyme Classification.
??????????, ????? ??????????? ??? ???????? ??????????? ??????????????? ?????????????
????????????? ??????????? ????????? ? ???????? (Mendelian Inheritance in Men, ??.
http://ncbi.nlm.nih.gov/Omim).
???????? ??????????????? ?????? ???? ???????? ? ???????????? ? ╚????????????????? ???????? ??????????? ????????╩ (? 3-? ?., ??? ???. ????. ?.?. ???????????) ??? ?? ??????? ╚???????????
?????????????╩ (??? ???. ?.?. ???????????).
????????? ?.?.?., ??????????? ? ??????, ?????? ??????????????? ?????? ??????????.
???????, ????????? ??????? ? ???????? ??????????? ??? ?????????, ?????? ???? ????????.
?????? ???????????? ?????????? ?????? ?????????, ??????????, ?????????? ? ??????????????
??????? ? ???????? (???????? ???) ??????????? ???????????? ??????????????, ????? ?????????????
? ??????. ??? ???????? ??????? ????????? ??????????? ? ???????????? ?????? ???? ???????????? ?
?????? ??? ?? ?????? ??????????. ?? ??????????? ?????????? ??????? ????, ???? ???? ??? ????? ???????????.
???? ????????????? ???????, ??????? ????????? ? ?????? ????????? ???????? ?????? ???? ??????? ? ??????? ??.
8. ????????? ?????? (?????????)
????????? ?????? ? ?????? ???????? ???????? ?????????? ?????????? ? ????????????? ? ?????????? ?????????????? ???????? ? ????? ??????, ????????????? ??????. ????????? ?????? ???????? ?? ????????? ???????????? ?? ????? ????? ??. ?.?. ???????? ???? ??? ????????? ????????? ? ????
???????? ? ????????????? ???????? ?????????? ?????????. ????????? ?????? ?????? ???? ???????????? ?? ??????? ? ?????????? ?????.
?? ????????? ? ?????? ???????? ?????? ???? ??????? ???? ????????????, ?? ??? ?? ?????? ??????????, ????? ?? ?????????? ? ??????? ?????? ?????? ??? ????????? ???????????? ??? ????? ?????????
??????????.
? ????????? ?????? ?????? ???? ???????? ?????? ???????????? ????? ??????. ??? ???????????? ?????? ?????????????? ????????? ?????????, ??????????? ????????? ?????? ? ?????????? ????,
??????????? ?????????? ??????????????, ? 4, 2013
State Medical University, Ministry of Health of the RF,
prospect Lenina, 40, Barnaul, 656038, Russian Federation;
2Prof. V.F. Voyno-Yasenetskiy Krasnoyarsk State Medical University, Ministry of Health of the RF,
ul. Partizana Zheleznyaka, 1, Krasnoyarsk, 660022, Russian Federation
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
70
??????? ??? ???????
???????? ? ??????, ??????????, ?????????? (??????). ?????? ???????, ????, ???? ?????? ??????????? ? ??? ??????, ???? ??? ?? ???? ?? ???????? ??????; ????? ??? ??????????? ?????????? ?????? ????????????? ????????? ? ??? ??????, ???? ??? ?????????? ???????? ??? ???????????? ??????? ? ?????
?????? ?????? ??????.
?????????? ???????? ????????????? ? ????????????????? ??????????. ???????????? ???????? ?????
??????????? ? ?????? ????????????? ????????, ?????? ?????????, ???????, ??????? ??????????? ???????????? ??????, ? ????? ??????, ???????, ?? ?????? ??????, ????? ???????????? ????????.
? ?????? ?????????? ?????? ?? ?????? ??????????? ????????, ???????????? ? ????????. ???????
????????? ???????? ????? ?? ?????? ??????, ????? ?????????? ?????? ?????? ???? ????????? ? ?????,
???????? ?? ?????????????? ??????????, ?????? ??????? ????, ????? ? ?????????? ????????????.
? ?????? ?????????? ?????? ??????? ???????? ??????? ?????????????? ???????????, ??? ????????
?????????? ???????????? ????????, ? ?? ????????? ?????.
?????????? ? ???????? ???????????, ????? ???????????????????, ????????? ? ??????????????
??????? ??? ???? ?? ??????????? ? ??????????? ??? ?????? ???????????? ? ????????? ??????.
????? ?????? ?????????? ?????? ???????????? ??????????? ?????????? (??????? ????????, ?? ??????? ????????? ?/??? ???????????? ?????????), ?? ?? ?????? ???? ????? 100?250 ????.
???????? ????? ?????? ????? ????? ? ??????? ? ?? ?????? ??????????? ????? ??????, ???????
?????????????? ???????????? ??? ?????? ?????? ? ????.
9. ?????????? ? ????????. ? ?????? ??? ??????????? (??????????, ?????, ?????????, ??????? ? ?. ?.) ????????? ?????????. ?? ??? ??????? ? ?????? ?????? ???? ???? ??????. ??????? ?????? ????????????? ??????????????? ????? ??????, ? ??????? ??? ??????????? ???????. ????????? ???????????
??????????? ? ?????? ? ???? ????????? ?????? ? ??????? tif ??? jpg, ?? ??????????? ????, ???????? ??? ????????, ????? ?????????? ??????????? ???????? ? ??? ?????????.
???? ?? ????????? (???????) ???????????? ?? ????? 5 ??????????, ?? ??? ??????? ?? ???????? (?????)
?????????? ???????????? ?? ??????? ???????, ? ?????-????? ? ?????????? ?????? ????????? ??? ??????, ???? ????? 5 ? ???????. ????????????? ???????????? ?????????? ?????????.
??????????? ????????? ?????? ???? ????? ???????? ????????. ??????? ?????? ???? ??????? ?? ?????
???????????. ??????? ?? ???????????? ?????? ???? ???????, ??????????? ?? ??????? ?????.
??????? ? ???????? ?????? ????????? ????????????? ??????????? ? ???????????, ? ??? ?????
???????? ?? ?????????????? ?????? ???????????? ? ?????????????? ???????? ??? ???????????? ??????????? ???????????????? ??????????????? ???????, ??? ???????? ??????????? ? ???????????? ????????. ? ???????? ? ???????????????? ?????????? ????????? ????? ??????? ????????? ? ??????????
??????? ? ?????????. ? ???????? ? ???????? ??????????? ??????????? ?? ???? ??????? ? ??????? ? ??????? ?????????, ?????????? ????????? ?? ?????? ??????.
???????, ?? ??????????????? ???????????, ????? ????????? ?? ??????, ????????? ?? ?????????
??????????????? ???????????? ???????? ??????????.
??? ????????????? ??????? ??? ??????? ?? ??????-???? ????????? ??????????? ?????? ?? ???????? ? ???????????? ? ???????????? ? ?????????? ??????.
10. ??????? ? ???????? ? ??????????? ?????? ?? ????????? ?????. ?????? ???????
?????? ????? ????? ????????? ? ??????????? ???? ??????????. ? ???????? ? ???????? ???????????
??????????? ?? ???? ??????? ? ??????? ? ??????? ?????????, ?????????? ????????? ?? ?????? ??????.
? ???????? ? ???????????????? ??????????? ????? ??????? ? ??????????.
11. ?????????? ??????: ?????? ?????? ?????????? ?????????? ????? ???????, ???? ?????? ??
????????. ?????????? ???? ? ???????? ?? ???????????. ??? ????? ? ???????? ?????? ??????????????? ?????? ? ?????? ? ??????????? ?????? ???? ?????????? ?????????????.
12. ????????????????? ?????? ???????????? ? ?????? ╚?????? ?????????? ? ?????????,
?????????????? ? ?????????????? ???????╩ ?????????????? ???????? ?????????? ??????????? ???????? (Uniform Requirements for Manuscripts Submitted to Biomedical Journals). ?????????? ???????? ???????????? ?????????? ? ??????? ?????????? ???????? ??????? ????, ??? ?????????? ?????????? ?????
?????? ??? ?????? ??????? ???????????? ?? ??????? ? ???????????, ? ??????? ??? ????????.
? ???????????? ??????? ??????????? ??????????? ?? ????? 25 ??????????, ? ??????? ?????????? ? ?? ????? 50, ? ??????? ? ?????? ?????????? ? ?? 15. ???????????? ?????? ????????? ?????? ????????????????
????? ?????????? ?? ????????? 5 ???.
? ?????? ?????????? ??? ?????? ????????????? ? ??????? ???????????. ????????????????? ??????
? ?????? ?????? ?????? ? ?????????? ??????? ????????.
?????? ?? ???????????????? ?????? ?? ???????????.
????????????????? ???????? ?????: ?????(?), ????????, ????? (??? ??????), ????? ????????? ?
???????? ????????????; ????? ????? ? ??????? ? ??? ???????. ???? ?????? ?????? ?? ????? ?? ?????:
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
71
??????, ???????? ?????, ????? ????? ???????? ╚? ??.:╩ ??? ╚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). ?????? ??????.
??????? ?????????????? ????????????? ?????????? ??????????
??? ????????????? ????? ??????
?????? ?? ???????:
Belushkina N.N., Khomyakova T.N., Khomyakov Yu.N. Diseases associated with dysregulation of programmed
cell death. Molekulyarnaya meditsina. 2012; 2: 3?10 (in Russian).
Zagurenko A.G., Korotovskikh V.A., Kolesnikov A.A., Timonov A.V., Kardymon D.V. Technical and economic
optimization of hydrofracturing design. Neftyanoe khozyaistvo. 2008; 11: 54?7 (in Russian).
?????? ?? ???????????? ???????:
Swaminathan V., Lepkoswka-White E., Rao B.P. Browsers or buyers in cyberspace? An investigation of electronic factors influencing electronic exchange. Journal of Computer-Mediated Communication. 1999; 5 (2).
Available at: http://www. ascusc.org/jcmc/vol5/issue2/ (Accessed 28 April 2011).
????? (??????????, ???????):
Kanevskaya R.D. Mathematical modeling of hydrodynamic processes of hydrocarbon deposit development.
Izhevsk; 2002 (in Russian).
From disaster to rebirth: the causes and consequences of the destruction of the Soviet Union. Moscow: HSE
Publ.; 1999 (in Russian).
Latyshev V.N. Tribology of cutting, vol. 1: Frictional processes in metal cutting. Ivanovo: Ivanovskiy Gos.
Univ.; 2009 (in Russian).
????????? ???????????:
Usmanov T.S., Gusmanov A.A., Mullagalin I.Z., Muhametshina R.Yu., Chervyakova A.N., Sveshnikov A.V.
Features of the design of field development with the use of hydraulic fracturing. In: New energy saving subsoil technologies and the increasing of the oil and gas impact. Proc. 6th Int. Symp. Moscow, 2007; 267?72 (in Russian).
??????????? ?????????? ??????????????, ? 4, 2013
??????? ??? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 4, 2013
72
??????? ??? ???????
????????-??????:
??? Style (2011). Available at: http://www.apastyle.org/apa-style-help.aspx (accessed 5 February 2011).
??????????? ???????????:
Semenov V.I. Mathematical modeling of the plasma in the compact torus. Dr. phys. and math. sci. Diss. Moscow;
2003 (in Russian).
Grigor?ev Yu. A. Development of scientific bases of architectural design of distributed data processing systems.
Dr. tech. sci. Diss. Moscow: Bauman MSTU Publ.; 1996 (in Russian).
????:
State Standard 8.586.5-2005. Method of measurement. Measurement of flow rate and volume of liquids and
gases by means of orifice devices. Moscow: Standartinform Publ.; 2007.
??????:
Palkin M.V. et al. The way to orient on the roll of aircraft with optical homing he; d. Patent RF, ? 2280590;
2006 (in Russian).
??????? ?????????? ?????? ?? ?????????? ??? ????????????? ????? ??????
?????? ?? ???????:
??????? ?.?., ?????????? ?.?., ????? ?.?., ??????? ?.?., ????? ?.?., ??????? ?.?. ? ??. ??????????????? ??????????? ????????? ??? ?????????????? ??????????? ???????? ?. ??????? ???????????. 2012; 1: 45?8.
??????? ?.?. ?????: ????? ???????? (??????????? ???????). ?????????????. 2010; ????. 1: 3?8.
Aiuti A., Cattaneo F., Galimberti S., Benninghoff U., Cassani ?., Callegaro L. et al. Gene therapy for immunodeficiency due to adenosine deaminas deficiency. N. Engl. J. Med. 2009; 360 (5): 447?58.
Glauser T.A. Integrating clinical trial data into clinical practice. Neurology. 2002; 58 (12, Suppl. 7): S 6?12.
?????:
????? ?.?. ?????????????? ?????????: ???????, ??????????? ????????? ? ??????????? ????????. ?.:
????????; 2003.
???????? ?.?. (???.) ??????????? ?? ???????????. 3-? ???. ?. 3. ?.: ?????????; 2005.
?????????? ?.?. (???.) ?????????????: ??????? ???????. ?.: ????; 2008.
Beck S., Klobes F., Scherrer C. Surviving globalization? Perspective for the German economic model. Berlin:
Springer; 2005.
Michelson A.D. (ed.) Platelets. 2nd ed. San Diego: Elsevier Academic Press; 2007.
Mestecky J., Lamm M.E., Strober W. (eds) Mucosal immunology. 3rd ed. New York: Academic Press; 2005.
????? ?? ?????:
??????? ?.?. ????????? ? ??????? ?????? ????????? ??????. ? ??.: ?????? ?.?., ??????????? ?.?.
(???.) ??????????????? ???????? ?????? ? XXI ????. ?.: ????-??????; 2009: 110?31.
Silver R.M., Peltier M.R., Branch D.W. The immunology of pregnancy. In: Creasey R.K., Resnik R. (eds).
Maternal-fetal medicine: Principles and practices. 5th ed. Philadelphia: W.B. Saunders; 2004: 89?109.
????????? ??????? ???????????, ???????????:
?????????? ??????? ??????????? ? ???????????????: ????????? ??????-???????????? ???????????. 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 M.M. 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://www.psvedu.ru/journal/201l/4/2560.phtml
????? ????? ??????????????? ?? ???????????? ????????????????? ??????.
?????? ??????? ?????????? ???????? ??????? ?? ??????: 119049, ??????, ????????? ?????., ?. 8,
????. 18, ???????????? ????? ??. ?.?. ???????? ????, ???????? ??????? ╚??????????? ??????????
??????????????╩; e-mail: izdinsob@yandex.ru; ???./????: 8 (499) 236-92-87.
??? ????????? ????????? ?????? ?????? ??????????????? ?? ?????.
????? ?? ?????????? ????????? ?? ?????????.
???????? ?????????????? ?????????? ?? ???????? 2
???????????? ? ????? (??. ???????).
?? ????????? ?????? ??? ??????? ? ???????????? ? ?????? ????? ????? ????????
???????????? ??????????? ?????????? ??????????????? ???????, ???????????????? ????
?????????? ?????????, ???????????? ????????. ?????? ??????????????? ?????????
?????????? ????????? ????????? ???????????????, ???????????? ????????? ????????? ?
?????????? ????????????? ??????? ???????????????? ??????????????. ??? ?????????
??????????? ??????????? ????? ??????????
?????????????, ???????????????? ?????????????? ????????? ???????? ????????????.
??????????
???????? ???????, ??????? ?? ??????????
??????????? ? ?????? ?????? ? ??? ????????.
???????? (?? ????. standard ? ?????, ???????)
? ??????? ?????? ????? ? ??? ???????, ??????, ??????, ??????? ??????????? ??? ???????? ??? ????????????? ? ???? ?????? ???????? ????????. ???????? ??????????? ?????? (???) ? ??? ?????????? ??????, ???????
? ?????? ???? ?????? ??????????????? ???????? ???????? ???????? ??????????? ??????. ? ???? ???????, ???????? ???????????
?????? ?? ????????????? ??? ???????? ?????? ???????? ???????: ??????????? ??????????, ???? ??? ???????? ?? ??? ?????????????? ? ??????????? ??????????? (?????? ?
??.), ????????????? ????????????? ????????,
????????????????? ???????? ?? ?????????????? ? ??????????? ???????????.
??????? ?????????????? ? ?????????????? ?
? ?????????????, ??????? ????????? ? ???????
5
?????????? ??-???????????? ? ?????
??????????? ?????????? ??????????????, ? 4, 2013
? ? ? ? ? ? ? ? ? ?. ??? ? ?????? ????????? ???????????????.
??????????
?????-????
1
2
4
3
4
5
3
6
7
8
9
2
10
11
12
1
1
3
5
7
9
11
13
15
17
?????-????
19
21
23
25
27
???????? ??????? ??-???????????? ? 12 ????????? 2-? ?????? ? ?????? ????????????????? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?????????????????????? ??????????, ??????????????? ??????????????? ? ???????? ??????? ?????? ???? ??????? ??????????? ?????,
??????? ? ????? ???????? ????????-?????????? ???????? (?????????????? ? ??????????????, ????????????? ??????????????, ??????
???????? ? ?. ?.) ? ?????????? ?????????? ????????????? ??????????????, ?????? ??????.
??????, ???????? ????????? ???????? ??????????????? ? ??????????? ????? ? ??????, ???????? ????? ??????????? ???????, ???????????? ?? ??????????? ??????? ?????????? ????????? ???????????? ? ????????? ???????????
???????, ? ??????? ???????????? ????? ????????? ???????? ??????????????, ???????? ?????????? ?????????? ? ?????????????? ?????????? ?????? ? ??????????.
???????? ??????? ????? ??. ?.?. ???????? ???? ???????? ???????? ??????????????????? ??????????? ?????? ????????? ?
????????????? ?????? ? ???????, ??????? ?????????? ?? ?????? ??????????????? ? ?????????? ??????? ????????????, ??????????????? ? ?????? ? 1956 ?. ??? ???? ??????
?????? ???? ???????? ???????? ? ? ???????????? ?????????. ?????????? ????????????
???? ????????? ? ??????????? ????? ???????????, ╚??????? ??????????╩ ???????? ??????????? ????? ??? ?????? ???????.
?????? ??? ?????-???? ??????? ?????????
? ?????????, ??? ?????? ?????? ??????????
???????? ?? ????????, ? ? ╚??????? ?????????╩
???????? ??????? ???? ?????????????? ?????????. ? ????? ??. ?.?. ???????? ????
????????? ??????? ?????????????? ??????????? ? ??????????? ???????? ???????? ? 80-? ???? ???????? ????????. ??? ???????????? ????????? ???? ?.?. ????????????, ?????????
???? ?.?. ????????, ?????-??????????????
???? ?.?. ??????????, ?????????? ?.?. ?????????? ?????? ?????? ?????? ??????? ? ?????? ????? ????????????? ????????? ???????
???????????????????? ??????????? [4, 10?16].
? 1998 ?. ???????????? ??????? ?? ???????????? ???????? ??????????? ?????? ??????
??????????? ?????????????? ???????????, ???
??????? ???? ??????????? ?????? ?????? [9,
17, 18]. ?????????????? ???????????? ?????????? ?????????????? ???????????? ? ???????????? ????????? ??? ????????? ???????
????????, ? ?????????, ??? ??????? ??? ????? ??????????? ????????? ????????? ? ???????????? ?????? ????????? ????????, ? ???
????? ? ?????????? ?????????? ? ??????????? ???????. ??? ?????? ?
Документ
Категория
Информационные технологии
Просмотров
15
Размер файла
1 340 Кб
Теги
клинические, кровообращения, физиология, 2013, 149
1/--страниц
Пожаловаться на содержимое документа