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153.Клиническая физиология кровообращения №3 2012

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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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Clinical Physiology
of Circulation
?????????????
??????-???????????? ??????
??????? ???? ??? ? ???????
??????? ? 2004 ?.
??????
3? 2012
?????? ?????? ? ???????? ????????????? ?????????????
??????-??????????? ???????, ??????????? ? ?????????? ?????????
? ????????????? ??? ????????????? ???????? ??????????? ???????????
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
Л??б?кзбн╦ к ка??збн╦
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?б ?б??мзс??
Дк?кнблмс д. Е., Й?╥?м г. Ю.,
Рк╞мс?? Ы. г.
Дс??бмзс??
Дк?кнблмс д. Е., Й?╥?м г. Ю.
Дсот╦?зб?л?? ?б?рзм?
к ???ык?брм?? с╥??╥сзм?
о?зб?к?н?
Гбтс?с?кл? Е. г., Осо?мс?? ж. М.
Гсоб? тс?ткр?л ? тб??з╦ 28.09.2012
Нс?о?з 60в88 1/8
Хб?. н. 8,0
Л?.-ка?. н. 7,61
Лрн. тб?. н. 7,84
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?
2012. ? 3. 1?68
ISSN 1814?6910
Мк??й 500 ?ма.
Хс?ткрлсх кл?бмр 84549
??????? ???????? ?. ?. ???????
???????????? ????????
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?. ?. ???????? (???. ????????
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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CONTENTS
??????
Reviews
Lobacheva G. V., Alymbek K. Z. Calcium sensitizers
in treatment of postoperative low cardiac output
syndrome in cardiosurgery
5
??????????? ?????????? ??????
??????? ?. ?., ???????? ?. ?., ??????????? ?. ?.,
???????? ?. ?. ???????????? ?????? ???????????????? ?????? ????? ?? ?????? ?????? ??????? ?????????????? ????????? ????????????? ??? ?????????????? ??????? ??????
?????????
??????? ?. ?., ??????? ?. ?., ???????? ?. ?., ???????? ?. ?., ?????????? ?. ?., ???????? ?. ?.
???? ??????????????? ??????????? ? ????????
????????????????? ??????????????? ? ????????? ????????????????? ??????? ? ?????????,
?????????? ????????????? ?? ?????? ? ???????? ?????????????? ??????????????
????????? ?. ?., ??????? ?. ?., ?????? ?. ?.,
??????? ?. ?., ???????? ?. ?. ?????????? ?????????????? ??????????? ??????? ????????????? ? ?????????????? ????????? ? ?????????
? ????????? ?????? ? ?????????? ?????? ??????????? ??????????
???????? ?. ?., ??????? ?. ?., ?????? ?. ?. ?????????? ?????????????? ??????? ??????????????? ??????????????? ?????? ?????????
Clinical Heart Physiology
Bockeria L. A., Kiknadze G. I., Bozhevolnov A. V.,
Gorodkov A. Yu. Realistic model of endocardial
blood flow based on exact solutions of non-steady
equations of hydrodynamics for whirlwind-like flow
of viscous fluids
10
Bockeria L. A., Nikitin E. S., Lobacheva G. V.,
Bakhtadze Z. Sh., Saydalieva Z. O., Makrushin I. M.
The role of interventricular septum in the course of
right ventricular failure in immediate postoperative
period in patients with heart interventions under
cardiopulmonary bypass
17
23
31
??????????? ??????????
???????????? ??????????????
??????? ?. ?., ???????? ?. ?., ?????????? ?. ?.,
?????? ?. ?., ?????????? ?. ?., ????????? ?. ?.,
???????? ?. ?. ?????? ??????????? ?????????????? ??????? ????????? ??????????????? ??????? ?? ?????? ??????????? ? ??????? ??????? ???????????
?????? ?. ?., ??????????? ?. ?., ?????????? ?. ?.,
??????? ?. ?. ????????? ????????????? ? ????????? ????????? ??? ?????????????? ? ?????? ??????????? ???????????? ?????????
Shchebunyaeva E. A., Muratov R. M., Skopin I. I.,
Babenko S. I., Soboleva N. N. Results of mitral valve
replacement using mechanic and biological prostheses in patients with sinus rhythm and state atrial
fibrillation
Vatolina T. V., Shipulin V. M., Lezhnev A. A. Results
of surgical treatment for postinfarction remodeling
of the left ventricle
Clinical Physiology of Regional
Circulation
Bockeria L. A., Aslanidi I. P., Serguladze T. N.,
Darvish N. A., Kacheishvili M. Yu., Trifonova T. A.,
Ozolinsh A. A. Evaluation of surgical results for brachiocephalic arteries lesions according to the data of
clinical and imaging methods of diagnosis
37
44
Tardov M. V., Bugrovetskaya O. G., Rudkovskii A. I.,
Tardova I. M. Disorders of arterial and venous blood
flow during instability in cervical spine motion segments
??????????? ?????????? ??????????????, ? 3, 2012
???????? ?. ?., ??????? ?. ?. ?????????????
??????? ? ??????? ?????????????????? ???????? ??????? ?????????? ??????? ? ??????????????
3
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
4
??????????
??????????? ?????????? ?????
??????? ?. ?., ????????? ?. ?., ????????? ?. ?.,
??????????? ?. ?., ??????? ?. ?., ????????? ?. ?.
?????????? ???????????? ????????????? ???????????? ???????, ???????????? ?? ????????????? ??????? ??????????? ??????? ??????
?????? ?. ?., ??????? ?. ?., ???????? ?. ?.,
????????? ?. ?., ???? ?. ?., ??????? ?. ?., ????????? ?. ?. ?????????????? ?????????? ??????????????? ?????? ??? ????????????? ?????????
????????? ??????? ??????
Clinical Blood Physiology
50
Bockeria L. A., Samuilova D. Sh., Klyuchnikov I. V.,
Samorodskaya I. V., Kozlova V. A., Borovkova U. L.
Results of complex laboratory examination of
patients referred to surgical treatment of ischemic
heart disease
56
Zvyagin R. Yu., Shukevich D. L., Golovkin A. S.,
Plotnikov G. P., Khaes B. L., Kokorin S. G.,
Grigorev E. V. Prevention of system inflammatory
response in the surgical correction of valvular heart
disease
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ???????????????
Public Health Organization
???????? ?. ?., ????????? ?. ?. ??????????? ???????????? ??????? ?????????????
??????? ? ????????-?????????? ???????? ? ??????? ????????????????????? ???????
62
??????? ??? ???????
65
Stupakov I. N., Zolotarev N. Yu. Optimization of formulary list of medications in cardiovascular surgery
using pharmacoeconomic analysis
Rules for authors
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
5
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╘ ?. ?. ????????, ?. ?. ???????, 2012
??? 616.12-008.6-089.168
????????????? ??????? ? ??????? ?????????????????? ????????
??????? ?????????? ??????? ? ??????????????
?. ?. ????????*, ?. ?. ???????
??????????? ????????????? ??????????? ???????????????? ???????? ? ????????? ???????????? ??? ?????????? ???????????? ???????????????? ??????? ????????? ????????????? ??? ???
???? ?? ???????? ????????????? ?????????? ??? ??????? ???????? ??????? ?????????? ???????
(????) ? ??????? ????????? ??? ???????? ?????????? ??????????????. ?????????? ??????????? ???????????? ? ????????? ? ???? ????? ??????????????????? ???????????? ????????????,
??? ???????????? ???????? ?????????????? ??????? ????????, ????????? ???????????????
????????????, ????????? ???????????????? ???????????, ??????????? ? ?????????? ????????? ? ??????????????? ??????????????, ? ??? ????? ? ??????? ?????????????? ? ???????????
???????????????? ???????.
?????????? ? ????????????? ? ????????????? ? ????? ????????????? ?????????? ????????????, ??? ???????????? ????? ???? ??????????? ? ??????? ?????????????? ??? ???????????? ??????????? ??????????????? III ? ??????? ???? ? ????????? ? ?????????????? ???????????????? ?????? ?????????, ??????? ???????? ????????????, ????????????? ????????????
??????????, ? ????? ??? ???????? ???????? ??? ?????????? ???????????????? ??????????????
? ??? ??? ???????????.
??? ?? ????? ?????? ??????? ?????????? ????????????? ? ?????? ????????? ????????? ???????
????????????: ?? ?????????????? ????????? ? ?????? ??????? ??????????????, ????????????
????? ??????? ???????????????? ??????? ? ??????? ?? ?????? ? ????????????? ? ????? ? ????
? ????????? ????????????? ???????? ?????? ?????????. ??????? ????????????, ???????????? ??
??????????? ????? ????????????? ? ??????? ???? ? ????????????? ? ????? ????? ???????? ? ???????? ??, ? ????????? ?????, ??????????, ???????? ???????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ??????? ??????? ?????????? ???????, ????, ?????????????, ???????????????? ?????????, ????????????? ???????, ????????????, ?????????? ?????? ??????, ????????????? ??????????????.
Levosimendan capacity to increase myocardial contractility and reduce afterload with constant concentration of intracellular calcium makes it possible to consider it as one of the most perspective substances
for the treatment of low cardiac output syndrome (LCOS) with high systemic or pulmonary vascular
resistance. Clinical studies results of patients with LCOS after cardiosurgical interventions confirm that
levosimendan improves myocardial contractility function, allows to stabilize hemodynamics, reduces
perioperative mortality and requirement for inotropic support and cardiopulmonary bypass including the
cases of refractoriness to the standard cardiotonic therapy.
Favorable results obtained in the studies of newborns and infants confirm that levosimendan can be used
in pediatric cardiosurgery as an alternative to phosphodiesterase III inhibitors in the treatment of LCOS
in patients with the left ventricle myocardial insufficiency, high pulmonary hypertension, functionally single ventricle as well as basic substance for cardiopulmonary bypass and with its termination.
However many aspects of levosimendan application in this category of patients are studied insufficiently: indications to start levosimendan therapy are not articulated, hemodynamic effects and influ* ????? ??? ?????????: e-mail: orit_lobacheva@mail.ru
??????????? ?????????? ??????????????, ? 3, 2012
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
6
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ence on the outcomes of the newborns and infants with LCOS and safe left ventricle systolic function
are studied insufficiently completely. Therefore presently the studies focused on certain sites of levosimendan in the treatment of LCOS in newborns and infants after cardiopulmonary bypass surgery are
undoubtedly topical.
K e y w o r d s: low cardiac output syndrome, children, neonates, cardiotonic support, calcium sensitizers, levosimendan, congenital heart defects, cardiopulmonary bypass.
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ????????? ???????
??????? ??????? ?????????? ??????? (????)
?? ?????????? ?????? ??? ???????? ?????? ????? ?
????????? ?????? ????????????????? ??????????
? ??????????? ? ????????????? ? ????? ??????? ???? ?????, ?????????? ???????? ? ???????? ?????????????? ?????????????? (??). ??????? ???? ????? ??????????????????? ???????????? ??????????
3?10% ? ??????????? ?? ???????? ????????? ? ???????? [2]. ???, ? 2004 ?. ???? ???????? ? 7,9% ?????????, ??????? ? ????? ??. ?. ?. ???????? ????
??????????? ???????? ? ???????? ??, ? ???????????
??? ?????? ?????????? ????????? 27,8%.
? ????? ? ???? ??????????? ??????? ????
????????? ??????? ???? ? ???????? ??????? ????????????????? ?????????? ? ?????????? ?
??????????????. ????????????, ??? ???????
???? ??????????? ? ??????????? ???????????
?????????? ??????? ? ??????????? ????- ? ???????????? ? ????? ?????? ??????????????; ???
???? ??????????? ??????? ?????? ??????????????? ????????????? ? ?????????? ???????? ?????????? ???????? ??????? ??????? ????????? ?
????????????????? ???? [1, 4, 8].
?? ?????????? ??????? ????????????? ? ????????????? ??????????? ??????????? ? ????????????? ?????????? ???????? ???? ???????: ???????????? (??) ? ?????????? ??????????????? III (???? III). ? ?? ? ?????? ????????? ????
????????????? ?????????? ?????? ????? ????????? ???????????? ???? ? ?????????????? ?
??? ????????? ? ???????????? ????????????????
??????? [8, 28].
????????? ????????? ????????? ??, ??????????????? ?? ??????????, ???????? ????????
???????????????? ?-???????????????? ??? ?????????? ??????? ??, ?????????? ????????????
????????, ????????????? ?????? ??????????????? ? ?????????? ??????????? ????????? ????????? [8]. ?????? ??????? ???????? ? ????????????? ??????????????, ?????????? ????????????,
????? ???????? ?????? ???????? ? ???????? ???????????? ??????????????? (????) [1, 4].
???? III ??????????????? ?????????? ?????????????? ? ????? ? ????????????? c ????
????? ???????? ? ???????? ?? [16]. ??????, ???????? ?? ??????? ????????????? ? ????????
???????, ??? ????????? ?? ???????? ??? ?????????? ? ??????, ??? ? ???????????? ??????? ???????????? ???? ??????????? ? ??????? ????.
? ??????????? ???????? ????????????? ??????? ? ?????? ????????????? ???????????? (c??????), ╚Orion pharma╩, ????????? ? ?????????
?????????? ???????? ????????????????????.
???????????? ? ????????????????
??????? ?????????????
???????????? ?????????????? ??????? ?????
?? ? ???? III ??????????? ?? ??????? ?????????? ???????? (????????? ??????? ???????? ? ??????????????) ??? ???????????? ????????????
???????????????? ??????? [5, 28]. ?????? ????????????? ???????????? ????????????? ????????
??????????? ????????? ?????????? OR?1896 ? ?????????? (75?80 ?) ???????? ?????????????, ?????????? ????????????? ? ????????????????? ???????? ????????????? ? ???????? ?????? ?????
??????? ??????????? ??? ???????? [19]. J. Lilleberg
? ?????. [23] ????????, ??? ?????? ????????????? ?
???? ???????? ???????? ???????????? ????????
?????????? ? 20 ?? 15 ?? ??. ??. ? ?????????? ?????????? ??????? (??) ? 4,3 ?? 5,4 ?/???/?2 ????????? ???? ????? 6 ? ? ??????????? ?? ??????????
7?9 ? 12?13 ???? ??????????????.
? ?????? ??????????? ??????? ????????????? ????? ?????????? ???????????????? ?????????????? ?????? ?????????????? ? ??????? ???
?????????? ?????????? ?????????? ?????? ?????? [6]. ????????? ????????? ????????? ????????
???????????? ???????? ?? ?????? ?????????????,
?? ? ?????????????? ??????? ??????????; ?? ???????? ???????????? ???????? ? ?? ???????????
??????????? ????????? ????????? [18, 28].
??????? ?????????????????? ??????? ????????? ???????? ????????? ???-????????? ???????? ??????? ??????? ???? ???????, ??????? ?
????????? ????? ????????? ???????? ??????? ?
??????? ?????????????? ?????????? [17]. ????????????? ?????????????? ????????? ????- ?
????????????, ??????????? ???????? ? ????????
??????? ? ?????????? ???????? ???????? [17].
????? ???????????, ??? ???????????? ????????????? ??????? ??????????? ?????????? ????????
[17], ????????? ??????? ???? ???????? ????????,
?????????? ???????????????? ????????? ? ??????????? ???????????? ?????? ???????????? [25].
???? ?????????? ?????????????
? ??????????????????? ???????
?? ??????????? ???? ???????????? ? ???????????? ????????????? ?????????????? ???????,
??????? ??????? ??? ???????????? ????????????? ? 40 ???????, ??????? ?????????? ????????? [5]. ? ???????????? ? ??????????????????
?????????? ? ?????????? (????????????? ??????? ?????? ????????????? ??????? ???????????
????????? ???????????????) ??????????? ??????????? ???????????? ????????????? ???????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????
???????????? ? ???????? ???????????????????
???????
? ????????????????? ?????????????? ????????????? ????????????? ? ???????????????????
??????? ??????? ????? ? ???????? ???????? ??????? ?????? ????????? (?? ??) ????? 30% ??????????? ????????????? ???????? ?????????? ??????? ????????? ?????????? ? ?? ??? ??????????
???????? ?????????? ? ????????? ?????????????,
?????????? ??????????? ?????????, ????????
???????? ????????????? ???????? (??) ? ??????????
?????????? ??????????? ????????? ?????????
[26, 30]. ???????????? ?????????? ???????? ? ????????????? ? ????????? ???????? ????? (? ???????? ?? ?? 19 ╠ 5%) [14, 21, 29], ??? ???? ???????????? ?????????? ?? ??????????? ??? ?????
60 ??? ????? ?????? ??????? ????????????? ?
????????? ??????? ????????? ?? ??? ????????????? ??????????? ???????????????? ?????????
?????????????? (????) ? ???? ????????? [29].
? ?????????? ??????? ???????? ???????
????, ?????????????? ???????? ?????????????
?????? ??????? ?????????????? ? ?????????
?????? ????? ?? ???? ? ???????????? ???????
?????????????????? ???????. ????????, ??? ???????????? (????? ???????? ?????????) ??????
??????? ????????????? ????? ????????? ????????????? ???????? ????????????:
? ?????????? ??????? ????????? ?????????? ?? ? ?????? ??????? (73 ?? ????????? ?
33%, p = 0,002) ? ??????? ???????????? ???
???? [20, 21];
? ?????????? ???????????????? ??????????? (2,7% ? ?????? ????????????? ?? ????????? ?
10,9% ? ?????? ???????, p < 0,001) ? ??????? ???????? ???? ? ????????????????? ??????? (6,3
?? ????????? ? 18,2% ??????????????, p < 0,001)
[22];
? ?????????? ?????????? ??????? ??????????? ?????????? (p < 0,01) ?? ????????? ? ???????? ?????????? ? ?????????????? ????????
???????? ?????? ????? 12 ? ????? ????????
(p < 0,05) [11];
? ?????????? ???????????? ?????????????
?????????? ?????? [11, 33], ?????????? ? ????????? ??????????? ??????? (p < 0,01) [33] ? ???????????? ?????????? ????????? (p < 0,05) ??
????????? ? ?????????? [11].
????? ???????????? ?????????? ??, ?????????? ??????????? ? ?? ? ???? ? ?????? ?????? ??????? ????????????? ?? ???? ??? ????????????
???? [2, 31], ? ??? ????? ? ????????? ? ?????????????? ???????????????? ?????? ????????? [18].
R. Harrison ? ?????. [15] ??????? ????????????
?????? 9 ???????????? (796 ????????? ? ????????
?? ?? ????? 40%) ? ???????????, ??? ???????
?????????????, ??????? ??, ?? ????? ??? ?????
????????, ????????? ??????? ????????? 30-??????? ??????????? ? ??????? ?????????????????
??????????.
????? ???????, ??????? ????????????????
???????? ? ???????????? ????????????? ? ???????? ??????????????????? ??????? ??????? ?????????? ????????. ?????????? ??????????? ????????????, ? ??? ????? ? ??????????????, ?????????? ??????? ???????? ??????????????? ? ??
???????? ????????????. ?????????? ???????????, ??? ? ??????????????????? ??????? (? ??????? ?? ????????? ? ?????? ? ??????????? ????????? ????????????????) ???????? ?????????????
???????? ????????????? ??????? ??????? ?????????????? ?? ???????????????? ? ?????????
???????????, ? ????? ??????? ???????? ????.
???? ? ????????????? ????? ????????
? ???????? ??
? ????? ?????????? ?????????? ???????????? ?????????????? ?????? ????????????? ? ??????? ???? ????? ??????????????????? ???????????? [12], ?????? ???? ??? ?????????? ? ????????????? ? ????? ????? ???????? ? ???????? ??
?????????. ? ???????? ??????? ????? ? ???????
??????? ???????????? ??????? ? ???????????
?????????? ????????? ? ??????? ???? ? ?????????? ????????????, ?????????????? ????????????? ???????? ???????????? ????????????? ?
????? ? ????????? ??????? ?? ????? ???????????? ??????????, ??? ??????????? ? ????? ???????
[27]. ???, ?? ??????????? ??????? ?????????? ??????? ???? ? ?????????? ????????? ??????????????, ???????????? ? 90 ???????? ?? 31 ??????????? ?????? (???????????? EuLoCOS-Paed),
34% ?????????? ?????? ???????????? ?????????,
24% ? ?????????? ? 22% ? ?????????? ????????????? ? ??????????? [35].
?. ?. ???????? ? ??. [2] ??????????? ????????
?????? ?????? 3-??????? ????? ?????????? ????????????? ? ??????? ?????????????????? ????
?? ???? ?????????????? ??????????????? ??????
????????? ? 75 ????? (? ???????? ?? 3 ??? ????? ??
2 ??? 10 ???) ? ????????, ??? ??????? ????????????? ????????? ??????????????? ???????????? ?
????????? ???? ? ???????????? ??????? ?????????????. ?????? ???????????????? ????????
?????????????, ??????????? ?????????????? ?????????? (p < 0,05), ???? ???????? ???????? ? ????? ?????????? ? 25 ?? 17 ?? ??. ??. ????? 6 ? ?? ?????? ???????? ?????????. ?????, ????? 12 ?, ?????????? ????????? ???????? ?? ? 42 ?? 53 ?? ??. ??.
? ?????????? ?? ?? ? 21 ?? 27%. ??????? ????????? ???????????? ??????? ? ? ????? ??????
??????????? [3, 24, 34].
????? ?????? ?????????? ???? ?????????
?????????? ????????????? ? ????????? ? ?????????????? ???????????????? ??????? ?????????
????? ????????? ??????? ????? [7] ? ???????????? ?????????? ?????????????? ????????????,
??????????? ?????????? ??????????????, ? 3, 2012
???? ? ???????? ?????????. ?????? ?????? ???????????????? ??????? ????????????? ? ??? ??????? ?? ????? ??????? ? ???????? ?????????, ?
???? ??????????????? ? ??????????????????, ?????????? ??????????? ?????????? ????????? ?
??????? ????? ? ????.
7
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 3, 2012
8
??????
?????????????? ????????????? ?????????????
? ?????????????? ??????? ???????? ? ????? ????? ????????-???????? ?????????? [32].
???????????? (24 ???/??; 0,2 ???/??/???) ???
??????? ??????????? ? ???????? ? ???????? 2 ???
? ???? ? ???????? ??????????????? ??????, ???????????? ? ??????? ????????????? ? ???? III.
????? ????? ???????? ???? ????????? ????????????? ?????????? ?????????? ?? ?? ? 25 ??
40%. ????? 12 ? ????? ?????? ??????? ????????????? ????? ????? ?????? ?????? ?? ???????????,
???????? ? ???????? ??????? ?? ?????? ?????
?????????? 50% ?? ??????????, ? ???2 ??????????? ? 55 ?? 180 ?? ??. ??. ??? ?????????? ??????? ?????????. ? ??????? ?????? 24 ? ???????
?????????? ?????????????? ??????? ? ???????????? ?????????? [9].
C. Garisto ? ?????. [13] ???????????? ???????????? ? 20 ????????????? ? ????????????? ????????????? ????????? ????? ???????? ??????? ?
?????????? ?????????? ?? ???????. ???? ????????? ??????? ????????????? ? ???? 0,1 ???/??/???
???????? ?? 24 ? ?? ???????? ? ?????????? ? ??????? 48 ? ????? ??????????? ? ????. ?????? ???????? ???????????? ??? ?????? ????????? ????????? ???????????? ???????????? ? ????????? ????????????????? ??????? ? ?????????????
???????? ?????????? ? ?????? 72 ? ?????????
???????????: ??????? ??????? ?????????? ?????????, ??????? ????????? ??????????????????
??????? ? ??????????. ??????? SvO2 ?? ????? ??????? ????????????? ??????????? ? 38 ?? 59%
(p<0,05). ??????????????? ???????????? ????????? 85%, ? ???????????? ??????????? ? 10%. ???
???? ??? ????? 5?6 ? ????? ???????? ? ????????
? ???????????? ???????? ????????? ?????????????? ????????????? ???????? ???????? (p<0,05)
?? ??????? ?????????? ?????????.
? ?????????????? ???????????? ????????,
??? ??????? ????????????? ???????? ?????????
? ???????? ???????? ? ????????????? ? ????,
??? ????, ?? ??????????? ?????????????? ?????????????? ???????, ???????????? ?????????, ????????????? ????????? ?????????? ? ?????????
????????? ???????? ??????? ?? ? ???? ???????
?????????????, ? ?? ? ??????? ?????????? ??
????? ??????????????? ???????? [10]. ? ??????????????? ???????????? ? ????? J. R. Egan ? ?????. [12] ????????, ??? ???????????? ?????? ??????? ????????????? ?? ????? ?? ? ?????????
?????? ????? ?? ???????? ???? ?????????????? ????????????? ???????? ??????????? ??????????, ? ?????? ??????? ????????????? ?? ????
???????????? ???? ? ?????????? ???????? ????????????? ????????, ?????????? ????????
????????, ??????????? ?????????? ? ??????????? ? ?????????? ?????????.
?????????? ???????? ???????? ??????? ??
???????? ?? ? ????? ?? ????????????. ? ?????????
??????? ?????????? ????????? ? ????????? ?????????? ? ??????? ??????? ???? ???????, ??? ????????? ????????? ???????? 20% ????????? ??? ??????? ?????????? ? ???? 0,03?0,05 ???/??/??? [2].
????? ???????, ?????????? ??????????? ???????????? ? ??????????? ??????????? ????
???????????? ╚????????????╩ ??????? ????????????? ?? ????????????, ? ????? ??? ????????????? ? ???????????? ? ????????????? ? ????? ?
???? ????? ???????? ? ???????? ??.
??????????
?? ??????????? ???? ???????????? ????????
???????????? ??????????????, ?????????? ???
?????????? ? ??????. ???????????????? ??????? ????????????? ? ?????????? ??????????? ???????????? ????????? ????????????? ??? ???
???? ?? ???????? ????????????? ?????????? ???
??????? ???? ? ??????? ????????? ??? ???????? ?????????? ??????????????. ??????? ???????????????? ???????? ? ???????????? ????????????? ? ???????? ???????????????????
??????? ??????? ?????????? ????????. ?????????? ??????????? ???????????? ?????????? ??????? ???????? ??????????????? ? ?? ????????
????????????. ???????? ??????? ????, ?????????????? ????????????? ????????????? ?
???????? ???????????? ????, ? ????? ????????
????????????? ?????? ??????? ?????????????? ?
????????? ?????? ????? ?? ???? ? ???????????? ??????? ?????????????????? ??????? [2, 11,
14, 18, 20?22, 26, 30?33].
??????, ???????? ?? ????????? ???????????? ?????????????, ???? ??? ?????????? ? ??????? ???? ? ????????????? ? ????? ????? ???????? ? ???????? ?? ?????????. ?????????? ? ????????????? ? ????????????? ? ????? ??????????
????????????, ??? ???????????? ????? ???? ??????????? ? ??????? ?????????????? ??? ???????????? ???? III ??? ???? ????? ?????????????
????????? ??? ? ??????????? ?????? ?????????,
??????? ?????? ?? ??; ?????????????? ???????????????? ??????? ?????????, ? ????? ? ????????? ? ????????????? ???????????? ?????????? ? ??? ???????? ???????? ??? ??????????
???????????????? ?????????????? ? ??? ??? ??????????? [2, 9, 34, 42]. ?????? ?????? ?????????? ????????????? ??? ??? ???????? ????????
????? ????????????? ????????????? ???? III,
??????? ? ???????? ??????? ?????? ????????
??????? ????? ? ??????? ???? ? ??????? ????????? ??? ???????? ?????????? ?????????????? [37].
??? ?? ????? ?????? ???????, ??????????
?????????? ????????????? ? ?????? ?????????
????????? ??????? ????????????, ??????? ?????????????? ???????????? ?? ?????????? ??????? ?? ???????????, ? ???? ?????????? ?????????
???????? ╚?????????????╩. ?? ??????????????
????????? ? ????????? ??????? ??????????????,
???????????? ????? ??????? ????????????????
??????? ? ??????? ?? ????? ? ????????????? ?
????? ? ????. ? ????? ? ?????????????? ???????? ???????? ??????? ??????? ? ????? ?????????? ? ????? ????? ??????????????????? ????????????. ????????????, ???????????? ?? ??????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????? ????? ????????????? ? ??????? ???? ?
????????????? ? ????? ????? ???????? ? ???????? ??, ? ????????? ?????, ??????????, ????????
???????????.
17.
18.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
??????? ?. ?., ???????? ?. ?., ??????????? ?. ?. ? ??. ????? ??????????? ??????????? ??????? ???????? ???????????? ??????????????? ? ????????????? ?????
??????????????????? ???????????? // ??????? ???????
?????? ? ???????. 2005. ? 3. ?. 39?44.
???????? ?. ?., ??????? ?. ?., ???????? ?. ?. ? ??. ??????????? ??????? ????????????? ? ????? ??????? ????
????? ? ?????? ????????? ???????????????? ????? ??????????????????? ???????????? // ??????????. ? ??????????. 2010. ? 5. ?. 23?27.
?????? ?. ?., ?????????? ?. ?., ???????? ?. ?. ? ??. ?????? ???? ??????? ?????? ????????? ??????????????? ?
?????????????? ????? ??????????????????? ???????? ?
?????????????? ????????????? (╚???????╩ ?????
╚Orion pharma╩) // ????????? ?????????????? ? ??????????????. 2004. ? 3. ?. 75?76.
??????? ?. ?. ??????????? ??????????? ??????? ? ????????????? ????? ??????????????????? ????????????:
???????. ???. ? ?-?? ???. ????. ?., 2008. 46 ?.
?????? ?. ?. ??????????? ????????????? ?????????????
??????? ????????????? ?????? ?????? ?????????? ? ????????????? ?????????? ????????? ??? ????????? ??????????????? ? ???????? ???????? // ????????? ???????????????. 2005. ?. 6, ? 1. ?. 33?45.
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????????? 16.07.2012
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??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
10
??????????? ?????????? ??????
??????????? ?????????? ??????
╘ ????????? ???????, 2012
??? 612.171.6:612.13
???????????? ?????? ???????????????? ?????? ????? ?? ??????
?????? ??????? ?????????????? ????????? ?????????????
??? ?????????????? ??????? ?????? ?????????
?. ?. ???????, ?. ?. ????????, ?. ?. ???????????, ?. ?. ????????*
??????????? ?????????? ??????????????, ? 3, 2012
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????
???????????? ??????????? ??????????? ?????? ????? ? ???????????? ?????? ??????? ??????????????, ??????????? ? ??????? ????????? 20 ??? ? ??????? ?????? ????????-??????????
???????? ??. ?. ?. ???????? ????, ????? ? ?????? ?????????? ?????????????? ?????? ???????????????? ?????? ?????, ?????????? ?? ?????? ???????? ?????????????? ????????? ????????????? ??? ?????????????? ??????? ?????? ????????.
?????? ????????????? ???????????????? ??????????? ????????? ???????? ? ???? ?????????, ????????????????? ?????????? ?? ??????? ?????????, ???????????????? ??????????? ????????? ???????? ?????????????? ?????, ?????????? ????? ? ?????????? ?? ??????????? ????????? ?????? ?????????????? ??????? ????????? ?????. ??? ??????? ?????
?????????? ????? ? ????????? ??????? ???????????? ???????????????? ???????? ???????
?????? ????????? ? ?????????????? ??????, ???????????? ? ???? ???????.
?????? ????????????? ??????? ?????? ????????? ???????????????? ?????? ? ??????????? ??
?????????? ??? ??????, ????????? ??????? ??????, ????????? ???????????? ????????????
(??????????????? ????????), ???????? ?????. ????????? ?????, ???????????????? ? ???????????? ? ?????????? ?????????? ??????????????, ????? ? ???????????? ?????, ???????
????? ??????? ?????? ?????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ?????????????? ??????????? ??????, ??????????????? ????? ?????, ?????
????????? ??????, ?????? ??????? ?????????????? ????????? ?????????????.
The study of intracardiac blood flow structure was carried out in the Bakoulev Scientific Center for
Cardiovascular Surgery of Russian Academy of Medical Science over the past 20 years formed the basis
for developing a mathematical model of intracardiac blood flow, based on exact solution of nonstationary hydrodynamic equations for the tornado-like flow of a viscous fluid.
The model reproduces the spatial displacement of fluid elements in the velocity field parametrized by
time-dependent functions, derived from the exact solution. These functions correspond to radial pressure gradient across the tornado-like jet, the circulation of the jet and the distance from the instantaneous position of the origin point of cylindrical coordinate system of the jet. These functions have a physical meaning and allow to bind the dynamic spatial anatomy of the left ventricular cavity and the
hydrodynamic characteristics of the flow formed inside it.
The model reproduces a wide range of states of intracardiac flow, which are depending on the orientation of the axis of flow, changes in the radius of the flow, the position of the azimuthal guide vanes
(intracardiac trabeculas), and the viscosity of the medium. The model flux, evolving in accordance with
known cardiodynamic principles occupies a 3D space similar to the shape of the left ventricular cavity.
K e y w o r d s: tornado-like swirling flows; intraventricular blood flow; left ventricle, exact solution of nonstationary hydrodynamic equations.
? 1994 ?. ?? II ????????????? ????????? ?? ??????????? ???? ??????? ?????? ????????? [8] ? ??????????? ??????????????? ???????? ?????????* ????? ??? ?????????: e-mail: agorodkov@bk.ru
???? ?????? ????? ? ??????? ?????? ??????? ?????????????? ????????? ????????????? ??? ?????????????????? ?????????????? ??????? ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
???????? [11]. ?????????? ??? ???? ???????? ????
??????????? ???????????? ? ??????? ?????? ????????-?????????? ???????? ??. ?. ?. ????????
???? ? ?????? ? ???????????? ?????????? ?????? ? ?????? ??????? ? ??????????? ??????? [5?7,
12, 13].
??????????? ???????????? ?????????????????
???????????? ?????? ????? ? ??????????? ???????
??????? ?????????????? ? ??????? ???????????
???????????? ? ?????????? ? ???????? ???????
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??????????? ????? ?????? ? ??????????? ??????????? ??????????????? ??????????? ??? ??????????????? ??????? ????????????????? ?????????????
?????? (????????????? ?????????, ????????, ????
??? ?????????????? ?????? ? ???????????, ?????????????? ??? ?????). ???????? ?????? ?????? ???????????????? ??? ? ??????, ??? ????????? ?????
?????? ? ????????????? ??????? ????? ?????????
??????????, ??????? ???????????????? ????????????, ????? ??????????? ??????? ? ???????
???????????? ????????????? [3]. ????????? ?????? ????????? ????????????? ??????? ? ???????
(???, ???????? ???????-???????????????) ?? ????????? ??????????? ????? ????? ???????????? ???????????? ???????? ? ?????????????? ????????
????????? ?????? ?????: ??????? ?????????? ???????????? ?????? ????? ??????????? ???? ? ??????.
?????? ? ???????????? ?????????? ????? ????????
????? ??????????????, ??????????? ??? ??????
????? ? ?????? ? ????????????? ??????? ? ?????.
? ????????? ???? ??? ?????? ??????? ?????????? ? ????, ??? ????? ????? ????????, ?????? ??????? ??????????????? ???????????????? ????????????? ???????????, ????????? ?? ??????? ? ????????? ???????? ??????. ??????????? ???????????
?????? ??????????????? ? ?????? ????????? ?????, ???????????? ???????????? ???????? ??????????? ?????? ? ???????? ?????? ? ?????? ? ????????????? ??????? (????? ? ???????? ???????), ?????
?? ???? ???????? ?????? ?????, ??? ? ??????, ??? ?
? ????????????? ????????, ??????????? ????
????? ?????, ? ??????? ???????? ???????? ?????????????? ? ???????????????? ???????? ?? ??????
?????????? ?????? [7, 12, 13].
??????, ??-??????, ?????????????? ??????
????????????? ????????????????? ???????? ?
????????????? ???????? ???????, ???????????? ?
???? ???????? ??????, ??? ????????? ??????????????? ????????????????? ???????????? ??????????? ??????? ??????????????. ??? ??????? ? ???,
??? ? ?????????? ??????????? ??????? ??????????
?????????????? ????????? ???????? ? ????????
[11], ??????????? ?????????? ???????? ???????.
??-??????, ?????????????? ?????? ??????????
??????????????? ?????? ????? ??????? ?????? ???????????? ????? ??????????? ?????????? ?????? ?????? ? ??????? ? ?????????????? ?????????
??????.
??? ???????????? ????????????????? ????????? ?????? ????? ?????? ???????????? ??????????-
11
???? ????????????? ? ??????? ?????? ????????
?????????. ???? ????? ??????? ?? ????????? ???????? ????????? ????????????? ??? ??????, ???????????? ?? ?????????? ?????? ???????? ????????,
????? ? ?????? ?? ??? ????? ????? ???? ???????
??????????, ???????????? ? ??????? ??????????? ??????? [5, 6]. ?? ???????? ??? ????????????
?????? ????????? ?? ???????? ? ?? ????????.
?????? ?????? ???????????? ????????? ??????? ??????? ?? ????????? ?????? ?? ????????????, ?? ??? ????? ?????????????? ????????? ??????. ????? ??????, ????????????? ??????? ? ??????? ????????? ??????? ?? ???????? ????????
????????? ????????????, ???????? ? ?????????
?????? ?????. ??? ???????, ? ?????? ???????, ? ??????????? ?????????? ????????????????? ??????
? ?????????????? ?????? ????????? ???????????
? ?????????? ?????????????? ?????? ?????????????? ??????????????? ??????????????, ????????????? ???????? ???????????? ??????, ???????
?????????? ?????? ? ?????????????? ??????????
?????.
??????? ??????? ???????????? ? ?????? ?????? ╚?????????╩ ?????? ?? ??????. ????????, ?????, ????????????? D. Garcia ? ?????. [3], ???????
?? ????????? ????????? ?????????? ???????? ? ??????? ?????? ????????? ? ????????? ???????? ???????? ??????? ???????? ??????????????????? ?????? ????? ? ????????? ???? ???????? ????????????. ?? ?????? ???????, ??????????? ??????????
????????????? ???? ????????, ??????????? ? ??????? ??????, ????????? ????????? ???? ????????? ??
????????? ?????????????. ?????? ?????????????
??????????? ?????????? ???? ????????? ? ????????
?????? ??? ???????????? ????????? ????????? ?
??????????? ???????. ???????, ??? ?????????????? ????? ? ??????? ?????? ????????? ????????
?????????? ?????????????? ?? ???????, ??????????????? ????? ?????????? ????????????? ???,
???????? ????? ???? ????? ??????? ?? ?????????
??????? ?? ????? ???? ???????? ??????? ????????????? ???????? ? ????????. ??????? ???????? ???????? ???????????, ???????????? ???????? ? ????????? ??????, ?????????????? ?? ????? ??? ??????????? ????????? ??????????? ???????? (??
??????????? ??????? ? ???????? ??? ?????????? ?
?? ??????? ????? ????????? ?????? ?? ? ??????????? ??????? ??? ????????), ? ??????????????? ?
???? ???, ??? ?????????? ??????? ?????????????
???????????? ???? ???????? ???????? ??? ????????? ?????????? ??????? ?????? ?????????.
? ??????? [1, 2, 4, 9, 10], ??????????? ? ???????
?????? ????????-?????????? ???????? ??. ?. ?. ???????? ????, ????????, ??? ????? ????? ? ???????????? ???????? ??????? ?????????????? ???????????? ????? ??????????? ?????, ???? ?????????
? ???? ???????? ??????? ??????????? ??????? ????????? ?????????????? ????????? ????????????? ?????? ???????? [11] ? ?????????? ?????????? ?????????? ?????????? ?????? ?????? ? ????????????? ???????.
??? ??? ???????????? ?????????? ? ?????????????? ???? ??????? [3, 7, 9], ?????? ??????? ? ??-
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ?????????? ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
??? ???? ????????? ??????????? ??????????????
???????, ?????????????????? ??? ?????????? ??????????? ? ??????????? ???????, ?????????? ???? ??? ????????? ??????????? ?????????? ?i:
2vB
Wr = C0(t)r + r ,
Wz = -2 C0(t)z + C 2 (t),
??????????? ?????????? ??????????????, ? 3, 2012
W? =
?0 (t)
2?r
+?
i
?i (t)
2?r
(1)
? [(C1+1), ?i (t)r 2],
??? Wr (t), Wz(t), W? (t) ? ???????????? ??????????
??????? ???????? ? ?????????????? ??????? ????????? {r; z; ? }; v ? ?????????????? ????????; ?0(t),
C2(t), ?0(t), ?i (t) ? ?i (t) ? ???????????? ??????? ???????; ??????? ?2(t) ? ?????????? ?, ?1 ?????? ????????? ? ????????? ??????? ??????????????
?????.
?? ????????????????? ???????????? ? ?????????????? ??????? ???????:
? ??? ???????????? ?????????????? ????? ?????????????????, ?? ???? ???????????? ???????
????? ? ????????? ??????? ? ????????? ??????
???????? ???????;
? ? ???????? ???????????? ????? ???????????
?????????????????? ??????? ???????? ?????, ??????????? ? ?????????????? ?????, ?????????? ?
???????? ??? ????????????, ? ? ??? ?? ???? ?????????? ??????? ??????????????? ????????????
????????;
? ?????????? ??????????? ????? ??????????
??????????????? ?????? ? ?????????? ?????? ?????, ? ??????? ????????? ???????????? ???????????
? ??????????? ??????? ??? ??????????????? ??????????????? ??????; ????????? ??????????? ?????
?????????? ??????????? ????????? ? ???? ????????
??? ???????, ????????? ????????? ?????;
? ? ??????? ???????? ????? ???????????? ??????? ???? ? ??????? ??????? ?????????????? ???????????? ?????????????? ????? ???????? ??? ??????????? ??? ?????? ?????? ? ????????? ??? ???
???????, ??? ?????? ???????? ????? ???????????
?????? ??????????? ????? ? ???? ????????;
? ??????????? ????? ????????? ?? ??????????
????????????? ???????????? ?????????? ??????????? ???? ?? ?????? ???? ?????? ????????, ???
???????????? ??????????? ???????????? ?????
???????? ?????? ??????? ??? ???????? ??????????? ????? ?????. ? ??????? ?? ??????????? ?????
?????????? ? ???????????? ??????? ??????? ?????? ???????????? ???? ?? ????????????? ????? ??????.
?????? ??????? ???? ???????????? ??? ????????????????? ????????? ? ??????????????? ??????? ?????? ????? ? ????? ????????? ?????? ? ????? [2, 3, 8?10].
? ?????????? ??????????? ????????????:
? ???????? ????????? ???????????? ? ????????? ??????????? ????? ?????; ????????, ??? ????? ???????????? ? ?????????? ?????????????? ?????
? ?????????? ???????? ??????, ???????? ??????
? ???? ????????, ? ? ??????????? ???????? ??????-
??????? ???????, ?????? ????? ????????? ?????????????? ???????????? ????? ???????? ? ???????????? ?????????? ???????-????????? ????????????? ??????;
? ????????? ?????????????? ???????? ???????? ?????????? ??????????? ????? ? ????? ? ???????? ????????????, ??????? ??????????? ?????????? ???????????? ?????????????? ??????? ????? ?
?????? ? ????????????? ???????;
? ?????????? ?????????????? ????? ????? ??????????????? ???????????????? ?????????? ?????? ?????? ? ??????? (??????? ???????????? ? ?????????? ??????????? ? ??????? ??????? ??????
??????????????? ????????, ?????????? ???????
?????) ? ??????? ???? ?????????????? ??????? ??
?????????? ????? ?????????? ????? ? ???????? ?
????????????????? ????????;
? ????????, ??? ? ????? ????????? ?????? ??????????? ? ?????????????? ????????? ??????????? ????? ? ???????????? ??????????? ?0(t), ???????? ??????? ???????????? ?????????? ?? ??????? ?????????? ? ??????????? ???????????????
????????. ??? ????? ?????????? ? ??????? ?????
?????? ?????? ????????? ?? ?????????? ????? ?????????? ????? ? ??????????? ?????????? ?????????????:
Wr (t)= -C0(t)r,
Wz(t)=2C0(t)[z+z0(t)],
W? (t)=
[
(
?0 (t)
C (t) r 2
1 - exp - 0
2?r
2?r
(2)
[(
12
,
??? C0(t) ? ?0(t) ? ???????????? ???????, ????????? ?? ??????? ? ???? ???????????????? ??????,
??? ???? ??????? ?0(t) ???????? ???????? ?????????? ???????????? ???????? ????? ??????? ??????????? ?????, ??? ????????? ?????? ????? ??? ?????????? ???. ??????? ?0(t) ????????????? ?????????? ??????????? ?????. ???????? z0(t) ????????
???????????? ???????? ???????, ?????, ??? ???????????? 2?0(t) z0(t) ?????? 0 ? ????? ?????? ??????? t. ??? ???????????? ????????????? ??????????
???????? ????? ? ????? ?????????? ?????? ? ?????????? ??? ????????? ???????.
???? ?????????????? ?????? ??????? ? ?????????? ?????????????? ?????? ?????? ????? ? ??????? ?????? ?????????, ?????????? ???????? ???????? ????????? ?????? ??? ?????????? ?????????
??????????????? ??????????????, ?? ?????????
?????? ??????? ?????????????? ????????? ????????????? ??? ?????????????? ??????? ??????
???????? [11].
?????? ??????????? ?? ????????? ?????????????? ????????????????? ? ????????????? ??????,
???????????? ?????????????? ? ?????????????
???????? [1, 2, 4, 8?10], ? ????????? ??????????????? ?????????????? ???????? ????????? ??????
???????? ????? ????????????? ??? ?? ??????????
?????? ????? ? ???????????? ? ?????????? ???????? ?????????????? ???????. ??? ???? ? ??????
?????????????? ????????? ????????? ?????? ?
????????, ????????? ??????, ?????????????? ?????-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
?? ?????, ??????????? ?????????? ??????????????? ????????, ??????????? ???????? ???????, ????? ?????.
?????????????? ?????? ???????????? ??????????? ??????, ???????????????, ????????? ?????????? ?????????????????? ????? ????????? ?????????? ???????? ?????? ???????? ? ????? ??????
? ?? ?????? ? ?????. ???? ????????? ? ????? ?????? ??????????????? ? ??????? ???? ????????? ??
??????? ??????? ?0(t), ?0(t) ? Z0(t), ???????? ??????? ??????? ?? ???????? ???????????????? ???????????? ???????. ?????????? ????? ???? ???????
???????? ?? ?????? ??????? (1) ? ??????? ???? ????????? ? ???????? ?????????? ??????????. ???,
??????? ?0(t), ???????????? ???????? ?????????
?????????? ? ?????????? ???????????? ????????, ??????? ? ????????? ?????? ?????????? ? ?????????, ???????????? ?????????? ? ?????????? ???????? ?????. ? ??????????????? ?????
??? ??????? ???????? ???????? ????????????
?????????? ? ???????????? ??????. ??????????
????? ?0(t), ???????????? ???????? ?????????
???????????? ???????????? ???????? ???????????? ??????, ??????? ? ?????? ? ???????????????? ??????????? ? ?? ????????????? ???????? ?
???????? ? ??????????? ????, ????????????
???????? ??????. ?????? ? ???? ?????????? ?????? ????????? ???????? ???? ? ???????? ??????
??????????? ?????????? ????????? ??????, ??????????? ? ???????????????? ???????? ?? ??????????? ??????? ? ?????????? ????????? ??????????????? ???????????? ??????? ?????? ???
?????????? ?????? ?????? ????????? (??????????
?????? ? ???????? ??????). ?? ????? ???? ???????? ???????? ?????? ?????????????? ??????????? ??????????? ???????? ?????? ? ????????????
???????, ??????????? ???????????? ???????
????????? ?????? ?????? ????????? [1?4, 8?10] ?
?????????????? ????? ??? ╚???????? ?????? ?
?????????? ??????╩. ? ???? ???? ?????????? ????? ????????? ???????? ?????? ? ???????????
????? ??????????? ????????????? ? ??????,
??????????? ??????????? ?????? ?????????????
??????? ??? ??????????? ???????? ???????????
?????? ?????. ????????????? ???????? ????? ?
???????????? ??????????? ?????????? ???????????? ???????? ? ?? ??????? ?????, ????? ????????????? ?????? ?????? ???? ????????? ? ???? ?????????? ??????????. ??????? Z0(t) ????????????
????? ?????????? ????? ?????????? ????????
???????? ? ??????????? ?????? ? ????????????
?????? ?????? ????????? ?????. ??? ??????? ???????? ??????????? ?????? ????????? ????? ?????????? ??? ?? ??????? ? ???? ???????? ??????????????? ???????. ? ?????? ???????????? ?????? ??????? ??? ????????????? ??? ???????
Z0(t) ???????? ???????? ???????? ?????????? ???????????? ???????? ?? ???? ???????? ????????
???????? ?? ????? ?????????? ???????????????
??????. ???????????????? ??????? ?0(t) ? Z0(t)
???????????? ?????????? ? ??????????? ????? ????? ?????, ? ??????? ?????????? ? ?????????? ???????????? ???????? ????? ?? ?????????? ? 0.
13
?????????? ????? ??????? ?0(t) ? Z0(t) ??????
????? ? ????????? ???????????? ? ????????? ??????????? ????? ????? ? ?????? ? ?????????????
???????. ?????????????, ??? ????? ?????????????
?? ?????????, ??? ???????? ????? ??????????
????? ????????????? ???. ????? ??????????? ? ?????? ????? ????????????? ??? ?????? ????????
?????????? ???? ?????????????? ??????????????? ??????. ???? ????????? ?????????????? ?????
?????????? ?? ???? ?????? ?????? ??????? ???
?????? ???? ????????????? ???????? ?????? ?
????? ??? ??? ???????? ??????. ??? ????? ???????
???????? ?????????? ????????????? ??? ?? ??????? ???, ????? ???? ????? ????? ????????? ????????? ???????? ?? ????? ?????????? ?????-??????,
??? ?? ??????? ??? ?????????????? ????????, ?
??????????? ?? ????????.
??????????????? ?????????? ??? ???????????
?????, ??????????? ? ??????? ?????? ????????? ?
?????????? ? ?????, ?? ???????? ???????????? ???
?????? ????????????. ? ????? ????, ??????? ? ?????????????? ??????? ????????? ????? ???????,
??????????????? ?? ???????? ? ??????????????
??????????????? ??????? ?????? ????????? ??????
? ?????, ?? ???? ??????? ? ????????????? ?????????? ????. ? ?????????? ?????? ????????????? ???
????? ???? ???????????? ?????????? ??????? ?????? ???????? ?????????? ????? ?????, ?????????
???? ?? ?????? ? ???????????? ???, ????? ??????????????? ??????????? ???????? ??? ?? ? ?????. ???
???? ??????????? ? ?????? ????? ??????????? ???????? ???????????? ?????????????? ?????? ??????????????? ??????? ? ?????????????? ??????????
?????, ?????????? ? ????????????, ???????????
??????????? ??? ????? ? ???? ???????, ?????????
?? ???????? ????????? ?????, ??????????? ???? ?
??????. ??? ???? ?? ???? ????? ?????????? ??????
????? ??? ???????? ??????????? ??????????? ??????, ? ??????? ????????????? ????????? ????????????? ?????? ???????? (1) ?????????????? ????????? ????????????? [11]. ???????? ????? ????? ??
?????? ?? ????? ????????, ?? ??????? ??????????
???, ?? ???????? ???????????? ni ????? ??????? ??????? ? ?????? ? ?????????? ???????????, ? ???????? ??????? ?? ??????? ??????????? ???????:
Ri2(Zi+Z0) = ?onst, ?0(t) = const ? ?0(t) = const, ?? ???? ?
?????? ?????????? ????? ??????? ????? ??????????????? ??? ???????????? ?????????????? ?????.
?? ??????? ???????? ????? ???????? ????????
????????, ??? ???????? ???????? ??????. ????????, ??? ?????, ??????????? ??? ??????????? ???????? ???????? ?? ?????? ??????? ? ??????, ????,
????????? ?????????? ????? ?? ???? ? ???? ???????? ?????????? ???????????????? ??????. ?????
???????, ?????? ???? ni, ?????????? ????? ????????????? ??? ????????? Zi, ??????????????? ????????????? ?????????? ?0, ?0 ? Z0.
????????? ????????????? ??? ???????????? ?
???? ???????, ?????? ????? ??????? ????????????
????? ??? ?? ?????? ??????? (1), ????? ???????
?????? ???? ?????????? ?????, ????? ??????? ????? ??????? ?? ??? ?????????? ?????. ??? ?????????? ????? ????? ??? ?????????? Z ?????? ????? ???
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ?????????? ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
?
Wz (t)=2C0(t)Z0(t)z?ort,
(
??????????? ?????????? ??????????????, ? 3, 2012
[(
[
?0 (t)
C0(t)?r 2
1
exp
W? (t)= ?
2v
2?r
?
(3)
.
zort ???????? ????????? ??????????? ???,
????? ?
???????????????? ??????????? ?????????? ???????????? ????????.
???????? ????? ????????????? ???????, ???????????? ????????? (3), ???????? ??????????????
???????? ?????????? ?????????? ??????? ????????, ?????????? ? ???????? ???? ?????????, ?????
??????, ????????? ??????????? r (t) ??? ?????????
r (0). ?????? ???? ????????? ??? ?? ??????????????? ????? ?????????? ?? ??????? ????????? C0(t),
?0(t) ? Z0(t), ? ????????? ?????? ???????? ?????
?
?????????
????? ???????????? ???????? Wr (t),
?
?
Wz (t) ? W? (t).
? ?????? ??????????? ???????? ?????????????? ???????? ????????, ???????? ??? ? ???????
????????????? ??? ??? ????????????? ?? ???????????????.
?????? ??????
?????? ??????????? (3) ????????? ?????? ???
??????????? ??? ??????????? ??????? C0(t), ?0(t) ?
Z0(t).
??? ????????????? ??????????????? ???????????? ??????, ????????? ???????? ???????? ???? ??
?????? ??????? ?? 0, ?????????? ?????????? ?????????? ???????: ? ????? ?????? ??????? t ???????? C0(t), ?0(t) ? Z0(t) ?????? ?????? ???? ?????? 0.
????????, ??? ?????? ???????? ? ???????????
??????, ? ???????, ??? ???????????? ????? ???????? ???????? ? ??????? ?????? ????????? ? ?????????? ?? ???? ?? ?????? ??????? ?? t0 = 0 ?? t? = T,
????? ???????????? C0(t), ?0(t) ? Z0(t) ????? ??????
???? ???????????. ????????? ???????? ??????????, ??????????????? ???? ?????????? ?????? ?????????, ??????? ???????? in, ? ???????? ??????????, ??????????????? ???????? ?? ?????? ?????????, ? ??????? ???????? out. ???????????, ???
??? ??????? ???????? ??????. ????? ?
zort = z ??? ????? t ? ??????? ??????? ? ?????????? ????? ????-
? r(t)
? r(t)
= - C0(t) r ?
= - C0(t) ? t .
?t
r
(4)
????? ??????? ????? ????? ???
(
T
r(t)= A exp - ? C0 (t? )dt? ,
0
(5)
??? ? ? ?????????.
????????????? ? ????????? ??????? r (0)=
=A exp(0)=r in, ??? r in ? ??????????? ?????????? ?????? ??????? ??? ??????????? ??????????? ??????? ?? ?????? ?????????? ?????????.
??? t=T ??????? ????? ??????, ?????? ??????????? ??????????? ??????? ??? ?????????? ??????????? ??????? r out:
(
T
r out= r (T )= r inexp - ? C0 (t? )dt? .
?????
(
(
?
Wr (t)=-C0(t)r?,
????. ??? ?????? ?????????????? ??????????? ??
???? ??????? ??????? ? ?????? ???????? ???, ?????? ????????????? ?? ??????? ????????????
???????.
????????? ??? ?????????? ???????????? ???????? (2) ???????? ???????????? ???????????? r(t).
??? ????? ? ???? ?????????????? ??????? ????????? ??? ? ????:
(
?????? ????. ?????? ??????? Z0(t) ??? ???????
???????? ????????????? ??? ? ??? ??????????????
????????, ?????????? ?? ???????? ???????? ?????
??? Z ? ?????????????? ??????? ?????????? ?0(t)
?? ??? ????????.
????????? ??????? ???????? ???????? ???????????? ??????? ? ????????? ?????????. ?????????
??????? ?? ???????????, ????????? ??????? ??
?????????? ? ??????????????, ??? ??????????????
?? ??????? ???????????? ????, ??? ??????? ?? ?????? ???????.
????? ???????, ?????????????? ??????? ?????
?????????????? ????????? ????? ?????????????
???. ?????? ??????? ??? ?????? ??????? ????? ?????????? ? ????????? ???? ????????? ???????:
(
14
out
-ln r in =
r
0
(6)
T
? C0 (t? )dt? .
(7)
0
??????? (7) ???????????, ??? ? r = r out ? ??????
??????? t=T ? ??????? ??????????? ??????? ???????? ?????? ?? ???????, ??????? ?????? ?????
?????????? ?????? ? ?????? ??????? t = 0. ? ????
?????? ? ???? ???????? ????? ?? ????? ?????????
??????????? ?????? ? ???????????? ????? ?????????? ? ?????????? ?????????, ? ?????? ??????????? ????? ?????????? ?? r in ?? r out.
? ?????? ??????????????? ?????? ????????????? ????????????? ?? ?????????? ???????? ???????? ?? ????????????????? ???????? ??? ?????????? ????????? ? ???????? ?? ????????? ? W zin ?
W zout ??????????????.
. ????????? ??? ?????????? ????????????
??
???????? (2) ???????:
2C0(0)Z0(0)=W zin,
2C0(T )Z0(T )=W zout.
(8)
???????? Wz(t) ?????? ????? ??????? ??? t,
??????????????? ??????? ????????? ??????????
????????? ? ?????? ???????? ?? ????. ??? ??????? ?
???????????? ??????????? ??????????? ??????????? ???????? ? ???? ??????. ????? ???????,
??? ???????? C0(t) ? Z0(t) ?????????? ?????? ??????? tmin, ??? ??????? ???????????? C0(tmin)Z0(tmin)
?????? ?????? ???????????? C0(t)Z0(t) ??? ?????
?????? ???????? t.
????? ????? ??????, ??? ????????, ???????? ?
?? ??? ??? ??????????, ????????? ???????????
??????? ? ?????? ??????? t=T. ????? ????? ??? L,
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
????? ??????? ?????????????? ?????, ????? ????
??????? ? ???????????? ?? ????????? ????????????:
T
2? C0 (t? )Z 0(t? )dt? ? L.
(9)
0
?? ????????? ? C0(t) ? Z0(t) ???????? ?0(t) ???????? ???????????? ?????????. ????? ??????,
????? C0(t) ? Z0(t), ????? ??????? ????? ??????????? ?0(t), ??????? ????????? ???????????????
??????? ???? ??????? ??????????, ?????????????
????????? ??????? ? ??????? ????? ??????????
?????.
??????? ???????
?????????? ? ?????????
??????????????????? ???????
? ??????? ?????? ?????????
?????????? ?????????? C0(t), ?0(t) ? Z0(t) ????????? ????????????? ??????? ?????? ????????? ???????? ??????????? ????? ??? ?? ????? ????????????, ????????????? ??????? ????, ??? ? ?? ??????????? ????????, ?????? ?????????????? ?????????
?????????????? ????????????? ????? ???????? ? ???????????? ?????????? ????????, ? ?????????????, ? ???????? ??????????? ??????.
????? ???????????? C0(t), ?0(t) ? Z0(t) ??????????? ?? ????????? ??????????? ???? ??????? ?????? ? ???????????, ?????? ?? ????????, ???????????? ?? ?????? ???????????????? ?????????
? ????????? ? ??????? ???????????????? ???????????? ?????????? [1?4, 8?10]. ????????,
??? ? ?????????? ???? ????????? ???? ????????
?????????? ?????? ????????? ?0/?0 ??? ?????????
???????, ??????????????? ???????????? ???????? ???????, ??? ??????????? ???????? ????? ???? ??????? ? ????? ?????????????? ??????????
??????.
285
270
255
240
225
210
195
180
165
150
135
120
105
90
75
60
45
30
15
0
C0(t)
Gamma0(t)
Z0(t)
C0/Gamma0
100 200 300 400 500 600 700 800 900 1000 1100
15
? ?????????? ??????? ????? ????? ???????? ?????????? ?????? (??????? ???????????? ? ????????
???, ???????? ????????, ??????? ????????? ????????? ?? ??????? ??????? C0(t), ?0(t) ? Z0(t)), ??????? ????????? ????????????? ???????? ???????,
???????????? ? ??????? ????? ? ??????? ??????
?????????, ????????? ??? ???? ? ??????? ????????????, ???????? ???????????????? ????? ? ???????? ??????? ?????? ????????? (???. 1, 2).
????? ???? ????????? ??????????? ????? ???????? ????????????, ??????? ?? ????? ???????????? ? ?????? ??????? ?????? ????????? ??????.
?????? ????? ???? ?? ????? ? ??????? ?????? ????????? ????????? ? ???????????? ???????????????
???????? ????????? ?????? ?????? ?????????, ?????? ????? ???? ??????, ??????????? ?? ???????,
????????? ? ????????????? ???????? ? ??????????? ???? ????????? ?????? ?????? ?????????
?????? (???. 2, 3). ??? ???? ? ????? ??????????????
??? ???????? ???????, ?????????????? ???????? ????????? ?????? ????? ? ??????? ??????: ??????? ?????????? ???????, ?????????? ??????????
???????? ? ???? ?????????? ??????????, ?????????????? ?????? ? ??????????? ??????????? ???????
? ???? ??????????????? ?????????? ? ?????????
?????? ? ???? ????????. ???????? ????? ??? ????????? ?? ??????????? ? ??????? ??????????? ??????? ????????? ? ??????????? ????????? ?????????
? ?????? ?????????? ??????????. ????? ????? ??????????? ????????? ???????? ????? ?????????
??? ?????????? 1 ?, ??? ????? ???????????? ?????????? ?????.
????? ???????, ????????????? ?????? ??????? ?????????????? ????????? ?????????????
??? ?????????????? ??????? ?????? ???????? ?
????? ????????????? ???????????????? ??????
????? ????????? ????????????? ???????? ???????
???????? ????????? ????? ? ???????? ?????????
????? ????????????? ???. ????????? ?????? ???-
C0(t)
Gamma0(t)
Z0(t)
C0/Gamma0
399,3
379,335
359,37
339,405
319,44
299,475
279,51
259,545
239,54
219,615
199,65
179,685
159,72
139,755
119,79
99,425
79,44
59,895
39,93
19,965
0
133,1 266,2 399,3 532,4 665,5 798,6 931,7 1064,81197,9 1331 1464,1
???. 1. ??? ???????? ??????? ????? ???????????? C0(t ), ?0(t ), Z0(t ) ? C0(t )/?0(t ) ? ??????? ?????? ????? ???????? ?????????????? ????? ????? ????????????? ??? (?0?10-1 ?-1; ?0?10-3 ?2?-1; Z0?10-3 ?; ?0/?0?1 ?-2)
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Time=1 s
Viscosity=0.000005 m*m/s
C0=1.5096984 1/s
gamma0=0.0079368 m*m/s
Z0=0.1107369 m
Time=1 s
Viscosity=0.000005 m*m/s
C0=8.441761 1/s
gamma0=0.0002367 m*m/s
Z0=0.0444121 m
??????????? ?????????? ??????????????, ? 3, 2012
???. 2. ??? ???????? ????????????? ????? ???? ?????????????? ?????, ???????????? ????????? C0(t ), ?0(t ), Z0(t )
(????????????? ?????? ??????? ?? ???. 1), ??????? ?????????????? ????? ????????????? ???, ???????????????
??????? ??????? ?????? ????????? (?? ?????? ?? ????????). ?????? ?????? ??????? ???????????? ?????,
?????????????? ???????? ?????, ???????? C0(t ), ?0(t ), Z0(t ) ? ???????? ?????? ?????
?
?
???. 3. ????????? ??????????? ?????? ?????? ????????? (a) ? ????? ????, ???????????????? ? ??????? ?????? (? ).
????? ??????, ??? ?????? ????????? ???????????????? ??????????? ????? ???? ? ???????????? ? ???????????? ??????????????? ????????
?????? ??? ???????? ??????? ????????? ??????,
???????????? ?????????? ??????????? ??????????? ?????????? ?????????????? ???????????
?????.
4.
??????????
5.
1.
2.
3.
??????? ?. ?., ???????? ?. ?., ??????????? ?. ?. ? ??. ?????? ????????? ???????????????? ?????? ????? ?? ????????? ???????????? ????????????? ?????????????? ????
?????? ????????? // ????. ?????????? ??????????????.
2011. ? 4. P. 18?28.
???????? ?. ?. ?????? ????????? ???????????????? ???????????? ?????? ????? ?? ????????? ???????????
?????????????? ??????? ?????? ????????? ?????? // ???.
????? ??. ?. ?. ???????? ????. 2003. Vol. 4, ? 9.
P. 61?66.
???????? ?. ?. ?????????????? ?????? ??????????? ??????????? ????????????? ?????? ????? ? ????? ????????? ?????? ? ?????: ???. ... ?-?? ????. ????. ?., 2004.
6.
7.
8.
Bockeria L. A., Kiknadze G. I., Gachechiladze I. A., Gorodkov A. Y.
Application of tornado-flow fundamental hydrodynamic theory to the study of blood flow in the heart ? further development
of tornado-like jet technology proceedings of the ASME 2011
International Mechanical Engineering Congress & Exposition
ASME2011 November 11?17, 2011. Denver, Colorado, USA
IMECE2011-63769.
Cheng Y., Oertel H., Schenkel T. Fluid-structure coupled CFD
simulation of the left ventricular flow during filling phase //
Ann. Biomedic. Eng. 2005. Vol. 33, ? 5. P. 567?576.
Domenichini F., Querzoli G., Cenedese A., Pedrizzetti G. Combined
experimental and numerical analysis of the flow structure into
the left ventricle // J. Biomechanics. 2007. Vol. 40. P. 1988?1994.
Garcia D., del аlamo J. C., TannИ D. et al. Two-dimensional
intraventricular flow mapping by digital processing conventional color-Doppler echocardiography images. IEEE transactions on medical imaging. 2010. Vol. 29, ? 10,
P. 1701?1713.
Gorodkov A., Dobrova N. B., Dubernard J.-Ph. et al.
Anatomical structures determining blood flow in the heart left
ventricle // J. Mat. Science: Materials in Medicine. 1996.
Vol. 7, ? 3. P. 153?160.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
9.
10.
Kiknadze G. I., Gachechiladze I. A., Gorodkov A. Yu. Selforganization of tornado-like jets in flows of gases and liquids
and the technologies utilizing this phenomenon //
Proceedings of 2009 ASME Summer Heat Transfer
Conference July 19?23, 2009. Westin St. Francis, San
Francisco, California USA.
Kiknadze G. I., Gachechiladze I. A., Gorodkov A. J. et al. 3D
quantitative analysis of flow velocity field inside the aorta during
one cardiac contraction // CIMTEC 2002 ? 3rd Forum on new
materials 6th Int. Conf. ╚Materials in Clinical Applications╩ /
Eds P. Vincenzini, R. Barbucci Techna Srl, 2003. P. 301?307.
11.
12.
13.
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Kiknadze G. I., Krasnov Yu. K. Evolution of a spout-like flow of
a viscous // Fluid. Sov. Phys. Dokl. 1986. Vol. 31, ? 10.
P. 799?801.
Markl M., Kilner Ph., Ebbers J. T. Comprehensive 4D velocity mapping of the heart and great vessels by cardiovascular
magnetic resonance // J. Cardiovasc. Magn. Res. 2011.
Vol. 13. P. 7.
Morbiducci U., Ponzini R., Rizzo G. et al. Mechanistic insight
into the physiological relevance of helical blood flow in the
human aorta: an in vivo study // Biomech. Model
Mechanobiol. 2011. Vol. 10. P. 339?355.
????????? 24.08.2012
╘ ????????? ???????, 2012
??? 616.124.6:616.124.3-008.64:616.12-089.168.1
???? ??????????????? ??????????? ? ????????
????????????????? ??????????????? ? ?????????
????????????????? ??????? ? ?????????, ??????????
????????????? ?? ?????? ? ???????? ??????????????
??????????????
1????
╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????; 2 ??? ????? ??. ?. ?. ????????, ??????? ???????????????
? ?????????? ?????????, ?????? ??????????? ??????
? ???????, ?????????? ????????????? ?? ?????? ? ???????? ?????????????? ??????????????,
? ????????? ????????????????? ??????? ????? ??????????? ????????????????? ???????????????. ????????? ?????????? ????????? ???????? ???????? ???????????????? ???????
?????????, ????????? ???????? ??????????????? ???????????, ??????? ??????????? ???????? ????????, ???????? ????????? ??????????????? ?????? ?????? ????????? (??? ??) ??
????????? ? ???????? ??? ??????????? ??? ?????????? ??????? ??????? ??, ?????? ????????
?????? ??????????????? ????????????? ? ???????? ????????????? ????????.
???????? ? ??????. ?????? ???????????? ????????? ????????? ??????????? ??????????, ??????????? ? ????????? ????????????????? ??????? ? 63 ???????, ?????????? ?????????????
????????????? ?? ???????? ??????. ? ???? ??????? ????????? ????????????????? ???????????????.
??????? ??????? ??????? ???????? 59,0 ╠ 1,2 ???? (?? 33 ?? 85 ???), ??????? ???? ?
171,9 ╠ 0,9 ?? (?? 162 ?? 198 ??), ??????? ????? ???? ? 78,9 ╠ 1,3 ?? (?? 51 ?? 106 ??). ??????
???? 22, ?????? ? 41.
???????? ?????????????? ?????????????? ????????? ???????? ????????? ????????? ?????????: ??????????? ??????? ?????? ? 26 ?????????, ?? ??? ? 7 ???? ?????????????? ?????????
?????? ?????????, ????????? ?????? ?????? ? ? 24 ???????, ????????? ??????????? ??????
??????? ????? ? ? 13 ?????????.
??? ??????????? ????????????????? ??????????????? ???? ???????? ???????????? ???????
????????.
* ????? ??? ?????????: e-mail: leoan@heart-house.ru
??????????? ?????????? ??????????????, ? 3, 2012
?. ?. ???????1*, ?. ?. ???????1, ?. ?. ????????1, ?. ?. ????????1, ?. ?. ??????????1,
?. ?. ????????2
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18
??????????? ?????????? ??????
??????????? ?????????? ??????????????, ? 3, 2012
??????????. ? ?????? ????????? ???????? ??????????????? ??????????? ?????????? ???????????? ??????? ???????? ????????? ?????????????? ??????????? ????????????. ???????????? ???????? ??? ???? ???????????, ??? ?????????, ?? ??????????, ??? ?? ?????????????
?? ???????? ????????, ???????? ????????? ? ?????? ????? ?????????????.
????? ???? ??? ????????????????? ???????? ??????????????? ???????????, ????????????????? ? ?????????????? ??????????? ??????? ?????????, ???? ???????? ??? ???? ?????? ?????????.
??????????. ?????????? ?????? ??????????, ??? ????????? ???????? ??????????????? ??????????? ? ????????? ????????????????? ??????? ? ?????????, ?????????? ????????????? ?? ???????? ??????, ??????????? ?????? ?? ?????????????????? ??????? ?????????. ?????????? ?? ???????? ??????????? ? ?????? ???????? ???????? ???????, ???????????
?????????????? ????????? ??????????????? ? ???????? ? ????? ??? ?????? ?????????? ??????????? ???????????? ?? ???? ???????? ????????????, ???????????? ? ????????? ???????????????? ??????? ????????? (??????????? ????????? ?????????? ?????? ?????????? ???????) ? ?????? ????????? ???????? ??????????????? ???????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ??????? ????????????????? ???????????????, ??????????????, ????????????????? ??????????.
Preface. Patients undergoing cardiac surgery under cardiopulmonary bypass are at risk for development of right ventricular failure in immediate postoperative period. The main criteria of the latter was the
reduction of right ventricular contractility, impaired motion of ventricular septum, high central venous
pressure, reduction of left ventricular end-diastolic volume compared to the baseline level in terms of
retained or increased left ventricular ejection fraction (LVEF), abrupt decrease in total peripheral resistance and decrease in arterial pressure.
Material and methods. The background of the study was the material of clinical studies in immediate
postoperative period in 63 patients, who underwent surgical intervention on the open heart. Right ventricular failure developed in all patients.
Mean age was 59.0╠1.2 years (from 33 to 85 years), average height was 171.9╠0.9 cm (from 162 to
198 cm), mean body weight was 78.9╠1.3 kg (from 51 to 106 kg). There were 22 female patients and
41 male patients.
The main nosologic characteristics of patients included several different diagnoses: ischemic heart disease in 26 patients, among them 7 patients had postinfarction aneurysm of the left ventricle, 24 patients
had valvular heart diseases, 13 patients had ascending thoracic aorta aneurysm. Intravenous infusion of
mesatonum was improved to compensate right ventricular failure.
Results. While the interventricular septum has any disturbances, intravenous infusion of mesatonum
allows correcting of the central hemodynamics. Thus, arterial blood pressure increases, central venous
pressure decreases, stroke volume elevates, LVEDV elevates to baseline values, oxygen delivery to tissues also increases.
After septal motion recovery, contracticle ability of the right ventricle was also recovered and mesatonum dose gradually decreased.
Conclusion. The data show that the abnormal interventricular septal motion in immediate postoperative
period in patients after open heart interventions significantly influences on the left ventricular efficiency.
IV administration of mesatonum is the method that allows correcting heart failure and normalizing a number of important parameters of central hemodynamics due to decrease of preload, afterload and
increase of contractility of the right ventricle (by improving of right coronary artery filling) during the
abnormal interventricular septal motion.
K e y w o r d s: treatment of right ventricular failure, cardiosurgery, postoperative complications.
? ???????, ?????????? ????????????? ?? ?????? ? ???????? ?????????????? ??????????????, ?
????????? ????????????????? ??????? ?????
??????????? ????????????????? ???????????????.
????????? ?????????? ????????? ????????
???????? ???????????????? ??????? ?????????
(??), ????????? ???????? ??????????????? ??????????? (???), ??????? ??????????? ????????
???????? (???), ???????? ????????? ??????????????? ?????? ?????? ????????? (??? ??) ?? ????????? ? ???????? ??? ??????????? ??? ?????????? ??????? ??????? ?????? ?????????
(?? ??), ?????? ???????? ?????? ??????????????? ????????????? ? ???????? ?????????????
???????? [2].
?????? ????????? ? ?????? ?????, ?????????
?????? ????? ?????????? ?????????????? ??????????????? ?????? ?????????. ??? ????? ??????????
?? 1/3 ?? 1/4 ????? ?????? ?????????.
??? ?????? ???????????? ???????? ?????, ??????? ????? ???????????? ??????? ???????????
????? ???????? ??????????? ? ???????, ??? ?????? ????????????? ??? ?????????? ??????? ?/???
?????????? ??????? ??? ?????? ????????. ????????, ?????? ????????? ??????? ?????? ???????????? ????????? ??????????????? ??????? ?? ??????????? ? ????????. ????? ???????, ?????? ?????????
?????????????, ? ?? ????? ??? ????????? ?????? ?????? ????????? ???????? ? ??????????? ? ????????? ??? ??????????? ?? ???????? ? ????????? [5].
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?????????, ??? ????????? ??????? ???????
????????? ???????? ? ???????? ?????????
??????? ?????? ????????? [6]. ????????? ??????
???? ??????????? ?????????????, ??? ??????
??????? ????????? ?? ????? ???????? ??? ?????????? ????? ??????? ?????? ? ????????? ????? [14]. ? ????? ?????? ?????????? ?????????
?????? ??????? ????????? ?????????? ? ???????????? ?????? ?????????????? ??????? ??????? ? ????????? ? ?????? ?????????? ?? ??? ???,
???? ?? ?????????? ???????? ? ???????? ???????
[8]. ????????, ??????????????? ??????????? ?
?????????????? ??????? ????????? ?????? ??
????? ?????????????? ??? ??????????? ?? ???
???, ???? ?? ????????? ?????????????? ????????
?? ?????? ????????? [11].
????? ?????? ?????? ???????? ???????? ????
??????????????? ??????????? ? ???????? ????????????????? ??????????????? ? ?????????
????????????????? ??????? ? ?????????, ?????????? ????????????? ?? ?????? ? ???????? ?????????????? ??????????????.
???????? ? ??????
?????? ???????????? ????????? ?????????
??????????? ??????????, ??????????? ? ????????? ????????????????? ??????? ? 63 ???????, ?????????? ????????????? ?????????????
?? ???????? ?????? ?? ?????? ? 2001 ?? 2009 ?.
????????? ????????? ????????? ? ???????????? ???????? ????????????? ?????????????????
???????????????, ??????? ????????????????? ??
????????? ???????? ???????????????? ???????
?????????, ???????? ???????????? ????????? ????????, ????????? ???????? ???????????????
???????????, ???????? ????? ?? ????????? ?
???????? ??? ??????????? ??? ??????????
????, ??????? ???????? ?????? ??????????????? ????????????? ? ????????????? ????????.
??????? ??????? ??????? ???????? 59,0 ╠ 1,2 ???? (?? 33 ?? 85 ???), ??????? ???? ? 171,9 ╠ 0,9 ??
(?? 162 ?? 198 ??), ??????? ????? ???? ? 78,9 ╠ 1,3 ??
(?? 51 ?? 106 ??). ?????? ???? 22, ?????? ? 41.
???????? ?????????????? ?????????????? ????????? ???????? ????????? ????????? ?????????: ??????????? ??????? ?????? (26 ?????????,
?? ??? ? 7 ???? ?????????????? ????????? ??????
?????????), ????????? ?????? ?????? (24 ????????), ????????? ??????????? ?????? ??????? ????? (13 ???????).
??????? ????????? ??????? ? ????????? ????????????????? ??????? ?? ???????????????
??????????? ????????? ???????? ?? ?? ??????????????? ???????. ????????????? ??????????
?????? ????????? ????????????????? ???????????? Puritan Bennett 7200a ????? PuritanBennett (???), ??????? ? ?????????? ?????????????? ?????????? ????? ????? ????????
??????? ?? ????????????.
?????????? ?? ??????????? ?????????????
????????? ? ?????????????? ??????????? ????????? ????? Hewlett-Packard. ? ????????????
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???? ????????? ????????? ???????????????????? (?????) ???????????? ? ????????, ? ??????? ???????? ?????????? ????????? ????????
??????????????? ???????????, ??????? (?? ??),
???????? ????????????? ? ?????????????? ?????? ?????? ?????????, ?? ??. ????????? ????????? ???????? ????? ? ??????? ????? ???? ? ???????????? ????? ?? ?????? a. radialis, ????????????
???????????. ??? ??????????? ?????????? ??????????? ???????????? ???????????? ????????????? ?????????.
??? ??????????? ????????????????? ??????????????? ???? ???????? ???????????? ??????? ????????.
?????????? ???? ?????? ??????????? ??????????, ??? ????????? ???????? ??????????????? ??????????? ? ??????????? ????????? ????????? ??????????? ?????? ?? ??????????????????
??????? ?????????.
?????? ?????????? ??????????? ???????????? ? ????????? ???????? ??????????????? ??????????? ??????????? ?? ??????? ??????. ??????
????????? ??????????? ??? ??????????? ???????? ?? ???????????? ? ????????? ??????????, ?????? ? ????? ?????????? ?????????????? ???? ???????? (????????? ??????????? ??????????? ?
????????? 1,49 ╠ 0,08 ???/??/???), ?????? ? ?????
?????????? ?????????????? ???? ????????, ??????? ???? ????????????? ? ??????????? ???????
??? ????????? ?????????? ??????????? ???????????? ? ???????? ?????, ????????? ????????? ?
????? ?????????? ????????????????? ???????????????, ??? ??????????????? ??????????????
???????? ??? ? ??????? ???????? ???? ???????? ? ???? ??????.
?????????????? ????????? ?????? ?????????
?? ???????????? ?????????? ? ??????? ??????????? ?????? Microsoft Excel ? ?????? ?????????? ???????? Statistica for Windows v. 6.0, StatSoft
Inc. (???). ?????????????? ?????? ???????????? ? ???? ???????? ??????????????? ? ??????????? ?????? ????????. ??? ?????????????? ???????? ??? ?????????? ??????? ? ????.
??????????? ????????????? ??????????? ???????????? ?? ???????? ??? ??????? ?? ??????????? ??????????????? ??????? ? ????????????
?????????? ????????? ???????????. ?????????????? ???????? ??? ?????????? ?????? 1,
?????? ??? ? ?????? 2, ????????? ? ?????? 3 ?
?????????????? ???????? ??? ? ?????? 4. ?????????????? ?????????? ???????????? ?????????? ?????????? ?? ???????? ?. ?. ??????????.
??????????
???????? ????????? ?? ???????????? ? ????????? ?????????? ????? ??????????? ?????????
????????? ? ?????????? ??????????? ????????????????? ???????????????, ????????????? ?
?????? ???????????? ??????????? ????????????.
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??????????? ?????????? ??????
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20
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?? ?????? ??? ?????????? ????????? ????????
??????????????? ???????????, ????????????? ?
?? ???????, ? ???? ??????? ???? ???????? ?? ?????????????? ????????. ???????? ????? ????????
??? ?? ?? ????????? ? ???????? ??? ??????????? ??? ?????????? ?? ??.
1-? ?????????. ?? ?????? ??????????? ????????????? ???????????? ???????? (???) ?????????? 86,6 ╠ 0,9 ?? ??. ??., ??????????? ???????? ???????? (???) ??????????????? 14,3 ╠ 0,3 ?? ??. ??.,
?? ?? ?????????? ? ???????? 49,5╠0,7%. ??? ????
??? ?? ???????? 115,0╠2,8 ??, ? ???????? ??????
????????? (??2) 459,8╠6,3 ??/???/?2. ?? ?? ?????????????? ???? 57,2 ╠ 1,2 ??. ???? ?????????? ?
???? ?????? ?????????? 0,120 ╠ 0,008 ???/??/???.
? 35 ????????? ??? ????? ???????? ?????????????? ???????? ???, ? 23 ? ?????? ??? ? ?
5 ??????? ?????????????? ????????? ???.
2-? ?????????. ????? ?????? ???????? ????????
????????????? ???????????? ???????? ???????? ??
105,2 ╠ 0,9 ?? ??. ??., ? ??? ?????????? ???
10,7 ╠ 0,2 ?? ??. ??. ?? ?? ????? ???????? ? ????????? 50,6╠0,7%. ??? ???? ??? ?? ?????????? ??
129,7 ╠ 2,9 ??. ??2 ????????? 529,5 ╠3,1 ??/???/?2,
???????????? ??? ?????????? ???????????. ???
???? ?? ?? ?????????? ?? 65,4 ╠ 1,2 ??. ????
?????????? ? ???? ?????? ???? ??????? ??
0,068 ╠ 0,003 ???/??/???.
?? ?????? ??? ? 26 ????????? ??????????
?????? ??????????????? ???????????, ? 30 ? ?????????? ?? ?????????????? ???????? ? ? 7 ? ?????????.
3-? ?????????. ????????? ??? ?????????? ???????, ???? ???????? ???? ????????? ? ?????????
2,34 ╠ 0,1 ???/??/???.
??? ?????????, ????????????? ????????????
???????? ????????? ?? 130,2 ╠ 1,2 ?? ??. ??.,
??? ????????? ?? 7,2 ╠ 0,1 ?? ??. ??. ?? ??
???????? ?? 51,3 ╠ 0,7%. ???????? ??????????
??? ?? ?? 146,1 ╠ 3,4 ??. ??? ???? ??2 ????????
582,5 ╠ 2,7 ??/???/?2, ?? ?? ?????? ?? 73,8 ╠ 1,3 ??.
???? ?????????? ? ???? ?????? ???? ???????????
??????? ? ???????? ?? 0,05 ╠ 0,002 ???/??/???.
????? ????? ?????? ? 4 ????????? ??? ?????
???????? ?????????????? ???????? ??????????????? ???????????, ? 29 ? ?????? ???, ? 25 ??????? ?????????????? ????????? ??? ? ? 5 ????????? ???????? ?????????????? ???????? ???.
4-? ?????????. ????? ???? ??? ? 32 ?????????
???????? ??????????????? ??????????? ?????????????? ?????????, ? ? 31 ???????? ??? ???????
????????? ??????????????? ???????????, ?????????????? ??????????? ??????? ????????? ??????????????, ???? ???????? ???? ?????? ???????
?? 0,52╠0,08 ???/??/???. ??? ???? ???? ?????????? ????????? 0,039╠0,002 ???/??/???.
? ?????????? ????????????? ???????????? ???????? ??????????? ?? ?????????? ? ?????????
129,8 ╠ 1,4 ?? ??. ??. ??????? ??? ????????? ????????? ? ?????? 7,0 ╠ 0,1 ?? ??. ??. ?? ?? ????????
?? ??????? ??????, 51,9 ╠ 1,0%. ??? ???? ??? ??
???????? ????????????? ? ?? 141,4 ╠ 2,6 ??. ??2
????????? 574,5 ╠ 3,7 ??/???/?2, ????? ?????????-
??? ?????????? ???????????. ??? ???? ?? ?? ??????? ??????????? ??? ????????? ? 73,3 ╠ 1,1 ??.
???????? ??????????? ????? ???????????????
???????? ??? ? ????????????? ??????????
??????????? ???????????? (??. ???????).
??????? ????????, ??? ?????????????? ???????? ??? ? 24 ????????? ???????? ????? 3 ???, ?
26 ??????? ? ????? 4 ???, ? 7 ? ????? 5 ???, ? 5 ? ????? 6 ??? ? ? 1 ???????? ? ????? 10 ???.
??????????
?????????? ?????? ??????????, ??? ?????????? ???????? ??????????? ??? ?????????????????
???????????????, ????????????? ? ???? ??????? ?????????? ???????? ??????????????? ???????????, ???????? ???????, ??????????? ?????????????? ????????? ??????????????? ? ???????? ? ?????
??? ?????? ?????????? ??????????? ???????????? ?? ???? ???????? ????????????, ???????????? ?
????????? ???????????????? ??????? ?????????
(??????????? ????????? ?????????? ?????? ?????????? ???????) ? ?????? ?? ?????????????? ???????? ??????????????? ??????????? [2].
???????????????????? ???????????? ?????
?????? ???????????? ??? ??????????? ??????????????? ????????????. ??? ????????? ??????????? ?????????? ??????? ?????????????
??? ???????, ??? ? ?????? ?????????? ??????,
???????????? ??????? ????????? ? ????????
??????????????? ???????????. ??? ???????
???????, ??? ??-???????????? ???????? ????????? ??? ??????????? ?????? ????????? [16, 19,
20, 23].
??? ???????, ??? ???????, ???????? ? ???????? ????????????????? ???????????????: ???????? ???????????????? ??????? ????????? (? ??????????? ???? ??????? ? ???????? ?? ????
????????? ???????? ??????????????? ???????????), ?????????? ?????? ????????? ????????????? ? ?????? ????????? ????????????.
?? ?????? ??????????????? ???????????? ???????? ??? ???????? ???????? ????????????????? ??????????????? ? ????????? ?????????????? ??????????? ??????? ????????? ? ???????
??????????????? ???????? ??????????????? ???????????.
????????????????? ? ??????????? ???????????? ????????, ???, ???????? ?? ??????? ?????????? ????????? ?????? ??????? ?????????, ??? ?????? ???????????? ??????????? ??????????????
?????? ?????? ????????? ? ??????????????? ???????????.
????????? ??????????????? ??????????? ???????? ?????? ???????? ???????? ???????????????? ?????????. ??????????????? ???????????
?????????? ?????? ????????????? ????? ???????
?????????, ???? ? ????? ??? ?????????? 1/3 ??????? ?????? ??. ????? ???????????? ?????? ??????? ????????? ????????, ??? ????????????? ???????? ????????????, ??-??????, ????? ??????????
?????????? ??????????????? ???????????, ????????, ??????????? ????????????? ????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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14,3
3
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??????????? ????? ????? ? ???????? ????????? ???????? ??? ? ????????? ??? (?), ?????????????? ?????????????
???????? (?), ??? ?? (?), ?? ?? (?), ?? ?? (?), ??2 (?)
??????????????? ??????????? ? ??????? ???????
????????? ? ???????, ????????????? ? ?????????????? ????????? ???. ????????????? ???????? ??????????????? ??????????? ? ??????? ??????? ????????? ???? ????????? ??????????????
???????? ???????????????? ????????? ???????? ?
??????? ?????????? ?????? ??. ??????????????
???????? ??????????????? ??????????? ????????
???????? ? ?????? ??????? ???????????????? ????????? ????? ??????? ?????????? ???????? ???????????? ??????? ????????? [1].
?????????? ?????? ????????? ????????? ? ????????? ?????????????? ???????? ? ????????
?????? ??????? ????????? ????? ???????? ???????? ?? ????????? ?????? ?? ? ??????????????
????????? ???????????????? ????????? ???????? ????? ???????, ??? ??????? ??????????????? ??????????? ? ????? ??????? ???????? ??-
??????????? ?????????? ????????? ?????? ??????? ????????? [1].
?????????? ???????????? ????????, ??? ??????? ??????? ????????? ??????? ?? ?????? ?? ???????? ??? ????????? ??????, ?? ? ?? ??????? ??????????????? ??????????? [4].
? ???? ????????????????? ???????????? ??????????, ??? ????? ????????? ?????? ??????? ????????? ? ??? ???????? ??????? ?? ???????? ????????????. ???, ???????? ????????? ?????? ???????
????????? ? ?????, ????????????? ?? ????????? ???????? ????????????? ? ????????. ??? ????????????
? ??? ?????? ????????, ??? ??????? ??????? ????????? ?? ?????? ???????????? ??? ????????? ???????, ?? ? ?????????????? ???????? ?????? ????????? ? ??????????????? ??????????? [9, 10, 22].
??? ?????? ??????????? ? ???????????? ????????????????? ? ??????????? ???????????? [12, 13,
??????????? ?????????? ??????????????, ? 3, 2012
1
1
4
130,2
?? ??, %
2
4
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3
15
14
13
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Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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22
??????????? ?????????? ??????
18], ??????????, ??? ??? ?????????? ?????????
?????? ??????? ????????? ??????? ?????????? ???????????? ???????? ?????? ????????? ? ??????????????? ???????????. ???????? ????????????
??????????????? ??????????? ???????? ? ?????
??????? ???????????????? ????????????.
???? ??????????, ???, ???????? ?? ?????????? ?????????? ????????? ?????? ??????? ????????? ??? ??????????? ??????? ??????????????? ???????????, ?????????????????? ???????
????????? ?????????????? ????????? ???????????? ?????? ????????? ? ??????????????? ??????????? [12, 17, 21].
?????? ????????? ????????????? ??? ?????????? ?????? ???????? ? ???????? ???????, ??
????? ???????????? ? ?????????? ????????????,
??? ????? ??????????? ?????? ?? ??? ?????????????? ??????????? [7, 19, 23].
????????? ???????? ? ?????? ??????? ??????,
????????????? ?????? ????????????????? ????????????????, ???????? ? ??????? ??????????
?????? ????? ?? ????????? ??????, ?????????????
??? ??????? ?????????, ???????? ????? ?? ??? ???????. ????????? ???????? ?????? ? ???????? ??????????????? ??????? ????????? ??????.
?????????????????? ??????? ????????? ? ????
?????? ????? ??????, ? ????? ?????? ?????? ?? ???????? ??????? ????????????. ???????? ? ?????
?????????, ??? ????????? ???????? ? ?????????? ?????????? ????????, ????????????? ???????? ???????? [3].
????????????? ???????? ????????? ????????
???????? ??????? ????????? ??? ? ???????, ??? ?
? ???????? ?? ???? ????? ???????? ? ????? (?????????????? ? ???????????????) [2, 15]. ???????
???????? ???????? ? ???????? ???????? ? ?????? ????????? ? ?????? ??????????, ??? ???????????? ???????? ?????? ????? ?? ???????? ??????? ??, ?? ???? ? ???????? ????? ????????
??????? ?????????. ??? ???, ? ???????? ?????, ?
???????? ? ????? ???????????????? ??????? ?????????, ?????????????? ???????? ??????????????? ???????????, ? ? ?????????? ? ??????????
????????????????? ??????????????? [3, 15].
????? ???????, ????????? ??????????????? ??????????? ???????? ?????? ????????, ???????????? ???????? ???????????????? ?????????. ??????? ??????? ????????? ?? ?????? ????????????
????????? ??????? ??????? ?????????, ?? ? ?????????????? ???????? ??????????????? ???????????.
????????? ???????? ??????????????? ??????????? ??????????? ?????? ?? ?????????????????? ??????? ?????????. ?????????? ???????? ???????? ???????, ??????????? ?????????????? ?????????
??????????????? ? ???????? ? ????? ??? ?????? ?????????? ??????????? ???????????? ? ?????? ????????? ???????? ??????????????? ???????????.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
??????????
1.
??????? ?. ?., ???????? ?. ?., ?????????? ?. ?. ? ??. ?????????? ???????? ??????? ????????? ??? ???????????
??????? ??????. ?.: ????? ??. ?. ?. ???????? ????,
2010. 324 ?.
23.
??????? ?. ?., ??????? ?. ?., ???????? ?. ?. ? ??. ???????
????????????????? ??????????????? ? ????????? ????????????????? ??????? ? ?????????, ?????????? ????????????? ?? ?????? ? ???????? ?????????????? ?????????????? // ????. ??????. ????????. 2012. ? 1. ?. 10?16.
??????? ?. ?., ??????? ?. ?., ???????? ?. ?. ? ??. ??????????? ???????? ???????? ? ?????? ??????? ?????? ? ????????? ????????????????? ??????? ? ?????????, ?????????? ????????????? ? ???????? ??????????????
?????????????? (????????????????? ??????????????? ?
??????? ??????????????, ?????? ?? ????????) // ????.
??????. ????????. 2011. ? 2. ?. 78?80.
???????? ?. ?., ????????? ?. ?., ?????????? ?. ?., ?????????? ?. ?. ???? ??????????????? ??????????? ??? ?????? ???????????? ??????? ??????? ????????? // ??????????. ???. ? ????????????. 2002. ? 1. ?. 54?62.
???? ?. ?., ???? ??. ?. ?????????? ? ?????????????? ???????? ???????. ?.: ????????, 1995. 668 ?.
Berger H. J., Johnstone D. E, Sands J. M. et al. Response of right
ventricular ejection fraction to upright bicycle exercise in coronary artery disease // Circulation. 1979. Vol. 60. P. 1292?1300.
Bernstein A. D., Parsonnet V. Bedside estimation of risk as an
aid for decision-mahing in cardiac sugery // Ann. Thorac.
Surg. 2000. Vol. 69. ?. 823?828.
Brooks H., Kirk E. S., Vokonas P. S. et al. Performance of the
right ventricular under stress: relation to right coronary flow //
J. Clin. Invest. 1971. Vol. 50. P. 2176?2183.
Donald D. E., Essex H. E. Pressure studies after inactivation of
a major portion of the canine right ventricle // Am. J. Physiol.
1954. Vol. 176. P. 155?161.
Donald D. E., Essex H. E. Studies on chronic effects of legation
of the canine right coronary artery // Am. J. Physiol. 1954.
Vol. 176. P. 431?438.
Geiran O., Molaug M., Kiil F. et al. Compensatory cardiac mechanisms evoked by acute occlusion of the right coronary artery in
dogs // Acta Physiol. Scand. 1984. Vol. 120. P. 185?195.
Goldstein J. A., Harada A., Yagi Y. et al. Hemodynamic importance
of systolic ventricular interaction, augmented right atrial contractility and atrioventricular synchrony in acute right ventricular dysfunction // J. Am. Coll. Cardiol. 1990. Vol. 16. P. 181?189.
Goldstein J. A., Tweddell J. S., Barzilai B. et al. Importance of
left ventricular function and systolic interaction to right ventricular performance during acute right heart ischemia //
J. Am. Coll. Cardiol. 1992. Vol. 19. P. 704?711.
Guiha N. H., Limas C. J., Cohn J. N. et al. Predominant right
ventricular dysfunction after right ventricular destruction in
the dog // Am. J. Cardiol. 1974. Vol. 33. P. 254?258.
Hirsch L. G., Rooney M. W., Wat S. S. Norepinephrine and
phenylephrine effects on right ventricular function in experimental
canine pulmonary embolism // Chest. 1991. Vol. 100. P. 796?801.
Hoeper M. M., Galie N., Murali S. ?t al. Outcome after cardiopulmonary resuscitation in patients with pulmonary arterial hypertension // Am. J. Respir. Crit. Care Med. 2002.
Vol. 165. ?. 341?344.
Klima U., Guerrero J. L., Vlahakes G. J. Contribution of the
interventricular septum to maximal right ventricular function //
Eur. J. Cardiothorac. Surg. 1998. Vol. 14. P. 250?255.
Lopez-Sendon J., Garcia-Fernandez M. A., Coma-Canella I.
et al. Segmental right ventricular function after acute myocardial infarction: two-dimensional echocardiographic study in
63 patients // Am. J. Cardiol. 1983. Vol. 51. P. 390?396.
Mebaza A., Karpati P., Renaud E., Algotsson L. Acute right ventricular failure ? from pathophysiology to new treatments //
Intens. Care Med. 2004. Vol. 30. ?. 185?196.
Moreira M. M., Terzi R. G., Vieira R. W. et al. Pre- and postpulmonary tromboendarterectomies capnographic variables //
Rev. Bras. Cir. Cardiovasc. 2007. Vol. 22. ?. 509?512.
Santamore W. P., P.R. Lynch, J.L. Heckman et al. Left ventricular effects on right ventricular developed pressure // J. Appl.
Physiol. 1976. Vol. 41. ?. 925?930.
Starr I., Jetfers W. T., Merse R. H. The absence of conspicuous
increments of venous pressure after severe damage to the right
ventricle of the dog, with discussion of the relation between
clinical and congestive heart failure and heart disease // Am.
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Vieillard-Baron ?. Assessment of right ventricular function //
Cur. Opin. Crit. Care. 2009. Vol. 15. ?. 254?260.
????????? 24.08.2012
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
23
╘ ????????? ???????, 2012
??? 616.125-008.318:616.126.42-089.168
?????????? ?????????????? ??????????? ??????? ?????????????
? ?????????????? ????????? ? ????????? ? ????????? ??????
? ?????????? ?????? ??????????? ??????????
?. ?. ?????????*, ?. ?. ???????, ?. ?. ??????, ?. ?. ???????, ?. ?. ????????
??????????? ?????????? (??) ? ???????? ???????????????? ????????? ????? ??????. ?? ??????? ? ????? ????????? ?????????? 1?2%. ?? ????????????? ? ??????????? ??????????,
??????? ???????? ? ?????? ?????????????????? ??????????, ????????? ??????????????? ?
??????????????, ?????????? ???????? ?????, ????????? ????????????? ?????????? ????????
? ??????????? ?????? ?????????. ? ?????????? ??? ??????????? ????????? ??????? ?????????? ? ????????? ? ????????? ?????? ? ?? ? ?????????? ?????? ????????.
???? ????????????: ????????? ??????????? ?????????????? ??????????? ??????? ?????????????
? ?????????????? ????????? ? ?????????: 1) ? ????????? ??????, 2) ? ???????????? ??????????.
???????? ? ??????. ? ???????????? ????? 203 ????????, ??????? ? 1993 ?? 2007 ?. ?????????
?????? ??????????? ??????? ?????????? ???????? ???????????? ? ????????????? ????????.
????????? ???? ? ?????????? ??????? ??????????????? ? 54 ?????????: ? 21 ? ? ?????????????? ????????? ? ? 33 ? ? ????????????? ?????????. ?????????? ????? ??????????? ?????????? ???????? ? 149 ?????????: ? 51 ? ? ????????????, ? 98 ? ? ???????????? ????????.
??????? ????????? ?? ?????? ???????? ????????? ?? 60 ?? 72 ???.
???? ?????????? ? ?????? ????????????????? ???????? ?? 2 ?? 144 ???, ? ??????? 73,3 ╠ 30,3 ???
(5,5 ???), ? ?????? ???????????? ???????? ? ?? 5 ?? 144 ??? (? ??????? 5 ???). ??????? ?????????? ????????? 90%.
??????????. ????? ?????????????? ??????????? ??????? ????????????? ? ?????????????? ????????? ????????????? ??????????? ??????? ? ????? ? ???????????????? ??????????? ?? ???????? ??? ? ?????? ? ????????? ??????, ??? ? ? ?????? ? ?????????? ?????? ??. ???????
?????????????????? ?????????? ???? ???? ????? ?????????????? ??????????? ??????? ????????????? ????????? ? ?????? ? ?????????? ?????? ??. ??????? ??????????????? ??????????
????????????? ?? ?????????? ????? ?????????????? ????????????? ? ?????????????? ????????? ??? ? ?????? ? ????????? ??????, ??? ? ? ?????? ? ?????????? ?????? ??. ???????? ??????????? ?????????? ???????? ????? 6 ??? ????? ?????????????? ??????????? ???????.
??????????. ? ????????? ? ?????????? ?????? ??????????? ?????????? ?????????????? ??????????? ??????? ???????????? ???????? ???????? ???? ?????????????????? ??????????,
?? ?? ?????? ?? ????????????. ? ????????? ? ??????????? ? ?????????? ??????? ????????
??????? ???? ????????? ????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ?????????????? ??????????? ???????, ???????????? ???????, ??????????,
???????????????? ??????????, ???????????.
Atrial fibrillation (AF) ? is the most common heart rhythm disorder. Its frequency is 1?2% for total population. AF is associated with increase of death, frequency of insults and other thromboembolic disorders, heart failure and hospitalizations, worsening of quality of life, decrease of exercise tolerance and
dysfunction of the left ventricular in patients. In literature, there are results of comparison of morbidity
with sinus rhythm and AF, and various types of prostheses.
Objective: comparison of results of mitral valve replacement with mechanical and biological prostheses
in patients with sinus rhythm and AF.
Material and methods. 203 patients who underwent mitral valve replacement by different models of
mechanical and biological prostheses from 1993 to 2007 were included to the study.
Sinus rhythm in the long-term period was in 54 patients: 21 patients with biological prostheses and 33 with
mechanical prostheses. Constant form of atrial fibrillation was in 149 patients: 51 patients with biological
prostheses and 98 patients with mechanical prostheses.
The age of patients was from 60 to 72 years at the moment of performing the operation. The follow-up
period in the group of bioprostheses was from 2 to 144 months (in average 5.5 years), in the group of
mechanical prostheses ? from 5 to 144 months (in average 5 years). Complete follow-up exceeds 90%.
Results. After replacement of mitral valve with mechanical and biological prostheses statistically significant difference of the general and valve-dependent mortality was noted neither in the group with sinus
* ????? ??? ?????????: e-mail: elenaandelena@list.ru
??????????? ?????????? ??????????????, ? 3, 2012
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
24
??????????? ?????????? ??????
rhythm nor in the group with constant form of AF. Thromboembolic complications rate was higher after
replacement of mitral valve with mechanical and biological prostheses in the group with constant form of
AF. Hemorrhagic complications rate did not differ after replacement with mechanical and biological prostheses both in the group with sinus rhythm and in the group with constant form of AF. Bioprosthesis
degeneration signs were noted over 6 years after replacement of mitral valve.
Conclusion. In the patients with bioprosthesis with constant form of atrial fibrillation replacement
of mitral valve with mechanical prosthesis increases the risk of thromboembolic complications but
does not affect survival. Reoperation risk remains high in the patients with bioprosthesis in the
mitral position.
??????????? ?????????? ??????????????, ? 3, 2012
K e y w o r d s : replacement of mitral valve, mechanical and biological prostheses, valve-dependent complications, mortality.
???????? ?? ????? ??????????? ??????? ???????? ???????? ???????? ??????, ? ????????? ????? ? ???????? ?????????????? ??-???????? ??????? ??? ???? ????????: ????????????? ? ????????????. ???????? ????? ??? ????????? ?????????
????????? ???????? ????????????. ? ?????????
???????? ???????? ????????????? ?????? ????????
???????? ??????.
??????????? ????????? ? ????? ?????? ????????? ?? ???????? ? ??????? ??????? ??????, ??????????? ???????????? ?????????? (??). ???
????????, ??????????? ? ??????? ? ?? ????????????? ?????, ? ???? ????????? ? ? 5 ??? [21].
??????????? ?????????? ???????? ? ?????????? ??????? ?????? ??????????, ?????????
??? ?????????????? ???????, ? ?????????? ??????????? ??????? ?????????? ? ????????? ??????????? ???? ?????? ?????????? ?? ???? ??????????
?????????? ?????? ?????? ????????? ? ? ?????????? ????????? ? ???? ?????? ??????????. ????? ????, ?? ??????????????? ?????????? ???????
??????????? ????? ? ?????????? ???????????.
?????????? ????? ??????? ?????????, ? ??? ??????????????? ????????? ?????? ??????? ???
??????????? ? ??????? ??????????? ?????????
[5]. ??? ????????? ???????????? ? ??????? ????????? ????? ??????????? ????? ???????????????? ?????????????? ??????????.
????? ?????????? ???????????? ????????
????????? ??????????? ?????????????? ??????????? ??????? ? ????????? ? ?????????? ??????
?? ? ?????? ???????????????? ??????????.
???????? ? ??????
? ?????? 1993 ?. ?? ??????? 2008 ?. 203 ????????? ????????? ?????????????? ???????????
???????. ??? ??????? ???? ?????? 60 ???. ? 1-?
?????? ????? ???????? ? ????????? ??????, ??
2-? ? ? ??.
? ???????????? ???????? ???????? ? ????????????? ??????? ??????????? ???????, ? ?????
??????? ? ??????? ??????????? ??????? ? ????????????? ?????????? ??????????????? ???????
??? ????????????? ??????????? ???????? ?????? (???). ???????? ? ????????????? ?????????? ??????????? ??????? ?? ?????????? ? ????????????.
?????? ????????????? ?? ??????????? ?? ????????, ?? ??????????? ?? ??????????? ????? ?
????????? ?????? (????. 1).
????? ??????? ? ?????????? ?????? ?? ??????????? ??????? ? ???????????, ? ????? ??????? ? ????????? ?????? ? ? ???????????? ??????????? ???????, ???????????? ????????????
? ??????????? ?????????? ????????????????.
???? ?????????, ??????? ?????????????? ????????????? ??????, ??????????? ? ????? ? ??????????? ??????? (???? ? ?????????????, ???? ? ??????????????).
??? ???????? ??????????? ?? ????????? ??????????? ? ???????? ?????????????? ?????????????? ? ??????????? 26?30 ╟?. ? ???????? ????????????????? ????????? ????????? ??? ??????????????, ??? ? ???????? ????????. ????? ?????????
????? ???? ?? 40 ?? 240 ???, ????? ?????????????? ?????????????? ? ?? 60 ?? 413 ???, ? ???
?? ??????????? ????? ???????? ?????????????
(? > 0,05).
? ?????? ? ????????? ?????? ???????????
?????????????? ??????? ????????? ? 21 (38,9%)
????????, ????????????? ??????? ? ? 33 (61,1%)
?????????. ????????????? ??????????????
??????????? ??????? ????????? 26 (48,1%) ?????????, ? ????????? ? ????????? ??????????????? ??????? ? 25 (46,3%) ???????, ? ??????????????? ??????????????? ??????? ? 2 (3,7%)
???????. ????????????? ???????????????
???????????? (???) ????????? 13 (24%) ?????????. ? ???? ????????? ??????????? ????????????? ??????? ?????????????? ????????? ╚????????-3╩.
? ?????? ????????? ? ?? ??????????????
??????????? ??????? ??????????? ???????????
51 (34,2%) ????????, ???????????? ???????? ?
98 (65,8%) ???????. ????????????? ?????????????? ????????? 50 (33,6%) ???????, ? ????????? ?
????????? ??????????????? ??????? ? 86 (57,7%),
? ????????? ? ??????????????? ???????????????
??????? ? 10 (6,7%) ???????. ?????????????
??? ? ?????? ?????? ????????? 21 (14,1%) ????????.
??? ?????????????? ??????????? ??????? ???????????? ????????? ?????? ?????????????
(╚??????╩, ╚???????╩, ╚Labcor╩, ╚Sorin?
Pericarbon╩, ╚Medtronic-mosaic╩, ╚Carpentier?
Edwards╩) ? ???????????? (╚????╩/╚?????╩,
╚????╩, ╚??????╩, ╚St. Jude Medical╩, ╚Carbomedics╩, ╚Sorin Bicarbon╩, ╚ATS╩) ????????. ????
?????????????? ????????????? (╚??????╩) ? ???????????? (╚????╩, ╚??????╩) ??????? ?????????????? ????????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
25
??????? 1
??????????? ?????????????? ???????, ???. (%)
???????????
?????????? (n = 149)
????????? ???? (n = 54)
???????/???????, ???. (%)
35/19 (64,8/35,2)
??????? ???????, ???
?
121/28 (81,2/18,8)
0,014
63,9 ╠ 3,0
63,9 ╠ 2,8
0,96
?????????????/???????????? ???????, ???. (%)
21/33 (38,9/61,1)
51/98 (34,2/65,8)
0,54
????????? ???????????:
?????????
??????????
???????????? ??????????
?????????? ??????????????? ?? ???? ???
?????????? ???????
26 (48,1)
15 (27,8)
6 (11,1)
4 (7,4)
3 (5,5)
???? ????????? ? ????????????? ????????? ?
????????? ? ?????????????? ????????? ? ?????????? ?????? ?? ?????????? ????????? ???????? ??????????????. ????????? ? ????????????? ????????? ? ????????????? ????????????
????????????? ????????????????? ?????????
(???) ?? ?????? 2,0?3,5, ????????? ? ?????????????? ????????? ? ?? ?????? 2,0?3,0. ?????????
? ?????????????? ????????? ? ????????? ??????
???????????? ????? ???????? ??????????????? ?
??????? 3 ??? ? ?????????? ????????? ?? ????????????.
?????? ? ????????? ? ?????????? ??????? ???? ???????? ??? ????? ????????????, ??? ????????????? ????????? ??? ?? ????????.
?????????????? ????????? ?????????? ??????????? ??????????? ? ?????????????? ?????????
Microsoft Excel ??? Windows ? ????????? Statictica 7, ? ??????? ??????? ??????????? ????? ??????????? ????????????? ??????.
????????????? ???????? ???????????? ?????????? ????????? ? ?????????????? ???????? ?2.
?????? ?????????? ??????????? ????????? ??? ?????? ?????? ????????????, ??????????? ?? ?????? Kaplan?Meier. ????????????? ???????? ??????
??????????? ?????? Cox?Mental. ????? ???? ???????????????? ?????????? ?????????? ??? ????????? ??????? ???????, ????????? ? ?????????? ???????. ??????????? ???????? ??????? ??????? ? ?????? Kaplan?Meier ??????? ??? ? < 0,05.
132 (88,6)
7 (4,7)
8 (5,4)
1 (0,7)
0 (0,0)
0,0001
??????????
?????????? ????????????
? ????????? ? ????????? ??????
???????????
? ????????? ? ????????? ?????? ? ?????????? ??????? ??????????? ????????? 21,1% ? ??????
? ?????????????? ????????? ? 18,2% ? ?????? ?
????????????? ????????? (????. 2). ? ?????? ?
???????????? ???????????????? ??????????? ???????? ?????? ? ???? ?????????, ??? ?????????
10,5%. ??? ???? ???? ?????????, ?????????? ????????, ??????? ?? ?? ??? ???????????? ???????,
??????? ?? ?????????-????????? ????????????.
??????? ??????????? ?? ?????? ?????? ?? ????
??????????? ? ?? ????????????? C. W. D. Akins
???????? ? ?????? ???????????????? ???????????
[6]. ? ?????? ? ????????????? ????????? ???????????????? ??????????? ????????? 9%, ???? ????????? ?????? ?? ??????? ????????? ?????????
?????????????? ?? ???????????? ????, ???? ?
?? ???????? ???????, ? ????? ?????? ???????
?????? ?? ????????.
????? ????????? ???????????? ? ???? ???????
????????????? ?? ?????????? (?=0,93) ? ?????????
? ????????? ? ???????????? 84,4 ╠ 8,3% ????? 5, 8
? 10 ???, ? ????????? ? ????????????? ????????? ?
86,3 ╠ 6,5% ????? 5 ??? ? 71,7 ╠ 1,0% ????? 8 ???
(???. 1, ?).
??????? 2
??????? ?????????? ???????????, n (%)
????????? ????
??????? ??????
????????????????:
????
??????? ???????
????????????
??
??????? ?? ????????
??????????
????????????
???????
??????????? ??????????
?
??????????
????????????
???????
?
2 (10,5)
0 (0,00)
0 (0,00)
1 (5,2)
0 (0,00)
1 (5,2)
3 (9)
1 (3)
1 (3)
0 (0)
0 (0)
1 (3)
0,87
5 (9,4)
1 (1,9)
0 (0,0)
1 (1,9)
2 (3,8)
1 (1,9)
15 (15,3)
6 (6,0)
3 (3,0)
2 (2,0)
0 (0,0)
4 (0,0)
0,31
???????????
0 (0)
3 (9)
0,18
7 (13,2)
2 (2,0)
0,005
??????
2 (10,5)
0 (0,0)
0,06
1 (1,9)
1 (1,0)
0,66
??????
4 (21,1)
6 (18,2)
0,8
13 (29,5)
18 (18,2)
0,37
??????????? ?????????? ??????????????, ? 3, 2012
??????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
26
??????????? ?????????? ??????
%
%
100
100
p = 0,93
p = 0,12
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
0
2
?
4
6
8
10
12
14
16
0
2
4
?
????? ????? ????????, ???
6
8
10
12
14
16
18
????? ????? ????????, ???
????????????? ???????
???????????? ???????
???. 1. ????? ????????? ???????????? ? ????????? ? ????????? ?????? (?) ? ?????????? ?????? ??????????? ?????????? (?)
%
%
100
100
??????????? ?????????? ??????????????, ? 3, 2012
p = 0,77
p = 0,75
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
0
?
2
4
6
8
10
12
14
16
????? ????? ????????, ???
????????????? ???????
0
?
2
4
6
8
10
12
14
16
18
????? ????? ????????, ???
???????????? ???????
???. 2. ???????????????? ???????????? ????????? ? ????????? ?????? (?) ? ?????????? ?????? ??????????? ?????????? (?)
???????????????? ???????????? ? ???? ??????? ????? ????????????? ?? ??????????? (? = 0,77,
???. 2, ?), ? ????????? ? ???????????? ????? 5,
8 ? 10 ??? ????? ??????????? ??? ?????????
86,6 ╠ 7,6%, ? ????????? ? ????????????? ????????? ? 82,3 ╠ 7,6% ????? 5 ??? ? 74 ╠ 1,1% ????? 8 ???.
???????????????? ??????????
? ????????? ? ????????? ??????, ???????
??? ????????????? ????????????? ??????, ???????? 100% ??????? ?? ?????????????????? ?????-
?????. ? ????????? ? ????????????? ?????????
????????? ??????? ?? ?????????????????? ?????????? ? 8-?? ???? ????????? 80 ╠ 0,1% (???. 3, ?).
????????? ??????? ?????????????????? ?????????? ? ?????? ? ????????????? ????????? ????
?????????? ???????, ???????? 5,7% ???????????
(9 ??????? ??????? ????????? ????????? ??????????????).
????????? ??????? ?? ???????????? ????????????? ?? ?????????? ? ???? ??????? (? = 0,79) ? ??
???? ???? ?????????? ????????? 93,3%, ? ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
%
27
%
100
100
p = 0,12
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
p = 0,049
0
0
0
2
?
4
6
8
10
0
2
?
????? ????? ????????, ???
4
6
8
10
12
14
16
????? ????? ????????, ???
????????????? ???????
???????????? ???????
???. 3. ????????? ??????? ?? ?????????????????? ?????????? ? ????????? ? ????????? ?????? (?) ? ?????????? ?????? ??????????? ?????????? (?)
%
%
100
p = 0,79
100
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
0
2
?
4
6
8
10
12
14
16
????? ????? ????????, ???
????????????? ???????
0
?
2
4
6
8
10
12
14
16
18
????? ????? ????????, ???
???????????? ???????
???. 4. ????????? ??????? ?? ???????????? ? ????????? ? ????????? ?????? (?) ? ?????????? ?????? ??????????? ?????????? (?)
??? ? ????????????, ??? ? ? ????????????? ????????? (???. 4, ?). ????????? ??????? ????????????
? ?????? ??????????? ????????? 1,8% ???????????
(2 ??????) ? 1,9% ??????????? ? ?????? ???????????? ???????? (3 ??????).
?????????? ???????????? ? ?????????
? ?????????? ?????? ??????????? ??????????
???????????
????? ??????????? ? ????????? ? ?????????????? ????????? ????????? 25,5%, ? ????????? ?
????????????? ? 18,2%. ????? ?????? ??????????? ??????? ???????????? ???????? 6 ????????? ?????? ?? ?????????????????? ??????????
(?????? ????????? ????????? ??????????????
?? ???????????? ????), 3 ? ?? ???????? ???????,
2 ? ?? ????????????, ? 4 ????????? ??????? ?????? ???????? ?? ??????? (????. 2). ? ????????? ?
?????????????? ????????? ??????? ?????? ????
?????? ?????? ?? ??????? ????????? ?????????
?????????????? ?? ???????????? ????, ???? ?
?? ????????????, ???? ? ?? ??????????? ???????.
????????? ?????????? ???? ???????? ??????
??????????? ?????????? ??????????????, ? 3, 2012
p = 0,52
90
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
28
??????????? ?????????? ??????
??????????? ?????????? ??????????????, ? 3, 2012
???? ????????? ? ?????? ????????????????? ?????????????? ????? 6 ??? ? 2 ???? ????? ????????.
????? ???????, ???????????????? ??????????? ?
????????? ? ????????????? ????????? ?????????
15,3%, ? ? ????????? ? ???????????? ? 9,4% (??.
????. 2).
????? ? ???????????????? ???????????? ?
????????? ? ????? ?????? ???????? ? ??????????
?????? ??????????? ?????????? ?????????????
?? ?????????? (? < 0,05). ???????????? ????? ??????????? ????????????? ???????? ????? 5, 8 ?
10 ??? ????????? 70,8 ╠ 6,8%, ????? ???????????
???????????? ???????? ????? 5 ??? ? 86,2 ╠ 3,7%,
????? 8 ? 10 ??? ? 70,0 ╠ 8,0% (? = 0,12) (??. ???. 1, ?).
???????????????? ???????????? ????? ??????????? ??????????? ????????? 87,8 ╠ 5,1% ????? 5, 8 ? 10 ???, ????? ??????????? ????????????
???????? ????? 5 ??? ????? ???????? ?????????
88,1 ╠ 3,5%, ????? 8 ? 10 ??? ? 78,1 ╠ 5,7% (? = 0,75,
??. ???. 2, ?).
???????????????? ??????????
????? ????????? ? ?????????? ?????? ??
??????? ?? ????????????? ???? ?????????????
???? ? ????????? ? ?????????????? ?????????
(? = 0,049, ??. ???. 3, ?).
????? ????????????????? ????? 5, 8 ? 10 ???
????????? ??????? ?? ????????????? ?????????
94,3 ╠ 3,8%, ????? ?????????????? ?????????????
????????? ????? 5 ??? ? 85,5 ╠ 3,7%, ????? 8 ??? ?
81,9 ╠ 4,3%, ????? 10 ??? ? 65,6 ╠ 15%. ?????????
??????? ????????????? ? ?????? ????????????
???????? ????? ???? ??????? ? ????????? 3,9%
??????????? (24 ??????), ? ?????? ??????????? ?
0,8% ??????????? (????? 2 ??????).
????????? ??????? ???????????? ???? 2,7%
??????????? ? ?????? ??????????? (7 ???????) ?
2,1% ??????????? ? ?????? ???????????? ????????
(13 ???????).
??????? ?? ??????????????? ?????????? ? ????????? ? ?????????? ?????? ??????????? ?????????? ????????????? ?? ?????????? (? = 0,52)
(??. ???. 4, ?). ????? 5 ??? ????????? ??????? ??
???????????? ????? ?????????????? ?????????????? ????????? ????????? 87,3 ╠ 5,3%, ????? ?????????????? ????????????? ????????? ? 89,5 ╠ 3,5%.
????? 8 ? 10 ??? ????? ?????????????? ?????????????? ????????? ????????? ??????? ?????????
78,6 ╠ 9,5%, ????? ?????????????? ????????????? ????????? ? 81,6 ╠ 5,6%.
??????? ????? ?????? ?? ????????
?????????? ??????? ??????????? ???????
? ?????? ???????????? ?? ???????? ?? ??????
?????? ???????? ?????????????? ???????. ? ????????? ? ????????????? ????????? ??????? ??????? ?????????? ? ??????? ? ????????? ?????? ?
???????????? ?????????? ????????????? ?? ?????????? (? < 0,05). ????????? ??????? ????????
??????? ? ?????? ? ????????? ?????? ?????????
1,3% ??????????? (2 ??????), ? ?????? ? ?????????? ?????? ?? ? 0,8% ??????????? (4 ??????).
????????? ??????? ?? ?????????? ? ?????????
%
100
90
p = 0,154
80
70
60
50
40
30
20
10
0
0
2
4
6
8
10
12
14
16
18
????? ????? ????????, ???
????????????? ???????
???????????? ???????
???. 5. ????????? ??????? ?? ?????????? ?????????
? ?????????????? ? ????????????? ?????????
? ????????????? ????????? ?? ???? ?????? ?????????? ????????? 98,7 ╠ 0,7%, ? ????????? ? ???????????? ????? 5 ??? ? 100%, ????? 8 ??? ? 72,7 ╠
╠ 17,6%, ? ????? 10 ??? ? ?????? 54,5 ╠ 20,5% (???. 5).
????????? ??????? ????????? ???????? ? ?????? ?
????????????? ????????? ????? 0,2% ???????????, ? ?????????????? ? 0,8% ???????????.
????????? ????????? ???????? ? ????????? ?
????????????? ????????? ???? ????????? ?????????? ? ??????? ???????, ? ????????? ? ???????????? ? ??????????? ???????. ? ?????????? ??????? ??????????? ?????????? ???????? ? 6 ?????????, ?? ?????? 3 ???? ?????????????. ????
????????? ?????????? ?? ?????????? (???? ?? ????????? ???? ?? ??????????? ????????? ???????????????), ???? ????????? ? ????????? ????????.
????????, ??? ??????? ?? ????????????????????
????????? ??????????? ?????????????? ???????
????? 5 ??? ???? 100%, ????? 8 ??? ? 72,7 ╠ 17,6%,
? ????? 10 ??? ? ????? 36,4 ╠ 20,2%.
??????????
? ???? ????????? ????? ??? ????????????????? ???????????? ?? ????????? ??????????? ?????????????? ???????? ?????? ????????????? ?
?????????????? ?????????: The Department of
Veterans Affairs trial ? The Edinburgh heart valve trial
[16, 26]. ?????? ????????????, ??????????? ?????? ????????, ???????? ????????????????.
??????? ????????, ??? ??? ?? ? ????? ???????????? ?? ?????????? ?????????? ??????????????
???????? ?????? ? ????????? ? ?????????? ?????? ??????????? ??????????.
? ??????????? ???????????? ?? ??????? ??????? ? ????? ??????????? ????? ??????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ??????? ????????????? ? ?????????????? ????????? [9, 10, 12, 15?17, 19, 20, 22, 25,
28, 30]. ???????????????? ??????????? ? ???? ???????????? ?? ??????????? [15, 22, 23, 28]. ?? ?
?????? ??????? ????????? (?????? 65 ???) ???????????????? ??????????? ???? ???? ? ??? ? ?????????????? ????????? [24, 30].
? ????? ???????????? ?? ????? ?? ???????
????????????? ??????????? ??????? ? ????? ?
???????????????? ??????????? ??? ? ????????? ?
????????? ??????, ??? ? ? ????????? ? ???????????? ??????????.
??????? ?????????????????? ??????????, ??
?????? ???? ????????????????? ? ????? ??????????????? ????????????, ?? ??????????? ? ????????? ? ????????????? ? ?????????????? ????????? [13, 22, 25?28, 30]. ?????? ????????????,
????????, ???????? ????? ??????? ???????
?????????????????? ?????????? ????? ??????
???????? ?????? ????????????? ????????? [12,
15, 23].
?????? ??????, ??????????? ??????????? ????????????????? ???????? ??????, ??????????????? ? ??????? ???????????????????? ????????????? ???????? [1, 2, 4, 11, 14, 29]. ???? ?????????????????? ?????????? ????? ?????? ???????????
??????? ?????????????? ?????????, ?? ??????
????????? ????????????, ?????????? ?? 0,6 ??
3,2% ? ???.
???? ???????????? ????????, ??? ??? ???????? ? ????????? ?????? ????? ??????????????
??????????? ??????? ????????????? ????????
???????? ?? ?????????????????? ??????????.
?? ????? ????????, ??? ????? ??????? ? ?????????? ?????? ???????????? ?????????? ???????
?????????????????? ?????????? ???? ? ????????? ? ????????????? ?????????. ??? ???? ?????
????????????????? 6 (11,7%) ????????? ? ?????????? ?????? ?? ?? ?????? ???????????? ??
????????? ???????? ??????????????, ???? ??
??? ????????? ????????????. ? ???? ????????? ??
???????????????? ?? ?????? ?????? ?????????????????? ??????????.
? ?????????????? ???????????? ?? ????????????? ?? ?????? ???????? ?????????????? ???????.
???????? ?? ???? ???????? ??????? ????????? ??????? ?????????????????? ?????????? ?
????????? ? ????????????? ?????????, ??? ?
?????? ? ???????????? ??????????, ??? ? ? ?????? ? ????????? ??????. ??????? ???????, ??? ???
????? ???????????? ????????????? ??????????
??? ????? ?????? 60% ?????????, ? 30% ???????? ???????????????. ???????? ???????? ???????????? ??????? ????? ? ????? ?????? ????????
?????????? ??????. ??? ??????? ?? ?????? ? ???????????? ???????? ???, ???????????? ??????????? ???? ?????? ????????????, ?? ? ? ??????????????????? ????????? ? ?????????????? ????????? ?????? ? ???????? ?????? ?????????.
? ??????????? ???????????? ???????? ??????? ??????? ???????????? ????? ?????? ??????????? ??????? ????????????? ????????? [15,
29
17, 18, 23, 28, 30]. ?????? ??????????????, ????????, ??????? ? ?????????????? ???????????? ??????? ??????? ??? (?? 2,5 ?? 3 ??? ????
4) ? ????????? ? ????????????? ????????? ? ?????????? ???????.
? ????? ???????????? ??????? ???????????? ?
????????? ? ????? ?????? ???????? ?????????????
?? ???????????. ???? (33%) ????????? ? ???????????? ? ????????? ?????? ?? ?????? ???????????? ????????? ???????? ??????????????. ? ????
????????? ??????????? ??????????????? ??????????.
??????? ????????????? ?????????? ? ?????
???????????? ???? ?????????. ????????????????
????? 2 ?????? ?????????? ??????????? ?????????????? ??????? (0,8% ???????????) ? ???? ? ????????????? (0,2% ???????????). ??? ??????????????? ????????????? ?????? ???? ??????????????? ? ?? ????????? ??????????.
????????? ? ?????????? ??????? ????????
???????? ?? ?????????????????? ??????????, ??
???????? ??????????? ????????? ????????. ???????? ??????????? ??????????, ?? ?????? ?????????? ????????????, ?????????? ??? ????? 6 ???
????? ?????????????? ??????????? ???????. ? ???????, ??????????? ?????????????????, ??????????? ??????????? ??????????? ?????????? ?????
6?8 ??? ????? ????????, ? ?????????? ?????????????, ???????? 60% ? 15 ????? [3, 8, 11, 16, 22, 28].
???? ????????? ???????? ???????? ???????,
???????? ?? ?????????????????? ?????????????, ???????????????????? ? ???????????????
???????????. ? ????? ? ???????????? ?????????????? ??????? ????? 3 ???????? ???? ??????? ????????????? ? ????????. ??? ???????? ????????? ?? ???????? ? ??????? ?????????, ? ???????????????? ?????????????? II? ?????? ? IV
?????????????? ??????? ????????? ??????????????? ?? NYHA.
???? ????????? ? ????? ???????????? ?????????? ?? ????????? ????????, ???????????? ???
??????? ?????? ??????. ???? ?? ????????? ????
?? ??????????????? ????????? ???????????????
????? 5 ??? ????? ???????????????? ??????????
??????????.
?? ????????? ????????????? ????????????? ???????? ???????????, ???????????? ?????????? ??????, ??????????? ?????????? ? ?????????? ??????? ???????? ?????????, ???????
?? ????? ??? ?? ? ????????? ????????? ?????????????? ???? ????? ???????????????? ? ??
?????? (????? I) [7].
??????????? ????????????? ??????? ????????
????????? ?????? 65 ??? ? ?????????? ??????
??????????? ??????????. ??????????? ?????????? ? ????????? ?????? 65 ???. ??????????? ?????????? ???????? ? ????????? ? ????????? ?????? ?????? 65 ???, ???????? ???????? ????????
????? ? ??????????? ??????? ???? ?????????
???????? (????? II?) [7].
??????????? ?????????????? ???????????
?????????????? ????????? ? ?????????? ??????? ????????? ?????? 70 ??? [11, 15, 23, 30].
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ?????????? ??????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
30
??????????? ?????????? ??????
????? ???????, ? ????????? ? ?????????? ?????? ??????????? ?????????? ?????? ??????????? ??????? ???????????? ???????? ????????
???? ?????????????????? ??????????, ?? ??
?????? ?? ????????????. ? ????????? ? ??????????? ? ?????????? ??????? ???????? ??????? ????
????????? ????????. ??????? ?????????????????? ?????????? ? ????????? ? ?????????????
????????? ????, ??? ? ??????????????, ??
??????????? ?? ????? ???????????????? ?????????? ?? ??????? ?? ???? ???????. ???????? ??????????? ??????? ????????? ????????????????, ????????? ? ?????????? ?????? ??????????? ?????????? ??????? ????????????? ??????
??????????? ??????? ???????????? ????????.
????????????? ?????? ????? ?????????????? ????????? ?????? 70 ??? ? ????????? ??????, ?? ?
??????????????? ? ????????? ??????????? ??????? ? ????? ????????? ????????.
??????????
1.
2.
3.
4.
5.
??????????? ?????????? ??????????????, ? 3, 2012
6.
7.
8.
9.
10.
11.
???????? ?. ?., ???????? ?. ?., ????????? ?. ?. ?????????? ???????? ??????: ???????? ? ???????????. ????????, 1995.
??????? ?. ?., ?????????? ?. ?., ???????? ?. ?. ?????
????????????? ????????? ? ?????? ??????? ? ??????????????. ?.: ????? ??. ?. ?. ???????? ????, 2002.
????e?????? ?. ?. ?????????? ???????? ??????: ???????
? ????????? ????????????? // ????????????????. 1994.
?. 2, ? 4. ?. 165.
??????????? ?. ?., ???????????? ?. ?., ??????????? ?. ?.
? ??. ????????????? ??????? ???????? ??????. ?.: ????????, 1988. ?. 84?88.
??????? ?. ?., ??????? ?. ?., ????????? ?. ?. ? ??.
??????????? ? ??????? ??????????? ??????????. ???????????? ???? ? ????. ?.: ????, 2011. ?. 10.
Akins ?. W. D., Miller C., Turina M. I. et al. Guidelines for
reporting mortality and morbidity after cardiac valve interventions // Ann. Thorac. Surg. 2008. Vol. 85. P. 1490?1495.
Bonow R. O., Carabello B. A., Chatterjee K. et al. 2008 Focused
update incorporated into the ACC/AHA 2006 guidelines for
the management of patients with valvular heart disease:
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Surg. 2001. Vol. 71. P. 257?260.
????????? 24.08.2012
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
31
╘ ????????? ???????, 2012
??? 616.124.2-089.168
?????????? ?????????????? ??????? ???????????????
??????????????? ?????? ?????????
?. ?. ????????, ?. ?. ???????, ?. ?. ??????
????????. ?????? ? ????????????? ?????????? ???????????????? ???????? ? ????????? ?
?????????????? ???????????????? ?????? ????????? (????) ?? ??? ??? ???????? ?? ????????. ? ?????? ????????????? ???????????? ????????? ?????????? ???????????????? ???????? ?? ?? ? ??????????? ?? ????????? ???? ??????????????? ???????????????, ??????? ?????????????? ??????????.
???????? ? ??????. ???????? ???????????? ???? 112 ????????? ? ??????????? ????????
?????? (???), ?????????? ???? ??????? ???????? ??? ????? ? ???????? ??????? ?????? ????????? (?? ??) ????? 46%. ? 1-? ?????? ???? ???????? ? I ????? ??????????????? ??????????????? (n = 29). ?????????? ?????? ?? 2-? ?????? ???????? ??????????????? II ? III ????? ??
M. Di Donato (n = 83). ???? ????????? ?? 1-? ?????? ????????? ???????????????? ???????? ??
??????? ??. ????????? ?? 2-? ?????? ??? ???????????? ????????? ?????????????????? ????????????. ??? ???? ???????? ????????? ???????? ??????????? ???????????? (n = 34) ????
???????? ??????????? ???????????? ? ????????? ? ?????????????? ?? (n = 49).
??????????. ? ?????? ?????? ?? ?????????? ????????????? ??????? ?? ? ????????? ?? II ????? ? ?????????? ????????????????? ??????? ???????????? ??????? ??????????????? ??.
??? ????????? ??????????? ????????????? ????????????? ??? ??????? ? ????????????? ????????????????? ? ????????? ? III ????? ??????????????? ??????????????? ?? ???? ???????????
?? ???? ???????? ????????????? ??????????? ???????. ????????????? ??? ???????????????
????? ????????????? ?? ?????????? ? 22,7% ?????????. ? 11,4% ????????? ??????? ??????
(??) ??? ? ???????? ?????, ??? ???? ????????????? ????????. ?????????? ????????? ????????? ???? ??????????????????, ?????, ??? ? ?????? ?? ????????? ??. ? 11,36% ????????? ?
????????????? ???????????????? ?????????? ????? ? ???????? ??. ? ???? ???? ?????? ????????? ??????? ???????? ?????????????? ??????????. ????????? ???? ????????? ??????????
????????????? ??? ?????????.
??????????. ? ?????????? ???????????? ???????????? ???????? ????????????? ??????????
???????????????? ???????? ? ????????? ? I ? II ?????? ??????????????? ??????????????? ?
?????????? ???????????????? ????????? ??????? ?? ? ????????? ? III ????? ??????????????? ???????????????. ???????? ????? ???????????? ??????????? ? ?????????????? ??????????? ?? ????????. ?? ????????? ???????? ?????? (??) ? ?????????? ????????????????? ??????? ?????????? ????????????? ?? ?? L. Menicanti ???? ??????????, ?????????????
?????????? (?????????????? ??????? ??) ??????????? ????? ????????????? ?? ?? V. Dor.
??? ?????????? ?????????? ?????????????? ??????? ?? ????????? ????????????????? ??????????????? ????? ?????????????? ???????? ? ????? ?????????? ?????????? ???????.
? ?????? ????????? ??????? ?? ?????????? ???????????????? ????????? ???????????????.
?????????????????? ????????????????? ??????????????? ??????????? ? ????????? ? ????????? ??????????? ???????? ??, ??????????? ????????????????? ??? ?????????????, ??? ?
?????????????? ????????? ???????????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ?????????????? ??????????????? ?????? ?????????, ????????????????
???????? ?? ????? ?????????, ?????????????? ??????????, ????????????????? ???????????????.
Introduction. The problem of reconstructive surgeries need in the patients with left ventricle postinfarction remodeling (LVPR) is still not solved. Results of reconstructive surgeries on LV depending on basic
type of postinfarction remodeling, availability of diastolic dysfunction are studied in this prospective
investigation.
Material and methods. The objective of the investigation was 112 patients with ischemic heart disease
(IHD) who underwent one or more myocardial infarctions with left ventricle ejection fraction (LV EF) less
than 46%. In the first group there were patients with I type of postinfarction remodeling (n=29).
Selection criteria to the second group were II and III type M. Di Donato remodeling (n=83).
Reconstructive surgeries on LV cavity were performed in all the patients from the first group. Stratified
randomization was carried out in the patients from the second group. The patient had also coronary
??????????? ?????????? ??????????????, ? 3, 2012
???? ╚??? ???????????╩ ?? ????, ?. ?????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
32
??????????? ?????????? ??????
artery bypass grafting (n=34) or coronary artery bypass grafting associated with LV reconstruction
(n=49).
Results. LV remodeling process continues in case of refusal to perform reconstruction of LV cavity for
the patients with the II type in the late postoperative period. Statistically significant difference with
respect to all factors was not revealed during comparison of surgical results of its cavity with isolated
revascularization in the patients with the III type of postinfarction remodeling. Progressive remodeling
after LV reconstruction was noted in 22.7% patients. In 11.4% of patients stroke index (SI) was within
normal limits, ?SI had positive values. Clinical state of the patients was satisfactory, better than in the
group with SI loss. 11.36% of patients with progressive remodelling also had the decrease of SI. All the
patients of this group had signs of diastolic dysfunction. The state of these patients was clinically evaluated as deterioration.
Conclusion. As a result of the study performed there was shown the need of reconstructive surgeries in
the patients with I and II types of postinfarction remodeling and absence of feasibility to reduce LV cavity in the patients with the III type of postinfarction remodeling. Operative mortality associated with diastolic dysfunction before the operation was revealed. According to the stroke volume (SV) in the late
postoperative period L. Menicanti LV reconstruction results were the best, negative results (LV cavity
hypercorrection) were noted after V. Dor LV reconstruction. With adequate reduction of the dilated LV
cavity secondary postsurgical remodeling has compensatory character with a view to the stroke value
increase. Heart failure progress in this category of patients is not noted. Decompensated postsurgical
remodeling develops in patients with excessively decreased LV cavity, manifests both as systolic and
diastolic heart failure.
K e y w o r d s : left ventricle postinfarction remodeling, left ventricle reconstructive surgeries, diastolic dysfunction, postsurgical remodeling.
??????????? ?????????? ??????????????, ? 3, 2012
????????
??? ????????, ?????????????? ??????????????? ?????? ????????? (????), ??? ????????? ?
????????? ???????, ???????? ???????? ???????? ???????????????? ????????? ??????????????? ? ????????? ? ??????????? ???????? ??????
(???). ???????? ????? ?????????????? ???????
???? ???????? ???????????? ?????????? ???????? ????????? [3]. ?? ????????????? ??????????? ?????????? ????????????????? ????????
??????????????? ???????? ???? ????????? ?
???????? ??????????? ?? ?? ????? ??????????
??????????? ???????????? [5]. ????? ???????
???????? ???????????? ? ?????????? ??? ???????
???????????? ??????? ?? ?? ????????????? ??????? ? ??????? ?????????? ????????? ????????.
??? ????????? ??????? ??????????? ????? ???????????? ????????, ??? ??? ??? ??????? ??????
? ???, ??????? ?? ????????? ??????? ??, ????????? ?? ???????????? ???????? ??????????????????, ??? ???????????? ????????????????? ? ?????????? ????????? ???????????????.
??? ??????? ??????????? ?????????? ?????????????? ??????? ?? ?????????? ?? ?????????
????????? ????????, ???????????? ???????? ?????????? ?????????? [4]. ?????? ???????????? ?????????? ???????? ? ?????????? ??????????? ? ??????????? ?? ????????? ????????? ???????? [2].
????? ?? ????? ??????? ??????????????? ????????????????? ????????????, ?????????? ?
????????? ?????, ???????? STICH, ?? ?????? ???????? ???????????? ? ?????????????? ?? ??????????? ???????? ????? ????????????? ????????????? ?????? ????????? (????) ? ???????????????? ???????????? (???) ?? ????? ???????? [4].
????????????? ??????????????? ???????
????????? ?? ? ??????????? ????????? ???????
?? ?????????? ???????? ? ???????????????-?????????????? ???????? ??, ? ????? ? ???????-
??????? ???????????? ????????, ??????? ??? ????????? ? ?????????? ?????????????? ???????????. ??? ??????? ??????????? ??????? ?????????
??? ??? ???????, ???????? ??????? ? ???????, ????????????? ????????????? ????????????? [1].
?. Di Donato ? ?????????, ?????? ???????? ? ????? ?? ? ????????? ? ????, ???????? ??? ???? ?
??????????? ?? ?????????????? ?????????? ????
?? ????????? ? ????????? ???????????????
?????????. ??? ?????????? ??? ???? ?? ????????? ?????? ? ???????????? ??????? ?????, ???
??????????????? ????? ?????? ??????? ??? ???????????????? [2].
?????????????? ?????????? ???????? ??????????? ???????????????? ???????? ? ???????????
?? ???? ????, ? ????? ? ????????? ? ????????????? ???????? ??? ?????????? ??????? ?? (?????????? ????????????, ??? ? ????????? ? ????????? ??????????? ???????).
????? ???????????? ??????? ???????? ??????????? ?????????????? ??????? ????????? ? ????,
????????????? ? 2008 ?? 2010 ?.
???????? ? ??????
? ?????? ????????????? ???????????? ???????? 112 ?????????, ??????????? ??????? ? 2008
?? 2010 ?. ??? ????????? ???????????? ???????????? ??????????????? ????????, ????????????
???? ???????? ????????? ?????????.
?????????? ????????? ? ???????????? ????:
????????????? ???????????? ?????????? ???????, ???? ??????? ???????? ? ????? ? ????????,
??????? ???????? ????????? ??, ???????????????
?????????????? II?IV ?????????????? ???????
?? NYHA, ??????? ??????? (??) ?? ????? 45%.
???????? ??????????: ?????? ??????? ????????, ????????? ??????? ?????? ?????????????
?????????, ??????? ?????? 70 ???, ????????????
??????????? ? ?????? ?????????????, ???????
???????????????? ? ???????????? ???????,
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????
?? ??????? ??). ??? ????????? ???????????
????????? ??, ?????????? ????????? ?? ????? ???????????? ???????????? ?????????????:
??? = ((??1???2)/??2) в 100%. ??? ?????? ???
??? ??????????? ???????? ? 20% ?? ?????????
? ??????????????? ??????????. ????? ???????, ??? ??? ????? 20% ?????????? ????????????? ???????? ????????, ??? ???????? ??????????? ?????????? ??????? ??, ?????????????? ???????????????? ???????? ? ??????????
????????????????, ??? ??? ????? ?20% ?????????? ???????????????? ???????? ????????? ?????????????????????, ?????????? ?? ?20 ?? 20
???????? ???????????????????, ? ???? ???????
?? ?????????? ??? ???????????? ????????????? ? ????? ? ??????? ???????? ????????? ???????? ? ?????????????? ? ????????????????
(???????????????).
??? ?????? ?????????????????? ??????????????? ?????????????? ????????????? ?? ???? ??????? ??? ?????????? ?????????? ??????????????? ????? ????????????? ????????????? ???????
??. ??????????? ??? ?????????????????? ??????????????? ?????????????? ? ???????, ?????
??????? ??????????????? ?? ?????????? ? ???????? ?????? ????????????? ??????????????,
????? ???????? ????????????? ?????? (???) ????? ???? ????????? ????? 80% ?? ?????????????? ????????. ????????????? ???, ????? ???????
??????????????? ???? ???????? ???????????? ?
???????????, ???? ????????? ???????????????
????? ???????????? ???????, ?????????????? ? ?????????, ? ?????? ???? ??? ??? ?????? 80% ??
?????????????? ????????.
??????????
?? ???????? ?????? ?????-????????????
??? ??? ???? ??????????????? ???????????????
?????????? ??????????? ?? ?????????? ?? ??:
??? I ???? ??? ???? ??????????, ??? III ? ?????????? (????. 1). ?? ????????? ??????????? ??????????? ???????? ?? ??????????.
? ?????? ????????????????? ??????? ??????
9 ???????. ???????????? ??????????? ? ?????? ????????????????? ??????? (?? 30 ???? ????? ????????) ????? ???????????????? ???????? ?? ??
??????? 1
???????? ?????????????? ?? ?????? ?????
? ??????????? ?? ???? ??????????????? ???????????????
??????????
??? ??, ??
??? ??, ??
??? ??, ??/?2
??? ??, ??/?2
?? ??, %
?? ??, ??
??, ?/(?2????)
??
I ??? (n = 29)
II ??? (n = 51)
III ??? (n = 32)
? (ANOVA)
209 ╠ 45
130 ╠ 39
105 ╠ 22
67 ╠ 19
38 ╠ 7
80 ╠ 16
2,7 ╠ 0,6
0,58 ╠ 0,09
225 ╠ 51
143 ╠ 48
116,8 ╠ 27,3
75,2 ╠ 26,5
35 ╠ 8
78 ╠ 16
2,8 ╠ 0,7
0,59 ╠ 0,07
236 ╠ 63
158,4 ╠ 52,9
116,3 ╠ 26
79,9 ╠ 26
33,7 ╠ 7,5
78,8 ╠ 20,8
2,84 ╠ 0,7
0,65 ╠ 0,11
0,2
0,08
0,1
0,1
0,008
0,3
0,6
0,1
? ? ? ? ? ? ? ? ? ? . ?? ? ????????? ??????; ?? ? ?????? ???????????.
??????????? ?????????? ??????????????, ? 3, 2012
? ??? ????? ?????????? ????????????? ??????????? ????? ??? ???????? ????????? ??????????
???????.
??? ??????????????? ??????????????? ??
?????????????, ???????????? M. Di Donato
(2009 ?.), ??????????? ? ???????????? ??????? ??
?????, ??? ??????????????? ????? ?????? ??????? ??? ???????????????? [3]. ?????? ??? ? ???????? ?????????, ????? ??????? ??? ???????
????? ????????????? ? ?????????? ?????????; II ??? ? ?????????????, ??????? ???? ????
??????? ????? ????????????? ? ??????????
?????????; III ??? ? ??????????? ??????????????, ??? ??????? ?????????? ?????????? ??? ??????? ????????.
? 1-? ?????? ???? ???????? ? I ????? ??????????????? ??????????????? (n = 29). ??????????
?????? ?? 2-? ?????? ???????? ???????????????
II ? III ????? ?? M. Di Donato ? ?????????? ?????
????????????? ?? ??????? ?? ??????????? ????????? ?? (n = 83). ???? ????????? ?? 1-? ??????
????????? ???????????????? ???????? ?? ??????? ??, ??? ?????????????????? ?????????? ????? ???????????????. ????????? ?? 2-? ??????
??? ???????????? ????????? ??????????????????
????????????. ??? ???? ???????? ?????????
???????? ??????????? ???????????? (n = 34) ???? ???????? ??????????? ???????????? ? ????????? ? ?????????????? ?? (n = 49).
???? ????????? ?? ???????? ?????????
?????-????????????, ????????? ?????? ??,
??. ???????? ??????? ?? ????????? ?? ???????? ?????????? ??????? ? ???????? ?????? (??).
??? ?????????? ???????????????? ??????????
???????????? ??????? ?????? (??), ?????????
?? ? ??????? ??????????? ????.
? ????? 1, 6 ? 12 ??? ????? ???????? ????????? ??????????? ????????????, ??????????
?????. ?????????, ??????? ?? ?????? ????????
?? ??????????? ????????????, ????????? ?????????? ???????? ? ????? ???????? ????????????. ????????????? ?????????????? ??????? ????????? ??? ?? ??????????? ????????? (??????? ????????? ???????????????, ???????????
??????????????? ??????), ??? ? ?? ?????. ???????? ?????????, ?? ???????? ?????? ? ????????
??????? ??, ??????? ????????? ?? (??????-
33
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
34
??????????? ?????????? ??????
??????????? ?????????? ??????????????, ? 3, 2012
????????? 10,2% (n = 8), ????? ??? (?????????????? ??????? ??? ????????????? ??) ? 2,94%
(n = 1). ? ????????? ????? ???? ?? ???????????
???????? ??????????? ????????? 7,69% (n = 6), ???
?????????? ?????????????????? ?? 2,94%
(n = 1). ????? ??????? ??????????? ???????? ?
III ????? ??????????????? ???????????????, ??????????? ?? ??????????? ???????? ? ?????????
? III ????? ????????? 18,75% (n = 3), ?????? ????????? ??????????????? ??????????? ? 43,75%
(n = 7) ???????. ?????????????? ?????????? ? 30%
(n = 18) ????????? ??????? ??????? ?????? ????????? ???????????????. ????????, ??? ??????
????????? ??????????????? ??????????? ? 88,2%
(n = 10) ????????? ? ????????????? ????? ?????????????? ??????????, ? 44,3% (n = 4) ? ?????????????? ??????????? ?? ???? ?????????????????? ? ? 9,96% (n=4) ????????? ? ?????????????? ??????????? ?? ???? ??????????
????????????. ? 12,8% (n = 6) ??????? ?????????????? ?????????? ??????? ? ?????????? ?????? ?
??????????? ????????? ? ????????? ?? ???????? ????????????? ????? ?????????????? ?????????? (n = 5).
???? ???????????? ????????, ??? ? ???? ??
6 ??? ?? 1 ???? ? ???? ????????? ??????????? ????????? ????????????????? ??????????????? ??????? ??. [1]. ?? ???? ?????? ?????????????????? ??????? ???????? ?????????????? ??????????
??????? ????????? ???????????????. ? ?????? ??
6 ??? ?????? 2 ????????: 1 ??????? ?? II ?????
??????????????? ??????????????? (???????
?????? ? ????????? ??????? ????????), 1 ??????? ? III ????? (?? ??????? ??????????? ??????????). ? ???? 6 ??? ????? ???????? ???????????
44,5% (n = 44) ???????? ????? ???????? ??????120
%
???: ? I ????? ??????????????? ??????????????? ?
13 ?????????, ?? II ? 23 (15 ????????? ????? ????, 8 ? ????? ???), ? III ? 15 ???????
(7 ? ????? ????, 8 ? ????? ???). ? ?????? ?? 6
?? 12 ??? ????? ??? ???? 1 ??????? ? III ?????
??????????????? ??????????????? ?? ?????????? ???????? ????????. ? ???? 12 ??? ????? ???????? ??????????? 63% (n = 63) ????????: ? I ????? ??????????????? ??????????????? ? 21 ???????, ?? II ? 25 (14 ????????? ????? ????, 11 ?
????? ???), ? III ? 17 ??????? (9 ? ????? ????,
8 ? ????? ???).
? ????????? ? I ????? ??????????????? ??????????????? ???????? ?????????????? ??????
(???) ????? 1 ??? ????? ???????? ?????????? ??
36%, ????? 6 ??? ? ?? 33%, ????? 12 ??? ? ?? 28,5%
(? < 0,05). ????? 1 ??? ????? ???????? ??? ???
?????? ????????? ?? 50,7%, ????? 6 ??? ? ??
45,3%, ????? 1 ??? ? ?? 41,5% (? < 0,05). ?? ?????
1 ??? ????? ???????? ????????????? ?? 33,3% ??
????????, ????? 6 ??? ? ?? 25,6%, ????? 12 ??? ?
?? 28,9% (? < 0,05). ????? ???????, ???? ???????
? ?????????? ???????, ?????????? ??, ?? ???????? ? ????? ????????? ????????? ?????????????? ????????? ????????????????? ??????????????? (???. 1).
? ????????? ?? II ????? ??????????????? ??????????????? ? ?????? ? ???? ?? ?????? ??????
????? ???????? ?? ????????? ? ??? ??????????
?????????? ?? 33%, ????? 6 ??? ? ?? 26%, ?????
12 ??? ? ?? 21,7%. ????? 1 ??? ????? ????????
??? ?????????? ?? 42,4%, ????? 6 ??? ? ??
32,8%, ????? 12 ??? ? ?? 27,7% (? < 0,05). ?? ?????
1 ??? ????? ???????? ??????????? ?? 40%, ????? 6
??? ? ?? 19,4%, ????? 12 ??? ? ?? 22,2% (? < 0,05)
(???. 2).
120
100
100
80
80
60
60
40
40
20
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???. 1. ???????? ??????????? ????? ? ????????? ? I ?????
??????????????? ???????????????
???
???
??
??
?? ????????
????? ????????:
1 ???
6 ???
12 ???
???. 2. ???????? ??????????? ????? ? ????????? ?? II ????? ??????????????? ??????????????? ????? ???????????????? ???????? ?? ????? ?????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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120
%
? ????????? ??? ????????????? ??????? ??
??? ????? 1 ??? ???? ?????? ????????? ?? 15,7%,
????? 6 ??? ? ?? 15,2%, ????? 12 ??? ? ?? 14,4%.
??? ????? 1 ??? ?????????? ?? 19,7%, ????? 6 ??? ?
?? 20%, ????? 12 ??? ????? ?? 20% (? < 0,05).
?? ?? ?????? ?????? ????? ???????? ????? ?????? ???????? ?? 14,7, ????? 6 ??? ? ?? 22,5%, ?????
12 ??? ? ?? 25,8%. ???????? ?????? ????????????? ????????? ????????????????? ?????????? ?
????????? ? III ????? ??????????????? ??????????????? ????? ???? ? ??? ????????????? ??????? ?? (???. 5). ????????????? ???????????
??????? ?? ???????????? (? > 0,05), ??? ?????????? ? ??????? ???????????? STICH.
??????????? ?????? ??????????? ???? ?? ????? ???????????????? ???????? ???????, ???
????????? ?????????? ? ????????? ?? ??????????? ? ????????? ????? ?????????????????? ??
L. ??nicanti: ? 4 (36,3%) ????????? ?? ??? ????
?????????????? ???????? ? ? 7 (63,6%) ???????
??????? ???????, ?? ???? ??????? ?? ?????????????? ?????. ????????????? ?????????? ??????????? ???? ????? ?????????????????? ?? V. Dor,
? 14 ??????? (46,6% ?? ???????????????? ?? ???????? V. Dor ?????????) ??????????? ????????
??. ?????????? ?????? ????????? ??????? ??????????, ??? ??? ?????????? ?????????????????? ?? V. Dor ???? ?????????? ?????????? ?????????? ??????? ??, ?? ??????????? ???????????
??????? ??, ? ?????????? ???? ??????????? ????????? ?????? ????? ????????, ??? ?????????????
?????????? ??????? ????????? ???????????????.
????? ? ???? ?????? ????????? ???????????? ??????? ?????????????? ?????????? ? ????????????????? ???????, ??????????????? ??????????
???????????? ?????? ?? (? ???? ????????? ??
140
%
120
100
100
80
80
60
60
40
40
20
20
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0
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?? ????????
????? ????????:
1 ???
6 ???
12 ???
???. 3. ???????? ??????????? ????? ? ????????? ?? II ????? ??????????????? ??????????????? ??? ????????????? ?????? ?????????
???
???
??
??
?? ????????
????? ????????:
1 ???
6 ???
12 ???
???. 4. ???????? ??????????? ????? ? ????????? ? III ????? ??????????????? ??????????????? ????? ???????????????? ???????? ?? ????? ?????????
??????????? ?????????? ??????????????, ? 3, 2012
? ????????? ? ??????, ??? ?? ???????????
???????????????? ????????????? ?? ??, ?????
1 ??? ????? ???????? ??? ?????????? ?? 13,4%,
????? 6 ??? ? ?? 1,7%, ????? 12 ??? ? ?? 3,4%
(? < 0,05). ????? 1 ????? ????? ???????? ???
??? ?????? ?????????????? ???????? ?? 24,3%,
????? 6 ??? ? ?? 12,1%; ????? 12 ??? ? ?? 8,3%.
?? ????? 1 ??? ???? ?? 19,6% ?????? ????????,
????? 6 ??? ??? ??????????? ?? 17,6% ?? ????????? ? ??????????????? ??????????, ?????
12 ??? ? ?????????????? ? ???????? (???. 3). ????? ???????, ????? ???????, ??? ? ?????? ??????
?? ????????????? ??????? ?? ? ????????? ??
II ????? ??????????????? ???????????????
?????????? ??????????????? ???????????????,
??? ?????????? ? ?????????? ??????? ? ???????? ??, ???? ??? ??????? ???????????????? ?
?????????????? ???????????????? ???????? ????????????? ????? ???????? ? ????????? ??????? ? ?? ??????. ??? ?????????? ?????????????????? ?????????? ??????????? ??????????
??? ? ???, ?????????? ??, ??? ???????? ????????????? ????????? ??? ?????? ?????? ?????????.
? ????????? ? III ????? ??????????????? ??????????????? ????? ???????????????? ???????? ?? ?? ??? ????? 1 ??? ????? ????????
?????????? ?? ????????? ? ???????????????
??????? ?? 39,2%, ????? 6 ??? ? ?? 23,2%, ?????
12 ??? ? ?? 26% (? < 0,05). ??? ????? 1 ??? ?????
???????? ???? ?????? ????????? ?? 47,6%, ?????
6 ??? ? ?? 33,3%, ????? 12 ??? ? ?? 45% (? < 0,05).
?? ????? 1 ??? ????? ????????????? ?? ????????????? ?? 32,3% ?? ????????? ? ??????????????? ??????????, ????? 6 ??? ? ?? 23,5%, ?????
12 ??? ? ?? 29% (? < 0,05) (???. 4).
35
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
36
120
??????????? ?????????? ??????
%
100
80
60
40
20
0
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?? ????????
????? ????????:
1 ???
6 ???
12 ???
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???. 5. ???????? ??????????? ????? ? ????????? ? III ????? ??????????????? ??????????????? ??? ????????????? ?????? ?????????
????????? ?? ????? ???????? V. Dor ??????????
??????? ?????????????? ??????????).
????????? ?????? ?????????????????? ??????????????? ??. ????????????? ??? ??????????????? ?????????? ? 10 (22,7%) ?????????.
? 5 (11,36%) ????????? ?? ??? ? ???????? ?????,
??? ???? ????????????? ????????, ?? ???? ????? ???????, ??? ??????? ?????????????????? ??????????????? ? ???? ??????? ???? ?????????????? ????????. ?????????? ????????? ?????????
???? ??????????????????, ?????, ??? ? ?????? ??
????????? ??. ? 5 (11,36%) ????????? ? ????????????? ???????????????? ?????????? ????? ?
???????? ??, ??? ??????? ?? ?????????? ??????????????? ????????? ?????????? ??????? ?? ?
?????????? ????????????????? ???????. ? ????
???? ?????? ????????? ??????? ???????? ?????????????? ??????????. ????????? ???? ?????????
?????????? ????????????? ??? ?????????.
???????? ?????????????? ?????? ????? ????????? ?? ? ???? ??????????????? ???????????????. ?????????? ?????????? ???????? ? ???????????
??? ? ????????? ? ??????? ?????? ??????????????? ???????????????, ?????????????? ?????
????? ??????. ????? ???????, ?? ????????? ?? ??
?????? ???????? ????????? ???????? ????? ??????????? ????????, ?? ???? ?? ???????? ?? ????????? ??????? ???? ???????????? ??????? ?, ????????, ?????????????? ????????, ???????????????? ? ????????????????? ??????? (?????????).
??????????
? ?????????? ?????????? ?????? ?????? ????????? ??????????? ??????????????? ?? ?????
????????????? ????????? ? ??? ???? ? ????????-
??? ??????? ?????????. ??? ?????????? ??????
????????, ?????????? ?? ?????? ?? ?????? ?????????????????? ????????, ?????????? ??????????? ??????????? ?????? ??????? ??????????
??????? (??) ? ????????????????? ??????? (??
6 ??? ?? 1 ????, ? ????? ?? ??????? ?????????????? ???????????????? ????????) ?????????????.
? ??????? ????????????? ?????????? ???????
?? (??????? ?????????? ????????? ???????? ?
III ???? ????), ?????????? ?? ??????? ?? ???????? ? ?????????????? ????????? ??????????
???????? ?? ? ????????????????? ???????.
? ?????????? ?????????? ?????????????? ?????????, ???????????? ?? ?????????????? ?????????? ???????. ????????? ????????? ????????????????? ???????????????. ??? ???? ??????????
╚??????????╩ ?????????????? ?? ??????????,
?????????? ???? ??????????? ??????? ?????????? ???????. ????????? ????????? ??????????
??????????????????, ??????????? ????????
? ??????? ??????????????? ??????????????.
? ?????? ??????? ?????????????? ??????????
?????????????? ???? (? ????? ???????????????
????????? ? ?????????? ????????) ???????????
??????? ?? ???????? ?????????????????? ???????????, ???? ???????? ??????????????
??????, ? ????? ????????? ?? ???????? ??????????? ????????? ? ?????????? ????????? ???????????????.
??? ??????????? ????????? ?????????
?????, ?????????????? ?????????????? ?????????? ????????? ???? ????? ??, ??? ????????
???????????? ????????? ????? ? ??????????????
??????????? ?????????????? ??????????? ??????
??????? ????????????. ????? ???????, ???????
?????????? ?????????????? ?????????? ??????
???????? ????????? ???????????? ?????? ?? ?,
?????????????, ??????? ??????????????. ? ????
???????? ?????????? ?????????, ???????? ?????
?????????????? ?????????????. ???????????????? ?????????????? ?????????? ????? ?????????????? ?????????? ??????????? ?????? ??, ?
????? ???????????? ?????????????? ??????????
??. ?????????? ?????????????? ??????? ?? ????????????? ???????? ?? ??? ??????. ? ??????????
??????????? ?????????? ???????????? ????????
?????????, ?????????? ??? ???????????? ?, ???
?????????, ?????????? ?? ?? ????? ????????,
??????????? ????? ?????, ????????????? ? ????? ? ????????.
??????
1. ?????????? ?????????? ????????????? ????????????? ??????? ?? ???????? ????????????? ? ????????? ? I ? II ?????? ??????????????? ???????????????, ? ????????? ? III ?????
?????????? ???? ?????????????? ? ??????????? ???.
2. ???????????? ??????? ?????????????? ?????????? ?? ?????????? ???? ????????, ??? ????????????? ??? ?????????????? ?????????? ???????????? ????????????? ?????? ????????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
??????????????? ?? ????? ???????????? ??????? ?
? ?????? ????????????????? ???????, ??? ????????????? ??????????? ?? ??????????? ??????? ?
?????? ????????? ???????.
3. ??? ?????????? ??????? ?????????? ??????????? ?? ???? ????????????? ?? ????????, ???
????????????? ?? ?? L. ??nicanti ???????? ?????
?????????????, ?? ???????? ????????? ?????????? ??????? ??, ??? ?????????????? ??????????? ???????? ?????? ? ??????????? ??????????????????? ?????????? ??????????????? ? ??????
????????? ???????.
4. ??? ???????????? ????????? ? ?????????
????????????????? ???????????????? ????????, ??? ??? ?????????? ?????????? ?????????????? ??????? ?? ????????? ????????????????? ??????????????? ????? ?????????????? ???????? ? ????? ?????????? ?????????? ???????. ? ?????? ????????? ??????? ??
?????????? ???????????????? ????????? ???????????????. ?????????????????? ????????????????? ??????????????? ??????????? ? ????????? ? ????????? ??????????? ???????? ??,
??????????? ????????????????? ??? ?????????????, ??? ? ?????????????? ????????? ???????????????.
37
??????????
1.
2.
3.
4.
5.
6.
7.
8.
??????? ?. ?., ?????????? ?. ?., ?????????? ?. ?. ??????????? ??????????????? ?????? ????????? (???????????????? ???????, ??????? ??????????? ? ???????).
?.: ????? ??. ?. ?. ???????? ????. 2002. 152 ?.
??????? ?. ?., ?????? ?. ?., ?????????? ?. ?. ? ??. ??????????????????? ?????????????? ???????? ?????????
? ?????????????? ???????????????? ??? ?????????
??????? ??????????????? ??????????? ???????????? ??????? // ??????? ? ????.-?????. ???. 2009. ? 5. ?. 37?41.
Di Donato M., Castelvecchio S., Kukulski T. et al. Surgical ventricular restoration: left ventricular shape influence on cardiac
function, clinical status, and survival // Ann. Thorac. Surg.
2009. Vol. 87. P. 455?461.
Dor V., Civaia F., Alexandrescu C. et al. Favorable effects of left
ventricular reconstruction in patients excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial //
J. Thorac. Cardiovasc. Surg. 2011. Vol. 141. P. 905?916.
Dor V., Sabatier M., Montiligo F. et al. Endoventricular path
reconstruction of Ischemic failing ventricle: A single center with
20 years experience // Heart Fail. Rev. 2004. Vol. 9. P. 269?286.
Jones R., Velazques E., Michel R. et al. Coronary bypass surgery
with or without surgical ventricular restoration // New Eng. J.
Med. 2009. Vol. 360. P. 1705?1717.
Kolh P., Wijns W., Danchin N. et al. Guidelines on myocardial
revascularization // Eur. J. Cardiothorac. Surg. 2010. Vol. 38.
P. S1?S52.
Menicanti L., Castelvecchio S., Ranucci M. et al. Surgical therapy for ischemic heart failure: Single-center experience with
surgical anterior ventricular restoration // J. Thorac.
Cardiovasc. Surg. 2007. P. 433?441.
????????? 24.08.2012
╘ ????????? ???????, 2012
??? 616.132.5-073.756.8-089.168
?????? ??????????? ?????????????? ??????? ?????????
??????????????? ??????? ?? ?????? ???????????
? ??????? ??????? ???????????
?. ?. ???????, ?. ?. ????????, ?. ?. ??????????*, ?. ?. ??????, ?. ?. ??????????,
?. ?. ?????????, ?. ?. ????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????
????????? ???? ???????????????? ???????? ??????????? 429 ??????? ? ??????????????????? ?????????? ??????????????? ???????: ????????????? ?????????? ???????????????
(???) ?? ?????????? ?????? ??????? (???) ? 319 (74%) ?????????, ???????? ? ??????????????? ??? ? 6 (1,3%), ????????????? ??????????? ??????? (??) ? 136 (31%). ????????? ???* ????? ??? ?????????: e-mail: serguladze74@mail.ru
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ??????????
???????????? ??????????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
38
??????????? ?????????? ???????????? ??????????????
????-???????????????, ???????????????????? ???????????? ? ???????? ? ?????????????? ????
MMSE, FAB, ????? ?????? ???????????? ?????????? ? ??????? ??????? (Functional Mobility
Assessment in Eldery Patients Tinnetti), ? ????? ???? ?????? ?????????????? ??????? ??????????? ? ???????????? ???????????? ??????????? ???????????? ?????????? (?????) ????????? ?????. ???????????? ????????????? ??????? ???????????????? ???????? ?? ?????????????? ????????-??????????????? ???????, ????????? ??????????? ???????????? ?
??????????? ?????????, ?????? ???????????? ????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ???????????? ????????????, ??????????????? ???????, ?????????? ??????, ???????????????????? ???????, ??????????? ?????????, ?????????? ???????????????.
??????????? ?????????? ??????????????, ? 3, 2012
429 patients with brachiocephalic arteries atherosclerotic lesions had the following types of reconstructive surgeries: 319 (74%) patients had one-sided carotid endarterectomy (EAE) from (BCA) 6 (1,3%)
of patients had resection and BCA replacement, 136 (31%) of patients had VA reconstruction. Clinical
neurological, neuropsychological assessment of vertebral artery with MMSE, FAB score, assessment
scores of motion activity in elderly Tinnetti (Functional Mobility Assessment in Elderly Patients Tinnetti)
as well as the whole spectrum of imaging methods of diagnosis and single-photon emission computed
tomography, cerebral SPECT was performed. Positive effect of reconstructive surgeries on restoration
of clinical neurologic functions, improvement of regional and hemisphere blood flow values, regional perfusion level was confirmed.
K e y w o r d s : cerebral atherosclerosis, brachiocephalic arteries, carotid stenosis, neuropsychological
function, cognitive lesions, carotid endarterectomy.
????? ?? ????????? ????? ????????-?????????? ???????? ???????? ???????????? ????????????? ???????? ?????????? ????????? ??????- ? ???????????????? ??????? ????????? ????? [1].
?????? ???????? ???????????? ??????????
???????? ??????????? ??????????????????? ????????? ????????????? ??????? ? ?????? ??????????
????????, ????? ??????? ????????? ???? ???????????? ??????????? ????? (???) ? ????? ??????
???????????? ?????? ????????? ?????. ?? ?????? ?????? ??????? [9, 10, 14], ????????? ????????? ????? ??? ???????? ??????????????? ???????
??????????? ?? ?????? ???????????? ?????????????. ??????????????????? ?????? ????? ???????? ?????????? ???????????? ?????????? ? ????????? ????????????. ?????? ?????????? ??? ?????????????? ???????? ????????? ?????????
??????????????, ??????? ????? ???????????? ??????????????????? ??????????? ?????????? ?????????????? ??????????? ??????? ? ??????????
?????? ??? ??????????? ?????????? [3].
???????? ? ??????
? ????? ?? ?. ?. ???????? ???? ? ?????? ?
2006 ?? 2011 ?. ?????????????? 429 (100%) ????-
??? ? ?????????????? ??????????? ??????????????? ???????. ??????? ??????? ????????? ??
35 ?? 85 ??? ? ? ??????? ???????? 58,4 ╠ 21,8 ????.
?????? ???? 298 (69,3%), ?????? ? 132 (30,7%).
? ??????????? ?? ??????????? ????????? ???????? ???? ????????? ?? ??? ??????: 1-? ? ? ?????????? ??????? ? ?????????? ????????, 2-? ? ?
?????????? ? ??????????????????.
? ??????? 1 ????????? ????????????? ???????
?? ????? ???????? ? ??????????? ?? ?????????????? ?????????.
????????? ???????? ? ??????? ????? ?????
???? ???????? ???? (95,9%), ??????????????
(57%), ??????? (52%), ???????? ?????? (44,9%),
???????? (26,2%), ????????? (5,6%), ??? ? ??????
(42,9%), ??? ? ???? (11,6%), ???????? (8,5%),
??????? ?????? ???????? (1%).
????????????? ??????? ?? ??????? ????????????????? ??????????????? (???) ???????? ????????????? ?. ?. ??????????? ? ?????. [7] ???????????? ? ??????? 2.
??? ???????? ????????? ???????????? ????????? ????? (??) ? ??????????? ???????????
????????? ? ?????????? ???? ??? ????? ????
?????????????? ??????? ???? ???? ?????????
??????????? ???????????????? ????????????,
??????? 1
????????????? ??????? ? ??????????????? ????????? ????????? ???????
??????????? (??) ? ??????????????????? (???) ????????? ?? ????? ???????? (n)
????????????? ?????????
????????
????????????? ??
????????????? ???????????? ? ???????????????
(?????????????/
??? ?? ???
??? ?? ???
???
????????????)
?????
????????????? ?????? ???
???????????? ?????? ???
?????? ? ????????????????? ???????? ???
????????????? ?????? ??? + ?????????????
?????? ??
???????????? ?????? ??? + ?????????????
????????? ??
???????????? ?????? ??? + ????????????
????????? ??
149
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?
49
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?
155
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19
?
22/9
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??????
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110
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136/9
578
? ? ? ? ? ? ? ? ? ? . ??? ? ?????????? ?????? ???????, ?? ? ??????????? ???????, ??? ? ???????????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
39
??????? 2
??????? ?????????? ?????? ????????? ????? ? ??????????? ?? ???? ???
? ??????? ? ??????? ? ??????????? ?????????? ???????????
? ??????????????????? ????????? ?? ????????
????? ???????, %
??? ???
1-? ?????? (?????????? ???????)
?????????????
?????
???
???
????? ???????
?????????? ??????? ???????????? ????????:
??????
?????????
??????????
2-? ?????? (?????????? +
+ ?????????????????? ???????)
2,7
10,9
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?????????? ?????????????? ??????, ?????? ??????????? ????, ?????????? ????????????????? ????????????, ??-??????????? ? ???????????? ??????????, ???????????? ???????? ????????? ?????
(??) ??????? ????? ? 99mTc-HMPAO (???. 1?6).
??????????? ???????????????? ????????????
?????? ???? ????? ???? ????????? ? 429 (100%)
???????. ???????? ???????-???????????????
????????? ???????, ??????????? ? ??????? ???????????? ????????????? ? ????????????? ????????? (??????????? ???????, ????????), ???????
? ?????????????????? ????????? ???????, ????????? ????? ??????????????? ??????????????.
???? 429 (100%) ??????? ????????? ??????????? ?????????????? ???????????? ???????????? ????????? ?????. ???????????? ????????
???????? ????????? (???, ??/?) ??????????? ??????? ??????????????? ??????????? ????????????
(????) ? ???????? ?????????? ?????? ??????? ?
???? ???????: ?? ??????? ??? ? ????????., ? ??????? ??????? ??? ? ???????. ? ????? ??????? ? ?????????? ??????? ?? ???? ? ?????????. (????. 3); ???
???? ???????? ??????? ????????????? ????????
????????? ?? ?????????? ?????? ???????. ??????
????????? ????????? (????????), ??? ???????
???????? ?????????, ?????????????? ??????? ????????? ?????? ????? ?? ?????? ???????, ???
?????????????? ????????? ?????, ? ????????????? ????? ????????? ???????? ??? ? ????????????? ? ?????????? ??????? ???????????? ???????????? ??????? ? ???????? ????????? ? ????????????? ??????? ?????? ??????? ? ?????????:
???????? = ((V?????. ? V??????.) / V?????.) в 100 (%),
??? V?????. ? ??? ? ????????????? ?????? ???;
V??????. ? ??? ? ?????????? ?????? ??? ????? ???????????? ???????.
?????? ????????? ????????? ???????????? ????? ??????????????? ???????????????? ??????????, ??????????????? ????????? ????????? ?
????????? ?? ?????? ??????? ? ??????????? ??
??????? ??????????? ????????? ? ??????? ???????.
? ??????? 3 ???????????? ?????????? ???????? ???????? ????????? ? 429 ??????? ?? ?????-
???. 1. ??-??????????? ???
???. 2. ????? ?? ? 99mTc-HMPAO. ????????? ?????????????? ? ??????? ? ?????? ??????? ?????? ?????????
??? ??????????? ??????? ????? ???
??????????? ?????????? ??????????????, ? 3, 2012
? ? ? ? ? ? ? ? ? ? . ????? ? ????????? ?????????? ??????????????? ????????? ??????????????, ??? ? ???????????????? ?????????????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 3, 2012
40
??????????? ?????????? ???????????? ??????????????
???. 3. ??????????? ??????????? ?????? ???? ?????. ??????????? ?????? ? ??????? ?????????? ?????? ??? 90%
???. 4. ???? ? 90% ?????? ?????? ???
???. 5. ??????????? ??????????? ?????? ???? ?????. ???????? ???
???. 6. ????. ???????? ?????? ??? ? ??????????????
?????????? ?? ???
???????? ??????? ?????????? ??????? ??? ????????? ????????? ????????? ??????? ??????????? ? ??????????????????? ????????? (?????????
1??1? ? 2??2?), ? ????? ??????? ????????????
?????????????? ????????? ????? ?? ???????????
??????.
??? ????? ?? ??????? 3, ???????? ??? ????
????? ??????????????? ???????? ???????? ????
????????????? ????????, ??? ?????????????????
? ????????? ????????? ? ??????? ????????
?????????? ??????????? ? ?????????? ???????
???. ???, ??????? ??? ????????? ?25,3 ╠ 1,2%
??? ??????? ?????????? ????????? ????
70,7?84,7% ?27,2╠1,7% ? ? ?????? ??????? ??????? 56,2?61,1% ?23,6 ╠ 1,4% (???????? ??
???????? ?????????? ???? ??????????????,
? = 0,034), ??? ????????????????? ? ?????????????? ????????? ? ??????? ??????? ????????? ???
????????? ????? ??????????? ????????.
??? ??????????? ????????? ??? ? ????????? ?????????? ????? ??????? ???????? ?????
??????????? ???????? ? ??????????? ?????????
?? ??????????? ????????, ????????????????
??? ? ???.
??? ???????????? ????????? ??? ??? ??????? 75% ? ????? ???????? ????????? ?? ??????????? ???????? ????????? ?? 9,5 ╠ 0,9 ??/?, ???
??????? ??????? 95% ? ????? ??? ?????????
7,8 ╠ 0,6 ??/?. ??? ????????????????? ? ????????????? ???????? ??? ???????? ??????? ?? ???????????? ? ??? ?????? ????? ??? ?? 40%.
??????????? ????????????? ????? ? ??????
??????????? ? 345 ??????? 1-? ? 2-? ?????. ?????
? ?????????? ????? ?????? ??????? ???????????
??? ????????????? ???????????? ????????, ?????????? ?? ????? ??????? ???????????, ?? 120 ??
145 ?? ??. ??. ????? ????????? 1-? ?????? ????????????? ????? ??????, ??? ??????? ??????? ????????? ?? ??? ????? ?? ????? ??? ?? 50%, ???????? ? 25 (34,2%) ???????. ????? ??? 14 (19,1%)
????????? ???? ? ????????????? ??????????
???, 11 (15%) ? ? ????????????. ???????-????????????? ?????, ??? ??????? ??????? ?????????
?? ??? ????? ?? ????? ??? ?? 60%, ???? ? 39
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
41
??????? 3
?????????? ???????? ????????, ??????? ????????? ??????? ????????? ? ?????????????
? ?????????? ??? ????????????? ????????? ??? ? ?? ?? ?????? ???? ?? ????????
??????????
1-? ?????? (?????????? ???????)
1?
?????? ??????????
????????? ????
????????. ?? ???, ??/?
??? ?? ???????., ??/?
??? ?? ?????????., ??/?
???????? ???, %
?????????. ?? ??, ??/?
??? ?? ???, ??/?
??? ?? ???, ??/?
??? ?? ???, ??/?
??? ?? ??????????? ???????, ??/?
???, %
????, ??/?/?? ??. ??.
1?
1?
28,1╠1,7% 56,2╠2,4% 61,1╠5,2%
2-? ?????? (?????????? +
+ ?????????????????? ???????)
2?
2?
2?
42,6╠2,2%
70,7╠6,9%
84,7╠9,1%
?????
59,7╠2,91 57,9╠4,1
58,4╠3,63 57,1╠3,24
58,1╠2,9
59,3╠4,1
58,1╠2,3
120╠5,8 129,4╠5,6
92,9╠4,65 90,7╠4,42 109,3╠8,1
112,9╠9,1
?
44,6╠3,7
43,5╠4,1
42,5╠1,47 43,6╠2,95
40,1╠3,2
38,6╠3,6
?
?25,3╠1,2 ?24,1╠2,1 ?27,2╠1,7 ?23,6╠1,4
?31,1╠2,9
?35,6╠3,2
+0,3╠0,012
40,2╠3,1
39,6╠4,5
38,1╠4,1
28,3╠3,7
25,2╠4,8
19,5╠5,9
41,5╠6,2
83,2╠8,7
58,6╠6,9
52,3╠5,3
71,0╠6,7
56,2╠7,5
54,3╠6,8
91,9╠10,9
69╠7,7
62,4╠7,2
61,4╠7,2
71,3╠8,4
68,1╠7,6
57,3╠6,3
97,1╠10,7
76,1╠6,3
72,7╠7,2
74,4╠6,9
68,1╠7,8
64,1╠9,3
41,2╠8,2
79,1╠12,5
11,9╠2,4
8,1╠2,1
7,9╠3,8
10,1╠3,1
8,2╠2,3
7,8╠2,6
12?15
18,5╠3,2
12,1╠4,2
7,6╠2,3
9,1╠1,7
8,3╠1,5
5,6╠1,8
32
2,7╠0,12 1,96╠0,15 0,97╠0,13 1,53╠0,086 0,94╠0,074 0,51╠0,075
????? 3,2
(53,4%) ???????, ?? ??? ? 10 (13,6%) ? ? ????????????? ?????????? ???, ? 27 (37%) ? ? ???????????? ? ? 2 (2,7%) ? ?? ???????? ??? ? ????????????????? ????????? ???. ??? ????????????
????????? ??? ????? ?????? ??????????? ? ????? ??????. ? 8 (10,9%) ??????? ?? ???????? ??? ?
????????????????? ????????? ??? ????? ????
????????????? ?? ??????? ??????? ? ???????????? ????????????. ???????? ????????? ?? ??? ?
???? ?????? ????????? ????? ??? ?? 60%.
????? ???????, ? ??????????? ??????? ????
?????? ????????????? ????? ? ?????? ??????????
???????????????????.
????? ??????? 2-? ?????? ? 51 (69,8%) ?????
?????? ???? ?????????????, ? 17 (23,3%) ? ???????-????????????? ? ? 5 (6,8%) ? ?????????????.
?????????? ???? ????????? ? ??????? ?????????????? ????? ? ?????? ???? ? ??????? ? ????????????? (24,6%) ? ???????????? ?????????? ???
(21,9%). ???????-????????????? ????? ??????????? ? ?????? ? ???????????? ?????????? ??? ?
????????????? ?????????? ?? (15%). ????????????? ????? ???? ? 5 ???????. ?? ??? 2 (2,7%)
??????? ???? ? ????????????? ?????????? ???
? 3 (4,1%) ? ? ???????????? ?????????? ??? ?
??. ???????? ???????? ??????? ? ????????? ?
??????? ????????? ?? ????? ?????? ??????????? ?? ????? ????????????? ? ? ?????? ?????????????? ????????? ?????????.
???? ????????? ???????????? ??????? ???????????????? ? ??????? 2-? ?????? ? ??????????
??. ? ???????? ????? ???? ????? ???????? ???
?? ??? ? 21 ????????? ???????????, ??? ?????????? ?? 25 ?? 45 ??/?. ????? ????????? 2-? ??????
? ????????????? ?????????? ?? ??????? ????????
??? ?? ??????? ????????? ????????? 9,1 ╠ 0,8%
? 18,4 ╠ 1,5% ? ?? ??????????????? ???????.
??? ???????????? ????????? ?? ???????? ???
????????? 8,7 ╠ 1,2% ?? ??????? ???????? ?
10,5 ╠ 1,7% ? ?? ???????????????. ?? ???????????
???????????? ??? ?? 2-? ?????? ???? ???????????, ??? ??????? ??? ?? ??? ????????? ? ???????
? ????????????? ?????????? ?? (10,1%), ? ???????????? ?????????? ?? (8,4%), ????????????
?????????? ??? + ????????????? ??????????
?? (7,2%). ????? ??? ????????????? ????????
??? ???? ??????????? ? ??????? ? ????????????
?????????? ??? + ???????????? ??????????
?? (?4,5%) ? ? ????????? ??? + ????????????
?????????? ?? (?4,5%).
???? ???? ????????? ?????? ????????? ????????????? ????????????? ??????? ?? ??????
???????????????? ?????????????? (????) ? ?????????? ???????? ??????? ????????????????
????? (? 5?7% p??2 ? ??????? ????? ???????)
(?????????????? ?. ?., ?????????? ?. ?., 2001).
????????????? ??????? ?? ??????? ??????????? ????????? ?????????????? (??? ??????????
??????????, ??????????? ????) ???????? ????????? ???????: ?? ?????? ????? ?????????
(429, ??? 100%) ? ?????? ??????????? (????
2,5?3,2) ?????????? 42,3%, ??????????????
(???? ?? 2,5) ? 46,2%, ????????????? (????
????? 1,2) ? 11,5%.
??? ??????? ??????????? ???????????? ??????????? ???????? ????????, ??? ??????????
????? ????????? ?????????? ? ?????? ??????????????.
?? ?????? ????? ??????? 34 (44,7%) ????????
????????? ??????????? ???????. ?? ??? ??
??????????? ??????????????? ??????? ????
????? ? 12 (35,3%) ???????, ?????????????? ?
? 14 (41,1%), ? ?????????????????? ???????? ?
? 4 (11,8%) ? ???????????? ? ?????????? ? ?????????????????? ????????? ? ? 4 (11,8%). ??? 34 (100%)
????????????? ??????? ? ??????????? ????????? ?????????? ? ????????????????? ???????. ??
??? 20 (58,8%) ????????? ??????????? ???????
????? ???? ??? ?????, 6 (17,6%) ? ????? ?????? ????,
6 (17,6%) ? 6?12 ??? ?????, 2 (5,9%) ? 4?6 ??? ?????.
??????????? ?????????? ??????????????, ? 3, 2012
? ? ? ? ? ? ? ? ? ? . ??? ? ????????, ??? ? ??????? ? ??? ? ?????? ???????? ???????; ??? ? ?????? ????????????????; ???? ?
?????? ????????????? ????????????? ???????; ???? ? ????????????? ??????? ????????? ?????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
42
??????????? ?????????? ???????????? ??????????????
???????????? ??????? ???????? ? ????: ???????-??????????????? ?????? ? ??????? ???????????? ?????????? ? ??????? ?? ????? ???????
[14], ???????????????????? ???????????? ? ?????????????? ??????? ????? ?????? ???????????? ??????? (MMSE) [17], ??????????? ??????
?????? ?????????? (Frontal Assessment Battery ?
FAB) [15], ????? ????????? ????? [22]. ??????????
????? FAB ?????????? ? ???????? ?? 0 ?? 18 ??????.
??? ???? 18 ?????? ????????????? ??????? ??????????? ????????????. ??? ??????????? ?????? ?????? ??????????, ? ??????????? ???????? ?
???????????????? ?????????? ?????? ?????
????? ???????? ????????????? ??????????? FAB ?
MMSE [15]. ? ?????? ???????? ??????? ??????
?????? ????????? FAB (????? 11 ??????) ??? ???????????? ??????? ?????????? MMSE. ?????? ???????????? ??????? ??????????? ?? 2?3 ??? ??
???????????? ??????? ??????????? ???????. ? ???????? ???????????? ??????????????? ? ???????????????????? ??????? ?????????????? ?????
8?10 ???? ? 3 ???.
???????????? ????????? ????????? ?????????
??????? ????? ? 76 ????????? ?? ? ????? ???????????????? ????????. ????? ??????????? ??
??????????????? ?????-?????? ECAM ?????
Siemens ?? ??????????? ????????. ??? ????????????
???????? ???????? ????????????? 99m??-?????
(╚???????╩), ???????????? ???????? ???????? ?????????? ? ????????????? ? ???????? ?????????
????? ??????????????? ????????? ?????????.
????????????? ???? ? 0,5 ?? d,l ?????-???????,
????????? 185?740 ??? 99m??.
????????????? ????????????????????? ???????? (???) ???????????????? ??????????, ?????????????? ????? ???????? 99m?? ? ????????????????????????????? (?????, ??? ╚???????╩
????? ╚???????╩), ??????? ????????? ??????????????? ? ????????? ?????????????? ??????????? ? ??? ???????????? ??? ?????? ????????
????????? ?????. ??????? ???????? ????????
??????? ? ??????? ?????? 10 ??? ????????????
?? ??????? 8?10 ??? ?? 1 ?? ????? ????. ???????????? ???????? ????????? ?????????????? (??) ?
????? ????????? ???????? ? ????????? ???? ???
?????????? ??????????, ???????????? ? ???????????? ???????????. ?????????? ?????? ?????????
????????????????? ????????? ??????????????
(????) ??????? ????????? ??????????: ?????????????? ? ?? 60?72%, ????????? ? 45?60%, ?????????? ? 45% ? ????? (?????????? ?. ?. ? ?????., 2005).
?????? ???????????????? ??????????? ????????? ????????? ? ????? ? ??? ????????? ? 76
(100%) ??????? ? ????????????? ??????? ? ????????????????????? ??????? ? ??????????? ??
?????? ?????????-???????? ???????????????
(???) ?? ????????????? ?. ?. ??????????? ? ?????????????? ??????? ? ?? ?????? ????? ??????????????? (????. 4).
??????????? ?????????? ??????????????, ? 3, 2012
??????? 4
?????????? ???????? ?? ? ??????????? ?? ??????????? ????????????????????
?????? ? ???????????? ?????????? ? ??????? ? ?????????? ????????
?????????-???????? ??????????????? ?? ? ????? ????????
??????????
????????
?? ????????
????? 8?10 ???? ????? ????????
1 ??????
MMSE
FAB
???? ????????? ?????
????, %
?????, %
21,5╠4,3
15,6╠2,3
7,8╠2,6
70,1╠15,7
+8,9╠3,7
28,6╠0,06
17,60╠0,29
8,2╠1,9
?
?
2 ??????
MMSE
FAB
???? ????????? ?????
????, %
?????, %
19,2╠3,5
13,8╠1,9
6,9╠1,5
63,8╠9,5
+3,2╠2,2
25,6╠1,05
14,7╠0,87
8,4╠0,68
?
?
27,4╠1,43*
16,0╠1,22**
8,6╠0,87
69,1╠7,1
+7,1╠3,1
3 ??????
MMSE
FAB
???? ????????? ?????
????, %
?????, %
16,3╠2,8
10,3╠1,4
5,9╠1,6
47,5╠10,1
?4,8╠2,1
27,19╠0,64
15,5╠0,47
8,55╠0,35
?
?
28,64╠0,20***
16,82╠0,32***
9,27╠0,44**
55,9╠8,3
+1,9╠0,8
25,41╠0,68
14,35╠0,53*
8,12╠0,45
?
?
21,3╠0,65***
15,51╠0,51***
8,53╠0,37**
50,1╠8,4
?5,4╠2,3
4 ??????
MMSE
FAB
???? ????????? ?????
????, %
?????, %
13,8╠2,4
8,4╠1,7
4,4╠1,2
32,9╠7,9
?13,1╠5,3
????? 3 ??? ????? ????????
29,6╠0,24
17,8╠0,20
10,0╠0
75,6╠12,5
+14,2╠4,2
? ? ? ? ? ? ? ? ? ? . ???????? ?????????? (p ? 0,05): *????? 1-? ? 2-? ???????; **????? 1-? ? 3-? ???????; ***????? 1-? ? 4-? ???????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
??????????
?????????????? ?????????????? ??????? ???????????? ?????????? ????????? ????????? ?????, ? ????? ????? ? 99mT?-HMPAO ? ??????????
? ?? ??????? ?????? ??????????? ?????????
?????????????? ?????? ??? ?????? ???????????? ? ??? ????? ?????????????? ? ???????????
??????? ??????? ??????? ? ???????????? ??????????? ??.
?? ?????? ????? ??, ? 46% ??????? ?? ???????????????? ???????? ?????????? ?????????? ?????????????? ??? ??? ???? ??????? ? ????????? ?????????? ??????????????? ??????????
?????? ??????? ? ?????????? ???????????? ????????? ????????? ???????? ????????? ??????????????.
??? ?????????? ????? ? 99mT?-HMPAO ????????, ??? ????? ???????? ?????????? ??????????????? ????????? ???????? ????????? ?????
???????? ??????????? ?? ???????? ?????????????? ??????????? ???????, ????????????????????? ????????? ? ???????????? ?????????? ???????? ?? ?????? ????????? ??????, ? ?????? ??????? ?? ????????? ??? 80?95% ?? 37,7%, ?
??????????? ????????????????? ??? ? ? ???????
?? 34%.
??? ?????????? ??????????? ???? ??????????? ??????????? ????????? ??????????? ?????????, ??? ? ??????????, ??? ? ??????????????????
?????????, ??????? ?????? ??????????????
????? ? ???????????? ???????????? ????? ??.
?? ??????????? ????????????? ??????? ????????? ??????????? ??????? ? ?????????????? ??????????? ??????? ????????? ????? ? ?????
????????? ??????????? ????????????? ?????????????.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
????????? ?. ?., ??????? ?. ?., ??????? ?. ?. ???????.
???????? ???????????, ??????? ????????????. ?.,
2002. ?. 208.
???????? ?. ?. ??????? ?????????? ??????????????? ??
??????????????? ? ???????????????????? ???????: ???????. ???. ? ????. ???. ????. ?., 2006. ?. 14?22.
????? ?. ?., ????????? ?. ?., ??????????? ?. ?. ? ??. ???????? ???????? ? ?????????? ????????? // ????????
?????. 2006. ?. 2, ? 13. ?. 10?14.
????? ?. ?. ??????????? ????????-??????????? ??????????????? ???????????? ???????????????? ????????????? ? ???????????? ???????????: ???????. ???. ? ????.
???. ????. ?., 1996.
??????? ?. ?. ?????? ????????? ??????????? ???????
???????, ?????????? ???????????????? ???????? ??
?????? ????????: ???. ? ????. ???. ???? ?., 2008. ?. 117.
?????????????? ?. ?., ?????? ?. ?. ? ??. ?????????????
?????? ??????????? ?????????? ??????????????? ? ??????????? ?? ??????? ???????? // ????????????????
? ??????? ?????????????? ??????????. 2007. ? 3.
?. 49?53.
?????????? ?. ?., ???????? ?. ?. ???????????????????
??????? ?????? ??????? ? ????????????? ????????????
??????????? ????????? ????????? ?????????????? //
????????? ?????? ??????? ? ???????? ????????????
????????. ?., 2002. ?. 182?197.
??????? ?. ?., ??????? ?. ?., ?????????? ?. ?. ? ??. ??????????????? ????????? ? ??????? ???????? ???????
??????????? ?????????? ??????????????, ? 3, 2012
????? ???????, ????????????? ?????? ???????? ????? ????????????? ????????? ??????
???????. ????????????????? ???????? ???????? ??????, ??? ??????? ?????????? ???????? ?
?????? ??????? ???????????? ??????????? ????????? ?????????????? (???, ?????????????,
?????? ????????????? ???????????? ???????) [6].
?????????? ?????????? ???????? ????????????? ???????? ????????? ?? ????????????????
??????? ?? ????? ????????????? ???????? ???
?????? ??????? ?????????-???????? ???????????????. ???????? ?????????????? ???????? ?????????? ???????? ???????????? ???? ? ???, ?
????? ?????????? ???????? ????????? ????? ??
????? ?? [6, 7].
???????? ?????????????? ???????????? ?????????? ??????????? ????????? ?????????????
??????? ????????? ????? ???????? ?? ???????????
???????? ?????????? ????????? ? ???????? ???????? ??????????????, ? ?? ???????????? ?????????? ? ?????? ?????????????? ? ??????? ????????????? [6, 12].
??? ???? ??????? ??? ??????? ?????? ?????????????? ????? ????? ???????????? ????,
????? ? ??????? ???????????????????? ??????
(r = 0,523; ? = 0,0013). ?? ?????? ?????????????????? ???????????? ???????? ??????? ?????
?????? ???????????? ??????? (MMSE) ?????
???? ????? ????????? ? 1-? ??????? ????????????????? ??????????????? ???????? 28,6 ╠ 0,6;
?? ?????? ????? ???????? ? 3-? ??????? ?
26,91 ╠ 0,36; ??????????? ?????????? ??????????
?????????? ????? ?? ???? ????? ? ??????? ?? 2-?
? 4-? ??????? ? 25,6 ╠ 1,63 ? 25,59 ╠ 0,53 ??????????????; ???????? ????? 1-? ? 3-? ????????
(p = 0,026), 1-? ? 4-? ???????? (p = 0,01) ????????????? ????????. ?? ????? ??????????? ??????
?????? ?????????? (FAB) ????? ???? ?????
????????? ? 1-? ??????? ???????? 17,2 ╠ 0,37; 2-?
??????? ? 15,2 ╠ 1,31; 3-? ??????? ? 15,27 ╠ 0,33 ?
? ????????? ? 4-? ??????? ? 13,53 ╠ 0,51. ?? ?????
????????? ????? ????????????? ?????????? ?????????? ?????? ???????? ? 1-? ? 4-? ???????
(p < 0,05) (????. 4).
?????? 8?10 ???? ????? ?????????????? ????????????? ?? ?????? ??????? ?????????? ???????????????????? ?????? ?????????? ?? ?????????????? ??????.
? ?????????? ?????????? (????? 3 ???) ???????????? ?? ??????? ????? ?????? ????????????
??????? (??SE) ??????????? ????????? ??????????? ?????????? ????? ????? ?? ???? ??????? ???????, ?? ????????????? ??????????? ???
???? ? ????????? ?? 2-?, 3-? ? 4-? ??????? (????? ????????? ? 1-? ??????? ???????? ??????????
?? ???? ????? ??? ???????). ?????????????
?????????? (p < 0,001) ????? ???? ?? ????? ╚??????? ?????? ??????????╩ (FAB) ?? ????????? ?
???????? ???????????? ???????????? ?????
????????? 3-? ? 4-? ?????. ?????????? ????????? ? ???? ????????? ????? ? 3-? (p = 0,008) ? 4-?
?????? (p = 0,01) ??????????? ???? ?????????
(????. 4).
43
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
44
9.
10.
11.
??????????? ?????????? ???????????? ??????????????
??? ????????????? ?????????? ?????????? ?????? ??????? // ???????????????? ? ??????? ??????????????
??????????. 2007. ? 3. ?. 26?31.
?????????? ?. ?., ?????? ?. ?., ??????? ?. ?. ? ??. ???????? ?????? ??????????? ??????? ??? ?????????????
??????? ??????? ?????????? ?????? ??????? // ??????
?????????? ? ??????????. 2002. ? 4. ?. 21?25.
Aleksic M., Huff W., Hoppmann B. et al. Cognitive function
remains unchanged after endarterectomy of unilateral internal
carotid artery stenosis under local anaesthesia // Eur. J. Vasc.
Endovasc. Surg. 2006. Vol. 31. P. 616?621.
Barnett H., Mohr J., Stein ?. et al. Pathophysiology, diagnosis and
management // Stroke. New York: Churchill Livingstone, 1992.
12.
13.
14.
15.
Bond R., Rerkasen K., Rothwell P. M. Systematic review of the
risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery // Stroke. 2003. Vol. 34.
P. 2290?2303.
Brand N., Bossema E. R. Left or right carotid endarterectomy
in patients with atherosclerotic disease: ipsilateral effects on
cognition // Brain Cogn. 2004. Vol. 54. P. 117?123.
Caplan L. R., Hennerici M. Impaired clearance of emboli
(washout) is an important link between hypoperfusion,
embolism and ischemic stroke // Arch. Neurol. 1998. Vol. 55.
P. 1475?1482.
Dubois B. A., Slachevsky A., Litvan I. et al. Frontal assessment
battery at bedside // Neurology. 2000. Vol. 55. P. 1621?1626.
????????? 24.08.2012
╘ ????????? ???????, 2012
??? 612.133/.134:611.711.1
????????? ????????????? ? ????????? ?????????
??? ?????????????? ? ?????? ??????????? ???????????? ?????????
?. ?. ??????*, ?. ?. ???????????, ?. ?. ??????????, ?. ?. ???????
??????????? ?????????? ??????????????, ? 3, 2012
?????????? ??????-???????????? ????? ??????????????????? ?? ?. ??????
????. ???????? ???????????? ????????????? ? ????????? ????????? ??? ??? ??????????????
? ?????? ??????????-???????????? ????????? (???) ? ??????? ?? ???? ????????????? ??????
?????????? ???????.
???????? ? ??????. ??????????????????? ???????????? ????????? ? ??????????? ????????
(??), ????? ?????? ? ??? ???????????? 50 ????????? 20?40 ??? ? ?????-?????????? ??????? ????????? ?? ? ????? ????? ? ?????????? ??????. ???? ??????? ????????? ???????????
????? ? ??????????? ???????? ????????????? (??), ??????????????? (??) ? ???????????
???????????? (????) ??? ???????? ??????? (??), ??, ?????? ? ??????? ???????? ???????.
???????? ??????????? ??????: ?? ????? ?????????? ???????, ????? ????? ????? ? ????? 6 ???
????? ?????.
??????????. ???????? ??????????? ????????? ?? ? ?? ?? ???? ???????? ????????. ????? ????? ?????????? ??????? ????????: ?????????? ??????? ?????????? ?????????, ???????? ??????????????? ????????????? ? ???????????? ??????? ?? ??????????? ????? ? ??, ????????
?? ? ???? ? ??, ?? ? ?????? ???????? ???????; ?????????? ?????????? ?????????? ????????
??????? ? ???????? ???????? ????????? ? ???. ??? ????????? ??????????? ? ??????? 6 ??? ????? ?????????? ???????.
??????. ??-??????, ??? ?????????????? ?????? ???????????? ????????? ?????????? ????????? ??????????????? ????????????? ? ??????????? ????????????????? ??????? ? ????????????-?????????? ??????? (???) ?? ???? ??????????????? ??????????, ? ????? ????????????? ????????? ???????? ???????? ????????? (???) ? ?? ??? ??????????? ????? ?
???????????? ???????? ???????? ? ???????? ??? ?????? ? ???. ??-??????, ?????????????
??????? ?????????? ??????? ?? ?????? ???????? ??????????? ??????? ??????? ?????????????? ?????? ???, ?? ? ???????????? ???????????? ?????????? ??????? ? ??? ? ?????????
????????? ?????? ? ?????????? ??????????? ???????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ??????????? ???????, ?????????????? ??????????????, ??????????? ?????,
?????????????? ???????????? ????????? ??????? ?????? ????????????.
Objective. Investigation of the neck arterial and venous blood flow peculiarities associated with instability in the neck vertebral motional segments (VMS) and influence of the soft tissues manual therapy on it.
Material and methods. Dopplerographic test of blood flow in vertebral arteries (VA), scalp vein and
neck was performed in 50 patients at the age of 20?40 with cervico-occipital pain syndrome before and
after head rotation. Respiratory samples with vasodilatation index (VI), vasoconstriction (VC) and vaso* ????? ??? ?????????: e-mail: mvtardov@rambler.ru
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
45
????????
? ????????? ????? ?? 80% ????????? ? ???????
????? ?????????? ??????????? ????, ?????????
? ????????????? [6, 14]; 15?20% ?? ??? ????????
?? ??????? ????????? ?? ?????? ??????, ??? ?
???????? ??????? ?????????????? ??????????????? ? ????????????? ???????????. ????? ??????? ?????????????????? ????????? ?????????
??????? ? ?????????? ??????? ? ???????? ???????????? ????????? ??????? ?????? ????????????
[3, 4, 9]. ? ?????? ????? ????????????? ?????????
?????????, ?????????????? ???????? ? ????????????????? ????????, ???????? ????????? ????????????? ???????? ????????? ?????????????? ? ????????????-?????????? ??????? (???)
[1, 2]. ???? ????????? ????????? ?????, ?????????????? ? ???? ?????????????? ???, ?????????
??????????, ??? ? ???????????? ??????? ??????? ?
????????? ???????????? ??????????, ?????? ???
?????? ?? ??????????? ? ???????? ??????????????. ???????? ???????? ???????? ? ????????????
? ????? ???????????? ????????? ??????? ?????? ?
? ?????????????? ? ?????? [8].
?????? ?? ?????? ????????? ??????? ??????
???????????? ???????? ? ???????? ????????????
??????? ???????? ??????????? ??????? (??).
????? ???????? ???? ??? ?????????????? ???????????? ??? ???????????, ? ???? ???????????????
??????? ?? ?? ? ???? ????????? ?? ???????????? ? ?????????? ???????? ?? ?? ????? ??????????.
?????? ??????? ??????????? ???????, ???????????? ?? ????? ????? 70% ??????, ????????????? ?
?????? ?????????? ????????? ?????? ?????????,
? ?????????????, ?? ????????? ? ??? ???????????
????? ????????? ????????????? ??????????
?????? ???????????? ????????? [6, 7]. ??? ?????? ??????????? ????????? ??????? ?????? ???????????? ? ????????? ????????? ? ??? ???????
???????? [11, 17] ?????????????? ??????????? ???????? ??????????? ????????? ?? ?????? ? ???????? ??, ?? ? ? ?????, ??????????????? ???????
?????????, ?????????? ???????????? ????????
????? ?????????? ????? ?? ???? ?????? [18] ??????????? ???????????????? ?????? ??????????????
???????.
?????????? ??????????? ?? ??????????? ???????????? ????????? (???) ??????? ?????? ????????????? [14]. ????????????? ???????? ????? ????????? ???????????????? ? ?????????????? ???
??? ?????? ????????????? ?????? ??????????
???????. ??????????? ?? ?????? ????? ???????????? ??????????? ??????????? ?? ????????? ? ??.
????? ??????????? ?????? ?????????? ??????? ??
?????? ??? ???????????? ???????? ??????????
????? ? ?????????? ?????? [12, 16] ??? ??????????????? ?????? ???????????? ?????????? ???????????. ? ?????????? ??????? ????????? ??????????????????? ??????????? ? ?? ??? ????????????
???????? ?????? [13]. ? ????? ????? ??????, ?????????????? ????? ?????????????? ??????? ????????? ????????? ? ??????, ??????????? ????? ?????????? ???????? ??????. ????? ???????, ??????????? ?????? ????????? ????????? ? ?? ???
?????? ?????????????? ??????? ???????????? ?
???????? ?????????? ????? ?????????? ???????? ?
????????? ????? ?? ????????? ?????????, ??? ?
?????????? ???? ???????????? ? ??????? ????????
????????? ? ??????????? ???????? ??? ?????????????? ? ?????? ???, ??? ????????? ??? ?????????
?????? ? ??????? ????????????? ?????? ?????????? ??????? ?? ???????????? ????????.
???????? ? ??????
????????? ???????????? ? ??????? 50 ????????? (16 ?????? ? 34 ??????) ? ???????? 20?40 ???,
???????????? ?? ????? ? ????????? ? ??????????? ????????? ? ????? ? ???????? ?? ???? ? ??????
? ?????????? ????????. ? ???????????? ????????
?????????, ??????????? ??????? ??????????? ???
????????????? ???????? ???? ? ???????????? ?
????????????? ?????????????? ???????? ?????
[9] ? ??? 11.2.1, ??? ????????????? ???? G44.841 ?
????????????? ????????????? ???????? 10-??
??????????. ?????? ???????? ????????? 20 ???????????? ??? ???????? ?????, ???????????? ?? ???? ? ???????? ? ????????. ??????????? ?? ???????? ???????, ?? ????????? ???????????? ?? ????? ???????? ??????.
???? ????????? ????????? ?????????????? ??????????????????? ???????????? ???????
??????????? ?????????? ??????????????, ? 3, 2012
motor reactivity (VMR) for the basilar artery (BA), VA, posterior and medial cerebral arteries were performed in all patients. The patients were examined three times: before manual therapy and immediately
after the course and in 6 months period after the course.
Results. Significant increase of CPB in VA associated with pain syndrome was detected. After manual
therapy course we noted the decrease of degree of blood flow asymmetry, decrease of peripheral resistance and evidence response on pendulum test in VA, decrease of CPB and VMR in VA, BA and posterior
cerebral arteries; decrease of the number of located venous trunks and reduction of blood flow speed.
All changes are saved during 6 months after the end of treatment.
Conclusions. Firstly, increase of peripheral resistance and hemodynamic reserve in vertebral-basilar
system (VBS) due to constrictor component for unstable cervical motor segments and asymmetric
changes of linear blood flow velocity (LBFV) in VA during pendulum test and formation of venous disgemias in venous systems of head and neck. Secondly, soft tissue methods of manual therapy are not
only effective methods of treatment of instability of cervical spinal motion segment but they contribute to
normalization of vascular responses in VBS and improvement of venous return with long-term effect of
preservation.
K e y w o r d s : vertebral artery, ultrasonic dopplerography, pendulum test, instability of motional segments
of cervical spine.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ??????????????, ? 3, 2012
46
??????????? ?????????? ???????????? ??????????????
?????? ????????????. ??? ???????????? ????????? ? ??????????????? ???????? ????????????
????????????? ?????????? ╚???????-350╩ ? ????????? 2 ? 4 ???. ?? I ????? ????????? ???????????? ?? ??????????? ???????? ? ?????, ?? II ?
???????????? ?? ? ??????? ???????? ????? ???????????? ?????????? ????????? ?????? ?? ???????????? ???? ?? ??????? ? ??????? (???????????
?????). ?????????????? ??????????????, ??????????????? ???????? ?????????? ????? ? ??????????? ??????? ????? ?????????? ????????; ?????????? ? ??????????? ????????? ??????? ? ??.
????????? ???????????? ???????? ???????? ????????? (???) ? ?? ?????????? ??????????, ?????????????????? ??? ? ?? ? ??? ? ????? ? ?????????? ?????? ????????, ???????? ??? ? ??
?????? ? ????? ???????. ?????? ???????? ??????? ??????? ??????????????? ?????????????
(???????) ??? ?????????, ????????? ????????
????????? ?????? ?? ??????????????? ???????? ??
?????. ?? III ????? ????????? ????? ? ???????????????? ? ????????? ??????? ? ???????????
???????? ???????????? ??, ??????? ????????,
?????? ???????? ? ???????? (??) ???????: ?????? ????????????? (??), ?????? ??????????????? (??) ? ?????? ???????????? ????????????
(????). ?????? ??????????????????? ? ??????????????????? ?????? ??????? ????????? ????????? ?????????? ??????????? ??????? ??????
????????????.
?????????????? ???????????? ???????? ??????? ???????????????? ??? (??????? ???????? ?
???? ?????????) ??? ???????? ????? ??????????????? ???????? ???????. ????? ??? ???????????
???????????? ?????????????? ?????? ? ???????
???? ?????, ??????????? ???????? ?????????.
???????? ?? ?????????? ??????? ???? ?????????
?? ??????? ╚???????-500╩ ???????? ????????
7,5 ???. ????????????? ????? ?????????? ???????? ???????, ????????? ???????, ? ??? ? ???.
????? ?????????? ??????????????? ????????
????????? ???????? ?????? ????????? ????????????? ?????????? ??????? ? 6?8 ???????? ?
?????????? ? 2?4 ??? ?? ?????????? ??????? ????????. ??? ?????????? ??????? ???????? ?????????? ????? ??????????????? ? ???????????????? ???????, ??????? ?????????? ?????????????? ? ????????????????????? ?????. ????
???????? ?????????????? ???????????? ????????? ??????: ?? ????? ?????????? ???????, ?????
????? ? ????? 6 ???.
??? ????????? ???????????? ???????????? ??????????????? ????????, ? ???? ????????????
???? ???????? ????????? ????????? ??????????? ???????????????? ??????-??????????????????
???????????? (?????). ?????????????? ????????? ?????????? ??????????? ????????? ??? ?????? ??????????? ??????? ????????? Excel 2010.
??? ?????? ?????????????? ????????? ???????????? ???????? ????????? ??? ????????? ????? ?
?????? ???????? ????????? ??? ??????? ??????
????????? ?????????; ???????????? ????????
????????? ?????????????? ?? ???????? ?2 ?
???-??????. ???????? ????? ?????????????
?????????? ?????????? ????????????? ???????????? ??? ?????? ?????????? ? < 0,02.
??????????
??? ????? ??????????? ?????????? ???????
???? ? ?????????? ? ???????????? ??????????
??????? ?????-??????????? ???????? ????????,
????????????? ? ????????? ??????????? ??????? ??????? ?????? ????????????, ?? ? ?????????? ?????????????? ?????? ???. ?????????
?????????????? ??????? ? ?? ???? ???????? ?
68% ?????????. ????? ????? ?????????? ???????
?????????????? ??????? ? ?? ???? ?????????? ?
70% ?????????, ????? 6 ??? ?????? ??? ? ?? ???????? ? 60% ??????? (???. 1).
?????????? ???????? ??? ? ??????- ? ???????????????? ???????? ??? ???????? ? ??????????? ????? ?????????? ?? ???????????. ????? ??
???? ???????????????? ??????????? ????????
??? ? ????????? ???????? ?????? ?? ? ????? ???????. ??? ?? ????? ???????? ?? ???? ????????
?????????? ??????? ???????? ??????? ??????????????? ????????????? ??????- ? ???????????????? ????????? ?? ? ????????? ???????? ??????
?? ????????? ? ???????????????? ????????????
? ??????????? ?????? ?? ??????? (???. 2).
????? ????? ?????????? ??????? ?????? ??????????????? ????????????? ? ??????- ? ???????????????? ????????? ?? ?????????? ???????? ?
??????? ?? ??. ????? 6 ??? ????? ?????????? ????? ??????? ???????? ????????????? ?????????
??????? ??????? ? ?? (V3?V4) ? ? ?? (???. 3).
??? ???????????? ????????? ????? ??????? ??????? ?????????????? ?????????? ??????????? ????? ???? ???????? ? 92% ?????????, ????? ????? ?????????? ??????? ? ? 20%, ? ????? 6 ??? ? 56% ????????? ???????????????? ????????? ???????????????
??????? ?? ????? ? ?????????? ?????? (???. 4).
???????????? ???????? ???????????? ???????????? ??????? ???????? ??????????? ????????? ?? ? ???????? ??? ???????????? ???????????
?????? ????????, ??? ????????????? ???????????? ???????????? ??????? ? ???????? ? ?????????
? ???? ??????????? ??????????? ????????????????? ??????? ? ???, ???????????????? ?????????? ?????????????? ???????????? ????????????
???????, ??????????? ? ╚???????╩ ???????????????? ??????????? (????. 1). ??? ???? ?? ???? ???????? ??????????? ???????? ????? ???????? ??
??, ? ????? ?? ?? ??? ??????? ???????? ???????.
????? ????? ?????????? ??????? ?? ????????
??????????? ???????? ? ?? ? ???? ?????????
???? ?????: ??? ????????? ?????????? ????????? ?
??? ???????? ?????? ? ??, ?? ? ?????? ????????
??????? ? ? ??????? ??????? ?????? ? ?????????.
????? 6 ??? ????? ???????????? ??????? ? ????
?????????, ??????????? ??? ????? ???????????, ???????????? ??????????? ????????. ???
?? ????? ??? ?????????? ??????????? ????????
??? ? ?????????? ??????????????? ????????????? ??????- ? ???????????????? ??????? ?????
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???????.
???V4
???????? ??????
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0,7
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10
0,6
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0,5
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0,4
0,65
0,2
0,53
0,52
0,54
0,45
0,47
0,46
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?????? ? ???????? ???????.
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* p < 0,01 ?? ????????? ? ???????
* p < 0,01 ?? ????????? ? ???????
???????? ? ??????????? ????????, ? ????? ?????
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???????? ????????? ??????? ????????? ? ???????
??, ?? ? ???? ?????????? ?? ╚????????????????????╩ ??????.
? ???? ????????????? ??? ???? ??????????
??????? ????. ?????? ???????? ?????? ???? ????????????? ? ???????? ?????? ? ?????? ????????: 40?70% ?? ????? ???????. ????? ???????? ????? ?????????? ????????????????? ???????? ??????? ? ??????? ???? ?????, ??????????? ????????
?????????; ? ????? ???????????????? ? ???????
???????? ???? ? ???? ?????????. ? ????????? ??????? ? ????????? ???? ???????????????? ???????
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???????????.
??????????? ???????? ??? ? ????? ?????? ?
??? ????? ???????? ? ????? ????? ?????????????? ?????? ?????? ???????? ?? ????, ??????
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?? ??????? ???? ??????????? ????, ??? ? ???
??????????? ??????. ????? ???????????? ??????? ??????? ?????????? ?????????? ???????????? ??? ? ?????? ???????? ?????????? ????????? ? ??????????? ?? ??????, ?????????? ?????
??????????? ?????????? ??????????????, ? 3, 2012
20
0,1
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
48
??????????? ?????????? ???????????? ??????????????
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?????????? ???????????? ???????????????? ??????? ????????????? ???
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?? ???????
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????? 6 ???
22,4 ╠ 7,9
22,4 ╠ 7,9
22,3 ╠ 6,9
20,0 ╠ 5,7
20,0 ╠ 5,7
20,0 ╠ 5,7
36,2 ╠ 6,7*
27,2 ╠ 7,4**
21,5 ╠ 7,0
25,8 ╠ 6,9
25,8 ╠ 6,9
24,8 ╠ 6,9
55,2 ╠ 10,7*
48,2 ╠ 11,0**
43,4 ╠ 11,0
45,8 ╠ 6,0
45,8 ╠ 6,0
46,0 ╠ 6,0
?????
?? ???????
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16,5 ╠ 8,7
16,4 ╠ 8,9
15,0 ╠ 7,8
12,6 ╠ 4,9
14,1 ╠ 4,9
14,1 ╠ 4,9
32,6 ╠ 12,7*
22,4 ╠ 6,7**
16,4 ╠ 7,5
19,1 ╠ 6,0
19,1 ╠ 6,0
19,1 ╠ 6,0
40,0 ╠ 11,3*
30,0 ╠ 11,3**
29,0 ╠ 9,3
24,8 ╠ 4,5
24,8 ╠ 4,5
27,3 ╠ 6,5
?????? ????????
?? ???????
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28,4 ╠ 7,2
26,4 ╠ 7,5
21,7 ╠ 6,3
22,5 ╠ 7,0
23,5 ╠ 8,0
23,5 ╠ 8,0
43,6 ╠ 9,7*
25,6 ╠ 9,1**
21,3 ╠ 6,8
19,7 ╠ 5,6
20,0 ╠ 5,6
20,0 ╠ 5,6
48,3 ╠ 9,6*
36,4 ╠ 9,9**
35,4 ╠ 9,2
32,0 ╠ 6,1
32,0 ╠ 6,1
31,9 ╠ 7,1
??????? ????????
?? ???????
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29,8 ╠ 8,4
28,5 ╠ 7,4
27,1 ╠ 7,0
24,5 ╠ 6,7
25,7 ╠ 6,5
25,7 ╠ 6,5
33,5 ╠ 8,9
31,8 ╠ 8,6
26,4 ╠ 7,7
28,4 ╠ 7,8
29,3 ╠ 8,1
29,3 ╠ 8,1
48,8 ╠ 10,7
46,8 ╠ 9,7
45,9 ╠ 9,7
44,1 ╠ 5,6
43,7 ╠ 6,6
46,7 ╠ 10,6
** ??????????? ??????? (p < 0,01) ?? ??????????? ??????.
** ??????????? ??????? (p < 0,01) ?? ??????? ????????????.
? ? ? ? ? ? ? ? ? ? . ?? ? ?????????? ???????.
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?? ???????
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????
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12,6 ╠ 4,8
14,5 ╠ 5,0
13,2 ╠ 5,7
??
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13,8 ╠ 3,2
46
9,8 ╠ 2,9
4
10,8 ╠ 3,8
21*
11,2 ╠ 3,1
3
11,9 ╠ 4,3
30*
9,5 ╠ 3,5
4
???
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65
11
1
13,3 ╠ 4,0
22
12,2 ╠ 3,2
2
12,3 ╠ 3,9
30*
10,4 ╠ 3,0
2
??
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15,9 ╠ 4,8
72
11 ╠ 3,7
3
12,5 ╠ 4,6
30*
12 ╠ 3,2
3
13,2 ╠ 4,4
40*
10 ╠ 3,6
3
???
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40
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15
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26*
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2
* ??????????? ??????? ?? ???????? ??????????? (p < 0,01).
? ? ? ? ? ? ? ? ? ? . ?? ? ??????? ????; ?? ? ??????? ????; ??? ? ??????????? ???????? ?????????; ?? ? ???? ?????????; ??? ? ??????? ???????? ????.
?????? (? < 0,01) ????? 6 ??? ????? ???????: ??????? ? 4,46 ╠ 1,82, ????? ??????? ? 1,82 ╠ 0,95, ?????
6 ??? ? 2,52 ╠ 1,08.
????? ???????, ??? ? 7 ????????? ? ????????
??? ? ???? ????????? (18?22 ??/?) ? ? ??????????? ???????? ????????? (20?25 ??/?) ????? ?????
?????????? ??????? ???????? ??????? ? ???? ????????? ????????? ?? ??????????? ????????
(10?12 ??/?), ? ??????????? ???????? ????????? ?
???? ???? ????????? ?? ??????????? ?????????.
??? ?????? ????????? ????????? ? ??????? ?????? ? ???, ???????? ?? ???????? ?????????????? ???????? ???????? ??????? ?? ??????- ? ???????????????? ??????, ?? ????????? ?? ??????
?????????? ???????? ???????, ?? ? ?????????? ?????????? ???, ??????? ??????? ?????????? (????. 2).
??????????
?????? ????????? ? ???????? ????????? ?????
?????? ?? ??????????? ???????? ? ?????????????
?????? ? ????????? ??????, ?????? ??????????????
????????? ?? ?????????? ?????? ??????? ??????????????? ?????????? ? ??????? ?????????????? ? ??????????? ????????? ??????? ?????? ???????????? ?? ???????? ? ?? [18]. ???,
??????? ?????????? ??? ? ?? ? ??????? ???????? ??????????????? ????????????? ????????????? ???????????? ????????? ?????? ????????????
??????? ???. ??????? ????????? (????????????
?????????? ?????????? ? ??????????????? ????????? ? ??????????? ??????? ?????????) ???
? ?? ??? ?????????? ????????????? ????????????
???????? ????? ???? ??????? ???????? ????????????? ?????? ????? ? ?????? ??????????? ??????????????? ????????????????? ????? ??????????: ? ?????? ??????? ????? ??????? ????????????
???? ?????.
??????????? ????? ??? ?????????? ?????????????? ??????? ?? ?? ?? ???????? ????????? ???
? ??? ????? ??? ?? 10?15% [12]. ? ?????? ???????
???????????????? ??????????? ?? ?? ???????????? ????? ???????????? ???????????? ???????????
?? ???? ??? ??? ??????? [5], ? ????? ?? ???? ??-
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ???????????? ??????????????
????????????????? ??????? ? ??? ?? ???? ??????????????? ??????????;
2) ??? ?????????????? ?????? ??? ?????????? ????????????? ????????? ??? ? ?? ??? ??????????? ?????, ? ????? ???????????? ???????? ???????? ? ???????? ??? ?????? ? ???;
3) ????????????? ??????? ?????????? ???????
?? ?????? ???????? ??????????? ??????????????? ???????? ? ?????????????? ?????? ???, ??
? ???????????? ???????????? ?????????? ??????? ? ??? ? ????????? ????????? ?????? ? ?????????? ??????????? ???????.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
??????
17.
?????????? ?????????? ????????? ??????????, ???:
1) ???????? ? ?? ??? ?????????? ??????????? ?????? ??? ??????????????? ??????????
??????????????? ????????????? ? ????????????
18.
???????? ?. ?., ??????????? ?. ?., ????????? ?. ?., ????????? ?. ?. ?????????? ??????????? ???????: ??????????? ??????? ??? ???????? ????????????-?????????? ??????????????? ??? ??????? ??????? ??????????????
????????? // ?????????? ???????. 2006. ? 3. ?. 32?41.
????? ?. ?., ???????? ?. ?., ???????? ?. ?. ??????????????? ???????? ??????????? ?????????????????? ??????????????? // ?????????. 2007. ? 20. ?. 71?75.
???????? ?. ?., ????????? ?. ?., ??????? ?. ?. ????????
????????????? ????????? ??????? ?????????? ???????
??? ??????? ????????????????? // ?????????? ???????.
2004. ? 2. ?. 36?38.
??????? ?. ?. ???????????????? ?????????????? ???
??????????????? ?????????? ? ???????????????????
??????? // ?????? I ?????? ?????????? ?????????? ??????
(25?26 ?????? 1999 ?.). ?., 1999. ?. 71?72.
??????? ?. ?. ????????? ? ??????????? ??????????????
??????????????? ?????????????? ? ????????????-?????????? ???????. ????? ??????? ? ???????: ???. ? ?-??
???. ????. ?., 2005. 310 ?.
??????? ?. ?., ???????????? ?. ?. ???????-??????????????? ??????? ????????????-?????????? ??????????????? // ?????????? ???????. 2004. ? 2. ?. 87?88.
?????? ?. ?. ?????????? ??????? ?????????????? ???????????. ?.: ????????, 2008. 760 ?.
??????? ??. ?., ?????? ?. ?. ?????????????? ???? / ???.
? ????. ?.: ????????, 1989. ?. 1. 256 ?.
??????? ?. ?. ??????????? ?????????? ????????????.
??????, 2003. 469 ?.
???????? ?. ?. ??????????? ?????????????? ??????????? ????????? ?????????????? ???????: ??????-???????????? ???????????. ?.: ????? ??. ?. ?. ???????? ????,
2007. 310 ?.
Haynes M. J. Doppler studies comparing the effects of cervical
rotation and lateral flexion on vertebral artery blood flow //
J. Manipulative Physiol. Ther. 1996. Vol. 19, ? 6. ?. 378?384.
Haynes M. J. Vertebral arteries and cervical movement: Doppler
ultrasound velocimetry for screening before manipulation //
J. Manipulative Physiol. Ther. 2002. Vol. 25, ? 9. ?. 556?567.
Licht P. B., Christensen H. W., Ho/ ilund-Carlsen P. F. Is there a
role for premanipulative testing before cervical manipulation? //
J. Manipulative Physiol. Ther. 2000. Vol. 23, ? 3. ?. 175?179.
Manchikanti L., Singh V., Datta S. et al. Comprehensive review
of epidemiology, scope, and impact of spinal pain // Pain
Physician. 2009. Vol. 12, ? 4. ?. 35?70.
Mann T., Refshauge K. M. Causes of complications from cervical spine manipulation // Aust. J. Physiother. 2001. Vol. 47,
? 4. ?. 255?266.
Mitchell J. A. Changes in vertebral artery blood flow following
normal rotation of the cervical spine // J. Manipulative Physiol
Ther. 2003. Vol. 26, ? 6. ?. 347?351.
Rivett D. A., Sharples K. J., Milburn P. D. Effect of premanipulative tests on vertebral artery and internal carotid artery
blood flow: a pilot study // J. Manipulative Physiol. Ther.
1999. Vol. 22, ? 6. ?. 368?375.
Thomas L. C., Rivett D. A., Bolton P. S. Pre-manipulative testing and the use of the velocimeter // Man. Ther. 2008. Vol. 13,
? 1. ?. 29?36.
????????? 24.08.2012
??????????? ?????????? ??????????????, ? 3, 2012
?????????? ?????????. ??????? ??????? ? ???,
????????????? ????? ?????????? ?????, ?????
???? ???????????????? ??????????????????, ???
????????? ??????? ????????????? ? ????????????? ???????????? ??????????????????? ??????????.
????????? ??? ? ??????? ???????????????
????????????? ? ?? ????? ????? ???????????????
? ????????? ?????? ??????, ?? ???? ? ????????
????????????? ????????? ? ?????????, ? ?????
???? ?????????? ╚?????????????╩ ???????? ?????????? ??? ?????????? ????????????????? ???????? ?? ???????????????? ??????? ?????????,
???????? ??? ?????????? ??????????? ? ???????????? ????????? ??????? ??????.
???????? ??? ? ?? ????? ??????????? ????? ????? ????????? ?? ??????????? ??? ??????????? ?? ????? ????? ??????????????? ??????????? ?????????, ????????? ?????????????? ??????? ?? ?????????? ?????. ??? ????????????
??????? ??????? ???????????? ??? ? ?????? ?????????? ?????? ?????????????? ??????? ??????????? ??????? ???????? ??? ????????????, ??? ? ??????????? ?????????, ??????????????? ???? ?????????????? ???: ??????????????, ??????????
??????????? ? ??.
?????? ???????? ???????? ???????????? ???????????? ??????? ?????? ??????????? ???????? ?? ? ???? ? ???????? ??? ????? ????? ?????????? ??????? (? < 0,01). ?????, ??? ???????????? ???????????? ??????? ????????????????
??????? ??????????? ????? ?????????? ????? ?????????? ??????? ? ??????? ??????????? ???????,
???????? ?? ?? ??? ? ????? ????????? ?????????
??????? ???????? ????????. ???????????? ???????????????? ?????? ????????????? ? ?????????
?? ??????????????? ??????, ??? ?????? ????? ??
????????????? ????????????? ????????????? ?????????? ??????? ??? ??????? ??????? ????????? ?? ???? ?????????????? ?????? ???.
????????????? ??????, ??????????????? ???????? ????????, ?????? ??????, ???????? ?????????????? ???????? ???????? ??????? ? ??????????????? ????????, ???????? ?? ???????? ??????. ?????? ????????? ?????????? ?????????? ?
?????- ? ?????????????????? ?????, ?????????????????? ? ???????? ????? ??????????? ??????????? ?? ???? ????????, ????????? ???????????????? ????????? ????????????? ????????? ?????????. ??-????????, ??? ?????????? ????
???????????? ????? ?????????? ?? ??? ?? ??????? ?????????? ?????????? ?????????? ╚?????? ?????????╩ ???????? ??????? ? ???????????
???????? ??? ? ??? ????? ??????????????? ????????? ??????? ?????? ?? ??????? ??????.
49
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
50
??????????? ?????????? ?????
??????????? ?????????? ?????
╘ ????????? ???????, 2012
??? 616.12-005.4-089:616-07
?????????? ???????????? ?????????????
???????????? ???????, ????????????
?? ????????????? ??????? ??????????? ??????? ??????
?. ?. ???????, ?. ?. ?????????*, ?. ?. ?????????, ?. ?. ???????????, ?. ?. ???????,
?. ?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????
??????????? ?????????? ??????????????, ? 3, 2012
? ?????? ???????????? ?????????? ???????????????? ??????? ???????????? ??????????????? ????????????? ???????????? 2000 ??????? ? ???????? 49?68 ???, ????????????
?? ????????????? ??????? ??????????? ??????? ?????? (???). ??????? ????????? ?????????? ?? ??????????? ???????? ????????? ???????????? ??????????? ?????????? 1?30%.
?????????? ??????? ? ???????? ??? ?????????, ??? ? ????????????? ???????????, ????? ??
??????? ??????????????? ??????? ??? ??????????? ?? ????????????? ???????. ?????????
?????????? ???????? ???????????????? ???????? ?????????? ???????????? ??????????? ??
?????????????? ????? ? ?????????? ? ??????????? ???????????? ?????????????? ??????? ???.
? ? ? ? ? ? ? ? ? ? ? ? ?: ???????-????????????? ??????????, ??????????? ??????? ??????.
The results of retrospective analysis of complex pre-hospital laboratory study in 2000 patients aged
from 49 to 68 years who were referred for surgical treatment of ischemic heart disease are presented
in the article (IHD). The rate for deviation from referential meanings of certain laboratory indices is
1?30%. Deviations are associated with the presence of main and concomitant diseases, the part of
which is revealed for the first time on admission to surgery. Further evaluation of prognostic value of
deviations in pre-hospital laboratory indices along with immediate and long-term results of IHD surgical treatment is required.
K e y w o r d s : clinical biochemistry indices, ischemic heart disease.
????????
???????????? ??????, ??????????? ? ????????? ???? ? ????????????? ??????? ???????????
??????? ?????? (???), ?? ????????? ????????????? ???? ??????????, ?????????? ??????? ?????????????????? ???????. ?????????? ?????????????? ??????? ??????? ?? ?????? ?? ?????? ??????????? ????????, ???????????? ??????????????
?????????????? (??) ? ?????????, ?? ? ????? ??
?????? ???????????? ?????????? ? ???????? ????????????? ??????????? ? ????????. ?????????????? ???????????? ????????? ??????? ? ?????? ????? ????????? ? ????? ?? ?????????????
??????, ????????? ? ???? ????????? ???????????
?? ? ???????????? ??? ??????????? ??????? ??
????????.
???? ?????????? ???????????? ? ?????????????? ???????????????? ???????????????? ??????
* ????? ??? ?????????: e-mail: d.samuilova@gmail.com
??????? ??? ?? ????????? ???????????? ????????????? ???????????? ? ??????? ????????? ?????????? ? ????????????????? ???????.
???????? ? ??????
?? ?????????????? ????? ??????????? 2000 ???????, ??????????? ? ????????????? ???????
???. ??????? ????????? ? ???????? 49?68 ???.
??????????? ?????????????? ??????? ???????????? ? ??????? 1. ??????????? ????????????? ?????? ?????, ???????????? ????????? ??????? ????????? ?? ????????????? ??????????? AU-400
(╚Olympus╩), ????? ?????? ????? ? ?? ???????????????? ??????????? ??? (╚Nichon Kohden╩),
?????????? ???????????? ??????? ??????????
?? ???????????? Sysmex-1500, ??????? ???????????? ? ?? ???????????????? ???????????
AxSYM (╚Abbot╩), ??????? ????????? ???????????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? 1
??????????? ?????????????? ???????
??????????
?????
???????, n (%)
???????, ???
???, ?/?
??????????? ??????????:
I?II ??
III?IV ??
???????????? ???????????
??????? ????????
?????????? ?????? ????????
?????????????? ?????????????
??????????? ???????????
?????????????? ????????? ?????? ?????????
????????? ????? ??????
??????????????? ????????????
???????????? ??????????
???????????????? ? ????????
???????? ??????
??????????? ?????
??????????? ?????????-????????? ??????
??????????? ??????
49?68
1736/264
363 (18,1)
1377 (68,8)
127 (6,4)
53 (2,7)
80 (4)
1257 (62,9)
44 (2,2)
231 (11,5)
394 (19,7)
249 (12,5)
1631 (81,5)
196 (9,8)
377 (18,8)
734 (36,7)
928 (46,4)
427 (21,3)
? ? ? ? ? ? ? ? ? ? . ?? ? ?????????????? ?????.
??????????? ?? ??????????? Chronolog-400. ?????
?? ???????????? ???????? ????? ?? ???? ???????.
??????? ?????????? ???????????? ? ????
M ╠ m.
??????????
? ?????????? ??????? ???????????? ???????????, ?????????? ??? ???????????? ??????? ???
?? ?????????????? ? ??????????????????? ?????????, ?????????? ????????? ???????? ?????????? ?? ??????????? ????????, ??????????? ???
???????? ??? (????. 2).
? 36,2% ??????? ?????????? ????????????
???????? ????????? ??????????? ??????. ? 20,3%
?? ??? ???????????? ??????? ?????????? ? ???????? 7,1?18,2 ?????/? (9,14 ╠ 0,09 ?????/?).
? ????????? 15,9% ??????? ?????????? ???????
????????? ????? 6,1 ?????/?, ?? ?? ?????????
7,0 ?????/? (6,7 ╠ 0,008 ?????/?).
? 13,2% ??????? ???, ????????????? ?? ??????????????, ???????????????? ?????????? ?????????? ??????????. ??????? ?????????? ????????? ? ???????? 128?374 ??????/? ? ? ???????
???????? 156,4 ╠ 3,02 ??????/?. ? 9,2% ??????? ?????????? ?????????? ?????????? ???????? ???
????????????? ?????????? ?????????? ???????????? ??????????.
? 17,4% ????????????? ??????? ? ??????????
?????????? ???????? ????????? ???????????
??????. ??????? ?????? ?????????? ???????? ?
??? 21,2?117,4 ??????/? (27,4 ╠ 0,9 ??????/?).
? 7,4% ??????? ?????????????????? ???? ??????????? ??????????? ?????????? ??? ?????????
(7,81 ╠ 0,86 ??????/?), ??? ? ????????? ???????
(26,4 ╠ 0,71 ??????/?), ? ? 10,0% ??????? ??????????? ?????????? ?????? ????????? ???????
(19,1 ╠ 0,41 ??????/?).
51
? 22,5% ??????? ?????????? ?????????? ?????????? ? ????????? ????? ?????????????????????? (???) ?/??? ????????????????????????
(???). ????? ????? ?? ???? ??????? ????? ??????? ??????? ??????????. ???????? ????? (12,9%)
??????????? ????????????? ?????????? ???.
? 8,9% ??????? ?????????? ?????????? ?????????? ??? ? ????????? ? ?????????? ???????????
???, ? ????? 1,0% ??????? ????? ?????????????
????????? ?????????? ?????????? ???. ? 3,5%
??????? ?????????? ??? ????????? 108?164 ??/?
(122,6 ╠ 1,4 ??/?), ??? 103?288 ??/? (139,4 ╠ 4,67 ??/?).
? ?????????? ??????? ??????????? ???????????? ??????? ??????????, ??? ? 58,3% ???????
?????????? ??????????? ? ?????? ????? ????????? 4,02?8,95 ?/? (5,16 ╠ 0,02 ?/?). ? 4,0% ???????
??????????????? ?????? ??????? ??????????? ?
1,22?1,80 ?/? (1,62 ╠ 0,01 ?/?). ? 4,2% ???????
?????????? ???????? ?????????????? ?????????
????????????????? ????? (????) ? 22?27 ?
(25,7 ╠ 0,11 ?).
? 15,3% ??????? ?????????? ??????? ????????????? ?????????? ??????????? ? ????? ?? ???????? ????????????????? (???), ??????? ?????????? ? ???????? 66?86%, ? ? 8,9% ??????? ? ????? 40%.
?????? ??????????? ???????????? ??????????
??????? ??????? ????????????? ????????? ????????? ????????? ????????? ?????? ? ??????? ???.
? 50% ????????? ????????? ??????? ??????? ?????? ??????????? (7,15 ╠ 0,05 ?????/?), ????????????? ?????? ????????? (4,59 ╠ 0,1 ?????/?)
?/??? ????????????? (2,92 ╠ 0,38 ?????/?). ? 13,9%
?? ??? ???????? ??????? ??????????????????? ?
??????????? ?????? ??????????? 7,6?12,5 ?????/?
?/??? ??????? ???????????????????? ? ???????
????????????? 2,8?13,9 ?????/?, ??? ? ???????
????????? 8,59 ╠ 0,05 ? 4,2 ╠ 0,12 ?????/? ??????????????.
??? ??????? ???????????????? ??????????? ?
19,6% ??????? ?????????? ?????????? ?????????? ??????????? (?? 5,14 в 1012/? ?? 6,26 в 1012/?).
??????? ??????????? ? ??? ???????? 162,0?189 ?/?,
? ???????? ??????????? 47?53%, ?? ???? ?????????? ? ???????? ??????? ??????? ????? ??? ????????? ??. ? 5,6% ??????? ??????? ?????? ??????? ??????????? (77?127 ?/?) ? ???????????????? ??????????? ??????????? (?????????? ??
??????????? ? ???????????, ??????????). ? ????
?? ???? ??????? ???????????????? ???????????? ??????????. ? 0,9% ??????? ???????????????
?????????? ?? ??????? ???????????? ?????, ??????????? ???????????? ???????????. ??????????
?????????? ????????? ?? 9,4 в 109/? ?? 14,4 в 109/?.
? 3,0% ??????? ?????????? ?????????? ?????????
???? ????? ? ?? 3,7 в 109/? ?? 2,6 в 109/?, ? ???????
3,5 ╠ 0,02в109/?. ? 10 (0,5%) ?? ???? ??????? ?????????? ??????????????? ??????????? ?????????? ? ???????? 30?25%, ??? ??????????? ????
?????. ? 3,4% ??????? ???????????????? ?????????? ?????????? ??????????? ? ?????
(6?11%). ? ?????? ?? ??? ????????????? ?????????? ??????????? ???????? 47%. ? 5,0% ???????
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ?????????? ?????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
52
??????????? ?????????? ?????
??????? 2
??????? ????????????? ????????? ????????? ?????????? ???????????? ??????????? ?? ?????
? ??????? ??? ?????????????? ???????, ????????????? ?? ?????????????? ? ?????????
?
1.
???????
???????, %
???????????
????????
15,9
20,3
3,5?5,8
156,4 ╠ 3,02
13,2
60?120
9,8 ╠ 0,05
9,2
1,7?8,3
?╠m
???????????? ???????:
6,1?7,0 ?????/?
7,1?18,2 ?????/?
6,7 ╠ 0,008
9,14 ╠ 0,09
2.
???????????? ??????????:
128?374 ??????/?
3.
???????????? ????????:
9,4?13,7 ?????/? ??? ?????????? ?????? ??????????
4.
???????????? ?????? ??????????:
20,5?117,4 ??????/?
27,4 ╠ 0,9
17,4
1,7?20
???????????? ??????????:
????????? 5,2?58,2 ??????/?
????????? 16,0?59,2 ??????/?
7,81 ╠ 0,86
26,4 ╠ 0,71
7,4
?? 4,6
1,7?15,4
5
6
???????????? ?????????? ??????????:
16,4?48,7 ??????/?
7.
???: 108,0?164 ??/? ?/???
???: 103,0?288 ??/?
8.
9.
10.
11.
12.
13.
??????????? ?????????? ??????????????, ? 3, 2012
???????????? ??????????
14.
15.
19,1 ╠ 0,41
10,0
1,7?15,4
122,6 ╠ 1,4
139,4 ╠ 4,67
3,5
?? 35
?? 45
??????? ???????????:
4,03?8,95 ?/?
1,22?1,8 ?/?
5,16 ╠ 0,02
1,62 ╠ 0,01
58,3
4,0
1,8?3,4
????: 22?27 ?
25,7 ╠ 0,11
4,2
26?38
????????????? ?????????? ???????????:
66?86%
9?39%
71,7 ╠ 0,19
27,3 ╠ 0,43
15,3
8,6
50?70
?????????? ?????? ???????????:
7,6?12,5 ?????/? ?/???
?????????????: 2,8?13,9 ?????/?
8,59 ╠ 0,05
4,2 ╠ 0,12
13,9
?? 5,3
?? 1,7
169,2 ╠ 0,22
116,5 ╠ 0,94
19,6
5,6
130?160
?????????? ??????????:
9,4?14,4
2,6?3,7в109/?
10,9 ╠ 0,07
3,5 ╠ 0,02
0,9
3,0
4,0?9,0
?????????? ???????????:
400,0?583,0в109/?
100,0?170,0в109/?
362,7 ╠ 3,67
150,8 ╠ 1,05
5,0
7,9
180?400
18,7 ╠ 0,21
41,9 ╠ 2,27
30,3
9,0
5,0?15,0
??????? ???????????:
162,0?189,0 ?/?
77,0?127,0 ?/?
???????????? ????????????:
15,0?28,6 ??????/?
30,8?97,5 ??????/?
????????? ??????????? ? ??????????? ??????????? 400?583,0в109/?. ? 7,9% ??????? ???????? ??????????????? ? ??????????? ??????????? 100?170в109/?, ??? ? ??????? ?????????
462,7 ╠ 3,67в109/? ? 150,8 ╠ 1,05в109/? ??????????????.
? 30,3% ??????? ?? 500 ?????????????
?????????? ????????? ???????????????????? ?
??????? ???????????? 15,2?28,6 ??????/?, ? ?
9,0% ??????? ? ???????????????????? ???????
??????? ??????? ? ??????? ????????????
30,8?97,5 ??????/?.
??????????
????????????? ???????? ????? ?? ????????
???????? ????? ???????? ??????????? ?????????
??????? ? ?????? ?????????. ?????????, ??? ???
????????????? ??????????? ?????? ??????? ??????? ????? 7,0 ?????/? ??? ????????? ????????
╚???????? ??????╩ ?? ????????? ??????????????
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????? ?????????????? ?????????? ??? ?????? ???????? ???????????????, ??? ???????????? ????????? ? ????????? c ?????????? ?????????? [22].
?? ?????? ??????? ???????? ???????? ????????? ??????? ?????????? ????? ?? ???????? ??
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???????????? ? ?????????????? ???????, ??????????? ?????????????? ? ???????? ????????? ??????????????? [15, 16]. ?????????? ??????????
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??????????
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5.
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7.
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10.
11.
12.
13.
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???????????? ???????, ??? ??????? ????????????
???????????? ??????? ??? ?????? ?????? ??????. ? ??????? ? ?????? ??????? ???????????
????????? ???????? ??????????? ?????? ?? ????? ????????, ? ????????????????? ???????, ???????? ????????, ????????? ?????????????? ????????? ? ?????????.
?????????? ?????? ???????? ???????????????
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????????????, ??????????????? ? ?????? ???????????? ????????? ? ????????? ??????? ????????????? ????????????????? ???????????? ??????????.
??????????? ???????????? ????????? ???????? ???????????????? ??????? ?? ????????????????? ?????????, ? ??? ????? ? ?? ????????
???????, ??????? ???????? ? ???????? ?? ??????
?????????? ????????? ???. ? ??????? ? ???????????? ?????? ???? ?????? ?????????? ??????????????. ?????????? ?? ????????? ???????
??????????? ????? ?????????????? ???????? ????????? ? ????????.
?????????? ????????? ????????? ?????????
??????? ? ?????? ??????? ???? ? ??????? ???????? ??????????? ?????? ??? ????????-?????????? ????????????. ??????? ?????????? ????????? ?????????????? ?????????? ??????????? ?
??????? ??? ????? ????????????? ????????.
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??????? ????? ????????. ??????? ???????? ???????????? ????? ???? ??????? ? ???????????? ??????????????????, ???????????????, ??????????????? ? ????????????????? ?????????????.
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?????? ????????????????? ??????? ? ??????? ?
?????? ??????????? ??????????? ? ????? ?? ????????.
? ??????? ??????? ??? ?????????????? ??????????? ???????????. ????????????????? ?????? ? ???? ??????? ????? ??????????? ??????????? ??????? ???????????, ????????? ???????????? ? ????????????????????? ??????????.
? ?????? ???????? ???? ?????????? ???????? ????????????? ?????? ? ??????????? ?????????? ????? 50%. ???????????? ?????????????? ? ?????
??????????? ???????. ??????? ????????, ???
?? ????? ?????????????? ?????????? ??????????? ??????????? ? ??????????? ?????????? ?????????? ? ????????????????? ???????.
??? ?????????? ?????? ?????? ?? ???????????????? ??????? ????????????? ???????????????????? ? 500 ??????? ???. ????????????? ???????????? ?????? ???????????? ???????????
??? ??????????????????, ????????????????
?????????? ????????? ?????????????, ???????????? ??????????? ????????? ? ??????? ????????????????????, ????????? ????????????? ??????????? ???????????. ???????????????????? ??????????? ???? ???????? ????????? ??????????,
55
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
56
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????????? 20.08.2012
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? ???????????? ????????? ???????? ?????????????? ??????????????). ?????? ?????? ? 50 ?????????, ? ??????? ?????, ????????? ?? ???????????? ????, ????????? ? ????????? ????????
?????? ????? ??????????? ??????????????? ????????? ? ???????? Cell Saver. ???????????
??????????? ? ????????????? ??????????, ????????? ??????????? ????????????, ???????????? ???????? ?????????? ?????????? ? ????????.
??????????. ? ?????? ? ?????????????? ?????? ?????????? ????????? ????? ??????????? ?????????? ?????????? ??????????????? ?????? ??????????? ????? ??? ? ??? ???? ????. ? ???????? ?????? ????????? ???????????? ????????????????????? ?-??????????? ????? (hsCRP),
???????????? ??????????? ?????????, ???????????????? ?? ?????????? ???????-1 (sTREM-1),
????????????? IL-6 ? IL-10 ????? ???????? ????? ????? ?????????? ????????, ? ??????? ??????? ??????? ???????? (TNF) ????????. ? ?????? ? ?????????????? ?????? ?????????? ????????? ????? ???????? ?????????? ?????? ??????????? ?????????? ?? ????????? ? ??????? ??
??????????? ??????? ????????????????? ???????.
??????????. ?????????? ?????? ?????????? ????????? ????? ?? ????? ????????????? ????????? ????????????? ????????? ??????? ?????? ? ???????? ?????????????? ?????????????? ??
???? ?????????? ???????? ???????? ????????? ? ???????????? ??????? ?????????? ????????? ?????????????? ????? ? ???????? ???????? ??????? ?????????????????? ???????. ???
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ?????
57
???? ????????? ??????? ???????? ???????????? ???????????????, ??????????? ??????????? ? ???????????????? ? ???????????? ????????????? ?????????, ??????????? ?????????? ???????? ? ??????????, ??????????? ??????????? ? ??????? ??????????????????? ???????? ?????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ????????????? ?????? ??????, ?????????? ????????? ?????, ?????????
?????????????? ?????, ???????????? ???????????????, Cell Saver.
????????
?????????? ???????????, ??????????????,
?????????????? ? ?????????????? ? ?????????
????? ??????????? ????????? ?????? ? ????????? ??????????? ????????????, ???????????
????????? ? ?????????????? ?????????? ???????? ??????. ??? ???? ?????? ????????? ????????? ????? ???????? ????????????? ?? ????????????????? ? ???????????? ?????????????? ?????????????? (??), ??????????? ????????? ?
???????????? ???????. ??? ???????? ? ??????????? ????? ?????????? ??? ?? ?????, ??? ? ?????
???????? [6].
????? ?? ???????? ?????????? ??????????
??????????????????? ???????????? ? ????????
?????????????? ?????????????? ???????? ????????? ?????????????? ????? (???), ?????????
????????? ????????? ???????? ??????? ???????
??????? ????? ? ??????????? ????????????????????? ?????????????, ????????????? ??????,
????????????? ???????????, ??????? ???????????????? [2]. ????????????? ????????? ???????? ? ????????? ??????????-????????? ???????, ?????? ???????????, ?????????? ? ???????????. ???????????? ??? ???? ?????????????????
????????? ????????? ????????? ??????????????
???????, ??? ???????? ? ????????? ???????????,
??????????, ?????? ?????????, ???????? ?????????????? ??????? ? ????????, ?????? ? ???????
????????????????? ?????????. ?????????? ????????? ???- ? ????????????????????? ???????-
???, ? ????? ?? ????????? ???????? ?????????
???????? ???????? ?????????? ? ????????????????? ??????? ? ???????????? ???????????????
(???) [7, 9]. ??? ??? ???????? ????????? ??? ????????? ? ?????????????? ???????? ??????, ????????? ????????? ? ??? ????????? ??????????????? (??) ????????????? ???????? ? ??????????? ??????????? ?????????? ??????? ? ?????? ?
?????????? ??????????? ??????????? ????????.
????????? ??????? ????????? ?????? ?????????
??????? ???????, ???????? ???????? ????????
?????????????? ? ??????? ???????????? ???????
??????????, ??????????? ??? ?? ?????, ??? ?
????? ???????????? ????????????? ? ???????? ?????????????? ?????????????? [2].
? ????????? ????? ???????????? ?????????
??????????????? ? ?????????????????? ????????, ???????????? ?? ??????????? ??????????
?????????? ? ??????????? ???????? ???????????????? ??????????????? (?????????? ????????????????? ????????????????, ?????????????
???????? ?? ? ??????????? ??????????????????
??????????? ? ??????????????, ???????? ????????????????) [1, 5]. ??? ???????????? ??????????????? ? ???, ??? ????????? ?????????? ? ???????? ???????, ???????????? ? ?????, ??????????
? ??????? ?????????, ??? ?? ????????? ? ????????? ???????? ????? ????? ???????? ???????? ?????????? ??????????????? ?????? [12].
? ????????? ????????????? ???????? ??????????? ?????????? ????????? ?????????? ??????????
?? ???? ?????????????? ????????? ? ?????????
??????????? ?????????? ??????????????, ? 3, 2012
Objective. The aim of the study is to show that using of mechanical system for blood reinfusion with
washing of red blood cells may contribute to limitation of triggers for systemic inflammation into systemic
flow, thereby preventing its development and the degree of associated complications.
Material and methods. The study included 100 patients with acquired valvular defects undergoing surgical correction under cardiopulmonary bypass. Prospective randomization using even and odd numbers
was performed. Group I included 50 patients undergoing standard volume of intraoperative therapy
(blood sampling from operative wound was performed at all stages into cardiotomy reservoir used in
cardiopulmonary bypass). Group II included 50 patients in which the sampled blood from the operative
wound entered into systemic flow only after preconditioning in Cell Saver apparatus. Clinical and biochemical rates, parameters of central hemodynamics, dynamics of marker concentration for systemic
inflammation were studied.
Results. The group, in which the method of mechanical system for blood reinfusion was used, clinical
implication for the system inflammatory response was noted more than two times less often. In the main
group, increase of concentration of high sensitivity C-reactive protein (hsCRP) soluble trigger receptor,
expressed on myeloid cells-1 (sTREM-1), interleukins IL-6 and IL-10 after the procedure had a marked
character, and the level of tumor necrosis factor (TNF) decreased. The group, in which the method of
mechanical system for blood reinfusion was used, better clinical implications were noted in comparison
with the group with the standard volume of intraoperative therapy.
Conclusion. The use of the method of mechanical system for blood reinfusion was used during the surgical correction for acquired acquired valvular defects under cardiopulmonary bypass due to elimination
of starting factors that allow restricting system inflammatory response and improving the course of postoperative period. At that, the frequency of multiple organ failure is decreasing, need for sympathomimetic and respiratory support are decreasing, the length of patient?s stay is decreasing, less need in
extracorporeal clearance techniques.
K e y w o r d s : acquired valvular defects, mechanical system for blood reinfusion, system inflammatory
response, multiple organ failure, Cell Saver.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
58
??????????? ?????????? ?????
???????? ?????, ?????????? ? ???? ???????????
??? ??????????????????? ??????????????. ??????
?????? ????????? ???? ? ???????? ?????????????
?? ???????? ??????????? ????????????, ????? ???
?????? ???????? ?????? ????????? ? ??? ????????
?? ?????? ????????? ?????????. ????? ????, ? ?????????? ?? ??? ??? ??????? ?????????????? ?????? ?? ?????? ???????????????? ??????????????
?????????? ????? ? ???????? ??????????????????? ????????????, ???????? ???? ???????? ?? ?????????????? ????????? ???????????? [4, 11, 14].
????? ???????, ???????? ??????? ???????????? ??????????? ? ???, ??? ????????????? ??????
?????????? ????????? ????? ? ????????????
????????? ??????????? ????? ?????????????? ??????????? ????????? ???????? ???????? ?????????? ?????????? ? ????????? ????????, ???
????? ???????????? ??? ????????, ? ????? ???????????? ????????? ? ??? ??????????.
??????????? ?????????? ??????????????, ? 3, 2012
???????? ? ??????
???????????? ??????????? 100 ??????? ?
?????????????? ?????????? ???????? ??????,
??????? ??????????? ????????? ? ???????? ?????????????? ??????????????. ???????? ???????????? ???????????? ??????? ??????/???????? ????? (????? ???? ?????? ??????? ???????)
? ????????????? ???? ?????.
?????? ?????? ? 50 ????????? ? ???????? ?? 46
?? 69 ??? (??????? ??????? 57,5 ╠ 11,2 ????). ?????? ? ?????? ???? 37 (74%), ?????? ? 13 (26%).
?????????????? ????? ?? ?? NYHA ? III?IV.
???????? ?????? ?????? ?? ????? ????????? ?????? ???????? ??????????? ????? ????????????????? ??????? (??????? ???????, ????? ? ??????
?????????? ?????????? ??????????????? ???????? ? ??????? ??????????, ????? ????? ?? ????
?? ???? ?????? ???????????? ????????????? ?????????? ? ???????????? ????????? ???????? ?????????????? ?????????????? ? ??????????????
?????????? ???????).
?????? ?????? ? 50 ????????? ? ???????? ?? 43
?? 68 ??? (??????? ??????? 56,9 ╠ 10 ????). ??????
? ?????? ???? 40 (80%), ?????? ? 10 (20%).
?????????????? ????? ?? ?? NYHA ? III?IV.
????????? ?????? ?????? ??????????? ?????
??????? ?? ????? ????????? ?????? ??????????
??????? ?????????? ????????? ?????. ???, ??
????? ????????????? ??????? ? ?????????
????? ???????? ??? ?????? ??????? Cell-Saver
(Brat-2 ????, ???) ??????????? ?????? ????????? ????? ?? ???????????? ???? ? ????????? ????????. ????? ??????????? ??????????
?????????-?????????? ?????? ?????????, ? ?????????????? ?????? ???????????? ? ?????????
???????? ?????????????? ??????????????.
??????? ????? ???????????? ??????????????
????? ????????? 356,9 ╠ 89,9 ??, ? ????? ????????? ?????? (?? ??????? ???????????? ????????) ? 970 ╠ 380 ??, ??? ??????????????? ? ??????? 12 ╠ 3,5 ??/??.
???????? ????????? ? ????????????: ???????? ? ?????????????? ?????????? ????????
??????, ??????????? ? ???????? ??????????????
??????????????.
???????? ??????????: ??????? ????????? ????? 20 ???, ??????? ??????????? ?????????????????? ????????????????? ?????????, ?????????
? ???????????? ???????????, ??????????????
?????????.
??????????? ????????????? ? ????? ???????
??????????? ? ???????? ????????????????? ??????????????? ?????????????? ??????????????
(Terumo, ??????). ??? ?????? ???????? ????????????? ????????????????? ??????? ?????????
(Dr. France Kehler Hemy, ????????). ????????????? ??????? ?? ????, ????????, ???????????? ?????????????? ??????????????, ???????????? ??????????????? ??????????????, ????????? ?????????????? ?????? ?????? ? ???? ???????????
????????? ???????????? ? ??????? 1. ???? ????????? ??????????? ????????? ???????????? ?????????: ???????? ? ??????????? ? ???????? ? ????????? ? ??????????; ????????? ? ??????? ???
????????. ????????????? ?????????? ??????
(???) ?????????????? ????????-???????????
????????? ╚Draeger Primus╩. ???????? ??????????
??????????? ?????????????? ????????? (M ╠ ?)
??????????
???????/???????, ???. (%)
??????? (min?max), ???
??????? ???? (min?max), ?2
????? ???? (min?max), ??
???????????? ?? (?? ?? NYHA)
????????? ??????:
?????????, ???. (%)
???????????? ??????????, ???. (%)
???????????????? ?????, ???. (%)
?????????????? ??, ???. (%)
?????????????? ?? + ???????? ??, ???. (%)
?????????????? ?? + ?????????????? ??, ???. (%)
???????????? ?? (min?max), ???
??????? 1
1-? ?????? (n = 50)
2-? ?????? (n = 50)
37/13 (74/26)
57,5 ╠ 11,2 (46?74)
1,82 ╠ 0,19 (1,56?2,18)
74,4 ╠ 19 (52?105)
3,56 ╠ 0,42
40/10 (80/20)
56,9 ╠ 10 (43?72)
1,82 ╠ 0,22 (1,40?2,11)
76,7 ╠ 20,1 (51?107)
3,61 ╠ 0,39
19 (38)
14 (28)
17 (34)
14 (28)
25 (50)
11 (22)
138 ╠ 36 (102?174)
21 (42)
16 (32)
13 (26)
16 (32)
21 (42)
13 (26)
152 ╠ 46 (106?198)
? ? ? ? ? ? ? ? ? ? . ?? ? ??????????????? ??????????????; ?? ? ?????????? ??????; ?? ? ?????????? ??????; ?? ? ??????????????? ??????.
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ?????
??????????
? ?????? ????????????????? ??????? ? 1-?
?????? ?? ??????????? ??????? ????????????????? ??????? ? 91% ????????? ?????????? ???????
??????????? ????????? ?????????? ??????????????? ??????, ??? ???? ??? ???????? ? ? 51% ???????, ??? ? ? 40%. ?? 2-? ?????? ? ??????????????
?????? ?????????? ????????? ????? ???????????
?????????? ?????????? ??????????????? ??????
??????????? ????? ??? ? ??? ???? ???? ?? ????????? ? 1-? ??????? ? ? 44% ???????, ??? ???? ???
???????? ? ? 34%, ??? ? ? 10%.
???????? ???????????? ???????????? ???????? ??? ? 1-? ? 2-? ??????? ?????????? ?? ?????????? (????. 2). ? ?????? ????? ?????????????????? ??????? ???????? ??????????? ??????????
???????????? hsCRP, sTREM-1, IL-6 ? IL-10 ?
????? ???????. ??? ???? ?? 2-? ?????? ?????? ????????? ????? ????? ?????????? ???????? ? ?????????? ???????? ?????????? ?? ????????? ?
1-? ???????. ??? ????????? ????????? ????????????? ?????????????? ? ????????? ???????????? ????????? ??? ? ???????? ????????????
?????????????? ?????????? ???????????? ?????????? ?????????? ?? 2-? ??????, ??? ??????????? ?????????? ????????? ?????.
?????? ???????? ??????????? ???????? ???????????? TNF ? ?????? ?? ???????? ????????
?????????? ??? (??. ????. 2). ???, ? 1-? ??????
??????????? ??????????? ????????? ???????????? ? ?????? ????? ?????????????????? ???????,
????? ??? ?? 2-? ??????, ????????, ??????????? ??
??????????? ????????, ??? ????? ???????? ?????????????? ????????????? ?????????????????
?????????? ????????? ????? ? ??????????? ???.
???????? ???????? ??????????? ???????????
???????????? ? ??????? ????? ??????????? ???????? ? ????? ? ??????????????? ?????????????
??????????????? ???????????? ??????? (????. 3).
?????? ? ??? ????????????????? ?????? ? ??????
?? ??????????? ???????? ???????????????? ?????
?????????? ????????????????? ???????? ????????-?????????? ???????, ??? ???????? ???????????? ??? ?????????? ??????????????? ?????? ?
???????????? ???????? ????????? ?????????????? ???????? ????????. ????? ????, ?? 2-? ??????
? ????????????????? ??????? ??????? ?? ????
?????????? ???? ?? ????????? ? 1-? ??????? ???
??????? 2
???????? ???????????? ???????? ?????????? ?????????? (?╠SD)
1-? ?????? (n = 50)
??????
hsCRP
sTREM-1
TNF
IL-6
IL-10
?? ????????
?????? ?????
????? ????????
7,2╠1,07
53,21╠12,32
2,39╠0,26
2,21╠1,11
17,26╠5,23
27,68╠6,97*
79,91╠14,54*
3,08╠0,33*
56,13╠11,24*
121,34╠16,12*
** p < 0,05 ??? ??????????????? ?????????;
** p < 0,05 ??? ???????????? ?????????.
2-? ?????? (n = 50)
?? ????????
?????? ?????
????? ????????
7,9╠3,9
57,44╠9,41
2,69╠0,64
2,70╠1,05
16,78╠7,85
12,71╠5,23*,**
66,04╠17,3*,**
1,5╠0,4*,**
17,36╠9,87*,**
56,36╠11,54*,**
??????????? ?????????? ??????????????, ? 3, 2012
??????????? ???????????? ???????????? ? ?????????????? ???????? BSM-4103K (Nihon
Kohden, ??????) ? ???????? Swan?Ganz, ?????????????? ????? ?????? ??????? ???? (7 Fr,
Arrow). ??????????? ????????? ?????? (??),
???????? ???????????? ???????? ??????????
(????), ??????? ???????? ? ???????? ???????
(?????.), ?????? ???????-??????????? ????????????? (????), ?????? ?????? ???????????????
??????????? ????????????? (?????), ???????
???????????? ???????? (????.).
??? ??????????? ?????????? ???????????????
?????? ? ?????? ????????????????? ??????? ???????????? ???????????? ???????? ACCP/
SCCM [3]. ?????? ??????????? ???????-???????????? ??????????? ??????? ?????????????????
??????? ??????? ????????????? ??????? ?????????? ??????????: ???????????????????? ?-?????????? ????? (hsCRP), ??????????? ??????????
????????, ??????????????? ?? ?????????? ???????-1 (sTREM-1), ?????? ??????? ????????
(TNF), ???????????-6 (IL-6), ???????????-10
(IL-10). ????? ????????????: ?????? ? ??? ??????????? ???????? ? ????????????, ?????? ? ???? ?????? ????? ????? ????????.
???????? ??????? ?????????????????? ??????? ????????? ?? ???? ???????????: ???????????
? ?????????? ?????????????? ???????? ???????
(????), ??????????? ? ???? ????????????????,
? ??? ????? ????? ??????????????? ?????????,
???????????? ?????????? ? ?????????? ?????
???? ????? ? ????????????? ?????????? ????????????? ????????? ????? ?????, ??????? ???????? ???????????? ??????????????? ?? ?????
SOFA [13].
??? ???????? ????? ????? ????? ?????????? ?
???????????? ??????????? ??????????????? ????????. ?????? ???????????? ??????? ?? ?????????
?????????? ???????? ??? ??????????? ???????
????????-?????????? ??????????? ?? ????.
?????????????? ?????? ?????????? ? ??????? ????????????????? ????????? Statistica 6.0,
StatSoft, Inc. ?????? ???????????? ? ???????
? ╠ ?. ??? ??????????? ?????????????? ????????
??????? ??????? ???????????? ????????????????? ???? ??????????? ??? ??????????? ???????
? ???? ?????????? ??? ?????????. ???????? ??????? ???????????? ??? ?????? ??????????
? < 0,05.
59
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
60
??????????? ?????????? ?????
??????? 3
?????????? ??????????? ???????????? (?╠SD)
1-? ?????? (n = 50)
??????????
?? ????????
??, ?/(?????2)
????, ?? ??. ??.
?????., ?? ??. ??.
????, ??????c??5???2
?????, ??????c??5???2
????., ?? ??. ??.
2,99 ╠ 0,69*
11,00 ╠ 4,21
20,42 ╠ 10,1
295,4 ╠ 182,9
2801 ╠ 682*
77 ╠ 25*
2-? ?????? (n = 50)
?????? ?????
????? ????????
4,29 ╠ 1,07*,**
12,80 ╠ 7,27
22,00 ╠ 8,13
191,5 ╠ 141,6
1770 ╠ 748*,**
62 ╠ 12*,**
?? ????????
?????? ?????
????? ????????
2,95 ╠ 0,45*
12,90 ╠ 4,38
22,24 ╠ 9,42
302,8 ╠ 217,4
2674 ╠ 682*
80 ╠ 19*
3,51 ╠ 0,87*,**
10,30 ╠ 3,27
23,00 ╠ 7,13
241,5 ╠ 139,6
2357 ╠ 562*,**
76 ╠ 13*,**
** p < 0,05 ??? ??????????????? ?????????;
** p < 0,05 ??? ???????????? ?????????.
??????? 4
?????????????? ?????????????????? ???????
??????????
??????????? ?????????? ??????????????, ? 3, 2012
?????????? ???? ?? ??????????? ??????????, %
??????????? ? ???????????????? ????? ??????????????? ?????????, %
??????????? ? ???? ????????????????, %
???????????? ????????????? ????????? ????? ?????, %
???????????? ?????????? ? ???? ????? 2 ???, %
???????? ???????????? ??????????, %
??????? ??????? ??????????????????? ????????? ? ??????? ? ????????????????? ?????????? ?????????? ????? ????????????? ? ??????? ? ??? ???? ??????? ????????? ?????????????
??? ???????????? ???????????? (????. 4).
??? ?????? ????????? ??????? ??????? ?????????????????? ??????? ? ?????? ? ?????????????? ?????? ?????????? ????????? ????? ????????
?????????? ?????? ??????????? ?????????? ??
????????? ? ??????? ?? ??????????? ???????
????????????????? ??????? (??. ????. 4). ??? ?
??????????????, ?????????? ???????????? ?????????? ??????????????? ?????? ??????????????
???????? ??????? ???????? ???????????? ??????????/???????????????, ??????? ???????????
?? ????????? ????? SOFA. ??? ???? ?????????????? ????????? ???????????????? ??????? (?
?????? ?????? ????????-??????????) ?? ??????????? ????? ?? ????????? ?????????. ????? ???????? ???????? ??????? ???????????? ??????????
???????????? ?????????? ?? ???????????? ?????????? ? ????????? ?????????? ?, ?????????????,
?? ??????? ????????????????? ??????-??????????? ??????????.
??????????
?????? ?????????? ??????????????? ? ???,
??? ????????? ? ???????????? ????????? ?????,
?????????? ? ??????????????? ????, ???????????? ????????? ????? ??????????, ???????
??????????? ??? ? ?????????? ????????, ??? ?
? ???????? ????? ? ???????? ??????. ?????????????, ?????, ?????????? ?????????????? ?????????, ?????????? ???????????, ???????
???????????????? ???????? ???????, ??????
???? ??????? ?? ???????? ?????????? ?????????? ?????????? [11].
1-? ?????? (n = 50)
2-? ?????? (n = 50)
71
67
75
78
87
76
29
23
15
12
24
24
????????, ??? ╚????????????╩ ???????????
???????? ??? ???????????? ? ???????????? ??????? ? ??????? ?? ????????? ????????? ? ????????. ??? ???????? ????????? ??? ??????????????????? ???????, ????????? ??? ??????? ??? ??
??????? ????????? ? ??????? ????????? ?????????? ? ??????? ??????? ? ????? ????????? ???????????? ??? ?????? ????? ???????? ????????-???????? ??????????????? ? ???????????????? ???????????. ??????? ?????????? ??? ???????? ?
??????? ?????????? ? ??????????? ???? ? ???? ?
????? ??????? ??????? ??? ??????????? ?????????? ??????????????? ??????, ?? ??????????? ??
????????? ??????????? ??? ???????????? ? ??????? ? ????????. ?? ?????????, ??? ?????? ???
????????? ?????? ?????????????? ? ?????? ?????
????????, ????? ??? ?-?????????? ?????, ??????????????, ???????????-6, ???????????-8,
??????????? ?????????? ????????, ??????????????? ?? ?????????? ??????? ? ??. [8, 10]. ????????????? ???????????? ????????????? ???????
?????????? ? ??????????? ? ??????????? ???????? ????????????? ?????????? ???????????????
??????, ????? ??? ?? ????????? ??????????? ??????????? ????????? ??? ????????????? ??????????? ? ??????????????? ?????????? ??????????
(??????, ??????????, ????????? ????? ?????????????? ??????????????). ??????????? ??? ??????
????????? ??????????????? ? ??????????????? ?????? ???????? ???????? ???????????????? ? ??????? ╚???????????????╩ ????????? ??????????
?????????? [8, 10]. ? ???? ????? ???? ??????, ?????????? ?? ???????? ????????? ?? ????????????????? ????????, ????????????? ???????????? ????????????????? ????????? ????? ? ??????? ??????????? ?????????? ?????????? [8].
?????? ?????????? ????????? ?????????? ?
???????? ??????? ???????? ????? ?? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ?????????? ?????
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????????????????, ???????? ?? ?????? ????????????? ???????????, ????????????? ????????? ? ??.
????? ???????, ?????????? ?????? ?????????? ????????? ????? ?? ????? ?????????????
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?????? ? ???????? ?????????????? ?????????????? ?? ???? ?????????? ???????? ???????? ????????? ? ???????????? ??????? ?????????? ????????? ?????????????? ????? ? ???????? ???????? ??????? ?????????????????? ???????. ???
???? ????????? ??????? ???????? ????????????
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??????????, ??????????? ??????????? ? ???????
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
??????????? ?. ?., ??????????? ?. ?., ????????? ?. ?., ???????? ?. ?. ??????? ????????????????? ?? ?????????????
?????????? ??? ????????? ? ???????? ?????????????? ?????????????? // ????? ??????????????. 2011. ? 2.
Asimakopoulos G. Systemic inflammation and cardiac surgery:
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Committee // Chest. Vol. 101. P. 1644?1655.
Freischlag J. A. Intraoperative blood salvage in vascular surgery ? worth the effort? // Crit. Care. 2004. Vol. 8 (Suppl. 2).
P. S53?S56.
Harmoinen A., Kaukinen L., Porkkala T. et al. Off-pump surgery does not eliminate microalbuminuria or other markers of
systemic inflammatory response to coronary artery bypass surgery // Scand. Cardiovasc. J. 2008. Vol. 40. P. 110?116.
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induced inflammation: pathophysiology and treatment // Eur.
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soluble triggering receptor expressed on myeloid cells-1 in
patients with acute respiratory distress syndrome and abdominal diseases: a preliminary observational study // Crit. Care.
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Skrabal C. A. Pericardial suction blood separation attenuates
inflammatory response and hemolysis after cardiopulmonary
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Svitek V., Lonsky V., Anjum F. Pathophysiological aspects
of cardiotomy suction usage // Perfusion. 2010. Vol. 25.
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blood // J. Thorac. Cardiovasc. Surg. 2006. Vol. 131.
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????????? 24.08.2012
??????????? ?????????? ??????????????, ? 3, 2012
??????????, ??? ????? ????????? ????????????
???????? ?????????? ??????????. ?????? ? ??????
???????????? ???????? ? ???????????????? ??????????? ? ???????? ??????????? ???????? ??????? ? ????????? ?????????? ???? ?? ???????????. ? ???? ????? ?????????, ?? ?????? ??????,
??????? ?????????? ????? ????? ?? ??????????????? ???? ? ?? ??????????? ??????????, ????????? ?????????? ?????????? ?????????? ? ????????? ? ?????????????????? ??????????. ??????????? ??????? ?????? ???????? ??????????
???????? ??????????? ? ???????????, ??? ? ?????? ?????????? ?????? ??????? ?????????????
?????????? ????????????????? ?????? ? ? ????????? ??????? ?????????????? ????? [8, 14]. ???
?? ????? ??? ????????? ?????????? ????????? ?
???????? ????????? ????? ?? ??????? ??????????, ? ????? ???????????? ?????? ????????? ?
???????? ? ???????????? ????????? ? ??????? ???????????? ???????? ??????????????? ?????? ?????????? ?????????. ??? ??????????? ???, ???
?????? ????????, ? ??????? ?? ???????? ????? ??
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??????????? ????????? ???????? ????? ? ???????????? ????????? ????????? ?????????? ????????? ?????????????? ?????, ??????????? ????????? ???????? ?????????????????? ???????.
????????? ?? ????????? ?? ?????? ??????????????? ????????? ?????????? ?????????? ?? ???????????? ???? ? ????????? ????????, ?? ? ????????? ?? ????????? ???????? ????????? ?????????-??????????? ??????????, ?????????????? ???
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? ?????? ???????????? ? ??????? ?????????.
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?????? ? ???????????? ???????????? ???????????????) ??????? ??????????? ?????? ????????????,
????????????????? ? ?????????????? ?????????
? ????? ????????? ???? ??????????? ? ??????????? ??????. ??-????????, ????????????? ??????? ?? ???????? ???????????? ??????????? ? ???????? ???????? ???? ??? ?????????? ??????????? ???????????? ?? ????????? ?????????
?????????. ?????????????, ????????????? ?????????? ? ????????? ????????? ?? ??????????????????? ?????? ? ?????? ?????? ???????? ?
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╘ ?. ?. ????????, ?. ?. ?????????, 2012
??? 615.22(083.82):616.12/.14-089
??????????? ???????????? ??????? ????????????? ???????
? ????????-?????????? ???????? ? ???????
????????????????????? ???????
?. ?. ????????*, ?. ?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????
? ?????? ?????? ????????? ?????????? VEN-??????? ? ????????????? ??????????????? ??????, ? ????? ???????? ????????????????? ??????? ??????? ????????????? ???????, ??????????????? ? ????????-?????????? ????????. ? ????? ????????????? ???????????? ???????????? ?????????? ???????????? ?????????????? ????????? ??????? ?? ???, ????????????
?????????? ?????? ?? ?????? ?????? ??? ??????? ??????? ?????, ? ?????? ???????????? ?????? ????????? ? ?????? ??????????? ?????????? ????????? ?????????????? ??????, ????????? ??????? ╚???????????╩ ??????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ????????????? ???????????, VEN-??????, ?????????? ? ?????????? ??????, ????? ??????.
??????????? ?????????? ??????????????, ? 3, 2012
This article presents the results of VEN-analysis and statistically supportive data, and the problems of
multi-expert study of medicinal agents, used in cardiovascular surgery. In order to reasonably expend
medications it is necessary to revise periodically the categories of each of them, use Delfi expert evaluation to solve sophisticated problems, carry out extra analysis if expert opinions and standard documents data disagree, exclude purchase of ?duplicate? medications.
K e y w o r d s : VEN-analysis, formal and expert analysis, Delfi method.
????????
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??????????? ?????? ??-?? ??????? ????????????? ???????????? ???????? ??????????????? ??
????????????? ??????????? ?????? ? ??????????? ?????????? ???????????? ????????? ??????
???????? [3]. ? ?????? ???? ?????? ????? ???????? ????? ? ?????? 1990-? ?????, ????? ???????????? ???????? ??????????????? ????????? ?
??????????? ????????????? ???????? ? ?? ?????????? ????? ????????? ?????????????? ?????????, ?? ?????? ??????????? ???????? [4].
????????? ????? ??? ?????????? ????????
?????? ?? ?????? ?? ???????????? ?????????????
??????? ???????? ???????????? ??????? ?? ??????. ???????? ???? ? ??? ??????????? ??????????? ????????????, ??????????? ??????????
??????? ???????????? ????????? ???????? ????????????????? ???????, ??? ?????????????, ????????????, ??????? ????????????? ?????????? ??
???????? ?????, ???????? ? ???????? ???????,
??????? ???????????????????? ??????? ???????. ?????????? ?????? ????????????? ?????? ??* ????? ??? ?????????: e-mail: in.stupakov@rambler.ru
???????????? ??????????? ????????? ? ????????
??????????? ??????? ?????????? ???????????
?????????? ??? ????????????????? ????????????? ????????????? ????????, ???????????? ?? ??????? ????????????? ??????????.
???? ???????????? ? ???????????? ???????
????????????, ?????????????? ? ????????-?????????? ???????? ??? ??????????????? ? ????????????? ???????????? ?????????????? ?????.
???????? ? ??????
???????????? ????????? ?? ???? ?????
??. ?. ?. ???????? ????, ????????? ??????????
? ?????????? ???????? (?????). ????? 30% ???????????? ??????????, ? ?????? ?? ??????????????? ????????????? ????????, ?? 365 ???? ?????????????? ?? 2011 ?., ????? ? ??????????
╚?????, ??????? ?????????????╩ ? ╚????????-?????????? ???????╩ ?????????????????????? ?????
??????? ???????? ??????????? ? ????????? ????????????? ??????? (?????).
????????????? ????????????? ??????? ?? ??????? ?? ?????????? ????????????? ? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????????? ???????????????
????? ?? ????????? ? ???????????? ???????, ???????? ??????? ????????, ?????????? ????????
????????? ? ???????????.
??????? ??????????? ????????? ??? ???????
????? ???? ??????? ???????????? ? ??????? ???????????? ????????, ??????????? ???????? ?????????? ??????????? ??????????????????? ?
???????????? ?? ??????????? ????????? ??????????????????? [2].
????? ???????????? ??????????? ?????, ??????? ???????? ??????? ???????? ????? ?????
??????????, ????????????? ???? ? ??? ?? ??????????????? ?????. ???????? ????????????
?????, ?????? 1,0, ???????? ?????? ?????????? ?????????? ?????????, ? ???????? 0,0 ? ?????? ?????????? ???????? ????? ????. ???????????? ????????? ???????? ???????????? ?????, ??????
?1,0 (????????? ??????????????? ?????? ????????? ?? ???? ??????? ???????????), ? ??????
???????????? ?? ???????????.
??????????
?????????? ??????????? VEN-???????: ??
275 ?????????? (75,55% ?? ?????? ??????????),
???????? ? ?????? ╚V╩, ???? ?????????????
??????? ????? ??. ?. ?. ???????? ???? ?
????? ?? 83,84% ????? ??????; ?? 89 ??????????
(24,45% ?? ?????? ??????????) ?????? ╚N╩ (????????? ?????????, ?? ???????? ? ????????) ????????????? 16,16% ????? ??????.
???????? ????????? ??????? ???????????????
?????? ???????????? ? ?????? ????????????? ?
?????????? ???????????? (??????????? ???????? ? 0,29, ? < 0,001); ????????? (?? 83 ?? 100%) ????????? ??? 22,6% ??????????????? ??????????
[1, 6]. ??-?? ???????? ? ???????????? ??????????
?????????? ???????? ????????? ?????????????
? ???????????? ??????? ????????: W (2) = 0,66
(??? ????????? ? ?????? ????????? ???? ???);
W (3) = 0,4 (??? ????????); W (4) = 0,02 (?????? ????????); W (5) = 0,06 (???? ?????????); W??= 0,29.
????????? (?? 83 ?? 100%) ????????? ??? 22,6%
??????????????? ?????????? [5].
?????????? ??????????? VEN-??????? ????????, ??? ?? 171 ???????? (57,38% ?? ?????? ??????????) ?????? ╚V╩ ????????????? 79,9% ???????; ??
114 ?????????? (38,26%) ?????? ╚E╩ ? 18,81%;
1,28% ??????? ????????? ?? ?????? ╚N╩, ????????? ?? 13 ?????????? (4,36%).
??????????? ?????: ??????????? ?????????
╚V╩ ??????????? ? ??????????? ??????? ???????
???????? ????? 0,14 (? = 0,14), ??? ???????????
?? ?????? ????????? ? 0,13 (? = 0,14). ??????????? ????? ???????????? ??????? ? ??????? ???????? ??????? ???????????, ?????? 0,5 (? = 0,00).
? ????????? ?????????? ????????? ╚V╩ ??????????? ????? ????? ?????????? ??????????
????????? ? ????????? ╚V╩ ? ??????? ???????
???????? ???????? 0,14 (? = 0,14), ??????? ???????? ? 0,13 (? = 0,14), ?? ???? ?????? ??????? ??????????????? ??????. ? ?? ?? ????? ???????????
????? ????? ???????? ???? ????????? ????????
??????????? ?????????? ??????????????, ? 3, 2012
VEN-???????: ╚V╩ (vital) ? ????????????? ????????, ??????????? ??? ???????? ?????, ?????????
??????????? ??? ??????????? ?????, ? ??, ?????
??????????? ?????? ??????? ??????????? ??????? ??????; ╚?╩ (essential) ? ??????, ????????????? ??? ??????? ????? ???????, ?? ?????????
???????????; ╚N╩ (non-essential) ? ?????????????
???????? ??? ??????? ?????? ???????????, ????????? ???????????? ?????????????, ????????????? ????????? ? ????????????????? ???????????. ????????? N ??????????, ??? ?????? ????????????? ???????? ?????? ??????????? ????
??????, ?????????? ? ???????? (????????) ? ??????? ????? ??????? ????????? ????????.
?????????? ????? ╚V╩, ╚E╩ ??? ╚N╩ ?????????
????????? ╚??????????╩ ??? ╚??????????╩.
╚??????????╩ ?????? ????????????? ????? ????????????? ? ????????? ╚V╩ ?? ????????? ??????? ????????????, ??????????????? ? ????????????? ???????????? ???????????, ? ?????? ???????? ????? ?? 2012 ?., ????????????
????????????? ????????????? ?? ?? 7 ???????
2011 ?. ? 2199-?. ????????? ╚E╩ ?? ?????????????,
??? ??? ? ????????????? ??????????? ??????????
??? ??????? ?? ????? ?????? ?????????. ???? ?????????, ???????? ?? ╚V╩, ????????????? ??????
╚N╩. ??? ????????????? ??????? ╚??????????╩
?????????????? ??????????? ? ????? ?? ????
????? ???????????? ?? ????????? ????????????????? ??????. ??? ??????????????? ????????? ????????????, ??????? ? ??????????????? ?????
????? ??????, ????????????? ? ??????????, ???????? ????????? ?? ???????? ?? ?????? ??????
????, ?? ? ?????? ??????? ????????????, ?????????????? ???????????????? ?????????? ??????? ?????????.
??? ????????????? ????? ?????? ???? ????????? ??? ???????? ????? ??????, ????????????????? ?????????????? ????????????? ?????????
?????????? ????? ???????? ? ?? ??????????
???????????? ????????????? ?? ???? ???????????? ??????? ???????? ? ?????????? ?????? ????????? ?? ??? ???, ???? ???????? ???????? ??????
?? ????? ?????????? ? ?????? ??????? ?????????????? ????????? ????????? ???????????? ??????.
?????????? ??????????? ?????? ??????? ??????
????? ????????? ? ??????????? ????????, ? ?????????? ???? ????????? ????????????? ?????????? ????????? ? ????????? ??? ??????????? ???????? ?????????????? ??????????? ???????????
?? ??????????? ???????. ????? ????, ????? ??????????? ??????????????? ??????????????? ???????????? ???????? ??????????????, ??????????
?? ???????????, ???????????????? ??????????
??? ?????????????? ? ?????????? ????????????
[2]. ?????????? ?????? ?????? ????????? ??????? ?????????? ??????????????? ?? ?????? ?????
?????? ????. ??? ????????? ?????????? ??????
?????????? 6 ?????????.
??????? ???????????? ???????? VEN-???????
???? ????????? ???????? ???????? (╚V╩ ? 3 ?????,
╚E╩ ? 2 ?????, ╚N╩ ? 1 ????). ?????? ?? ???? ??????, ? ??????? ?????????, ??????? ??? ???????
63
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
64
??????????? ???????????????
0,5 (? = 0,000), ??? ??????????????? ? ???????? ?????????? ?????? ?????????, ?? ??????? ???????
??????????????? ????? ?????, ??? ? ??????????
????????? ╚????????? ????????╩ ?????????.
??????????? ?????????? ??????????????, ? 3, 2012
??????????
????? ???????, ????? 80% ??????? ????????????? ??????? ???????? ? ?????? ╚V╩, ? ??? ??????????????? ? ???????????? ????????????? ? ?????????? ????????? ?????????????? ???????
????????????. ????? ?? ????????? ?????????????? ? ?????????? ??????.
??? ????????? ????????? ??????????? ??????????? ? ??????????? ??????? ????????, ??? ?????????? ??????????????? ????????????? ???????? ??????????? ?????????? ????? ??????????
??????? ? ???????????, ? ????? ??????? ??????????? ? ???????????? ? ????????? ?????? ?????????????? ??????????. ????????, ??? ???????
???????????? ????????? ??????? ?????????? ??
???? ??????? ? ??????? ?????????? ???? ???????? ?????? ? ??????????? ?????????? ?????? ?
?????? ??????.
?????????????? ??????????? ???????????, ????????? ? ?????????? ???????? ?????? ?? ????????? ? ????????????????? ?????????????????
??????, ????? ???? ????????? ???????????????
????????? ? ?????? ?????????????? ????????-?????????? ????????. ? ???? ??????? ╚N╩ ??????????
????????? ?? ╚?????????????╩ ? ????????, ? ??
?????? ??? ?????????, ? ???????? ??? ???????
???????. ????? ????, ????? ?????? ???? ????????
?????????, ?? ???????????????? ?????? ???????????? ? ???????? ? ??? ?????????? ?????? ??
?????????????. ? ????? ? ???? ???????? ??????
???? ?????????? ???????????? ? ?????? ???????????? ? ?????? ?????? ??? ???????????? ? ????????????? ????????, ??????? ???? ???????????.
???? ? ???????? ????????????? ??????? ??? ????????.
2. ?????????? ?????? ??????????????? ? ???????????????? ????????????? ?????????? ??????
???????????? ?? ?????? ?????? ??? ???????
??????? ??????????????? ????? ?? ???????
????????? ????????-?????????? ???????? ? ??????????? ??????????????? (???????????? ????????? ? ???????????? ??????? ??????????? ???????????, ??????????? ????????????? ????????
?? ?????? ? ???????).
3. ? ???????? ?????? ?? ????????? ??????? ??????? ? ????????????? ?????????? (??? ?????????? ?? ????????) ??? ??? ???? ?????????????
???????, ? ?????? ???????????? ?????? ?????????
? ?????? ??????????? ?????????? (????????,
????????? ??????????? ? ??????????, ?? ???????
????????? ??? ???????? ???????????), ???????????? ?????????? ??????????????? ??????? ????
???????????? ? ?????? ????????????? ?????????????, ?????????????, ??????????? ?????????? ?
ABC-????????.
4. ????? ???????? ????????? ??????????? ???????????? ?????????? ???????????? ??????????? ????????????? ???????, ? ?????????? ???????
????????????? ???????? ?????????? ??????????? ??????? ╚???????????╩ ??????????, ?????????? ??????????????? ?????? ? ?????????? ??????? ?????????????? ???????????.
??????????
1.
2.
3.
4.
??????
1. ????????? ??????? ?????????????? ????????
?????? ???????????? ????????????????. ?????????? ?????????? ????????? ???????? ?????
????????????? ?????????, ??????? ????? ????-
5.
6.
??????? ?. ?., ???????? ?. ?. ?????????? ?????????? ?
?????? ????????????. ?.: ?????, 1998. 164 ?.
??????? ?. ?., ?????? ?. ?. ??????????-??????????????
?????? ?????????? ?????? // 2-? ???. ???????. ? ???.
?.: ??????????, 2000. 263 ?.
?????????? ?. ?., ??????? ?. ?., ??????? ?. ?., ????????? ?. ?. ???????????????????? ?????? ?????????
??????? ????????????? ????????? // ??????-??????????? ??????. 2001. ? 1. ?. 50?52.
??????????? ?. ?. ???? ??????????? ???????????? ????????????? ??????? ? ??????? ???????? ?? ?????????????
????????????? // ???????????? ????. ?????. ? 4. 2003.
?. 88?94.
???????? ?. ?. ?????? ??????????????? ??????. ?.: ??????? ???, 2000.
Bower K. M., Colton J. A. Why we don?t ╚Accept╩ the Null
Hypothesis // American Society for Quality, Six Sigma Forum,
2003. P. 16?19.
????????? 07.09.2012
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
??????? ??? ???????
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???????? ??????? ????? ????? ?????????????? ?????????? ?????? ? ??????? ?????????, ??????????, ??????????? ? ??????? ??????????? ?????? ? ???????, ? ????? ????????????????? ??????????? ????????????, ???????????? ? ???? ? ??????? ??????????????.
???????? ???????????? ??????? ?????????? ?????? ???????????? ??? ??????????
??????, ??????????? ????????????? ?? ?? ????????????? ??????? ? ???????????? ????????????? ????? ??????? ????????? ? ??????? ?????????? ??? ?????????? ????????????
? ????????????? ????????????.
??? ???????????? ???????? ???????? ???????????? ????????. ??????? ? ??????????? ????????????? ??????????? ???????????? ????????? ? ????????????
??????? ?? ????????? ??????? ???????????? ? ??????? ?????????? ????????????, ???
??????? ? ????????????? ?????????? ??????????? ? ?????? ?????? ???? ??? ????? ???????????, ? ??? ????????????? ? ??????????? ?? ?????????????? ??????????. ????
?????? ??????? ? ??????????, ???????? ????????? ?? ????? ????? ???????????? ??????, ?????????????? ??????? ?? ?????????? ?????????, ??? ????????? ??????????
??????.
???????? ?? ????????????? ????????, ????? ?????????????? ? ?????? ????????????? ????????.
?????????? ????????????????? ?????????????? ???????????? ?????? ????
????????? ? ???????????? ? ????????????? ??????????? ??? ???????????? ???????
??????? (http://www. consort-statement. org/).
????? ?????? ???????? ? ?????????? ?? ???? ????? ?? ????? ???? ???????? ???
???????? ? ????????? ?????????, ??? ?? ??? ?? ????? ???? ??????? ? ??????? ???????
??? ??????????? ???????? ???? ?????????? ??????.
?????? ??????? ???????????? ???????? ?????? ?????? ? ?????? ??? ?????????? ??
??????????? ?????? ? ?? ?? ????????? ???????? ??????? ? ??????????? ??????????.
??? ????????, ?????????? ?????????????? ??????, ?????? ?????? ????????????????
????????????????? ?????? ??????? ????????????, ???????, ????????????? ? ????????????? ??????????? ?? ??????????? ? ????????.
???????? ??????? ?????????????? ???? ???????????? ?????????? ? ???????, ???
??? ???????????? ? ???????? ???????? ?????? ???? ????????? ? ???????????? ? ?????
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??????? ? ??????????? ??? ?????? ?????? ? ??????????? ╚? ??.╩ (? ??????????? ?????????? ╚et al.╩). ? ?????? ?????? ?????? ???? ?????????? ???????? ? ?????????? ???????. ?????? ????????, ???-????? ? ???????????????? ?????? ?? ?????? ?????????? ?
?????? ??????. ???????????? ???????? ?????? ???? ??????? ? ???????????? ? Index
Medicus.
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1. ????????? ?. ?., ????? ?. ?., ???????? ?. ?. ? ??. ??????????? ???????????????????? ????????? ? ?????? ????????????????? ??????? ? ????? ??????? ???? ????? ?
??????????? ???????? ?????? // ????????? ????? ??. ?. ?. ???????? ????. 2008.
?. 9, ? 6. ?. 247?254.
??????? ????????????:
2. Rubens F. D., Labow R. S., Lavallee G. R. et al. Hematologic evaluation of cardiopulmonary bypass circuits prepared with a novel block copolymer // Ann. Thorac. Surg. 1999. Vol. 67.
P. 689?698.
?????:
3. ???????? ?. ?. ?????????????? ????????. ???.: ??????, 2000. 227 ?.
4. Ferraris V. A., Ferraris S. P. Fibrinolytic activation in cardiopulmonary bypass: impact
on the management of bleeding // Management of bleeding in cardiovascular surgery /
Ed. R. Piffare. Philadelphia: Hanley & Belfus Inc., 2000. 502 ?.
???????????:
5. ??????? ?. ?. ??????????? ???????? ? ????? ? ?????? ???? ?? 5 ??: ???. ? ????.
???. ????. ?., 2010. 208 ?.
??????-?????????? (???????? ????????: doi ? ??????????? ???????? ???????????):
6. Kazaz M., Celkan M. A., Ustunsoy H., Baspinar O. Mitral annuloplasty with biodegradable ring for infective endocarditis: a new tool for the surgeon for valve repair in childhood //
Interact. Cardiovasc. Thorac. Surg. doi: 10.1510/icvts.2005.105833.
?????????? ???????-???????????? ??????????? ??????? ?????????????????
??????? ??????? ????????????? ??????? ?????????? ??????????: ???????????????????? ?-?????????? ????? (hsCRP), ??????????? ??????????
????????, ??????????????? ?? ?????????? ???????-1 (sTREM-1), ?????? ??????? ????????
(TNF), ???????????-6 (IL-6), ???????????-10
(IL-10). ????? ????????????: ?????? ? ??? ??????????? ???????? ? ????????????, ?????? ? ???? ?????? ????? ????? ????????.
???????? ??????? ?????????????????? ??????? ????????? ?? ???? ???????????: ???????????
? ?????????? ?????????????? ???????? ???????
(????), ??????????? ? ???? ????????????????,
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???? ????? ? ????????????? ?????????? ????????????? ????????? ????? ?????, ??????? ???????? ???????????? ??????????????? ?? ?????
SOFA [13].
??? ???????? ????? ????? ????? ?????????? ?
???????????? ??????????? ??????????????? ????????. ?????? ???????????? ??????? ?? ?????????
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?????????????? ?????? ?????????? ? ??????? ????????????????? ????????? Statistica 6.0,
StatSoft, Inc. ?????? ???????????? ? ???????
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? < 0,05.
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??? ???????????? ???????????? (????. 4).
??? ?????? ????????? ??????? ??????? ?????????????????? ??????? ? ?????? ? ?????????????? ?????? ?????????? ????????? ????? ????????
?????????? ?????? ??????????? ?????????? ??
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???????? ??????? ???????? ???????????? ??????????/???????????????, ??????? ???????????
?? ????????? ????? SOFA. ??? ???? ?????????????? ????????? ???????????????? ??????? (?
?????? ?????? ????????-??????????) ?? ??????????? ????? ?? ????????? ?????????. ????? ???????? ???????? ??????? ???????????? ??????????
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??????????? ?????????? ????????, ??????????????? ?? ?????????? ??????? ? ??. [8, 10]. ????????????? ???????????? ????????????? ???????
?????????? ? ??????????? ? ??????????? ???????? ????????????? ?????????? ???????????????
??????, ????? ??? ?? ????????? ??????????? ??????????? ????????? ??? ????????????? ??????????? ? ??????????????? ?????????? ??????????
(??????, ??????????, ????????? ????? ?????????????? ??????????????). ??????????? ??? ??????
????????? ??????????????? ? ??????????????? ?????? ???????? ???????? ???????????????? ? ??????? ╚???????????????╩ ????????? ??????????
?????????? [8, 10]. ? ???? ????? ???? ??????, ?????????? ?? ???????? ????????? ?? ????????????????? ????????, ????????????? ???????????? ????????????????? ????????? ????? ? ??????? ??????????? ?????????? ?????????? [8].
?????? ?????????? ????????? ?????????? ?
???????? ??????? ???????? ????? ?? ???????
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??????????? ?????????? ?????
??????????. ????????? ?????, ???????????? ??? ????????????? ?????? ???????? ????? ?????? ????????? ? ???????????? ???????????????? ????????? ???????????? ?????????????????? ??????? ?
????????????????, ???????? ?? ?????? ????????????? ???????????, ????????????? ????????? ? ??.
????? ???????, ?????????? ?????? ?????????? ????????? ????? ?? ????? ?????????????
????????? ????????????? ????????? ???????
?????? ? ???????? ?????????????? ?????????????? ?? ???? ?????????? ???????? ???????? ????????? ? ???????????? ??????? ?????????? ????????? ?????????????? ????? ? ???????? ???????? ??????? ?????????????????? ???????. ???
???? ????????? ??????? ???????? ????????????
???????????????, ??????????? ??????????? ?
???????????????? ? ???????????? ?????????????
?????????, ??????????? ?????????? ???????? ?
??????????, ??????????? ??????????? ? ???????
??????????????????? ???????? ?????.
??????????
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
??????????? ?. ?., ??????????? ?. ?., ????????? ?. ?., ???????? ?. ?. ??????? ????????????????? ?? ?????????????
?????????? ??? ????????? ? ???????? ?????????????? ?????????????? // ????? ??????????????. 2011. ? 2.
Asimakopoulos G. Systemic inflammation and cardiac surgery:
an update // Perfusion. 2001. Vol. 1. P. 353?360.
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Svitek V., Lonsky V., Anjum F. Pathophysiological aspects
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P. 147?152.
Vincent J. L., Moreno R., Takala J. et al. The SOFA (Sepsisrelated Organ Failure Assessment) score to describe organ dysfunction/failure // Int. Care Med. 1996. Vol. 22. P. 707?710.
Westerberg M. Hemodynamic effects of cardiotomy suction
blood // J. Thorac. Cardiovasc. Surg. 2006. Vol. 131.
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????????? 24.08.2012
??????????? ?????????? ??????????????, ? 3, 2012
??????????, ??? ????? ????????? ????????????
???????? ?????????? ??????????. ?????? ? ??????
???????????? ???????? ? ???????????????? ??????????? ? ???????? ??????????? ???????? ??????? ? ????????? ?????????? ???? ?? ???????????. ? ???? ????? ?????????, ?? ?????? ??????,
??????? ?????????? ????? ????? ?? ??????????????? ???? ? ?? ??????????? ??????????, ????????? ?????????? ?????????? ?????????? ? ????????? ? ?????????????????? ??????????. ??????????? ??????? ?????? ???????? ??????????
???????? ??????????? ? ???????????, ??? ? ?????? ?????????? ?????? ??????? ?????????????
?????????? ????????????????? ?????? ? ? ????????? ??????? ?????????????? ????? [8, 14]. ???
?? ????? ??? ????????? ?????????? ????????? ?
???????? ????????? ????? ?? ??????? ??????????, ? ????? ???????????? ?????? ????????? ?
???????? ? ???????????? ????????? ? ??????? ???????????? ???????? ??????????????? ?????? ?????????? ?????????. ??? ??????????? ???, ???
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????????? ?? ????????? ?? ?????? ??????????????? ????????? ?????????? ?????????? ?? ???????????? ???? ? ????????? ????????, ?? ? ????????? ?? ????????? ???????? ????????? ?????????-??????????? ??????????, ?????????????? ???
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????????????.
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?????? ? ???????????? ???????????? ???????????????) ??????? ??????????? ?????? ????????????,
????????????????? ? ?????????????? ?????????
? ????? ????????? ???? ??????????? ? ??????????? ??????. ??-????????, ????????????? ??????? ?? ???????? ???????????? ??????????? ? ???????? ???????? ???? ??? ?????????? ??????????? ???????????? ?? ????????? ?????????
?????????. ?????????????, ????????????? ?????????? ? ????????? ????????? ?? ??????????????????? ?????? ? ?????? ?????? ???????? ?
?????? ???????? ????? ???????? ????????????
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61
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
62
??????????? ???????????????
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╘ ?. ?. ????????, ?. ?. ?????????, 2012
??? 615.22(083.82):616.12/.14-089
??????????? ???????????? ??????? ????????????? ???????
? ????????-?????????? ???????? ? ???????
????????????????????? ???????
?. ?. ????????*, ?. ?. ?????????
???? ╚??????? ????? ????????-?????????? ???????? ??. ?. ?. ????????╩ (???????? ? ???????? ???
? ???? ?. ?. ???????) ????, ??????
? ?????? ?????? ????????? ?????????? VEN-??????? ? ????????????? ??????????????? ??????, ? ????? ???????? ????????????????? ??????? ??????? ????????????? ???????, ??????????????? ? ????????-?????????? ????????. ? ????? ????????????? ???????????? ???????????? ?????????? ???????????? ?????????????? ????????? ??????? ?? ???, ????????????
?????????? ?????? ?? ?????? ?????? ??? ??????? ??????? ?????, ? ?????? ???????????? ?????? ????????? ? ?????? ??????????? ?????????? ????????? ?????????????? ??????, ????????? ??????? ╚???????????╩ ??????????.
? ? ? ? ? ? ? ? ? ? ? ? ?: ????????????? ???????????, VEN-??????, ?????????? ? ?????????? ??????, ????? ??????.
??????????? ?????????? ??????????????, ? 3, 2012
This article presents the results of VEN-analysis and statistically supportive data, and the problems of
multi-expert study of medicinal agents, used in cardiovascular surgery. In order to reasonably expend
medications it is necessary to revise periodically the categories of each of them, use Delfi expert evaluation to solve sophisticated problems, carry out extra analysis if expert opinions and standard documents data disagree, exclude purchase of ?duplicate? medications.
K e y w o r d s : VEN-analysis, formal and expert analysis, Delfi method.
????????
? ???????? ????????????? ? ?????????????
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????????????? ??????????? ?????? ? ??????????? ?????????? ???????????? ????????? ??????
???????? [3]. ? ?????? ???? ?????? ????? ???????? ????? ? ?????? 1990-? ?????, ????? ???????????? ???????? ??????????????? ????????? ?
??????????? ????????????? ???????? ? ?? ?????????? ????? ????????? ?????????????? ?????????, ?? ?????? ??????????? ???????? [4].
????????? ????? ??? ?????????? ????????
?????? ?? ?????? ?? ???????????? ?????????????
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???????? ?????, ???????? ? ???????? ???????,
??????? ???????????????????? ??????? ???????. ?????????? ?????? ????????????? ?????? ??* ????? ??? ?????????: e-mail: in.stupakov@rambler.ru
???????????? ??????????? ????????? ? ????????
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?????????? ??? ????????????????? ????????????? ????????????? ????????, ???????????? ?? ??????? ????????????? ??????????.
???? ???????????? ? ???????????? ???????
????????????, ?????????????? ? ????????-?????????? ???????? ??? ??????????????? ? ????????????? ???????????? ?????????????? ?????.
???????? ? ??????
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??. ?. ?. ???????? ????, ????????? ??????????
? ?????????? ???????? (?????). ????? 30% ???????????? ??????????, ? ?????? ?? ??????????????? ????????????? ????????, ?? 365 ???? ?????????????? ?? 2011 ?., ????? ? ??????????
╚?????, ??????? ?????????????╩ ? ╚????????-?????????? ???????╩ ?????????????????????? ?????
??????? ???????? ??????????? ? ????????? ????????????? ??????? (?????).
????????????? ????????????? ??????? ?? ??????? ?? ?????????? ????????????? ? ???????
Copyright ??? ╚??? ╚??????╩ & ??? ╚A???????? K????-C?????╩
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