History and Current Status of Cardiac Anesthesiology in Russia

Accepted Manuscript

History and Current Status of Cardiac Anesthesiology in Russia Vladimir V. Lomivorotov MD, PhD , Sergey M. Efremov MD, PhD , Mikhail Y. Kirov MD, PhD , Dmitriy V. Guvakov MD , Igor A. Kozlov MD, PhD , Vladimir N. Lomivorotov , Alexander M. Karaskov MD, PhD PII: DOI: Reference:

S1053-0770(18)30407-5 10.1053/j.jvca.2018.06.015 YJCAN 4763

To appear in:

Journal of Cardiothoracic and Vascular Anesthesia

Received date:

30 April 2018

Please cite this article as: Vladimir V. Lomivorotov MD, PhD , Sergey M. Efremov MD, PhD , Mikhail Y. Kirov MD, PhD , Dmitriy V. Guvakov MD , Igor A. Kozlov MD, PhD , Vladimir N. Lomivorotov , Alexander M. Karaskov MD, PhD , History and Current Status of Cardiac Anesthesiology in Russia, Journal of Cardiothoracic and Vascular Anesthesia (2018), doi: 10.1053/j.jvca.2018.06.015

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Title: History and Current Status of Cardiac Anesthesiology in Russia Affiliation: E. Meshalkin National Medical Research Center, Rechkunovskaya 15 street, 630055, Novosibirsk, Russia

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Vladimir V. Lomivorotov (corresponding author), MD, PhD e-mail: [email protected]; [email protected] Tel: 073832924103 Fax: 073833322437 E. Meshalkin National Medical Research Center, Rechkunovskaya 15 street, 630055, Novosibirsk, Russia Department of Anaesthesiology and Intensive Care

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Sergey M. Efremov, MD, PhD E. Meshalkin National Medical Research Center, Novosibirsk, Russia Department of Anaesthesiology and Intensive Care Mikhail Y. Kirov, MD, PhD Northern State Medical University, Arkhangelsk, Russia Department of Anesthesiology and Intensive Care Medicine

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Dmitriy V. Guvakov, MD Temple University Medical Center, Philadelphia, USA Department of Anesthesiology and Critical Care

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Igor A. Kozlov, MD, PhD Moscow Regional Clinical and Research Institute, Moscow, Russia Department of Anesthesiology

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Vladimir N. Lomivorotov E. Meshalkin National Medical Research Center, Novosibirsk, Russia Educational and Treaining Center

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Alexander M. Karaskov, MD, PhD E. Meshalkin National Medical Research Center, Novosibirsk, Russia Department of Cardiac Surgery

Funding None Conflict of interest None 1

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Key words: cardiac anesthesia, cardiopulmonary bypass, hypothermia, Russia; perfusionless hypothermia

Acknowledgment The author thanks Dr. Erina M. Ng for valuable assistance in correcting

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the English language of this article. As this article does not pretend to fully cover the history of cardiothoracic anesthesia in Russia, the author apologies for any omission of other physicians and scientists who have contributed

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significantly to this field.

Introduction

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Anesthesiology, the branch of medicine concerning anesthesia and management of the

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vital functions of patients undergoing surgery, has played an important role in the development of cardiac surgery. In the middle of the last century, medical professionals

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had little experience in the treatment of congenital and acquired heart diseases. Progress of cardiac anesthesiology in Russia, as well as in countries across the globe, was due to

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requests to increase the safety of surgical procedures and to improve survival rates for the

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increasing number of patients with complex heart diseases. The development of cardiac surgery and anesthesiology in Russia evolved in two directions simultaneously in the mid-1950s. Some surgeons widely accepted the use of perfusionless hypothermia (hypothermia caused by surface cooling without perfusion); others were in favor of cardiopulmonary bypass (CPB) technology. This review focuses on major historic milestones of cardiac anesthesiology in Russia, as well as its current status and the major problems it faces today. 2

ACCEPTED MANUSCRIPT 1. Major milestones and pioneers A subspecialty of cardiac anesthesiology originated with thoracic anesthesiology due to the anatomic proximity of the organs, similar operative techniques, and the need for mechanical ventilation in both thoracic and cardiac surgery. Prominent Russian surgeons, including Alexander Bakulev, Evgeny Meshalkin, Boris Petrovskiy, Alexander

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Vishnevskiy, and Vladimir Burakovskiy, highlighted the role of cardiac anesthesiologists such as Gennady Ryabov, Armen Bunatyan, Vladimir Vanevskiy, Tigran Darbinyan, and Ivan Vereshagin who made significant contributions to the development of cardiac anesthesiology in Russia.

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It has been said that the history of Russian cardiac anesthesia began on September 24, 1948, when Dr. Bakulev closed a patent ductus arteriosus in First City Hospital in Moscow (Figure 1) [1]. Anesthesia during the procedure was performed by cardiac

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surgeon Meshalkin, who was the first in Russia to implement tracheal intubation with general anesthesia, and who gained a PhD in 1950 for development of the technique

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(Figure 2). It is difficult to determine who was the first anesthesiologist in charge or who first handled anesthesia for cardiac procedures, but it could have been either Elena

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Damir from Moscow or Boris Uvarov from St. Petersburg, both of whom contributed

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greatly to the development of cardiac anesthesiology in Russia. During a surgical congress in London in 1946, Bakulev was presented with British-

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made anesthesia machines. Until that time, the use of local anesthesia was widely accepted among surgeons, as they did not believe new techniques would improve outcomes [1]. The development of cardiac surgery and anesthesiology in Russia took two directions in the mid-1950s. Some surgeons widely accepted the use of perfusionless hypothermia; others were in favor of CPB technology. Major milestones of the development of cardiac surgery and cardiac anesthesiology are presented in Figure 3. 3

ACCEPTED MANUSCRIPT On September 2, 1952, John Lewis and Mansur Taufic performed the first open-heart procedure when they closed an atrial septal defect in a 5-year-old girl under moderate surface hypothermia (perfusionless hypothermia) [2]. In subsequent years, cardiac surgery employing surface body cooling to achieve controlled hypothermia was successfully implemented in hospitals in several countries. The first open-heart procedure

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(pulmonary artery valvotomy) in Russia utilizing perfusionless hypothermia was performed in Moscow by Meshalkin in 1955. The patient was successfully discharged from the hospital. Meshalkin was also the first surgeon in the world to perform anastomosis of the superior vena cava with the pulmonary artery (“Glenn shunt”) in a

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patient with congenital heart disease [3].

In 1957, Meshalkin moved to Novosibirsk to lead the Institute of Experimental Biology and Medicine, renamed the Research Institute of Circulation Pathology in 1964. Afterwards, by combining perfusionless hypothermia with several medications, Elena

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Litasova (Figure 4) and her colleagues Ivan Vereshagin and Vladimir Lomivorotov were

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able to extend the maximum safe period of hypothermic circulatory arrest to 75 minutes. This limit was sufficient to operate on even complex cardiac defects with a low incidence

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of neurological complications [4].

In general, the perfusionless hypothermia technique can be described as follows. For

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monitoring, central venous and arterial lines were inserted (initially, in the mid-60s, non-

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invasive blood pressure monitoring was used throughout surgery), and a wide-bore cannula was placed in the femoral vein. Cooling was initiated by covering the body with finely crushed ice and cooling the head with an ice pack placed in a fabric helmet (Figure 5). When the patient’s temperature dropped to 29-30°C, the ice was removed from the body. The ice pack was kept around the head, however, for further cooling. The chest cavity was accessed via a bilateral thoracosternotomy (clamshell incision), and slings were passed around the aorta, superior vena cava, and inferior vena cava. During these 4

ACCEPTED MANUSCRIPT maneuvers, the temperature dropped further due to cooling of the head, and when it reached 24-28°C (depending on the expected aortic cross-clamp time), the intracardiac part of the operation was initiated. Several minutes before circulatory arrest, a 4% solution of sodium bicarbonate (2 mg/kg) was administered to prevent metabolic acidosis during hypothermic circulatory arrest. To avoid cerebral hypertension, blood was vented

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from the superior vena cava through a cannula passed from the right atrium at a rate of 0.5-1.0 mL/kg every 10 minutes during aortic occlusion. All collected blood was autotransfused. Rewarming was started by irrigating the pleural cavities with a warm physiological solution (42-43°C). After thorough hemostasis and once the patient’s

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temperature reached 33-35°C, the chest was closed. The patient was transferred to the intensive care unit, where rewarming continued.

With strict adherence to the protocol developed and refined at the Research Institute of Circulation Pathology, the use of perfusionless hypothermia in patients with congenital

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heart defects further reduced the mortality rate to less than 1% [5]. Perfusionless

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hypothermia (25-26oC) became widely accepted in several hospitals in Russia, especially in Siberia and the Far East, including hospitals in Novosibirsk, Pyatigorsk, Tomsk,

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Barnaul, Khabarovsk, Tyumen, and Irkutsk. These sites did not have wide access to the then-modern CPB machines, which were only available in the hospitals of Moscow and

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St. Petersburg. The technique of perfusionless hypothermia was also implemented in

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Russia by other surgeons such as Bakulev, Burakovskiy, Petrovskiy, and Fedor Uglov. On May 6, 1953, Dr. John Gibbon Jr. successfully closed an atrial septal defect with the

assistance of extracorporeal circulation, a technique he had been working on since the 1930s [6]. It should be noted that research in this field was also being conducted in Russia in the late 1920s and early 1930s. Another pioneer of CPB technology was the prominent Russian physiologist Sergey Brukhonenko, who developed the first CPB machine in 1924 (Figure 6). He and physiologist Sergey Tchetchuline conducted a series 5

ACCEPTED MANUSCRIPT of experiments on isolated perfusion of a canine head. Further development of the machine allowed Brukhonenko to conduct CPB surgeries on canines [7]. At the time when CPB technology was first being used for human cardiac surgery, the use of hypothermic perfusion was commonly accepted in the attempt to reduce the deleterious effects of CPB surgeries. The pioneer of perfusion hypothermia was Dr. Puchkov, who conducted his experiments in Brukhonenko’s laboratory [8]. On June 27, 1931, Puchkov

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cooled a dog to a core temperature of 13.5oC using a heat exchanger (coil) built-in arterial line and overlaying the dog with ice. The first successful open-heart procedures were performed on animals by surgeon Nikolay Terebinskiy in 1928 and 1929.

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World War II greatly suspended the improvement of CPB technology in Russia. In 1952, work resumed at the Research Institute of Experimental Surgical Equipment and Medical Instruments in Moscow. Dr. Vishnevskiy performed the first successful open-heart procedure in 1957 using the CPB-57 machine. Then, in 1959 and 1960, use of CPB

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technology began to take root in the leading hospitals across the Soviet Union. Changes

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in the political system after liberalization of the USSR opened up the international market of medical technology, equipment, and medication. This helped bring Russian surgery

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and anesthesia practices to international standards. The reforms also changed the domestic medical markets, because the governmental medical industry was not

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competitive. CPB machines became available across the country, pushing perfusionless

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hypothermia into the past. It is possible to say, without exaggeration, that one of the founding fathers of cardiac

anesthesiology in Russia was Professor Armen Bunatyan of the Boris Petrovskiy Russian Scientific Center of Surgery in Moscow (Figure 7). Born in 1930, he graduated from Moscow State Medical Institute in 1954 and gained his PhD in 1959. In the 1960s, he visited several leading hospitals in the United Kingdom and the United States of America to study the anesthetic management of cardiac procedures employing CPB technology. In 6

ACCEPTED MANUSCRIPT 1967, he published a monography, “Hypothermic perfusion in open heart surgery,” which served as a guideline for all cardiac anesthesiologists at that time. He also contributed to the development of anesthetic management of organ transplantation and vascular surgery [9]. In 1973, he implemented electronic anesthesia records into everyday practice. During anesthesia, analogue signals from invasive blood pressure monitors (arterial line, central

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venous line, left ventricle) were transmitted through analog-to-digital converters to a computer, where they were processed and printed if necessary [10]. The analysis and recording of cardiac output were also possible with the use of the Warner technique [11]. Bunatyan’s school was one of the few cardiac centers in Russia where all specialists from

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around the country were trained.

The first successful heart transplant, performed by Christian Barnard in 1967, was preceded by decades of experiments [12]. Among Russian scientists, a special place is devoted to one of the founders of transplantology, Vladimir Demihov, who had

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developed more than 20 techniques for heterotopic heart transplants by 1960. In the early

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sixties, immediately before Barnard’s his historic breakthrough, he was a visiting surgeon in Demihov’s laboratory in Moscow. In November 1968, 11 months after Barnard,

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Vishnevskiy performed the first heart transplant in Russia [13]. The procedure was performed in St. Petersburg (formerly Leningrad) at the S.M. Kirov Military Medical

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Academy. The recipient was a 25-year-old woman with acquired heart disease; the donor

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was a 19-year-old woman who had suffered multiple traumas. Unfortunately, the surgery was ultimately unsuccessful, and the patient died 33 days after her heart transplant due to severe right ventricular failure. Although anesthetic management for this case is not described in the available literature, details of the management of CPB technology and intensive care were mentioned. Anesthesiologists were responsible for donor management, operation of the CPB equipment during the heart transplantation, and management of the acute heart failure after surgery. The first successful heart transplant 7

ACCEPTED MANUSCRIPT in the USSR was performed on March 12, 1987 by the scientist and surgeon Valery Shumakov; he was assisted by Mikhail Semenovskiy and Mogeli Khubutiya. The 27year-old patient, who had dilated cardiomyopathy, survived for 8.5 years after the surgery [14]. The expanding role of anesthesiologists in the management of patients undergoing CPB

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surgery, including heart transplantation, was highlighted by prominent surgeon Denton Cooley [15]. In 1990, Igor Kozlov, an anesthesiologist from the Federal Research Center of Transplantology and Artificial Organs in Moscow, published an article describing the first experiences of anesthetic management for heart transplantation [16]. It summarized

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the results of the first 27 cases and described the intensive care of the donors in an attempt to improve heart function, as well as the anesthetic management and hemodynamic support of the recipients. Special attention was given to the treatment of right ventricular failure. Maintenance of the anesthesia was achieved with high-doses of

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opioids and low-doses of ketamine, benzodiazepines, and inhalational nitrous oxide.

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Isoproterenol and dopamine were used as inotropic agents. Today, this operation is performed in several hospitals in Moscow, St. Petersburg,

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Novosibirsk, Ekaterinburg, Krasnodar, and Kemerovo, and the role of the cardiac

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anesthesiologist in the success of heart transplantation is hard to overestimate.

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2. Current status

Presently, more than 110 hospitals in the Russian Federation perform open-heart

surgical procedures. More than 50,000 CPB procedures were performed in 2016. Among those were 36,881 coronary artery bypass graft (CABG) surgeries and 13,761 open-heart valve procedures (Table 1) [17]. Combined surgeries, surgeries for congenital heart diseases, aortic surgeries, pulmonary artery thrombectomies, heart transplantations, and other surgeries for cardiomyopathies are also performed. The overwhelming majority of 8

ACCEPTED MANUSCRIPT cardiac interventions are government-funded. The number of percutaneous coronary interventions has increased annually (127,584 in 2011 and 183,443 in 2016), whereas the number of CABG procedures is stable (36,632 in 2014 and 36,881 in 2016). All kinds of surgeries for congenital heart diseases are now performed in Russia, including Norwood and Fontan procedures, anatomical correction of malposition of the great arteries, and

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others. Currently, Russian cardiac anesthesiologists are highly trained specialists working in modernly equipped operating rooms. A wide range of standard medications is also available. These include volatile anesthetics (isoflurane, sevoflurane, desflurane), opioids

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(fentanyl, sufentanyl), ketamine, propofol, and dexmedetomidine. Available inotropic agents include catecholamines (isoproterenol, dobutamine, dopamine, epinephrine, and norepinephrine) and the calcium sensitizer levosimendan. The majority of open-heart procedures are performed under general anesthesia; however, epidural anesthesia (alone

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or in addition to general anesthesia) is not uncommon in some centers [18, 19].

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Standard monitoring in most Russian cardiac hospitals includes electrocardiography (ECG), pulse oximetry, invasive arterial pressure, capnography, and, in some hospitals,

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cerebral oximetry and monitoring of anesthesia depth. Perioperative monitoring of cardiac output and additional hemodynamic variables using Swan-Ganz catheterization or

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transpulmonary thermodilution is performed in high-risk and hemodynamically unstable

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patients. The number of cardiosurgical institutions is able to provide continuous cardiac output monitoring, mostly by pulse contour analysis. After cardiac surgery, patients are admitted to either the cardiac or general (depending

on the type of the hospital) intensive care unit (ICU). Upon ICU discharge, they receive follow-up care from intensivists. Postoperative care of cardiac patients differs slightly in most centers. For the majority of elective open-heart procedures, patients remain in the ICU for 1-2 days. Standard 9

ACCEPTED MANUSCRIPT continuous postoperative monitoring includes ECG, invasive blood pressure, pulse oximetry and gas analysis. Common multimodal postoperative analgesics include opioids,

non-steroid

anti-inflammatory

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and

paracetamol.

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echocardiography is performed by the attending physician in most hospitals. In the absence of bleeding, drainages are removed the first or second day after surgery. The

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rhythm-control strategy is commonly used for new-onset postoperative atrial fibrillation. There is an annual increase in cases requiring extracorporeal membrane oxygenation (ECMO) support; 270 procedures were performed by perfusiologists in 2016 (industry sources). Considering that anesthesiology and intensive care are united in this specialty in

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the Russian Federation, anesthesiologists are responsible for ECMO implementation.

In the 21st century, Russian cardiac anesthesiologists have increasingly been involved in the international scientific environment and publications, and have participated in multicenter clinical trials. However, the shortage of personnel is a substantial problem,

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even for leading cardiac surgical centers in the country. Anesthesiology is still not a

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popular specialty among graduates of medical universities due to the high intensity of the work and the lower salary in comparison to surgical specialties.

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As in many countries, problems regarding transplantation remain relevant in Russia. Despite the fact that different centers have mastered the technology of heart

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transplantation, these operations remain rare in most of them. This is due to

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organizational issues and the accessibility of donors, especially in remote regions of the country.

3. Status of intraoperative transesophageal echocardiography The importance and effectiveness of intra-operative transesophageal echocardiography (TEE) is no longer disputed, but its development in Russian cardiac surgery and anesthesiology remains slow. Consistent use of TEE by cardiac anesthesiologists began 10

ACCEPTED MANUSCRIPT in 2003 at the Federal Research Center of Transplantology and Artificial Organs in Moscow. Since that time, it has become an integral part of anesthetic management of cardiac surgical procedures at that center. Proposals have been formulated for the active introduction of echocardiography into domestic anesthesiology practice. Nevertheless, despite initial enthusiasm, TEE has not become widespread in Russia; it remains the

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choice of only a few hospitals and cardiac anesthesiologists [20]. The most important question regarding intraoperative TEE: who is responsible for the echocardiographic evaluation in the operation room? In the majority of Russian cardiac hospitals, it is performed by doctors of functional diagnostics and cardiologists. This

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leads to only sporadic use of TEE by anesthesiologists. It is only feasible for a cardiac anesthesiologist to use TEE in the presence of specific indications (i.e., surgery for hypertrophic cardiomyopathy, valve repair).

The widespread introduction of TEE has also been limited by organizational problems

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associated with the training and certification of cardiac anesthesiologists. Other factors

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include conservative thinking, the high cost of equipment, and legislative and regulatory

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restrictions on the use of the method by anesthesiologists.

4. Fellowship status

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Education in cardiovascular and thoracic anesthesiology and intensive care is not

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standardized, and curriculums differ among institutions. In 2017, the Ministry of Health of the Russian Federation published guidelines regarding standardized residency training for all physicians, including anesthesiologists and intensivists. The current model is a “6+2” plan, which requires 6 years of medical school followed by 2 years of specialty residency training (“ordinatura”) with further intention to prolong the subspecialty training to 3 to 5 years. Thus, anesthesiologists must complete 2 to 3 years of anesthesiology training after medical school before passing an exam to be certified as an 11

ACCEPTED MANUSCRIPT anesthesiologist-reanimatologist (intensivist). The general residency curriculum for anesthesiology-reanimatology

usually

includes

lectures,

practical

training

in

cardiovascular and thoracic anesthesiology, and 3 months of intensive-care practice. Currently, neither a certified cardiovascular anesthesiology training/fellowship nor an accrediting body exist to certify cardiac anesthesiologists in Russia. Most Russian cardiac

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anesthesiologists receive additional training according to their individual plans from the Departments of Anesthesiology and Intensive Care Medicine at major cardiac surgery hospitals. In many regional centers, they work both in operation rooms and in the ICU. From the very first surgeries performed under CPB in Russia, it was accepted that cardiac

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anesthesiologists were responsible for perfusion. Today, at least one month of training is required to perform perfusion, but no special certification is required. In large federal centers, anesthesiologists and intensivists work in separate departments within the subdivision of cardiac and vascular surgery. Thoracic interventions are also most frequently

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conducted separately from cardiac surgical departments. Furthermore, the majority of

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hospitals have a sub-division of cardiac ICUs for cardiac patients, including those receiving interventional cardiology procedures.

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As in other countries, online education is becoming more popular, especially among young anesthesiologists. Russian research in the area of clinical cardiac anesthesia is

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focused mainly on the choice of optimal anesthetic techniques, CPB techniques, organ

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protection, monitoring, goal-directed therapy and intensive care.

5. Cardiac Anesthesia Society status and development Cardiac anesthesiologists are represented by the Committee on Cardiac Anesthesia, which is part of the National Society of Anesthesiologists and Intensivists – Russian Federation of Anesthesiologists and Reanimatologists (FAR, www.far.org.ru). Currently, the president of FAR is Konstantin Lebedinskii (St. Petersburg) and the chairman of the 12

ACCEPTED MANUSCRIPT Committee on Cardiac Anesthesia is Evgeny Grigoriev (Kemerovo). The main goals of FAR include development of anesthesiology and intensive care medicine in Russia, coordination and strengthening of professional relations, creation of an optimal working environment for anesthesiologists and intensivists, protection of colleagues on different levels, and integration of FAR activity with different medical societies, including

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international contacts. The work of the Committee on Cardiac Anesthesia of FAR is aimed to combine scientific, clinical, and educational activity to optimize the work of anesthesiologists, perfusiologists, and intensivists in the field of cardiovascular surgery. Founded in 1992, FAR has grown to 64 regional branches and 8,014 members among

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almost 25,000 Russian anesthesiologists and intensivists in 2018. FAR conducts a biannual national congress, with several sessions devoted to the issues of cardiac anesthesia, CPB surgery and intensive care. It is organized by the members of the Committee on Cardiac Anesthesia. The challenges of cardiac anesthesia and intensive

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care are also discussed during annual congresses of cardiac surgeons in Moscow and

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during conferences of cardiac anesthesiologists in Novosibirsk on a biannual basis, as well as during several multidisciplinary meetings.

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Russian cardiac anesthesiologists actively participate in pertinent international events, including meetings of the European Association of Cardiothoracic Anesthesiology

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(EACTA), the European Society of Anesthesiology, the World Federation of Societies of

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Anesthesiologists, and other organizations. There is no specific professional journal dedicated to cardiac anesthesiology in Russia.

However, articles devoted to this subspecialty are published regularly in medical journals such as the Russian Journal of Anesthesiology and Reanimatology, the Messenger of Anesthesiology and Resuscitation, the Herald of Intensive Care, and Circulation Pathology and Cardiac Surgery.

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ACCEPTED MANUSCRIPT 6. Gaps and Challenges Although the outcomes of the majority of congenital and acquired heart diseases in Russia are comparable with leading centers all over the world, many problems have yet to be solved. First, the amount of cardiac procedures performed annually is still insufficient to cover

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the needs of the Russian Federation population. Last year, approximately 50,000 CPB procedures were performed.

Second, the treatment of patients with chronic and acute heart failure is the No. one problem for the Russian healthcare system. There is an insufficient amount of donor

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hearts available, as well as a lack of devices for long-term circulatory support of patients with congestive heart failure. Extensive implementation of ECMO is also necessary to improve treatment of post-surgical low-cardiac-output syndrome. In 2016, only 270 patients with low-cardiac-output syndrome were treated by ECMO in Russia. Expanding

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funding for national medicine could solve these issues, but only 3.5% of the gross

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national product was spent on health care last year. The situation is complicated by the absence of a national industry for the production of equipment and disposables for CPB,

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which are currently manufactured in foreign companies and imported. Another problem is the poor integration of Russian anesthesiologists into the worldwide

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community of cardiac anesthetists. While Russian doctors are well represented, especially

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within EACTA, cardiac anesthesiologists still only publish a small number of articles in international peer-reviewed journals. The low methodological quality of the majority of trials, absence of good statistics, and poor English impedes publication of Russian research in high-quality journals. The next paramount tasks include wider implementation of intraoperative TEE into the routine practice of cardiac anesthesiologist and the foundation of a society of cardiac

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ACCEPTED MANUSCRIPT anesthesiologists of Russia to provide high-quality education and promote research

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activities.

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ACCEPTED MANUSCRIPT Conclusion Over the last 60 years, there has been remarkable progress in the development of cardiac surgery and anesthesiology in Russia. Broad acceptance of new treatment technologies for congenital and acquired heart diseases has led to significant improvement in patients’ survival and quality of life. Cardiac anesthesiologists are now

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capable of managing all modern types of cardiac surgical approaches for patients in their first days of life all the way to senility with acceptable rates of major complications and survival. Nevertheless, limited federal financial resources reduce the availability of cardiac surgical care at this time. Extending fellowship programs in cardiac

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anesthesiology, wide implementation of intraoperative TEE, as well as increasing funding

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for cardiac surgical procedures are the main priorities for our specialty.

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ACCEPTED MANUSCRIPT References 1. Litasova EE, Karaskov AM: Do vysot iskusstva. 2nd ed. Novosibirsk: Academician Ye.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology Publ., 2016. (In Russ.) 2. Lewis FJ, Taufic M: Closure of atrial septal defects with the aid of hypothermia;

59, 1953

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experimental accomplishments and the report of one successful case. Surgery 1:52-

3. Meshalkin EN: Anastomosis of the superior vena cava with the pulmonary artery in patients with congenital heart disease with blood flow insufficiency in the lesser

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circulation: experiment. Eksp Khirurgiia 1:3, 1956

4. Litasova EE, Lomivorotov VN: Hypothermic protection (26-25 degrees C) without perfusion cooling for surgery of congenital cardiac defects using prolonged occlusion. Thorax 43:206-211, 1988

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5. Karsakov AM, Kitchlu CS, Lomivorotov VN: Cardiac surgery under perfusionless

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hypothermia: Siberian experience. Asian Cardiovasc Thorac Ann 10:3-7, 2002 6. Gravlee GP, Davis RF, Kurusz M, Utley JR, editors. Historical Development of

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Cardiopulmonary Bypass: Cardiopulmonary Bypass Principles and Practice. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 5.

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7. Konstantinov IA, Alexi-Meskishvilli VV: Sergei S. Brukhonenko: the development of

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the first heart-lung machine for total body perfusion. Ann Thorac Surg 69:962-966, 2000 8. Puchkov N.V. Dalneyshie issledovaniya anabioza u teplokrovnykh. Biol Zhurn 2:206213, 1933 (In Russ.) 9. Trekova NA: Anaesthesia and monitoring in cardiac and aortic surgery at Russian Scientific Surgical Center. Anesteziol Reanimatol 2:6-10, 2013

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ACCEPTED MANUSCRIPT 10. Buniatian AA, Kosenko RP, Flerov EV, Sablin IN. Analog-digital computer complex for studying the blood circulation and its use in anesthesiology. Vestn Akad Med Nauk SSSR. 1974;(7):38-45. [Article in Russian] 11.

Warner

HR,

Swan

HJ,

Connolly

DC,

et

al:

Quantitation of beat-to

beat changes in stroke volume from the aortic pulse contour in man. J Appl Physiol

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6:495-507, 1953 12. Barnard CN: The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town. S Afr Med J. 48:1271-1274, 1967

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13. Vishnevskiĭ AA, Kolesnikov IS, Portnoĭ VF, et al: Transplantation of the human heart. Voen Med Zh 12:8-15, 1968 (In Russ.)

14. Shumakov VI, Semenovsky ML, Kazakov EN et al: Transplantation of the heart. The first successful operations. Grudnaya khirurgiya 30:5-11, 1988 (In Russ.)

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15. Cooley DA: The anesthesiologist and the cardiac surgeon. Anesthesiology 33:126-

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127, 1970

16. Kozlov IA, Pilaeva IE, Gruzdev IuK, et al: Clinical experience of anesthesia

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management in heart transplantation. Anesteziol Reanimatol 3:3-9, 1990 (In Russ.) 17. Bokeria LA, Gudkova RG: Cardio-vascular surgery 2016. A.N. Bakoulev Scientific

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Center for Cardiovascular Surgery. 2017 (In Russ)

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18. Ovezov AM, Kim CY, Danilin AM, et al: Combined inhalation and epidural anesthesia, during aortocoronary bypass surgery on beating heart. Anesteziol Reanimatol 6:8-12, 2011 (In Russ) 19. Arakelian KA, Antonenko DV: Experience with epidural anesthesia during myocardial revascularization operations. Anesteziol Reanimatol 3:27-30, 2006 (In Russ)

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ACCEPTED MANUSCRIPT 20. Kozlov IA, Krichevskiy LA, Dzybinskaya YeV: Ten years of transesophageal echocardiography in domestic cardiac anesthesiology. Circulation Pathology and Cardiac

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Surgery 18:76-81, 2014 (In Russ.)

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ACCEPTED MANUSCRIPT Figures legends

Figure 1. The first cardiac surgical procedure in USSR was performed by surgeon

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Alexander Bakulev and anesthesiologist Evgeny Meshalkin on September 24, 1948 in

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Moscow.

Figure 2. Evgeny Meshalkin (left) and Alexander Bakulev are pictured in 1953 in Moscow.

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Figure 3. Major milestones in the development of cardiac surgery and cardiac anesthesiology in Russia CPB, cardiopulmonary bypass; PDA, patent ductus arteriosus; PH, perfusionless hypothermia; TEE, transesophageal echocardiography; FCAR,

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Federation of Anesthesiologists and Reanimatologists

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Figure 4. Surgeon Elena Litasova is pictured in the early 1990s in Novosibirsk.

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Figure 5. Surgery for congenital heart disease under perfusionless hypothermia

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Figure 6. Doctor and physiologists Sergey Brukhonenko is pictured in 1972 in Moscow.

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Figure 7. Armen Bunatyan is the chief of the department of Anesthesiology and

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Reanimatology at Boris Petrovskiy Russian Scientific Center of Surgery in Moscow.

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Table 1. Volume of cardiac interventions in the Russian Federation from 2014 – 2016

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PCI

127,5 84 156,8 53 183,4 43

Surgeries for heart rhythm disorders Pacemak Cathe er ter implanta ablati tion on 40,924 20,33 2 41,332 20,84 9 46,065 23,72 4

CABG

Valve surgeries

On Pum p

Off Pu mp

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Rep air

29,3 88 28,0 49 27,4 61

7,2 44 7,8 12 9,4 21

10,759

3,96 2 4,07 4 3,97 4

10,036 9,787

Congenital heart surgeries Tota On l pu mp

Aortic Heart surger transpla ies nts

15,5 22 16,4 74 16,8 36

4,507

111

5,018

89

5,315

143

8,3 42 9,3 29 9,0 73

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PCI, percutaneous coronary interventions; CABG, coronary artery bypass grafting

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