An important point in the provision of highly specialized cardiac surgical care for combat trauma is determination of the optimal time, method and volume of surgical intervention, taking into account the persisting threat of infection with the SARS-COV-2 virus and associated thrombotic complications. The aim. To investigate the mechanism of development and methods of prevention of thrombotic complications resulting from combat trauma against the background of the COVID-19 pandemic. Materials and methods. We analyzed clinical case of patient R., a 37-year-old soldier with a postinfarction thrombosed aneurysm of the left ventricle. The patient underwent standard clinical and laboratory tests, electrocardiography, echocardiography, coronary angiography, computed tomography of the chest, duplex scanning of carotid arteries, arteries and veins of the upper and lower extremities. It was established that 4 months ago, during a combat mission, the service-man received a mine-explosive injury, shrapnel wounds of lower extremities, multifragmentary fracture of the right ϐibula and a gunshot wound to the right chest. The causes of post-traumatic myocardial infarction are mine-explosive injury, intramural course of the left anterior descending artery, youngage, poorly developed collaterals of coronary arteries, long-term transportation during the stages of medical evacuation and post-traumatic stress disorder. A month ago, the patient was diagnosed with COVID-19, thromboembolism of the right main branch of the pulmonary artery, for which thrombolytic therapy was performed. Follow-up computed tomography showed the signs of thromboembolism of the pulmonary arteries. Ultrasound examination revealed thromboses of upper and lower limbs. Thrombotic complications against the background of combat polytrauma are the result of hypercoagulation, acute inϐlammation with the release of proinϐlammatory cytokines and damage of the endothelium. SARS-COV-2 infection triggers a state of hypercoagulation and creates additional conditions for the occurrence of arterial and venous thrombosis. Considering the nature of the thrombotic lesions, was made a decision to postpone the cardiosurgical intervention for 3 months. Conclusions. Thrombotic complications are an urgent problem after combat trauma. COVID-19 is an additional risk factor for hypercoagulation and a reason for delaying elective cardiac surgery. Conducting an electrocardiography to the wounded, regardless of age, is crucial for timely diagnosis andtreatment of acute coronary events. It is important to initiate anticoagulant therapy after eliminating all possible sources of bleeding due to the high risk of thrombotic complications against the background of chest trauma and limb fractures.

In the first year of the COVID-19 pandemic, there was a significant reduction in the number of cardiac surgeries, but recently, with the vaccination campaign, the former surgical activity is gradually recovering. Among cardiac surgery patients, many have had COVID-19. The effects of SARS-CoV-2 on the human body in general and vascular endothelium in particular cause multisystem damage, which is associated with a high risk of pulmonary, cardiac, neurological and thrombotic complications not only in the acute period but also in the long term. The issue of the timing of operations in cardiac surgery patients after COVID-19, among whom patients with complicated forms of coronary artery disease are the most severe, is very acute. Case description. Patient H., 42 y.o, was hospitalized to the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine with thrombosed postinfarction aneurysm of the left ventricle, polymorbidity, severe COVID-19 with 60% lung damage 2 months ago. According to the results of diagnostic study, the on-pump surgical intervention was indicated: coronary artery bypass grafting, left ventricular aneurysm resection with thrombectomy. The predicted mortality risk was 11.5% by the EuroSCORE II scale and 8.08% by the Society of Thoracic Surgery Score (STS). The heart team decided to perform the life-saving surgery. After stabilization of the condition and compensation of concomitant diseases, the patient was successfully operated and discharged from the Institute without complications on the 9th day after surgery. Conclusions. High-risk patients with complicated coronary artery disease require careful preparation for cardiac surgery and compensation of comorbidity. Preoperative risk stratification allows the heart team to make decisions, predict perioperative complications and take measures to prevent them, as well as plan the volume of operation. Polysegmental bilateral COVID-19-associated pneumonia within the last 2 months is not a contraindication to cardiac surgery in the conditions of artificial circulation, provided adequate training, stability of the radiological picture. An important point of the positive result of cardiac surgery is intraoperative reduction of ischemic time with the performance of the main stage of the operation in conditions of parallel perfusion.

The current problem of modern medicine is the lack of public awareness about personal health, late diagnosis of diseases, untimely prehospital care and treatment of existing complications. This applies to all branches of medicine, especially cardiology and cardiac surgery. Coronary heart disease occupies one of the leading places in the structure of mortality due to cardiovascular diseases. This is mainly due to the fact that patients seek medical care with complicated forms of coronary heart disease like sudden cardiac death, cardiac arrhythmia (ventricular fibrillation, AV blockade, sinus bradycardia and tachycardia), formation of left ventricular (LV) aneurysm, LV free wall rupture and LV false aneurysm, mitral regurgitation. In such cases, all actions must be early, staged, well established, and concordant with clear algorithm. The aim. To demonstrate our clinical case as an example of proper logistics, rapid response and timely surgical treatment of complicated forms of coronary heart disease. Clinical case. Patient F., born in 1964, was admitted to the clinic on March 24, 2021 with a diagnosis of coronary heart disease: acute non-Q-wave myocardial infarction of the posterolateral LV since March 22, 2021. Clinical death with successful resuscitation at the prehospital stage (03/22/2021). Ventricular fibrillation (03/22/2021). Multivessel coronary artery disease. Mitral valve regurgitation grade II-III. Tricuspid valve regurgitation grade I-II. Pulmonary hypertension grade I. Hypertensive disease grade III, degree 3, risk 4 (very high). Heart failure II A with a moderately reduced LV ejection fraction (47%). NYHA3. Closed chest injury (03/22/2021): fracture of the ribs without displacement: ribs 4-8 on the left, ribs 4-8 on the right. He considers himself ill since March 22, 2021, when he suddenly felt severe pain in his chest and fell unconscious. According to witnesses, the man got out of the subway and fell unconscious, without breathing and pulse. Due to the presence of defibrillators at the subway station, successful resuscitation was conducted by police officers before the ambulance crew arrival. Clinical and instrumental studies were performed after hospitalization. The patient was taken to the operating room on 03/24/2021 at 5:30 PM, 50 minutes after admission to the National Amosov Institute, Kyiv. Urgent off-pump coronary artery bypass grafting of 3 coronary arteries was performed. A cardioverter-defibrillator was implanted due to the history of clinical death and the conclusion of daily ECG monitoring. The intra- and postoperative period was uneventful, the patient was discharged in satisfactory condition for rehabilitation. Conclusions. Our clinical experience shows that timely prehospital care, proper logistics and surgical correction of coronary heart disease not only saves but also significantly improves the quality of life of the patient in the future.