Method for predicting atrioventricular heart blocks after radical cardiosurgical heart trouble correction in early age children

FIELD: medicine.

SUBSTANCE: method involves carrying out epicardial electrophysical study during operation on heart after having done the thoracotomy and exposing pericardium cavity. Programmed electrostimulation with continuously reducing extrastimulus delay is performed on the left atrium via an electrode. Relative refraction period of the right pedicle of His bundle, effective refraction period of the right atrium and effective refraction period of the atrioventricular node is found. The effective refraction period of the atrioventricular node being greater than the effective refraction period of the right atrium, postoperative atrioventricular heart block risk at the level of atrioventricular node is to be predicted. The relative refraction period of the right pedicle of His bundle value being greater than value being greater than the effective refraction period of the atrioventricular node, postoperative atrioventricular heart block risk at the level of His bundle and its branches is to be predicted.

EFFECT: high accuracy of prognosis.

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The invention relates to medicine, namely to surgery, and can be used to predict the atrioventricular after surgical correction of heart defects in children of early age.

A known method for the diagnosis of disorders of atrioventricular conduction by epicardial electrophysiological studies [1]. "Working heart" is the electrode on the ear of the right ventricle. Through the electrode is okadaya electrical stimulation of the right atrium until periodicals Samoilov-Wenkebach (point of Wenckebach). When the point values of Wenckebach below 180 per minute, there is a risk of atrioventricular block after the operation.

However, this method has a low predictive value and does not allow you to set the level of the atrioventricular blockade, which complicates the treatment of postoperative atrioventricular block.

The purpose of this invention is to improve the quality of treatment of patients with cardiovascular disease cardiac profile after heart surgery.

This goal is achieved by using epicardial programmed atrial pacing during heart surgery reveal hidden defects holding at the level of the atrioventricular node, p is CCA of GIS or his legs, that serves as predictors of atrioventricular after the operation.

The method is as follows:

after thoracotomy before sinularia great vessels and connected the heart-lung machine on the epicardial surface of the heart set four diagnostic electrode:

1) ear right atrium,

2) on the left atrial appendage,

3) on the right ventricle,

4) on the left ventricle.

To monitor electrophysiological complex output bipolar electrogram from all four electrodes.

Spend programmed electrical stimulation through the distal contact livepresets electrode with eight basic incentives and gradually decreasing the delay extrastimuli (10 MS at each step). On the monitor electrophysiological complex record surface lead electrocardiogram, and electrograms from the right atrium, right ventricle and left ventricle. The maximum delay of extrastimuli, on which there is expansion of the QRS complex on the type of blockade of the right bundle branch, consider the relative refractory period of the right bundle branch (PPR PNPG). The maximum delay of extrastimuli, in which there is no answer right atrium, consider the effective refractory period PRA is wow atrium (ETA PP). The maximum delay of extrastimuli, which document the response of the right ventricle without the capacity of the right ventricle, consider the effective refractory period of the atrioventricular node (ETA AVA).

In patients without the development of postoperative atrioventricular ETA PP exceeds ETA AVA (Figure 1). Thus after application testing extrastimuli unanswered poly (Figa) - the capacity of the right ventricle is not registered.

Patients with ETA AVA exceeds ETA PP, have a high risk of developing postoperative AV block at the level of the atrioventricular node (proximal blockade) (Figure 2). Thus after application testing extrastimuli unanswered poly (Figa) is the potential of the right atrium (Figb). Patients with PPR PNPG exceeds ETA AVA, have a high risk of developing postoperative AV block at the level of the bundle of his and its branching part (distal blockade) (Figure 3). Thus after application testing extrastimuli (Figa) observed the response of the ventricles by type of blockade of the right bundle branch (Figb) and an increase in the interval between the potentials of the right and left ventricles (Pigv).

An example of performing the method. B-e a-VA, 2 years 5 months. Operated in NIPC in 2001 about defec is and interventricular septum. Performed closing perimembranous defect patch consists of. When conducting electrophysiological study before the main stage of the operation the following indicators: ETA PP=170 MS, Earp AVA - less than 170 MS, the PPR PNPG - 260 MS. In the recovery period of the operation of cardiac arrhythmias is not marked. ECG: sinus rhythm with a frequency of 151 per minute, PQ=152 MS, QRS=81 MS, QT=263 MS. On the second day of the postoperative period are found to occur blockade of the right bundle branch, the next day - the emergence of atrioventricular block first degree (interval PQ=234 MS). The duration of the PQ interval was increased until the fifth day of the postoperative period (PQ=310 MS), followed by positive dynamics. However, the child was discharged from hospital with atrioventricular block first degree (PQ=204 MS) and incomplete blockade of the right bundle branch. Conducted before the main phase of the operation electrophysiological studies allowed us to determine hidden defect conduct, which is manifested in the postoperative period in the form of atrioventricular block first degree, and blockade of the right bundle branch. The obtained criteria (CSC PNPG > ETA AVA) help to talk about the pathology of the distal atrioventricular connection, indicating a possible long wavy during the siege and requires close the thinking in the observation.

For the period from January 2000 described method was used for epicardial electrophysiological study in 93 patients with heart disease at the age from 5 months to 5 years. Predictors of proximal atrioventricular block was detected in 15 children (14 of them after elimination of congenital defect recorded atrioventricular block: 7 - in the recovery period of operations, 3 - blockade of I degree, 3 - transient blockade II-III degree, one child - resistant complete atrioventricular block requiring pacemaker implantation). Predictors of distal atrioventricular block was detected in 9 children (in all cases after elimination of congenital defect fixed distal atrioventricular block: a 5 - in the recovery period, 3 - transient blockade II-III degree, one child - resistant complete atrioventricular block requiring pacemaker implantation).

Thus, the proposed method allows to perform the main stage of the operation to determine the risk of atrio-ventricular blockade in the postoperative period, and to set the level of the lesion during atrioventricular connections, which ultimately contributes to the selection of the correct individual tactics in the treatment of postoperative cardiac conduction.

Literature:

1. Yanchenko YA. Disorders of automaticity and conduction in the correction of congenital heart defects.//Abstract of thesis. CMN - Novosibirsk, 1999, page 16.

A method for predicting atrioventricular after radical surgical correction of heart defects in children of early age, including epicardial electrophysical study, characterized in that during heart surgery after thoracotomy and the opening of the cavity of the pericardium on the epicardial surface set four electrodes: right atrium, left atrium, right ventricle and left ventricle, to monitor electrophysiological complex output lead surface electrocardiogram and bipolar epicardial electrogram through the electrode on the left atrium spend programmed diagnostic electrical stimulation with a gradually decreasing the delay extrastimuli, the maximum delay of extrastimuli, on which there is expansion of the QRS complex on the type of blockade of the right bundle branch consider the relative refractory period of the right bundle branch (PPR PNPG), the maximum delay of extrastimuli, in which there is no answer right atrium, consider the effective refractory period of the right atrium (ETA PP), maximum delay extract the mule, in which document the response of the right ventricle without the capacity of the right ventricle, consider the effective refractory period of the atrioventricular node (ETA AVA) and when the values of ETA AVA, exceeding values of ETA PP, predict the risk of postoperative AV block at the level of the atrioventricular node, when the values of the PPR PNPG exceeding values of ETA AVA, predict the risk of postoperative AV block at the level of the bundle of his and its branches.



 

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