Method for preventing atrial fibrillation in patients with sinus nodal weakness syndrome and paroxysms of atrial fibrillation

FIELD: medicine, cardiology.

SUBSTANCE: one should carry out endocardial electrophysiological trial, moreover, one should implant a bipolar stimulating electrode into posterior-septal part of right atrium to register local electrogram of both right and left atria and detect the terms for stimulation onset in each atrium. Implantation site of stimulating electrode should be determined as the follows: the difference between the time for conducting stimulation in every atrium should not exceed 10 msec.

EFFECT: the innovation enables to decrease the number of repeated operations in patients with atrial stimulation.

2 ex

 

The invention relates to cardiology, in particular to methods for treating arrhythmias.

Atrial fibrillation (AF) remains the most common tachyarrhythmia. Often the OP is combined with various manifestations of the syndrome sick sinus. The most effective way to prevent this pathology is the implantation of a permanent pacemaker (PEKS).

The known method of prevention of AF - butreally stimulation fibrillation [5]. It is that for stimulation of the Atria implanted two electrodes. One electrode is placed in the appendage of the right atrium for pacing the right atrium, and the second in the coronary sinus to stimulate the left atrium. Two electrodes are necessary to reduce the time of excitation of the Atria. Then to the electrodes connected dual-chamber pacemaker (EX), is designed to work with two electrodes. Cheaper EX is single-chamber stimulator, designed to work with one electrode. The electrodes are connected to it through a special Y-shaped adapter. This leads to increased load on the EX and shorten its service life. In order biatrial stimulation is the prevention of AF in the background atrial ritmologiya [6]. This method has some drawbacks: for the implementation of this method is key requires the introduction of two electrodes, what increases the risk of complications associated with the displacement of at least one electrode, and increases the cost of operation. For stimulation of the left atrium necessary catheterization of the coronary sinus, which increases the duration of the surgery and, in addition, is more technically complex procedure, which requires more time fluoroscopy [14]. For implantation in the coronary sinus are expensive electrodes special configuration. Thus, the use of two electrodes, one of which is special, implantation of a specialized or triple EX significantly increases the cost of treatment. It is impossible not to be aware of the fact that the load on the battery of the FORMER in the form of two electrodes reduces the life of the FORMER and as a result requires more frequent replacement of the FORMER.

According to some authors there is a high threshold stimulation at the electrode installed in the coronary sinus (more than 3-4) [13], which leads to the need to install high amplitude stimulus and premature battery depletion EX. For this reason, disturbance sensitivity with atrial electrode that is installed in the coronary sinus [13]. Known high frequency displacement (dislocation) of the electrode installed in the coronary sinus (over 9%), resulting in the need for re-operation is th [13] and excessive trauma. Shows the lack of effectiveness of this method in relation to the OP. Postoperative prophylactic efficacy without treatment, 14.9% and 24.3% of patients with antiarrhythmic therapy, not efficiency obtained in 27% of patients. According to Levi efficiency in terms of duration and number of episodes of atrial fibrillation in biatrial stimulation does not differ when compared with standard stimulation vermelerinin departments right atrium [7].

Known method bifocal stimulation of the right ventricle [8, 9], which consists in the implantation of two electrodes in the various departments of the right atrium: in the eye of the right atrium and in the lower parts of the right atrium. In this way seek to reduce the time of excitation of the right ventricle during simultaneous stimulation of two areas of the right ventricle. The disadvantage of this method is technically difficult the introduction of two electrodes in the right atrium, which lengthens the time of surgery increases the risk of dislocation endocardial electrodes also require the use of expensive triple EX and specific adapter for the connection of the electrode and stimulator [10]. Frequency offset endocardial electrodes in this way exceeds 3% [11]. Received convincing evidence for prophylactic efficacy trims the ablation of the right atrium when compared with isolated stimulation of the ear of the right ventricle [12].

There is a method of stimulation of the Atria, chosen as a prototype by implantation endocardial electrode in the area of the mouth of the coronary sinus [8]. This method allows you to improve synchronization of excitation of the Atria, does not require the use of two electrodes, a double-door EX and specific adapters, i.e. free from the drawbacks inherent multifocal methods of stimulation. However, there is a high percentage offset endocardial electrode of this position (12%) and high-threshold stimulation of the Atria (more than 3). High threshold of stimulation required to increase the amplitude of the stimulating pulse (featured amplitude of the stimulus is equal to twice the value of the threshold stimulation) and leads to premature battery depletion EX. Thus, the total number of complications is more than 15% [8]. The elimination of the bias electrode and the replacement power of the FORMER is only possible when re-operation of the patient.

The present invention is to reduce the number of reoperations in patients with atrial stimulation. This is achieved by endocardial electrode for constant stimulation implanted in the posterior-septal region of the right atrium. The optimal location of the tip of the stimulating electrode in this area is such a place, the stimulation is vtorogo right and left atrium are reduced as synchronous. To select the optimum location of the implant during the operation, conduct a trial stimulation and register local electrogram the left and right Atria, reflecting the excitation process. Electrogram register diagnostic electrodes are introduced through the puncture of main veins during surgery. For each atrial determine the timing and compare them with each other. Optimal site of stimulation is the place of stimulation, when the time difference does not exceed a certain value (10 MS).

The positive effects of implementation of the invention is to reduce the number of re-operations, simplifying and reducing the time of the operation (including time fluoroscopy). This in turn leads to a reduction in treatment costs and improve its efficiency, reduce the harmful effects of radiation on the medical staff.

The proposed method involves the implantation of only one endocardial electrode complete with conventional single chamber EX. Reliable fixation of the electrode caused by the use of electrodes with an active fixation, which allows to obtain a stable minimum thresholds of excitation of the Atria, to minimize the possibility of dislocation endocardial electrode. Optimally selected site of implantation of the electrode in the ass the e-septal part of the right atrium allows to synchronize the excitation of the right and left Atria, eliminating local disturbance and prevents the development of AF.

The present invention is as follows. Under local infiltrative anesthesia is performed incision about 4-6 cm in the infraclavicular region. Allocated brachiocephalic vein or is used to puncture the Seldinger right subclavian vein. Injected into the veins standard endocardial electrode with an active fixation for constant stimulation. For selection of the maximum synchronization fibrillation uses two temporary diagnostic electrode, entered puncture and aspiration and located in the upper lateral sections of the right atrium and the coronary sinus. Spend endocardial electrophysiological study (EPS), which includes programmed stimulation of the Atria. Stimulation is carried out at a basic frequency, cycle time which was shorter cycle lengths sinus rhythm at 100 MS. Stimulation is carried out in the upper-lateral areas of the right ventricle. Estimated time of interatrial conduction in sinus rhythm and during stimulation of the right ventricle. The activation of the left atrium is determined by the activation of the distal coronary sinus. After confirmation of the violation of interatrial conduction electrode for constant stimulation of the Atria RA is placed in a posterior-septal region of the right atrium. The place of fixation of the electrode in the posterior-septal Department is selected such point for implantation, the stimulation of which the maximum sync excitation of the right and left Atria. The difference between the time of excitation of the right and left Atria should not exceed 10 MS. The location of the electrode in zadnelateralnoy region is also confirmed by the negative form-stimulated P-waves in II and III standard ECG leads. Then the electrode is fixed in the selected position under the control of the measuring acute stimulation thresholds and the value of the local electrogram. After implantation of the electrode for constant stimulation of the interatrial septum (CMP) diagnostic electrodes are removed. After implantation, the electrode is fixed by three ligatures to Vienna and surrounding tissues. The electrode is connected single-chamber pacemaker. The pacemaker is placed subfascial over the right pectoral muscles, after which the bed of the FORMER sutured. Further executes control of hemostasis and layer-by-layer suture wounds and applying bandages.

Several examples of the application of the proposed method in practice.

Example 1. Sick Hours, 75 years old, diagnosis: ischemic heart disease, atherosclerotic cardiosclerosis, hypertension stage 2, a weakness syndrome sinus node, C is katrianna blockade Brady's the form, paroxysmal atrial fibrillation, paroxysmal atrial tachycardia, atrial extrasystole. Complaints of dizziness, weakness, swelling of the lower extremities attacks of palpitation with the frequency of 3 times per month. The diagnosis of the syndrome sick sinus confirmed by transesophageal EPE ECG daily monitoring of ECG, which documented episodes of AF with HR 122 minutes ECG signs of violations vnutriepreserdna conduct in the form of increased duration of P-wave to 120 MS. Suffers from the disease within 10 years, medical therapy is ineffective. 16.04.2001 operation: constant EX fibrillation with implantation of the electrode in the interatrial septum. During the operation, according to endocardial electrophysiological studies revealed a local slowdown in the posterior-septal region of the right atrium. Time from the upper lateral sections of the right atrium to the distal coronary sinus was 150 MS. Method of registering local electrogram received a full synchronization of the excitation of the right and left Atria (the duration of the excitation from the site of implantation of the electrode in the interatrial septum to the right and left Atria was 83 MS). Thus, the achieved reduction in the time of excitation of the Atria and their poppy is emalina synchronization. Bipolar electrode YP 60-BP about company "BIOTRONIK" implanted in the selected location. Sharp threshold stimulation at the selected location was 0.8, and the value of electrogram in the same place - 2 mV. To the electrode chamber connected EX-300. Temporary electrodes removed. The wound is sutured. Healing by primary intention. On day 7, the patient was discharged from hospital. In the postoperative period the patient was observed for 2.5 years, during this time there has been a steady atrial stimulation in the AAI mode. Dislocation of the electrode was not. When the control programming via 2, the threshold of stimulation of 1.02 Century, signs of circulatory failure no. During the follow-up period of paroxysmal AF was not observed. The number of atrial extrasystoles registered before the operation was 3351 per day. After pacemaker implantation, the number of extrasystoles sharply decreased and amounted to $ 177 per day. Readmissions were not required.

Example 2. Patient P., 52 years old, diagnosis: myocarditis cardiosclerosis, weakness syndrome sinus node, sinoatrial blockade, Brady's the form of paroxysmal atrial fibrillation. Complaints of frequent palpitations with a frequency of 2-3 times per week. The diagnosis of the syndrome sick sinus confirmed by transesophageal electrophysiological study, daily monitoring of ECG, which for exerowa episodes of AF with HR 130 minutes ECG signs of violations vnutriepreserdna conduct in the form of increased duration of P-wave to 120 MS. Suffering from disease for 9 years, drug therapy allapinina, dizopiramida, sotalol, cordarone, rytmonorm ineffective. 28.09.1999 operation: constant EX fibrillation with implantation of the electrode in the interatrial septum. During the operation, according to endocardial electrophysiological studies revealed slowing of atrial conduction. Time from the upper lateral sections of the right atrium to the distal coronary sinus was 133 MS. Method of registering local electrogram confirmed by synchronizing the excitation of the right and left Atria (the duration of the excitation from the site of implantation of the electrode in the interatrial septum to the right and left Atria was 66 MS). Achieved by reducing the time of excitation of the Atria and the maximum synchronization. The duration of the R-wave on the background stimulation of the interatrial septum was reduced to 80 MS, and the interval PQ (StQ) was reduced from 160 to 120 MS. Bipolar electrode T Tendril DX firm "SJM" implanted in the selected place by twisting in a clockwise direction. Sharp threshold stimulation at the selected location was 1.3, and the magnitude of electrogram in the same place - 2 m is. To the electrode chamber connected customadapter the pacemaker Regency SR+. Temporary electrodes removed. The wound is sutured. Healing by primary intention. On day 7, the patient was discharged from hospital. In the postoperative period the patient was observed in 4.5 years, during this time there has been a steady atrial stimulation mode AAIR. Dislocation of the electrode was not. When the control programming through 4, the threshold of stimulation of 0.9 Century, signs of circulatory failure no. During the follow-up period of paroxysmal AF in patients receiving cordarone have been observed. Readmissions were not required.

The method is tested on 30 patients of both sexes. They observed for more than 3 years (average 2 years). 2 of them were aimed at re-operation. This was due to the fact that these patients were implanted electrodes outdated designs. Their fix was poorly adapted for fixation in the interatrial septum. To evaluate the effectiveness of the proposed method this time is sufficient, because according to the literature offset the stimulating electrode was observed within 7 days after surgery [12].

Literature:

1. Michelucci A,, Padeletti L., Chelucci, A., et al. Relationship between P wave signal-averaging and atrial conduction delay or dispersion of atrial refractoriness. (Abstract). // Pacing Clin. Electrophysiol. - 1995. - Vol.18. No. 5.- P1109.

2. Papageorgiou P., Anselme f, Kirchhof C.J., K. Monahan, C.A. Rasmussen, Epstein L.M., M.E. Josephson Coronary sinus pacing prevents induction of atrial fibrillation. // Circulation, 1997. - Vol.96. No. 6 - P.1893-1898.

3. Papageorgiou P., Monahan, K., Anselme f, Kirchhof J.C., M.E. Josephson Electrophysiology of atrial fibrillation and its prevention by coronary sinus pacing. // Semin. Interv. Cardiol. 1997. - Dec 2. - P.227-232.

4. Gilligan. D.M, Fuller I.A, Clemo H.F., Shepard R.K, Dan D., Wood M.A., Ellenbogen K.A. The Acute Effects of Biatrial Pacing on Atrial Depolarization and Repolarization. // Pace (Pacing Clin Electrophysiology) 2000 - July Vol.23. No. 7. - P.1113-1120.

5. J.C. Daubert, C. Leclercq, Pavin D, Mabo P. Biatrial synchronous pacing: A new approach to prevent arrhythmias in patients with atrial conduction block. In: Prevention of tachyarrhythmias with cardiac pacing. J.C.Daubert, E.N.Prystowsky, A.Ripart (eds.), Armonk, N.Y. // Futura Publishing Company. - 1997. - P.99-119.

6. Yu W.C., S.A. Chen, C.T. Tai, Feng A.N., Chang M.S. Effects of different atrial pacing modes on atrial electrophysiology: implicating the mechanism of biatrial pacing in prevention of atrial fibrillation. // Circulation - 1997. Nov 4. Vol.96. No. 9. P.2992-2996.

7. Levy T; Walker S; Rex S, Rochelle J; Paul V. No incremental benefit of multisite atrial pacing compared with right atrial pacing in patients with drug refractory paroxysmal atrial fibrillation. // Heart 2001 - Vol.85 - P.48-52.

8. Prakash A, Saksena S, Hill M, et al. Acute effects of dual-site right atrial pacing in patients with spontaneous and inducible atrial flutter and fibrillation. // J Am Coil Cardiol 1997; 29: 1007-14.

9. Ramdat Misier A, Beukema WP, Luttikhuis HA. Multisite or alternate site pacing for the prevention of atrial fibrillation. Am J Cardiol 1999; 83:237-40D.

10. Delfaut P, Saksena S, Prakash A, et al. Long-Term Outcome of Patients With Drug-Refractory Atrial Flutter and Fibrillation After Single - and Dual-Site Right Atrial Pacing for Arrhythmia Prevention. // JACC Vol. 32, No.7 1998: 1900-1908.

11. Daubert C, Leclercq C, Le Breton H, et al. Permanent left atrial pacing with a specifically designed coronary sinus lead. // Pacing Clin Electrophysiol 1997 Vol.20. - 2755-2764.

12. A. Kutarski, Oleszzak K., Poleszak K., et al. Possibility and problems of coronary sinus (CS) pacing with standard leads. PACE 1998. - Vol.4. No. 2. - R-1303.

13. Witte J, Reibis R, Bodke HJ, et al. Biatrial pacing for prevention of lone atrial fibrillation. Prog Biomed Res. 1998; 3: 193-196.

14. Malinowski K., .Kratshmer, M.Schaldach. Multisite Stimulation: Long-Term Performance of Coronary Sinus Leads. // Progress in Biomedical Research. Jan 2001. - P.31-34.

A method of preventing atrial fibrillation in patients with the syndrome sick sinus and paroxysmal atrial fibrillation by endocardial electrophysiological studies and placement of the stimulating electrode in the posterior-septal part of the right ventricle, wherein the implanted bipolar stimulating electrode, register local electrogram the left and right Atria and calculate the time of the proceedings in each auricle, and the site of implantation of the stimulating electrode is determined so that the difference between the time of the proceedings in each auricle does not exceed 10 MS.



 

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8 dwg, 2 tbl

FIELD: medicine.

SUBSTANCE: method involves carrying out cardiotocographic examination taking into account day rhythmostasis and following data analysis. Diagnostically significant cardiotocographic characteristics like basal rhythm, accelerations, acceleration durations, motor fetus activity and integral fetus state characteristic are determined. Non-conjugated estriol/progesterone coefficient is calculated with day rhythmostasis taken into account. Maternal and fetal blood circulation hemodynamic values synchronization coefficient is determined. Diagnostically significant characteristics values typical for fetus hypoxia are determined. When carrying out cardiotocographic examination, basal rhythm (strokes/min) is equal to 156±2.9 at 12 o'clock and 159±3.7 at 20 o'clock; accelerations (strokes/min) 3.0±0.2 at 12 o'clock and 2.2±0.3 at 20 o'clock; acceleration durations (s) 14.2±0.7 at 12 o'clock and 13.6±1.2 at 20 o'clock; motor fetus activity (during 10 min) 2.0±0.4 at 12 o'clock and 1.7±0.3 at 20 o'clock; integral fetus state characteristic 1.25±0.15 at 12 o'clock and 1.37±0.22 at 20 o'clock. When determining noncojugated estriol/progesterone coefficient: 0.57±0.05 at 8 o'clock and 0.67±0.06 at 20 o'clock. When determining maternal and fetal blood circulation hemodynamic values synchronization coefficient: 2.35±0.19 before 37 pregnancy weeks date and 2.78±0.18 after 37 pregnancy weeks date. The values corresponding to the above referenced ones, functional fetus state change and chronic fetal hypoxia are to be diagnosed.

EFFECT: high accuracy of diagnosis.

FIELD: medicine.

SUBSTANCE: method involves carrying out pulsating Doppler echocardiographic examination. Mean pressure is determined in pulmonary artery. Mean pressure in pulmonary artery being less than 13 mm of mercury column, no cardiac rhythm disorders risk is considered to take place. The value being greater than 13 mm of mercury column, complex cardiac rhythm disorder occurrence risk is considered to be the case.

EFFECT: accelerated noninvasive method.

1 tbl

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