Method for evaluating intra-atrial and inter-atrial stimulation process

FIELD: medicine, cardiology, arhythmology, functional diagnostics.

SUBSTANCE: one should register electrocardiogram in esophagus, apply an electrode in a site where the maximum signal amplitude is registered, increase the signal 5-fold, not less to be filtered in the range of 0.5-40 Hz to be registered at the rate of 100 mm/sec, not less. The time for intra-atrial process should be measured from the beginning of ascending part of the first positive wave of pre-P-tooth up to the top of the second adhesion of P-tooth; the time for inter-atrial process should be measured from the site of crossing a descending part of the first positive wave and the onset of obliquely ascending pre-P-interval up to crossing this interval with the point of abrupt increase of the first phase of P-tooth. The innovation provides more means for noninvasive evaluation of intra- and inter-atrial stimulation process.

EFFECT: higher accuracy of evaluation.

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The invention relates to cardiology, in particular to Arrhythmology, functional diagnostics.

It is now established that a violation of intra - and interatrial conduction plays a major, and in some cases leading role in the Genesis of the initiation and maintenance of tachyarrhythmias [16]. So, in the study of experimental models of atrial fibrillation (AF) have shown that the electrophysiological mechanism of this arrhythmia are multiple chaotic waves microre-entry, due to the unidirectional delay atrial conduction [19, 14, 17]. Thus, AF is maintained depolarization wave that continuously circulates in excitable tissue, as evidenced by slow notrepresent conducting and short period of refractoriness fibrillation. According to most researchers [13], the factors responsible for the occurrence of AF include FP in the absence of other supporting factors. As the substrate is considered a violation of intra - and interatrial conduction [15].

Known way to assess atrial conduction of excitation using standard surface electrocardiogram (ECG) in the conventional 12-lead (6) from limbs and 6 infants) [10]. In this method, the idea of atrial conduction is based on the analysis form, amplitude and glutelin the STI, and P wave, however, the accuracy in determining intra - and interatrial conduction of excitation is quite low, as we only evaluate the overall length of the tooth and correctly separate right - and livepresets components, and P wave not. In a number of pathologies is registered low-amplitude, smooth, and P wave, the assessment of which is extremely difficult[4, 10, 11].

There is a method of determining atrial conduction of excitation in patients with ischemic heart disease, was chosen as a prototype [Averros, Aiesecer, Awhole, Vigorous. Clinical evaluation of the use of non-invasive method of determining the intra - and interatrial conduction in patients with ischemic heart disease. - Therapeutic archive, 1999, No. 1, p.34-39]. On the people he follows. At the same time record the ECG in the second standard lead and echocardiogram in b - and M-modes. The timing of excitation of the left and right Atria are determined from the beginning of the electrical excitation of the Atria (P wave ECG) prior to mechanical contraction of the left atrium, determined at different points in the left atrium.

The method of determining the atrial conduction of excitation, performed by the authors on dogs, requires opening the chest, which is a complex and innenkapsel procedure.

The disadvantages of this is the procedure are low, the accuracy of the time atrial conduction of excitation. This is due to the fact that it is very difficult to draw a visualization of the left atrium when the heart turns associated with different Constitution of patients, overweight, and emphysema in the lungs, resulting in chronic lung disease [20]. All this makes it difficult or impossible visualization of control points on the left atrium.

The aim of our invention is to improve the accuracy of time measurement atrial conduction of excitation.

This is achieved in that the electrode to register themselves ECG. through the bow set in a certain place of the esophagus, the signal increase to 50 mm/mV and filtered in the range of 0.5-40 Hz. Registration of the received signal is performed at a speed of not less than 100 mm/s When measured at the registered ECG segment duration, intervals and spikes selected pre-R-wave and P-wave is determined by the timing of excitation of the left and right Atria, and the time of the interatrial and vnutriepreserdna of the proceedings.

The positive effect of this method is to significantly improve the accuracy of the measurement time of the excitation of the left and right Atria. Comparison of selected waves to measure the time of atrial conduction of excitation results simultaneously conducted e is decarvalho electrophysiological studies of the heart (Andolfi) allowed to measure with precision, close to the precision attainable in invasive research, which is considered the "gold standard" in cardiac electrophysiology [7, 18]. Based on these results we have developed a new way of exploring the electric potentials of atrial complex ECG and measurement vnutriepreserdna and interatrial conduction of excitation in norm and at a pathology. Unlike the prototype, the proposed method allows to measure the time inter - and vnutriepreserdna of the proceedings. The way legkonastraivaemy, does not require special expensive equipment (echocardiography) and therefore available to the majority of medical institutions, including for screening.

We performed 2017 research and the developed technique. Only two patients with nasal septum in the course of performing research is having difficulty with removing transesophageal electrode, probably due to swelling of the mucous membrane of the nasal passage. After intranasal instillation of epinephrine produced atraumatic extraction electrodes.

The method is carried out as follows. Lying down or sitting bipolar electrode inserted the patient into the esophagus through the nasal passage to a depth of 35-45 cm and optimal localization of the electrode is determined by the maximum amplitude and DV is faznoi form, and P wave with an initial positive phase, when recording ECG at the distal contact of the electrode. It is advisable distal end of the stylet electrode to impart a curved (arcuate) shape and, if necessary, for better visualization pravoberegnoe part of electrogram rotate along the axis based on the maximum intensity of the signal. To avoid dislocation of the electrode uses a special clamp lock. The distance between the proximal and distal electrode contacts 2,5 see Implemented unipolar registration electrogram with distal and proximal contacts of the electrode and bipolar, in which the active electrode Registrar is connected to the distal contact, and passive to the proximal contact. The most practical to use the electrode PADS-2 in connection with round shape and a sufficient amount of contacts, ensuring maximum contact with the walls of the esophagus and the ability to change the distance between the proximal and distal electrode contacts. Write research synchronously entered into the computer memory. Analysis of transesophageal electrogram is carried out at scan rate of 100-400 mm/s, with a sensitivity of from 20 to 100 mm/mV and subsequent manual measurement of time intervals with the help of sight. When you register and analysis of transesophageal filtered electrogram apply filters high the x and low frequencies in the range of 0.5-40 Hz.

When registering filtered Cpacg (1) we identified low-amplitude and low-frequency deviation of the preceding R-wave, there are two morphology:domed and smooth gentle wave (pre-R-prong).

On electrogram selected reference point to determine the intra - and interatrial conduction of excitation (figure 2).

The time of excitation of the right ventricle is determined from the beginning of the rising of the tribe of the first positive wave (pre-R-prong) to the point of intersection of the downward knee of this wave with the beginning Kotovskogo pre-R interval. Time interatrial conduction is measured from the point of intersection of the downward knee first positive wave with the beginning Kotovskogo pre-R interval to the intersection of this interval with the point of the steep ascent of the first phase-wave R. the Time of excitation of the left atrium is determined from the intersection point Kotovskogo pre-R interval with the point of the steep ascent of the first phase, and P wave to the top of the second spike of the P-wave. Time vnutriepreserdna holding is calculated from the beginning of the rising of the tribe of the first positive wave pre-R-wave to the peak of the second spike of the P-wave.

To assess intra - and interatrial conduction of excitation is the most informative is electrogram registered at the distal contact esophageal is electrode in connection with the maximum intensity of the signal.

The work was carried out on the complex for non-invasive (transesophageal) electrophysiological studies of the heart, automated "Astrocard-Polysystem - EP/L" ZAO Meditec Moscow.

The complex consists of a block of biopotential amplifiers, ADC interface card pacemaker "Astrocard ProgrammStim-2"cable to connect the interface card and the recording unit, the lead cable (12-channel), lead cable (for pilot channels), a set of electrocardiographic electrodes, a personal computer, printer, software. Interface card comes in the complex and is designed for input ECG and FORMER PC. Block ECG registration and the FORMER is intended to record the ECG in 12 channels (6 standard and 6 infants) and the EX 3 channels and input into the PC for further processing.

To identify the selected waves we used as the "gold standard" endocardial electrophysiological study of the heart, which was conducted in 15 patients referred for surgical treatment of paroxysmal reciprocal atrioventricular nodal tachycardia, paroxysmal reciprocal orthodrome atrioventricular tachycardia syndrome sick sinus.

In terms of the x-ray operation room endocardial electrodes are installed under the fluorescence is horoscopes.com and control electrogram. According to the method Sherlag Century [6] through the right femoral vein multipole electrode is placed in the projection septal folds tricuspid valve and registered the potentials of the lower sections of the right atrium (LRA), (H)-GIS capacity and oscillations of the right ventricle (RV). Second multipole electrode is placed in the high sections of the right atrium (HRA), in the region of the sinus node. Third multipole electrode through the right subclavian vein spend in the right atrium and installed in the area of the proximal, medial and distal coronary sinus (CSp.), (CSm.) and CSd.), characterizing the processes of excitation of the left atrium. Check electrogram was conducted at a speed of 100 mm/sec. at the same time is logged Cpacg as described above.

Simultaneous registration endocardial of electrogram with high and low sections of the right atrium, as well as with the proximal and distal zones of the coronary sinus, the potential of GIS and right ventricular established that spike potentials registered from the right and left Atria, time is an exact match with spike potentials registered on JPEG fibrillation (figure 3).

Due to the heterogeneity of the heart tissue and the existence of transitional zones at the initiation of the impulse coming from the sinus node, RAS is astronauts along the conduction paths in a strict sequence and appropriate time intervals alternately covers individual anatomoelectrophysiological units. The definition of the intervals between the spikes allows non-invasive estimate the timing of excitation in the Atria.

Figure 1 shows the uni - and bipolar Cpacg (variant rules):

E1 - registration unipolar Cpacg contact with the proximal electrode

E2 - registration unipolar Cpacg with distal contact electrode

E3 - registration bipolar Cpacg

I, II, III - standard ECG leads

1 - pre-prong P

2 - prong RV

Figure 2 presents unipolar and bipolar Cpacg a patient suffering from frequent and prolonged paroxysmal atrial fibrillation:

E1 - registration unipolar Cpacg contact with the proximal electrode

E2 - registration unipolar Cpacg with distal contact electrode

E3 - registration bipolar Cpacg

II - the second standard lead ECG

1 - the time of excitation of the right ventricle

2 - time interatrial conduction of excitation

3 - the time of excitation of the left atrium

4 - time vnutriepreserdna of the proceedings.

Figure 3 presents the synchronous recording endocardial of electrogram and Cpacg fibrillation:

HRA - electrogram of the top departments of right atrium

The CSp. - electrogram from the proximal zone of the coronary sinus

The CSm. - electrogram of medial divisions of the coronary sinus

CSd. - ElektroG the Amma from the distal zone of the coronary sinus

H - potential of the beam GIS

RV - electrogram right ventricle

VI - the first chest lead ECG

II - the second standard lead ECG

ESO - transesophageal electrogram

1, 2, 3 - bar on the ribbon diagram in Hz (speed registration andgram 100 mm/s).

Based on these results we have developed a method of non-invasive ECG registration, enabling the study of electric potentials of atrial ECG complex and evaluation vnutriepreserdna and interatrial conduction of excitation in norm and at a pathology.

References

1. Kistin A.D, Brill W.D, Robb G.P. Normal esophageal and gastric electrocardiograms. Description, statistical analysis and bearing on theories of "electrocardiographic position". Circulation 1950; 2:578-597.

2. Bincley P.F, Bush C.A, Fleisman B.L, Leier C.V. In vivo validation of the origin of the esophageal electrocardiogram. J Am Coil Cardiol 1986; 7:813-818.

3. Bagliani G, Meniconi L, Raggi F, Corea L. Left origin of the atrial esophageal signal as recorder in the pasing site. PACE 1998; 21:18-24.

4. THE Januskevicius, L.V. Characin, A.A., Pranevicius. Additionally reinforced cardiogram. - L.: Medicine, 1990.

5. Crawford T.M, Dick M, Jenkins J.M. Transesophageal atrial pasing. Med Instrument 1986; 20:40-44.

6. Scherlag B.J., S.H. Lau, Heffant R.A. et al. Catheter technique for recording His bundle activity in men. Circulation. 1969; 39:13-17.

7. Horowits L.N. Safety of electrophysiologic studies. Circulation. 1986; 2:1128-1132.

8. Brown, W.H. A study of the esophageal lead in clinical electrocardiography. Part I. The application of the esophageal lead to the human subject with observations on the Ta-wave, extrasistoles and bundle-branch bloc. Am Heart J 1936, 12:1-45.

9. F.G. Cosio, Anderson R.H., uck K.H., et. al. Living anatomy of the atrioventricular junctions. A guide to electrophysiologic mapping. A Consensus Statement from the Cardiac Nomenclatyre Study Group, Working Group of Arrhythmias, European Society of Cardiology, and the Task Force on Cardiac Nomenclatyre from NASPE. Circulation. 1999; 5:31-37.

10. Vinarov. Guide to electrocardiography. - M.: Medicine, 1983.

11. Maskouski. Heart arrhythmia. - S.-Petersburg: "Folio", 1998.

12. Schricket J.W., Bielik H., Yang, M., et al. Induction of atrial fibrillation in mice by rapid transesophageal atrial pacing. Basic Research in Cardiology. 2002; 6:452-460.

13. Sato, T., H. Mitamura, Y. Kurita, et al. Recovery of electrophysiological parameters after conversion of atrial fibrillation. Int J Cardiology. 2001; 79:183-189.

14. Saksema S, Giorgberisze I, Camm J.A., et al. Electrophysiology and endocardial mapping of induced atrial fibrillation in patients with spontaneous atrial fibrillation. Am J Cardiol 1999; 83:187-193.

15. M.A. Allessie, K. Konings, et al. Electrophysiologic mechanisms of perpetuation of atrial fibrillation. Am J Cardiol 1996; 77(3):10A-23A.

16. M.A. Allessie, Boyden P.A., Camm J.A., et al. Pathophysiology and prevention of atrial fibrillation. Circulation 2001; 103; 769-777.

17. Wijffels M.C., Kirchhof C.J., Dorland R, Power J, M.A. Allessie Electrical remodeling due to atrial fibrillation in chronically instrumented conscious goats. Roles of neurohumoral changes, ischemia, atrial stretch, and high rate of electrical activation. Circulation 1997; 96:3710-20.

18. Josephson M.E., L. Scharf, Kastor J.A., et al. Atrial endocardial activation in men. Electrode catheter technique of endocardial mapping. Am J Cardiol. 1977; 39:972-980.

19. Falk R.H. Atrial fibrillation. N Engi J Med. 2001; 344:1067-1078.

The way of measuring time vnutriepreserdna and interatrial conduction of excitation, including the registration of the electrocardiogram, wherein the electrocardiogram recorded in the esophagus, the electrode set is liveout in place, where is registered the maximum signal amplitude, the signal increase is not less than 5 times, filtered in the range of 0.5-40 Hz, record at a rate not less than 100 mm/s and time vnutriepreserdna conduct is measured from the beginning of the rising of the tribe of the first positive wave pre - R-wave to the peak of the second spike of the P-wave and the time of interatrial conduction is measured from the point of intersection of the downward knee first positive wave with the beginning Kotovskogo pre - R interval to the intersection of this interval with the point of the steep ascent of the first phase of the prong R.



 

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