Issues - Journal of arrhythmology №75, 15/02/2014

Late Assessment of Effectiveness and Safety of Catheter Radiofrequency Ablation of Ventricular Tachyarrhythmia from Aortic Sinus

E.A. Ivanitsky, V.A. Sakovich, E.B. Kropotkin, S.N. Artemenko. V.V. Shabanov, R.T. Kamiev, A.G. Strelnikov, I.G.Stenin, D.V. Elesin, A.B. Romanov, E.A. Pokushalov

To assess effectiveness and safety of ablation of ventricular tachyarrhythmia located in the aortic sinus area, the data of 79 consecutive patients (including 46 women) aged 40.6±21.8 years with frequent symptomatic ventricular premature contractions (VPC) or ventricular tachycardia (VT) were analyzed. Arterial hypertension was documented in 9 patients (11.4%); diabetes mellitus, in 2 subjects (2.5%). The daily incidence of VPCs was 20,789±12,432. Sustained VT was documented in 17 patients (21.5%). Cardioverters-defibrillators were implanted to 11 patients (13.9%) due to hemodynamically significant VT with syncope. Antiarrhythmic therapy was ineffective in 79 patients (100%).

According to the data of stimulation mapping, a significant correlation of the QRS complex morphology with the initial morphology of PVC or VT in 12 surface leads was found in 69 patients (87.3%), in 11 leads was documented in 9 patients (11.4%), and in 10 leads, in 1 patient (1.3%). The number of radiofrequency applications was 3.2±1.5. The duration of fluoroscopy and of the procedure was 7.6±4.2 min and 59.5±12.6 min, respectively. The early total effectiveness of ablation was 97.5% (77 subjects). The patients were followed for 46.6±9.4 months. Two patients (2.5%) were lost for follow-up 30 months after the procedure. The total effectiveness of the procedure after one procedure (without antiarrhythmic treatment) was 93.7% (74 patients), after repetitive procedures, 96.2% (76 patients). Thus, the radiofrequency catheter ablation of ventricular tachycardia originating from aortic sinus is a safe and effective technique of treatment confirmed during the long-term follow-up.

To assess effectiveness and safety of ablation of ventricular tachyarrhythmia located in the aortic sinus area, the data of 79 consecutive patients aged 40.6±21.8 years were analyzed.

Key words: ventricular premature contractions, ventricular tachycardia, left ventricle, aortic sinuses, coronary arteries, radiofrequency catheter ablation.

Types of Fibrosis and Its Prevalence in Atria during Atrial Fibrillation in Patients with Coronary Artery Disease and Rheumatic Heart Disease

L.B. Mitrofanova

To assess the area and type of myocardial fibrosis in atrial fibrillation (AF), studied were 40 hearts, hospital case reports, and autopsy reports of patients with coronary artery disease (CAD) and rheumatic mitral valve disease (RMVD) aged 38‑86 years (22 men and 18 women). Five groups of patients were identified. Group I consisted of 10 patients aged 68±10 years with CAD, but without AF. Group II consisted of 10 patients aged 68±10 years with CAD and paroxysmal AF. Group III included 10 patients aged 68±10 years with CAD and permanent AF. The patients with RMVD and paroxysmal AF (5 patients aged 53±9 years) constituted Group IV and those with RMVD and permanent AF (5 patients aged 59±7 years), Group V. For the histological study, the following structures were collected: 1) the right atrium wall in the area of crista terminalis, 2) Bachmann bundle, 3) the left atrium wall between the ostia of upper pulmonary veins, 4) the left atrium wall between the ostia of lower pulmonary veins, and 5) the left atrium wall in the middle between the ostia of upper and lower pulmonary veins. Hematoxylin eosin stain, Van Gieson's stain, and Masson's trichrome stain with additional hematoxylin stain (Bio-optica, Italy) of paraffin cuts were performed. In each atrial cut, the fibrosis type and its extent (0 through 4 points) were assessed.

In the patients with CAD without AF, a mild perivascular fibrosis was revealed (1-2 points) evenly distributed in all studied areas, the relative fibrosis area was 5‑8%. In patients with CAD and paroxysmal and permanent AF, the microfocal, perivascular, perimuscular fibrosis, and "armour fibrosis" were found. In case of permanent AF, the relative fibrosis area in all studied zones was statistically significantly more pronounced than in the coronary patients without AF. The consolidated group of patients with CAD and AF significantly differed from the CAD patients without AF by the fibrosis area in all atrial zones. In patient groups with rheumatic heart disease and permanent AF, the microfocal, perivascular, perimuscular fibrosis, and "armour fibrosis" were found, as well. When comparing the consolidated groups with CAD and AF and RMVD and AF, significant difference in the fibrosis area was shown (p=0.008). The extent of atrial fibrosis was more significant in the rheumatic patients.

Thus, in AF at the background of both AF and rheumatic heart disease, the microfocal, diffuse, perivascular, perimuscular fibrosis, and "armour fibrosis" are observed. The latter type of fibrosis is more pronounced in rheumatic subjects. The rheumatic patients are also characterized by a more disseminated coarse-fibred fibrosis and hyalinosis.

To assess the area and type of myocardial fibrosis in atrial fibrillation, studied were 40 hearts, hospital case reports, and autopsy reports of patients aged 38‑86 years (22 men and 18 women) with coronary artery disease and rheumatic mitral valve disease.

Key words: coronary artery disease, rheumatic heart disease, myocarditis, atrial fibrillation, autopsy, histological study, fibrosis, hyalinosis.

Late Outcome of Ablation of Ventricular Tachyarrhythmia from Mitral-Aortic Contact and Mitral Valve in Patients without Structural Heart Disease

E.A. Ivanitsky, V.A. Sakovich, E.B. Kropotkin, S.N. Artemenko. V.V. Shabanov, R.T. Kamiev, A.G. Strelnikov, I.G.Stenin, D.V. Elesin, A.B. Romanov, E.A. Pokushalov

To assess effectiveness and safety of ablation of ventricular tachyarrhythmia (VTA) located in the area of the mitral-aortic contact (MAC) and mitral valve (MV) fibrous ring, the data of 132 consecutive patients with VTA originating from the left ventricle (LV) were analyzed. VTA originating from the areas of MAC and MV were revealed in 21 patients (15.9%). Frequent symptomatic ventricular premature contractions (VPC) and/or VT paroxysms were found in all patients, antiarrhythmic therapy (AAT) being ineffective. Patients with structural heart disease were excluded from the study.

18,946±10,948 VPCs per day were documented. The sustained VT was documented in 4 patients (19%). In 20 patients (95.2%), monomorphic VPC/VT was observed. Cardioverters-defibrillators were implanted to 2 patients (9.5%) before the intervention. Antiarrhythmic therapy was ineffective in 21 patients (100%). The following 3 types of the ectopic foci location in patients with VPC/VT were identified: antero-lateral part of MV (n=7; 58%), posterior part of MV (n=2; 16.7%), and postero-septal part of MV (n=3; 14.3%).

The total early effectiveness of ablation was 100% (21 patients). No PVC/VT recurrence was revealed in early post-procedure period. Antiarrhythmic therapy was discontinued in all patients with the effective radiofrequency ablation. No post-procedure complications were observed in the study patients. The follow-up period lasted for 38.6±7.4 months. The long-term follow-up data were obtained for 20 patients (95.2%). In one patient from the MAC group (4.8%), the VPC recurrence developed 4.5 months after the primary radiofrequency ablation. The late effectiveness of the ablation of VPC/VT from MAC/MV in absence of AAT was 95.2% (20 patients) after the single ablative procedure and 100% (21 patients) after the repetitive ablation.

Thus, despite a relatively low prevalence, VTA originating from the MAC area and the MV fibrous ring, with a number of electrocardiographic features, can be successfully eliminated using radiofrequency ablation, which is a highly effective and safe method of treatment of the arrhythmia.

To assess effectiveness and safety of ablation of symptomatic ventricular tachyarrhythmia located in the area of mitral-aortic contact and mitral valve fibrous ring, 21 patients aged 44.2±19.4 years were examined and surgically treated.

Key words: left ventricle outflow tract, mitral-aortic contact, fibrous ring of mitral valve, ventricular premature contractions, ventricular tachycardia, electrocardiography, radiofrequency catheter ablation.

Radiofrequency Catheter Ablation of Ventricular Arrhythmias in Pediatric Patients: Assessment of Effectiveness and Risk Factors of Recurrence

O.V. Sorokvasha, M.A. Shkolnikova, S.A. Termosesov

To assess effectiveness of radiofrequency ablation (RFA) of idiopathic ventricular arrhythmias (VA) in pediatric subjects and risk factors of their recurrence, 259 children aged 13.4±3.1 years (5‑17 years, 153 boys) with idiopathic VA were examined and surgically treated. Patients with cryocatheter ablation of arrhythmic foci were not included into the study. The study assessment included anthropometry, blood and urine lab tests, electrocardiography, Doppler echocardiography, Holter ECG monitoring, stress-test (treadmill-test) according to the modified Bruce protocol for children. The invasive electrophysiological study was performed under general anesthesia (91%) according to the commonly accepted technique which included stimulation and activation mapping. In a majority of cases (82%), the electroanatomic mapping using the CARTO navigation system (Biosense Webster, USA) was carried out. The primary indications to radiofrequency ablation of arrhythmogenic foci were presence of signs of arrhythmogenic myocardial dysfunction and symptomatic VA.

Patients with frequent single and coupled ventricular premature contractions (VPC) predominated in the structure of VA (187 children; 72%). In 49% of these cases (127 children), allorhythmia was documented. In 26% of cases (67 children), VPC were associated with bursts of monomorphic ventricular tachycardia (VT). Paroxysmal VT occurred in 5 children (2%). Signs of arrhythmogenic myocardial dysfunctions (left ventricular dilatation and/or depressed ejection fraction at the background of the sinus rhythm) were found in 59% of patients (153 pediatric subjects). The most widespread location of VA foci was the right ventricle outflow tract (RV OT). The second widespread arrhythmogenic areas were the aortic sinuses and the RV inflow area, which were revealed 3 times less than RV OT. Rare locations of arrhythmogenic foci in pediatric patients were the left ventricle inflow tract, apical part of inter-ventricular septum, left ventricular outflow tract, sub-valvular space, which took place in 0.4-1% of subjects. In a majority of cases (98%), the focal type of arrhythmia took place.

The highest effectiveness of RFA of 96.1‑100% was observed in fascicular VT and VT originating from aortic sinus, whereas a lower effectiveness, in case of VA from RV OT and from the RV free wall (88.9% and 70.2%), respectively. The extremely low effectiveness was typical for ectopies in the apical of the inter-ventricular septum. The intra‑operational effectiveness after the primary RFA procedure was 86.5%. During the subsequent follow-up, a delayed or partial effect of RFA was noted in 7 patients (2.7%) and 6 patients (2.3%), respectively. In 7 children (2.7%), a repetitive intervention was performed, which turned out to be effective in 3 patients (1.2%). Other pediatric patients (n=21) did not undergo repetitive RFA. The recurrence after the primary RFA were found in 8.5% of cases (n=22), including 20 cases in the early post-operation period (91%) and 2 patients in the late post-operation period (9%). In 10 children (3.9%), a repetitive ablation was performed, which was effective in 8 cases (3.1%). Thus, RFA of arrhythmogenic focus is an effective and safe method of the VA treatment in pediatric patients. The total effectiveness of RFA in VA is 85% (100% through 70%) depending of the ectopic focus location.

To assess effectiveness of radiofrequency ablation of idiopathic ventricular arrhythmias and risk factors of their recurrence, 259 children aged 13.4±3.1 years (5‑17 years, 153 boys) with idiopathic VA were examined and surgically treated.

Key words: idiopathic ventricular arrhythmias, ventricular premature contractions, ventricular tachycardia, fascicular tachycardia, radiofrequency catheter ablation, recurrence.

Selection of an Effective Antiarrhythmic Therapy Using a Novel Technique of Multi-day Telemonitoring of Electrocardiogram

E.A. Tsurinova, S.V. Popov, E.R. Berngardt, N.I. Ananyeva, V.M. Tikhonenko, T.V. Treshkur

To assess potentialities of application of multi-day (MD) ECG monitoring with telemetry to reach an optimal time of correction of already diagnosed clinically significant arrhythmias, 30 patients were examined, including 8 patients with arterial hypertension, 5 patients with coronary artery disease, 2 patients with the connective tissue systemic dysplasia, cardiomyopathy of an undetermined origin, and congenital heart disease each, and 1 patient with idiopathic pulmonary hypertension, catecholaminergic ventricular tachycardia (VT), long QT syndrome, dilated cardiomyopathy and hypertrophic cardiomyopathy each. Nine patients had idiopathic arrhythmias.

Ventricular arrhythmias (VA) were revealed in 18 patients, 12 patients constituted the patient group with paroxysmal atrial fibrillation (AF). For MD ECG, the "Kardiotekhnika‑07" device with wireless channels in the GSM, G3, G4 standard and transfer of current or saved ECG onto CardioServer any time. The duration of selection of an effective antiarrhythmic therapy (AAT) in 30 patients was 11.3±3.2 days (4‑30 days).

The effectiveness of AAT, its doses and the time of intake was verified in all study subjects no less than within 3 days following the achievement of the treatment effect. In 3 patients with idiopathic VA, none of AATs taken was effective; the patients were referred for surgical treatment. In all patients with ventricular arrhythmias, MD ECG permitted one to select an optimal treatment strategy, either to find an optimal or to confirm ineffectiveness (and impossibility) of the medical treatment (conservative therapy) and to persuade patients to undergo RFA of an ectopic focus. In a half of patients with paroxysmal AF, the MD ECG technique permitted one to select the effective protecting AAT to maintain the sinus rhythm for 8.3±3.6 months. Thus, the use of MD ECG permitted one to perform the fast AAT selection in most patients.

To assess potentialities of application of multi-day ECG monitoring with telemetry to reach an optimal time of correction of already diagnosed and clinically significant arrhythmias, 30 patients were examined.

Key words: ventricular premature contractions, atrial fibrillation, multi-day ECG telemonitoring, antiarrhythmic therapy.

Radiofrequency Ablation of Cavotricuspid Isthmus: Is the Clinical Type of Atrial Flutter Important?

A.A. Nechepurenko, N.N. Ilov, A.A. Abdulkadyrov, D.R. Paskeev, D.G. Tarasov

To study peculiar features of radiofrequency ablation (RFA) of cavotricuspid isthmus (CTI) in patients with paroxysmal, persistent, and permanent atrial flutter (AFL), 197 patients aged 55.7±11.1 years (129 men; 65.5%) were examined and surgically treated. The patients with paroxysmal AFL (61.4%) constituted Group I and the subjects with persistent (14.7%) and permanent AFL (23.9%), Group II. Before the surgical treatment, ECG was recorded, transthoracic echocardiography (EchoCG) and duplex scanning of brachiocephalic arteries were performed, as well as coronary angiography (when indicated). Arterial hypertension was documented in 47% of patients; in one third of patients, Type I AFL was associated with paroxysmal atrial fibrillation (AF).

The intracardiac electrophysiological study was performed to all patients. RFA of CTI was carried out according to the standard technique: consecutive radiofrequency applications were made from the tricuspid valve ring towards the lower cave vein. Used were non-irrigated 8‑mm Blazer II catheters (Boston Scientific, USA) with the following parameters: temperature: 60°C, power: 70 W. When indicated, the power was increased to 80 W and a switch was performed to the irrigated ablation using the ExSteer or Celsius Thermocool catheters (Biosense Webster, Israel) in the following ablative regime: temperature: 43°C, power: 40 W.

The total procedure duration was 85 min (60‑110 min), the fluoroscopy time: 30 min (23‑41 min), the total dose: 712 Gy (578‑930 Gy), and the skin exposure: 8,064 mGy×m² (6,210‑10,230 mGy×m²). The effectiveness criteria were achieved in 85.3% of procedures. The recurrence of typical AFL 3 months after the operation, which required an additional intervention, was documented in 8 patients (4%). 24‑hour ECG monitoring was indicated in 15 patients due to pronounced sinus bradycardia after the sinus rhythm recovery (80%) or transient/complete atrio-ventricular (AV) block during radiofrequency application on the medial isthmus (20%). In the course of RFA of CTI during paroxysms of AFL (n=105; 53%), the sinus rhythm recovered in 66 subjects (63%). If AFL did not terminate during the ablative procedure, the overdrive anterograde pacing was performed. In 54.5% of cases, electric cardioversion was necessary to restore the sinus rhythm.

In the patients of both groups, RFA on the sinus rhythm was shorter: the overall duration of the procedure was 75 min (55‑105 min) whereas, at the background of AFL, it was 90 min (70‑120 min). The RFA effectiveness was 88% in patients on the sinus rhythm and 83.8% in other patients (p=0.1). In Group I, the most frequent finding was the bidirectional isthmus-block (88.4%), whereas it occurred only in 80.3% of cases in Group II. It was verified in 93% of subjects with the normal atrial size and only in 82.6% of subjects with the dilated right atrium (p=0.1). Thus, a longer duration of the procedure in the patients with persistent/permanent AFL is caused by an increased atrial size, which is developed in the course of the arrhythmia perpetuation. The obtained data regarding a lower effectiveness of the procedure in chronic forms of AFL are limited by the small sample of the study.

To study peculiar features of radiofrequency ablation of cavotricuspid isthmus in patients with paroxysmal, persistent, and permanent atrial flutter, 197 patients aged 55.7±11.1 years (men: 65.5%) were examined and surgically treated.

Diagnosis of Non-Coronary Heart Diseases in Patients with Ventricular Tachyarrhythmia

V.V. Grokhotova, R.B. Tatarsky, D.S. Lebedev, L.B. Mitrofanova, N.K. Mitrofanov, A.V. Pakhomov, E.S. Ignatyeva, K.N. Malikov, I.A. Pankova, L.A. Belyakova, O.V. Beshchuk

To study etiology of non-coronary ventricular tachyarrhythmia (VTA) based on the assessment of the endomyocardial biopsy data, 87 patients aged 39.9±1.7 years (50 men; 57.5%) were examined. The study group included 41 patients (47%) with episodes of sustained ventricular tachycardia (VT) and 46 patients (53%) with ventricular premature contractions (VPC) and/or non-sustained VT. Electrocardiography, 24‑hour ECG Holter monitoring, echocardiography, magnetic resonance tomography with contrasting and in the fat suppression mode, stress test, and coronary angiography to exclude the VTA ischemic origin were performed. The endomyocardial biopsy was carried out in the area of surgical treatment of the arrhythmia, which included catheter ablation and/or implantation of a cardioverter-defibrillator.

According to the data of endomyocardial biopsy, arrhythmogenic cardiomyopathy/right ventricular dysplasia (ACRVD) was diagnosed in 29 patients (33%), myocarditis, in 34 patients (39%), and postmyocarditic cardiosclerosis, in 24 ones (28%). The histological study of myocardial biopsy samples of the patients with ACRVD showed lipomatosis, microfocal fibrosis, as well as dystrophy and atrophy of the right ventricle muscular fibers. Signs of active myocarditis were found in 7 patients, of chronic myocarditis, in 2 ones. The relative area of lipomatosis was 34.3±14% (3‑90%); 32.7±13.4% in patients without myocarditis and 42.1±22.3% in patients with myocarditis. The relative area of fibrosis was 36.7±18% (2‑90%); 30±15% in patients without myocarditis and 37.2±17.2% in patients with myocarditis. Thus, the endomyocarial biopsy permits one to determine etiology of VTAs considered "idiopathic" during the standard (typical) non-invasive study. The most frequent causes of non-coronary ventricular arrhythmias were ACRVD (33%), myocarditis (33%), and post-myocarditic fibrosis (28%).

To study etiology of non-coronary ventricular tachyarrhythmia, assess the sensitivity and specificity of imaging techniques for the diagnosis of cardiac pathology, 100 patients were examined and surgically treated; during the surgery, endomyocarial biopsies were made.

Key words: arrhythmogenic cardiomyopathy/ right ventricular dysplasia, myocarditis, postmyocarditic cardiosclerosis, ventricular tachyarrhythmia, endomyocardial biopsy, echocardiography, magnetic resonance tomography.

Short communication

Dynamics of Heart Size after Radiofrequency Ablation of Idiopathic Ventricular Premature Contractions Originating from the Right Ventricle Outflow Tract

A.V. Kozlov, S.S. Durmanov

Presentation

Antithrombotic Therapy in Atrial Fibrillation

Yu.V. Shubik

The current concepts on antithrombotic therapy in atrial fibrillation are given; practical aspects of use of both vitamin K inhibitors and novel oral anticoagulants are considered, including those during surgical interventions in patients with acute coronary syndrome and stroke.

Key words: atrial fibrillation, thromboembolism, bleeding, Warfarin, Dabigartan etexilate, Edoxaban, Apixaban, Rivaroxaban.

Clinical case report

Risk of Damage of Permanent Cardiac Pacemaker during External Defibrillation

E.V. Pervova, A.E. Tyagunov, I.V. Samoylenko, K.V. Kotov, T.S. Smirnova, M.V. Murman, V.S. Izrantsev, T.V. Nechay

Two cases are given of the implanted permanent cardiac pacemaker failure after electrical defibrillation during cardiopulmonary resuscitation in patients with ventricular tachycardia which transformed into ventricular fibrillation.

Key words: cardiac pacemaker, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation, defibrillation.

Российский Научно-Практический
рецензируемый журнал
ISSN 1561-8641

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