Issues - Journal of arrhythmology №76, 15/05/2014

Clinical assessment of radiofrequency cardiac denervation

A.V. Evtushenko, V.V. Evtushenko, Yu.V. Sauchkina, S.M. Minin, K.A. Petlin, K.A. Smyshlyaev, B.Kh. Vaizov, A.M. Gusakova, T.E. Suslova, Yu.B. Lishmanov, S.V. Popov

To study radiofrequency cardiac denervation, 32 patients aged 60.0±9.4 years with acquired valvular heart disease (13 men and 19 women) were examined and treated. Mitral stenosis was documented in 15 patients, mitral insufficiency, in 13 subjects, and aortic stenosis, in 4 ones. According to the 6‑minute walk test data (6MWT), 21 patients were considered as heart failure subjects of Functional Class III (NYHA); 11 patients had Functional Class II (NYHA). The average functional class was 2.3±1.1. Beta-adrenoblockers (β‑AB) were received by 29 patients (90.6%), angiotensin-converting enzyme inhibitors (ACEI) and diuretics were taken by all study subjects; 5 patients (16%) took Digoxin. Coronary angiography was performed to all patients before intervention. The cardiac sympathetic tone was assessed using scintigraphy with ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG). The overall sympathetic activity was assessed on the basis of the heart/mediastinum ratio (H/M) and the indicator clearance. Valvular disease was surgically corrected in all subjects.

Group I consisted of 21 patients with long-term persistent atrial fibrillation (AF). In them, the surgical correction of valvular disease was accompanied by with the labyrinth radiofrequency atrial fragmentation with destruction of paraganglionic nervous plexuses. 11 patients with the sinus rhythm constituted Group II. No radiofrequency procedure was performed in them.

All study subjects were discharged from hospital. The sinus rhythm recovered in 19 patients (90.5%) of Group I; one female patient (4.75%) required pacemaker implantation, in one more patient (4.75%), left atrial incision tachycardia persisted. According to the 6MWT data, the functional class of heart failure improved in both groups by 1.2±0.7 functional class (NYHA) in Group I and by 1.1±0.2 functional class in Group II. Before the radiofrequency procedure, the H/M index in Group I was significantly lower (1.64±0.21 and 1.9±0.27, respectively; p<0.05) and the indicator clearance was significantly higher (30.21±10.43% and 21.94±15.01%, respectively; p<0.05) than in Control Group.

After the radiofrequency treatment, in Group I, the significant decrease in the H/M index as compared with the pre-operation data was noted (1.64±0.21 and 1.42±0.18, respectively; p<0.05) but an increase in the defect of the indicator accumulation occurred (11.1±5.6% and 24.9±7.56%, respectively; p<0.05). In Group II, after the procedure only a statistically significant fall of the H/M index was found (1.9±0.27 and 1.63±0.24, p<0.05). After the procedure, a significant inter-group difference was found for the ¹²³I-MIBG clearance (36±13.38% and 25.14±9.96%, respectively; p<0.05).

In addition, the H/M index after radiofrequency procedure in Group I was significantly lower than in Group II (1.42±0.18 and 1.63±0.24, respectively; p<0.05). When assessing the regional sympathetic activity in the patients of Group I, the ¹²³I-MIBG accumulation defect was significantly more pronounced than in Group II (24.9±7.56% and 13.7±5.81%, respectively; p<0.05). Thus, the ¹²³I-MIBG cardiac accumulation defect after the radiofrequency procedure and an increased clearance as compared to the pre-procedure data and the control group give evidence of a decreased number of norepinephrine receptors and, therefore, a decreased overall sympathetic cardiac tone.

To study effectiveness of radiofrequency heart denervation carried out using the penetrating technique, 32 patients aged 60.0±9.4 years with acquired valvular heart disease (13 men and 19 women) were examined and treated.

Key words: acquired valvular disease, long-term persisting atrial fibrillation, sympathetic modulation, radiofrequency catheter ablation, denervation, scintigraphy, ¹²³I‑metaiodobenzylguanidine.

Experience of treatment of cardiac perforations by endocardial electrodes for permanent pacing

A.V. Kozlov, S.S. Durmanov

To assess the experience of treatment of patients with myocardial perforations and to develop an algorithm of their management, the outcomes of 2,145 implantations of different devices were analyzed. 1,248 electrodes were implanted into the atria; 2,095 ones, into the ventricles, including 209 electrodes for cardioverters-defibrillators (ICD). Only endocardial steroid-eluting electrodes with active fixation were used. The atrial electrode was usually positioned in the right auricle, and in case of high pacing thresholds, in the free wall. The ventricular electrode was positioned in the medial or upper parts of the inter-ventricular septum of the right ventricle; no apical position was used. As the final step of the procedure, chest X‑ray was performed, with the corresponding image downloaded into the electronic medical chart. On the next day after the procedure, chest X-ray in two projections was recorded, ECG was recorded once again, and the pacemaker testing was performed. The cardiac perforation was defined as development of hemopericardium and/or extracardiac location of the electrode revealed on X-ray images. In the case of presence of hemodynamic alterations, pericardial drainage was made using the Marfan's technique under the radiological control. The drainage was removed after 1‑2 days of absence of pericardial effusion.

Eight perforations of myocardium were documented. The perforations were located in the right atrium (RA) in 3 cases and in the right ventricle (RV) in 5 cases. Five of 8 perforations were accompanied by hemopericardium. In 4 of them, the pericardial cavity drainage was performed; in one case the medical treatment was sufficient. Hemopericardium was detected in all cases of the RA perforation. The RV perforation was accompanied by hemopericaridum only in 2 cases of 5. Six of 8 perforations were of an acute nature; in one case, the sub-acute perforation of RV was detected (3 days following the procedure); and in one more case, the late RV perforation took place (6 months following the procedure). Three perforations of the RV were asymptomatic; they were revealed during scheduled X-ray assessments and were accompanied by dysfunction of the right ventricular electrode (both altered sensing and pacing). The electrode reposition was required in 3 cases when the electrode was located extracardially and its activity was impaired; in 2 cases of the RV perforation in them, no hemopericardium was detected.

No cases of the myocardial perforation led to a subject's death, no open-heart surgical intervention was required. In four cases, critical hemodynamic disturbances occurred; they required emergency pericardial drainage with evacuation of 250‑350 ml of blood. After that, no blood accumulation in the pericardial cavity was observed. In the current series of examinations, the electrode reposition was required only in one of five cases of hemopericardium. In all cases, the follow-up X-ray examination was sufficient to reveal the extra-cardiac electrode location; no computer tomography of the chest was required.

The authors' strategy of management of cardiac perforations based on the clinical signs and symptoms: hemopericardium with hemodynamic alterations was a subject of drainage and subsequent echocardiographic follow-up (in 1 hour, then every 3 hours) if the X-ray examination did not show an evident extracardial location of the electrode tip. In case of hemopericardium with stable hemodynamics and absence of signs of an increased pericardial effusion, and electrode dysfunction, the conservative therapy took place. In case of acute or sub-acute perforations without hemopericaridum but with the electrode dysfunction, the transcutaneous electrode reposition was carried out taking into the account the possibility of immediate start of open-heart surgery if the cardiac tamponade occurs. Thus, the presented experience of management of the cardiac perforations by endocardial electrodes permitted the authors to develop the algorithm based on assessment of hemodynamic alterations in case of hemopericardium as well as on presence/lack of extracardiac location of dislocated electrodes.

To analyze the experience of treatment of patients with cardiac perforation by endocardial electrodes and develop an algorithm of their management, 8 cases of perforation revealed after implantation of 2,145 devices are given.

Key words: cardiac pacemaker, cardioverter-defibrillator, endocardial electrode, active fixation, cardiac perforation, hemopericardium, electrode dislocation, pericardial cavity drainage.

Prevalence of atrial thrombosis and spontaneous echo contrast in patients with atrial fibrillation and flutter

E.S. Mazur, V.V. Mazur, E.A. Savinkova, A. al-Surayfi, A.V. Kovsar

To compare the prevalence of atrial thrombosis and the spontaneous echo contrast phenomenon (SEC) in patients with atrial fibrillation (AF) and atrial flutter (AFL) at the background of/without antithrombotic therapy (ATT), 205 patients with persistent non-valvular AF or AFL lasting for more than 48 hours were examined. In the study subjects, transesophageal echocardiography (TE EchoCG) was performed to assess whether the sinus rhythm can recover. The study group included 116 men (56.6%) and 89 women (43.4%) aged 20‑81 years (median age: 60.0 years). Atrial fibrillation was documented in 140 study subjects (68.3%); atrial flutter, in 65 patients (31.7%). The idiopathic arrhythmia was observed in 44 patients (21.5%); other patients had primary diseases which could potentially lead to development of AF and AFL. TE EchoCG and transthoracic echocardiography (TT EchoCG) was performed using the Vivid E9 device (General Electric, USA). The left auricle (LAU) assessment during TE EchoCG was performed from the medium esophageal access. During TT EchoCG, the left ventricle ejection fraction (EF) was assessed and the maximal left atrial volume (LAV) and right atrial volume (RAV) were measured.

During TE EchoCG, the LAU thrombus was observed in 62 patients (30.2%), SEC, in 103 patients (50.2%), and the high-degree SEC (Stage III‑IV), in 37 patients (18.0%). SEC was revealed in 82.3% (72.7-91.8) of cases in patients with the LAU thrombus and in 36.4% (28.5-44.2) of cases in the patients without thrombi. High-degree SEC was documented in 50.0% (37.6-62.4) and 4.2% (0.9-7.5) of cases, respectively (p<0.001 in both cases). Thus, SEC and especially high-degree SEC are found more frequently in the AF patients with the LAU thrombus than in those without thrombi. By the time of TE EchoCG assessment, the pre-cardioversion antithrombotic therapy has been conducted in 87 patients (62.1%) with AF and 29 patients (32.5%) with AFL. Other patients were free from anticoagulant therapy.

The LAU thrombus in patients with ATT was found in 27.6% (18.2-37.0) of cases of AF and in 0.0% (0.0-11.7) of cases of AFL (p<0.01) and, in ATT-free patients, in 56.6% (43.3-69.9) and 22.2% (8.6-35.8) of cases, respectively (p<0.02). The above data show that both ATT and the type of arrhythmia have a statistically significant influence on the thrombogenesis rate (χ²=25.4; p<0.001); the most significant influence of arrhythmia occurred at the background of ATT, and the most significant influence of ATT took place in patients with AFL. Two-way ANOVA test showed that the LAU circulation velocity depends on the presence of thrombus (F=226.2; p<0.001) as well as on the type of arrhythmia (F=14.2; p<0.01); the influence of the former factor is considerably more significant. In addition to the LAU thrombus and the type of arrhythmia, the LAU circulation velocity is influenced by the state of the left ventricle diastolic function; in the case of altered diastolic function, an approximately 6-fold increased thrombosis rate occurs from 5.5% (1.9‑14.9) to 34.4% (22.5-46.3) in patients receiving ATT and from 11.9% (5.2-25.0) to 70.2% (57.1-83.3) in patients free from ATT.

Thus, in the patients with AF, thrombi in LAU are revealed more frequently than in the patients with AFL, the SEC phenomenon is revealed with the same frequency. At the background of ATT, the LAU thrombogenesis improves but the SEC prevalence does not change. Irrespective of the arrhythmia type and intake of anticoagulants, the LAU thrombosis and SEC phenomenon are revealed more frequently in patients with an altered left ventricular diastolic function than with the normal one.

To compare the prevalence of atrial thrombosis and the spontaneous echo contrast phenomenon in patients with non-valvular atrial fibrillation and atrial flutter lasting for more than 48 hours at the background of/without antithrombotic therapy, 205 patients were examined, including 116 men (56.6%) and 89 women (43.4%) aged 20‑81 years (median age: 60.0 years).

Key words: atrial fibrillation, atrial flutter, left auricle, spontaneous echo contrast phenomenon, transesophageal echocardiography, antithrombotic therapy.

Endomyocardial biopsy from the right cardiac chambers in perdiatric patient with cardiac arrhythmias

E.S. Vasichkina, L.B. Mitrofanova, R.B. Tatarsky, D.S. Lebedev

To assess the results of endomyocardial biopsy (EMB) in pediatric patients with different cardiac arrhythmias, 19 patients were examined. When selecting appropriate candidates for EMB, guidelines and indications to EMB by AHA/ACC/ESC were followed. Cardiac arrhythmias were ventricular ones in 14 cases, 3 patients had atrial tachycardia, in one patient, the sick sinus syndrome was documented (tachy-brady syndrome: sinus bradycardia with paroxysmal atrial fibrillation), and in one more patient, paroxysmal atrial fibrillation. Indications to EMB were long-term persistent progressing cardiac arrhythmia, cardiac dilatation with or without a decreased ejection fraction, and resistance to antiarrhythmic therapy. In 16 cases (84.2%), EMB was carried out during the radiofrequency ablation (RFA) of ectopic foci and, in 2 cases (10.5%), during the cardioverter-defibrillator (ICD) implantation. In 1 case (5.3%), EMB was an independent procedure in the patient with the sick sinus syndrome, tachy-brady type. EMB was performed using a bioptome manufactured by Cordis, 5-8 tissue samples were collected from the right ventricle apex and inter-ventricular septum. The light and polarization microscopy of biopsy samples was performed; the standard protocol of endomyocardial biopsy was followed.

Eighty-six tissue samples were collected in 19 patients. No adverse events during any case of the EMB procedure were documented. According to the EMB data, the diagnosis of myocarditis was confirmed in 9 pediatric patients; in 5 cases, it was active myocarditis, in 2 subjects, borderline myocarditis; chronic and recovered myocarditis was found in 1 pediatric patient apiece. In 2 patients of the study group, signs of myocarditis were associated with those of arrhythmogenic cardiomyopathy/right ventricular dysplasia (AC/RVD). The viral genome was confirmed in cardiomyocytes in 4 children: parvovirus B19 in 2 patients, enterovirus and Epstein-Barr virus, in 1 patient apiece. In 3 patients (15.8%), morphological alterations were considered signs of primary cardiomyopathy. In 6 patients (31.5%), no pathological changes were found in the biopsy samples. In one case (5.3%), no morphological assessment was made due to technical issues.

Thus, according to the data of EMB performed in the authors' hospital in children with progressing cardiac arrhythmias, myocarditis was revealed in 47.4% of cases. It cannot be ignored indeed that such a high ratio of patients with the confirmed substrate of arrhythmia is caused by the thorough selection of candidates for the procedure and the initially high probability of myocarditis, predominantly its latent type, as a cause of malignant cardiac arrhythmia.

To reveal the morphological substrate of different cardiac arrhythmias, endomyocardial biopsy from the right ventricle and inter-ventricular septum was performed in 19 pediatric patients.

Key words: endomyocardial biopsy, myocarditis, arrhythmogenic cardiomyopathy/right ventricular dysplasia, dilated cardiomyopathy, magnetic resonance imaging, immunohistochemistry assessment.

Atrial fibrillation in patients with ischemic stroke

M.A. Baturova

Potentialities of up-to-date diagnostic methods of asymptomatic atrial fibrillation in patients after ischemic stroke and their effect on the strategy of prevention of thromboembolic events are considered.

Key words: atrial fibrillation, ischemic stroke, thromboembolic events, electrocardiography, Holter monitoring, event recorders, loop recorders.

Sudden cardiac death and wolff-parkinson-white syndrome

S.E. Mamchur, A.V. Ardashev

The causes of sudden cardiac death in patients with Wolff-Parkinson-White syndrome are considered; necessity of endocardial electrophysiological study and radiofrequency catheter ablation is considered, including those in asymptomatic patients with accessory pathways.

Key words: sudden cardiac death, atrial fibrillation, ventricular fibrillation, Wolff-Parkinson-White syndrome, endocardial electrophysiological study, radiofrequency catheter ablation.

Endocardial biopsy in adults and pediatric patients

E.S. Vasichkina, L.B. Mitrofanova, R.B. Tatarsky, D.S. Lebedev

The data on history, diagnostic potentialities, technical aspects, and complications of endomyocardial biopsy based on the experience of different hospitals and the expert opinions are presented.

Key words: endomyocardial biopsy, myocarditis, cardiomyopathy, heart transplantation, morphological criteria, immunohistochemistry assessment.

Evolution of indications and up-to-date concept of appropriate selection of candidates for cardiac resynchronization therapy

A.Sh. Revishvili, N.M. Neminushchy

The basics of cardiac resynchronization therapy are given, including its history, evolution of indications and the up-to-date concepts of appropriate selection of candidates for the therapy, as well as potential approaches to decrease the number of non-responders.

Key words: cardiac pacing, cardiac resynchronization therapy, chronic heart failure, left bundle branch block, electrocardiography, echocardiography, left ventricular ejection fraction.

Fixation of atrial electrode for permanent cardiac pacing in the area of tricuspid vavle fibrous ring

K.V. Davtyan, G.Yu. Simonyan, V.S. Churilina, S.E. Serdyuk, E.P. Mazygula

A case report is given of fixation of the atrial electrode for permanent cardiac pacing in the area the tricuspid valve fibrous ring which led to deterioration of chronic heart failure and regression of symptoms after the electrode replacement.

Key words: cardiac pacing, atrial electrode, fibrous ring of tricuspid valve, right atrium, chronic heart failure.

A case of application of combined surgical access during implantation of permanent epicardial cardiac pacing system in a pediatric patient after fontan surgery

A.A. Morozov, A.K. Latypov, E.S. Vasichkina, E.V. Grekhov, D.S. Lebedev

A clinical case report is given of replacement of the permanent epicardial cardiac pacing system which required the combined surgical access in a 12­-year-old pediatric patient after Fontan surgery.

Key words: Fontan surgery, complete atrio-ventricular block, permanent epicardial cardiac pacing, impedance, pacing threshold.

Reports

"Cardiostim-2014" congress report

IX regional meeting with international participation "Clinical electrophysiology and interventional arrhythmology"

Anniversary

Evgeny Vasilyevich Kolpakov

Российский Научно-Практический
рецензируемый журнал
ISSN 1561-8641

Санкт-Петербургское общество кардиологов им Г. Ф. Ланга
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