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Issues - Journal of arrhythmology №77, 15/08/2014


Characteristics of the left atrium miocardium structure in patients with atrial fibrillation and healthy volunteers according to the data of late gadolinium enhancement cardiac magnetic resonance imaging

O.P. Aparina, O.V. Stukalova, D.V. Parkhomenko, N.A. Mironova, E.A. Butorova, M.N. Bolotova, M.I. Makeev, S.K. Ternovoy, S.P. Golitsyn

To develop a method of detection and evaluation of the left atrium structural changes based on magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE), 20 patients with atrial fibrillation (AF) during the sinus rhythm (including 13 men) aged 38‑58 years (mean age: 52 years) and 5 healthy volunteers (including 3 men) aged 23‑39 years (mean age: 27 years) were examined. After the standard clinical examination, MRI using a 1.5 T scanner and commonly accepted scheme was performed. For assessment of the left atrial (LA) myocardial structure, LGE cardiac MRI was performed using the new high‑resolution MR‑sequence with ECG and breath synchronization. The analysis of the images obtained consisted of the LA semi-automatic contouring by two experts with subsequent assessment of intensity of the LA myocardium and the LA blood pool signal carried out using the novel software application (LGE Heart Analyzer).

An automatic algorithm of assessment of the LA structure with the use of new parameters, diffuse enhancement ratio (DER) and maximum enhancement ratio (MER), was developed. Both of them reflected the contract agent myocardial accumulation. Both DER and MER in the patients with AF were higher than in the healthy volunteers: 1.1 (1.06‑1.25) vs. 0.934 (0.923‑0.948), p<0.001, and 2.09±0.5 vs. 1.37±0.03, p=0.006, respectively). DER in patients with AF negatively correlated with the LA ejection fraction (EF) (r=-0.452, p=0.04).

The original method of detection of LA fibrosis was developed based on comparison of ER with threshold value, with HV MER used as threshold criterion. The extent of LA fibrosis was more pronounced in the patients with AF than in healthy volunteers (24.6±20.6% and 0.03±0.004%; p<0.001) and correlated with the presence of arterial hypertension (r=0.563, p=0.01).

The use of the original algorithm showed that DER, MER, and the extent of fibrosis in the patients with AF were higher than in healthy volunteers; it reflects the LA myocardium structural remodeling in the patients with AF. The contrast agent accumulation in the LA myocardium is related to a decreased LA EF and presence of hypertension. The approach mentioned above allows one to assess the LA myocardium structural changes in AF.

To develop a method of detection of the left atrium structural changes and evaluation based on the cardiac magnetic resonance imaging with late gadolinium enhancement, 20 patients with atrial fibrillation and 5 healthy volunteers were examined.

Key words: atrial fibrillation, atrial structural remodeling, fibrosis, late gadolinium enhancement magnetic resonance imaging


Home monitoring of implanted antiarrhythmic devices in control of effectiveness of therapy of chronic heart failure

S.E. Mamchur, E.A. Khomenko, N.S. Bokhan

To assess effectiveness of control over therapy of chronic heart failure (CHF) using the technique of home monitoring of implanted antiarrhythmic devices, 50 patients aged 63±7 years were examined. The patients were hospitalized in a planned manner due to the following indications: 13 patients (26%) with the sick sinus syndrome, 15 patients (30%) with the third‑degree atrio-ventricular block, 18 subjects (36%) with bradycardia-tachycardia syndrome, and 4 ones (8%) with ventricular tachycardia/fibrillation. All subjects had chronic heart failure; CHF II (NYHA classification) in 21 patients (42%), CHF III in 23 patients (46%), and CHF IV in 6 patients (12%). The following devices with the home monitoring function were implanted to the study subjects: Evia DR to 40 patients (80%) and Lumax DR to 10 patients (20%). The patients received the background therapy of the underlying disease with additional medical treatment of CHF; 2 patients (4%) received the therapy with angiotensin converting enzyme inhibitors (ACEI); 12 patients (24%), ACEI and diuretics; 29 patients (58%), ACEI, diuretics, and β‑adrenoblockers; and 7 patients (14%), ACEI, diuretics, and nitrates.

Within 10±3 months, the following parameters recorded by implanted antiarrhythmic devices were recorded: pacing threshold, impedance (including that on shock electrode), part of spontaneous and stimulated events, the atrial fibrillation burden, and the physical activity sensed by the device. Besides, the patient telephone questioning was carried out for subjective assessment of symptoms and the CHF deterioration/improvement.

During the follow-up period, 12 patients (24%) dropped out from the study due to inacceptable treatment compliance. In other patients, mean functional class of CHF decreased from 2.68±0.68 to 2.26±0.92 (p<0.00006). The correlation of the CHF functional class with pacing threshold was r=-0.2, p>0.05; with impedance on the shock electrode, r=-0.63, p=0.051; with the portion of spontaneous complexes, r=0.08, p>0.05; with the AF burden, r=-0.3, p>0.05; and with the physical activity detected by the device sensor, r=0.69, p<0.05. The visual analysis of graphs of the parameters studied, especially of the level of the subjects' physical activity sensed by the implanted antiarrhythmic device, was the most informative method of remote assessment of general well-being. The data obtained also correspond to those of the TRUST, COMPAS, and REFORM studies which showed a decreased number of the subjects' visits to the hospital by 45%, 55%, and 63%, respectively. Thus, the technique of home monitoring of implanted antiarrhythmic devices can be successfully used for control of effectiveness of the CHF treatment, even in absence of the thoracic impedance sensors. The parameters with the greatest informational value are the shock electrode impedance, the physical activity sensed by the device, as well as the visual analysis of the graphs.

To assess effectiveness of therapy of chronic heart failure using the technique of home monitoring of implanted antiarrhythmic devices, 50 patients aged 63±7 years were examined.

Key words: chronic heart failure, cardiac pacemaker, implanted cardioverter-defibrillator, cardiac resynchronization therapy, home monitoring.


Major risk factors of high-grade ventricular arrhythmias in the course of planned transluminal balloon angiopasty with stenting of coronary arteries in patients with chronic coronary artery disease

N.G. Gogolashvili, E.A. Nesterova, A.V. Protopopov, V.V. Kozlov, N.Ya. Novgorodtseva

To study ventricular arrhythmias (VA) registered before and after the planned procedure of transluminal balloon coronary angioplasty (PTCA) with stenting of coronary arteries and to reveal risk factors of high-grade VA, 106 patients aged 58.2±8.9 years (37‑80 years, 76 men and 30 women) with chronic coronary artery disease (CAD) were examined. The study subjects' assessment included questioning, physical examination, 12‑lead ECG at rest, echocardiography, and 72‑hour Holter monitoring.

Surgical revascularization of myocardium was performed in all study subjects: in 83% of cases, PTCA with stenting of coronary arteries was carried out; in 10.4% of cases, direct stenting of coronary arteries; and 6.6% of cases, PTCA without stenting. VA one day prior to PCI. (Day 1 of Holter monitoring) were revealed in 88.7% of patients. On the second day of Holter monitoring (PTCA, strict bed rest), the incidence of high-grade VA increased statistically significantly from 35.8% to 51.9% (p=0.0054), prevalence of Grade 4B ventricular premature beats (VPB), from 11.3% to 21.7% (p=0.037). On Day 3 of Holter monitoring, the incidence of VA decreased statistically significantly as compared with Day 2 from 91.5% to 83% (p=0.008). The incidence of high-grade VA on Day 3 decreased statistically significantly as compared with Day 2, as well, from 51.9% to 40.6% (p=0.0376) that is slightly higher than the baseline level (before revascularization), 40.6% and 35.8%, p>0.05, respectively.

For prediction of high-grade VA incidence on Day 2 of Holter monitoring, a logistic regression model was created. In the patients with a history of thrombolysis, the likelihood of high-grade VA during PCI and on the first day after the procedure is 14.9 times higher. In patients with altered RCA (according to the coronary angiography data), the likelihood of high-grade VA is 8.04 times higher than in patients with alterations of other coronary arteries. In the patients with a history of myocardial infarction, the risk of high-grade VA during and on the first day after PCI is 3.1 times higher and 1.2 times higher if the LDLP (low density lipoproteins) >3 mmol/l. The LDLP level exceeding 3 mmol/l, history of myocardial infarction, history of thrombolysis, and the alteration of RCA (according to the coronary angiography data) explain development of high-grade VA in 51.2% of patients. Thus, the patients with chronic CAD with an aggregate of the following factors: history of thrombolysis, alteration of RCA according to the coronary angiography data, history of myocardial infarction, serum LDLP >3 mmol/l have a high risk of clinically significant VA during the planned PCI and on the first day after it.

To study ventricular arrhythmias before and after the planned procedure of transluminal balloon coronary angioplasty with stenting of coronary arteries, 106 patients aged 58.2±8.9 years (37‑80 years, 76 men and 30 women) with chronic coronary artery disease were examined.

Key words: chronic coronary artery disease, coronary arteries, transluminal balloon coronary angioplasty, stenting, ventricular arrhythmias, Holter monitoring.


Risk stratification of sudden cardiac death of patients with dilated cardiomyopathy

T.G. Vaykhanskaya, A.V. Frolov, O.P. Melnikova, L.M. Gul, T.M. Koptyukh, I.V. Sidorenko, T.V. Kurushko

To reveal independent predictors of ventricular tachyarrhythmia (VTA) and predict the risk of sudden cardiac death (SCD), 209 patients with dilated cardiomyopathy and chronic heart failure (CHF) of Functional Class II‑III (NYHA) aged 47.2±11.7 years (17‑59 years), including 61 women (29.2%) and 148 men (70.8%) were examined. The sinus rhythm was documented in 129 patients (61.7%), atrial fibrillation, in 80 patients (38.3%). The QRS width was 123±29 ms. The complete left bundle branch block (LBBB) with the QRS complex width of 167±32 ms was found in 59 patients (28.2%). The follow-up period lasted for 32.8±7.4 months. All patients received the standard background therapy of CHF. The study assessment included physical examination, echocardiography, ECG Holter monitoring, and 6‑minute walk test. ECG was recorded within 7 minutes, including 2 minutes of ECG recording at physical exertion (power: 25 W; heart rate: 102±7.6 bpm) and 5 minutes of recording at rest, with analysis of ventricular ectopies, heart rate turbulence (HRT), QT interval dispersion, and microvolt T‑wave alternans (mTWA).

During the follow-up period (32.8±7.4 months), VTA were revealed in 45 patients (21.5%) with dilated cardiomyopathy, associated with syncope in 7 patients, successful cardio‑pulmonary resuscitation in 4 patients (1.91%); sudden cardiac death occurred in 11 subjects (5.26%). ECG Holter monitoring and telemetry of implanted devices revealed 30 patients (14.4%) with VTA. Cardioverters-defibrillators (ICD) were implanted as clinically indicated to 17 patients (8.13%), cardiac resynchronization therapy (CRT) was performed in 31 patients (14.8%), and resynchronizing devices with the cardioverter-defibrillator option (CRT‑D) were implanted to 28 subjects (13.4%).

mTWA was assessed in 126 patients (60.3%), the pathological mTWA was revealed in 39 cases, including 35 patients with SCD and/or VTA and in 4 patients without VTA. Negative mTWA tests were observed in 69 subjects without VTA and 5 patients with episodes of non-sustained ventricular tachycardia (VT). The HRT parameters were assessed in 69 patients. The pathological HRT was found in 43 subjects with SCD and/or VTA and 3 patients without VTA. The physiological HRT was revealed in 15 patients without VTA and 8 subjects with paroxysms of non-sustained VT. The QT interval dispersion was assessed in all 209 study subjects; positive tests were documented in 110 patients, and negative, in 99 ones. Episodes of VTA were revealed in 46 patients with the positive tests and were not found in 64 ones. The negative QT interval dispersion test was documented in 11 patients with VTA paroxysms and 88 patients without VTA. The highest predictive value was revealed for mTWA (sensitivity: 85%, specificity: 70%, area under the curve: S=0.826; CI 95%: 0.749‑0.902. p=0.000, with the mTWA cut point ≥33.5 μV) and the left ventricular dysfunction (threshold value of LV EF≤20.5%; sensitivity: 90%, specificity: 80%, area under the curve: S=0.903; CI 95%: 0.849-0.958, p=0.000).

Thus, the data obtained were in line with the results of multicenter studies of markers of myocardial electric instability, which affect the clinical prognosis of patients with depressed left ventricular contractile function. The use of the authors' prognostic model for screening stratification of patients with dilated cardiomyopathy permitted them to select a group of candidates for prophylactic implantation of cardioverter-defibrillator.

To reveal independent predictors of ventricular tachyarrhythmic events and predict the risk of sudden cardiac death with the aid of electrocardiography and echocardiography, 209 patients with dilated cardiomyopathy and chronic heart failure of Functional Class II‑III (NYHA) aged 47.2±11.7 years (17‑59 years) were examined.

Key words: dilated cardiomyopathy, chronic heart failure, ventricular tachyarrhythmia, sudden cardiac death, electrocardiography, echocardiography, heart rate turbulence, microvolt T‑wave alternans.


Potentialities of heart mri in detection of inflammation in patients with idiopathic abnormalities of cardiac conduction and clinical syndrome of dilated cardiomyopathy

E.M. Gupalo, O.V. Stukalova, N.A. Mironova, O.Yu. Narusov, L.V. Velichko, P.V. Chumachenko, A.N. Samko, S.P. Golitsyn

To assess sensitivity and specificity of the inflammation criteria revealed using magnetic resonance imaging (MRI) as compared to the data of endomyocardial biopsy (EMB), 25 patients aged 39.5±11.3 years (12 men and 13 women) with the clinical syndrome of dilated cardiomyopathy (CMP Group) were examined. All study subjects had clinical signs of heart failure, which corresponded to Functional Class II-IV (NYHA classification). At the study entry, the patients of CMP group received therapy with inhibitors of angiotensin-converting enzyme, β‑blockers, and diuretics. To reveal MRI signs of inflammation in patients with "idiopathic" conduction abnormalities, 27 patients (11 men and 16 women) aged 40.7±11.4 years were examined (Block Group).

MRI synchronized with ECG was carried out using the superconducting 1.5 T magnetic resonance tomograph Magnetom Avanto (Siemens, Germany) with superficial chest radiofrequency coil. To perform contrasting, immediately after cine-MR consequences, the contrast agent gadolinium-DTPA (Magnevist, Schering, Germany) was administered intravenously in a dose of 0.15 mmol/kg. The myocardial edema, as well as presence of the early (EC) and late contrasting (LC), was assessed in all 17 segments of the left ventricular (LV) myocardium on 3 cuts of the LV short axis according to the technique by M.D. Cerquera.

According to the EMB data, signs of active myocarditis were found in GMP Group in 16 patients (64%) of 25. In 4 cases (16%), no active inflammatory infiltration was revealed; however, the considerable focal and interstitial fibrosis was observed in the biopsy samples which corresponded to post-myocarditic cardiosclerosis transforming into dilated cardiomyopathy. In 5 patients (20%), no inflammatory infiltration in the myocardium was observed, as well, morphological alterations were typical for idiopathic dilated cardiomyopathy. MRI showed edema in 3‑11 segments in 10 patients (40%) of the CMP Group. EC was found in 3‑17 segments in 7 patients (28%) of the above group, the LC foci were observed in 12 patients (48%). In the patients of the Block Group, signs of edema were found in 2-7 segments in 5 patients (18.5%), signs of myocardial hyperemia were observed in 3-10 segments in 9 patients (33.3%). Zones of accumulation of gadolinium were found in the LC phase only in 2 subjects (7.4%) of the Block Group.

To clarify sensitivity and specificity of the MR criteria, presence of inflammation according to the MRI data was compared with the EMB data for the CMP Group. The Lake Louise criteria showed 33.3% of sensitivity and 77.8% of specificity. The sensitivity of the EC phenomenon was 31.3%, with 88.9% of specificity; the sensitivity of myocardial edema was 43.8%, and specificity, 66.7%. The maximal sensitivity (50%) with regard to the myocardial inflammation was shown for the LC phenomenon; however the specificity of the above phenomenon was 55.6%. Comparison of the heart MRI and EMB data in the CMP Group permitted one to determine sensitivity and specificity for both Lake Louise criteria and each particular MRI phenomenon. The most prevalent pathological MRI phenomenon in the CMP Group was LC foci revealed in 48% of cases.

Thus, the data obtained indicate that heart MRI conducted according to three standard techniques permits one to reveal pathological signs in one third of the Block Group subjects. Prevalence of patients with signs of myocardial hyperemia, i.e. with the LC phenomenon, in the Block Group is the same as in the CMP Group (p=0.94). The percentage of patients with Lake Louise criteria in the Block Group was two times lower than in the CMP Group. At the same time, it should be noted that the difference in the number of patients with MRI signs of active myocarditis between the study groups was not statistically significant (p=0.29). The only peculiar feature of the CMP Group was LC foci observed more frequently than in the Block Group patients (p=0.01) and affecting a significant area of the myocardium.

To assess sensitivity and specificity of the inflammation criteria revealed using magnetic resonance imaging, 25 patients aged 39.5±11.3 years (12 men and 13 women) with the clinical syndrome of dilated cardiomyopathy and 27 patients (11 men and 16 women) aged 40.7±11.4 years with "idiopathic" atrio‑ventricular and intra-ventricular blocks were examined.

Key words: magnetic resonance therapy, endomyocardial biopsy, dilated cardiomyopathy, atrio-ventricular block, inflammation, myocarditis.


Role of selectins and cell adhesion molecules in pathogeny of ventricular arrhythmias in patients with connective tissue dysplasia

A.V. Yagoda, L.N. Gladkikh, N.N. Gladkikh

To study plasma levels of selectins (E, L, P), intercellular (ICAM‑1), platelet-endothelial (PECAM‑1), and vascular (VCAM‑1) cell adhesion molecules and their interrelations with ventricular arrhythmias (VA), 82 patients aged 21.7±4.2 years (65 men and 17 women) with the connective tissue dysplasia (CTD) were examined. Most widespread symptoms of dysplasia included asthenic constitutional type (54.9%), scoliosis (41.5%), longitudinal flat foot (36.6%), teeth growth disorder and overcrowding teeth (29.3%). Less widespread symptoms included arachnodactylia (18.3%), and hypermobility of joints (17.1%), Grade I pectus excavatum (15.9%), Gothic palate (14.6%), atrophic striae (3.7%), and others. Also revealed were mitral valve prolapse (MVP) syndrome (84.1% of patients), unclassified phenotype (3.8%), myxomatous MVP (1.2% of patients), syndrome of hypermobility of joints (1.2%), and benign hypermobility of joints (1.2%). According to the ECG Holter monitoring data, all CTD patients were distributed into two groups. Group I consisted of 20 patients (16 men and 4 women) aged 22.5±4.2 years with VA. Group II consisted of 62 subjects (49 men and 13 women) aged 21.4±3.9 years without VA. Control Group consisted of 10 healthy persons (6 men and 4 women) of comparable age without signs of CTD. The immunoenzyme essay assessed plasma concentrations of L-, E-, and P-selectins, ICAM‑1, PECAM‑1, and VCAM‑1 (Bender MedSystems CmbH, Austria).

The statistical analysis showed that, in the whole group of the CTD patients, the plasma concentrations of E‑selectin, ICAM‑1, and VCAM‑1 were significantly higher and PECAM‑1, on the contrary, lower than in healthy subjects. The L- and P-selectin levels had no significant difference with the control. In patients with VA, the levels of E‑selectin, ICAM‑1, and VCAM‑1 were higher than those in healthy subjects. The patients with CTD without VA were characterized only by an increased ICAM‑1. The comparison of diagnostic values of different levels of increased E‑selectin, ICAM‑1, and VCAM‑1 for prediction of the VA risk in CTD (Table 4) subjects showed that more than a 2‑fold increase in the molecule concentration had high specificity, negative prognostic value, and accuracy. In case of simultaneously increased plasma concentrations of 2-3 molecules (e.g., E‑selectin, ICAM‑1, VCAM‑1), the risk of high-grade VPB increased 2.6 times (RR: 2.6, 95% CI: 1.1‑6.1). The sensitivity of the result is 63.6%, specificity: 88.9%, diagnostic value of the positive result: 87.5%, diagnostic value of the positive result: 87.5%, accuracy: 75%. Thus, established were peculiar features of plasma selectin levels and adhesion molecules in CTD, including that associated with VA.

To study plasma levels of selectins (E, L, P), intercellular (ICAM‑1), platelet-endothelial (PECAM‑1), and vascular (VCAM‑1) cell adhesion molecules and their interrelations with ventricular arrhythmias, 82 patients aged 21.7±4.2 years (65 men and 17 women) with clinical signs of the connective tissue dysplasia were examined.

Key words: connective tissue dysplasia, mitral valve prolapse, ventricular arrhythmias, ventricular premature beats, selectins, intercellular adhesion molecules, endothelial dysfunction.


Results of two-year survey of patients with permanent atrial fibrillation after training to improve the treatment compliance

S.L. Zharsky, E.A. Sirotsinskaya, I.M. Zharskaya, O.V. Baranova

To improve effectiveness of treatment of permanent atrial fibrillation (AF) by means of training, 120 patients aged 50‑72 years distributed into Study Group and Control Group of 60 patients each were examined. Anticoagulant treatment was indicated to all study subjects. The study group subjects were delivered a training course which consisted of four 60‑minute training sessions. The training sessions were aimed to test skills of self-check of heart rate (HR) and blood pressure (BP) and to explain significance of the heart rate control and selection of appropriate anticoagulant therapy. All patients were examined every 6 months within 2 years. During the survey period, Warfarin was continuously taken by 98.3% patients of the Study Group and up to 18.3% subjects of Control Group. The study group subjects showed an increase of 6‑minute walk test distance by 91 m, whereas no change was observed in Control Group. The above change was accompanied by an improvement of functional class of chronic heart failure (CHF). The part of patients with CHF I (NYHA functional class) increased from 6.6% to 26.6%, and with CHF III decreased from 28.3% to 0%. On the contrary, the part of patient with CHF III in Control Group increased from 21.6% to 30%. Thus, training of patients with chronic AF contributes to an improved treatment compliance and treatment optimization in accordance with the requirements of clinical guidelines. It is also accompanied by improvement of symptoms and functional class of CHF, hemodynamic signs, lipoprotein pattern, and quality of life. Training of patients with chronic AF is worth being included into the out-patient treatment strategy.

To ground a possibility of improvement of effectiveness of treatment by means of the patient training to improve the treatment compliance, 120 patients aged 50‑72 years with chronic atrial fibrillation were examined.

Key words: atrial fibrillation, chronic heart failure, antithrombotic therapy, treatment compliance, training, quality of life.


Antiarrhythmic activity of a novel amino-acid-containing compound nibentan

E.V. Blinova, S.Ya. Skachilova, D.S. Blinov, L.N. Singh, Yu.N. Elizarova, A.I. Meleshkin, E.A. Ivanova, E.I. Salyamova

To study the antiarrhythmic activity of L-glutamyl Nibentan racemate, experiments were carried out on 120 white mice of both sexes and the weight of 18‑20 g, rats of both sexes and the weight of 180‑220 g, as well as on 24 mongrel cats of both sexes and the weight of 2,800-4,000 g. The substance of a structural analog of Nibentan, L‑Glutamate-(RS)-Nibentan, synthetized and manufactured by Russian Scientific Center for Safety of Biologically Active Compounds (manufacturer's ID code: LHT‑01‑14) was studied. The acute toxicity of the compounds was studied during a single intraperitoneal administration of LHT‑01‑14 to white laboratory mice. The DL50 index was assessed using the probit analysis. The LHT‑01‑14 antiarrhythmic activity was studied on the models of aconitine arrhythmia in rats as well as early occlusion/reperfusion arrhythmia in cats. The initial dose of the study compound was determined as 5% of murine DL50 taking the interspecies dose scaling into the account. Nibentan was used as a comparator.

DL50 for LHT‑01‑14 made up 80.8±7.2 mg/kg (CI: 70.9-90.8 mg/kg), i.e., higher than that for Nibentan (50.2±3.4 mg/kg, p=0.012) and permits one to consider the study compound as of Grade III of toxicity. LHT‑01‑14 effectively prevented development of atrial arrhythmia caused by administration of aconitine nitrate. The antiarrhythmic index calculated for LHT‑01‑14 is higher than that for Nibentan. Therefore, LHT‑01‑14 has a higher therapeutic safety than the comparator. This fact gives evidence of a higher safety of LHT‑01‑14 with the same activity. Administration of LHT‑01‑14 in doses of 0.6 mg/kg and 0.3 mg/kg prevented ischemic arrhythmia and ischemic/reperfusion ventricular fibrillation in 100% of experiments (statistically significant as compared with the control, p<0.05) and decreased the risk of reperfusion ventricular arrhythmia to 33%. Thus, the novel medication manufactured in Russia, Nibentan racemate compound with L-glutamyl, is less toxic than its structural predecessor, has a more considerable therapeutic window, and has a similar strength and duration of its therapeutic effect on the model of transient ischemic and reperfusion arrhythmogenesis as its structural predecessor, Nibentan.

To study the antiarrhythmic activity of L-glutamyl Nibentan racemate, experiments were carried out on 120 white mice of both sexes and the weight of 18‑20 g, rats of both sexes and the weight of 180‑220 g, as well as on 24 mongrel cats of both sexes and the weight of 2,800-4,000 g.

Key words: antiarrhythmics, aconitine arrhythmia, occlusion and reperfusion arrhythmias, Nibentan compounds, acute toxicity.


Clinical value of elimination of concealed conduction revealed using adenosine triphosphate test after pulmonary vein radiofrequency isolation

E.V. Lyan, A.S. Klyukvin, A.N. Morozov, F.A. Tursunova, A.I. Kazakov, S.M. Yashin

To study the contribution of elimination of concealed conduction from pulmonary veins revealed with the aid of bolus administration of adenosine triphosphate to the effectiveness of radiofrequency catheter ablation (RFCA), 134 patients with paroxysmal and persistent atrial fibrillation (AF) and indications to RFCA were examined after the procedure. The patients were randomly distributed into two following groups: Group I (control group) where the concealed conduction was recorded but not subsequently eliminated (n=69) and Group II (n=65) where the concealed conduction was both registered and eliminated. No statistically significant difference in the clinical characteristics of the study group subjects was found. Most patients were men; three fourths of the study subjects had paroxysmal AF; in one fourth of the study subjects, typical atrial flutter was documented in addition to AF. The ablation catheter and circular 10‑polar catheter were introduced into the left atrium via a transseptal access. Radiofrequency applications were made around the pulmonary vein antra in an irrigated regime until signs of the pulmonary vein isolation appear and the circular line closes. Later on, the patients were monitored for 30 minutes. In case of acute recurrence, additional radiofrequency applications were made in the "breach" area. After the period of monitoring, adenosine triphosphate tests were performed in all study subjects. If the concealed conduction in pulmonary veins was found, additional radiofrequency applications were made in transient "breach" areas in Group II until the negative test was reached, whereas in Group I the concealed conduction was left intact. The scheduled ECG Holter monitoring was performed in 3 and 6 months, as well as every 6 months thereafter.

In all 134 cases, 268 ipsilateral pairs of pulmonary veins were isolated. The procedure duration was significantly longer in Group II (116±18 min and 130±16 min, respectively; p<0.0001). Nevertheless, the fluoroscopy time as well as the duration of radiofrequency applications did not significantly differ. The adenosine triphosphate test revealed concealed conduction in at least one ipsilateral pair of pulmonary veins in 31 of 134 subjects (23%). In total, the concealed conduction was found in 33 of 268 pairs (12%) of ipsilateral pulmonary veins. Within a three-year follow-up period, at least one sustained episode of AF or post-ablation tachycardia took place in 33 patients of Group I (48.8%) and 32 patients of Group II (49.2%), the difference was insignificant (log-rank test =0.084; p=0.77). Among 31 patients with the concealed treatment documented during the secondary adenosine triphosphate test, post-operation recurrence of arrhythmia occurred in 19 subjects (61%). At least one episode of AF or post-ablation tachycardia was found in 11 of 17 patients with concealed conduction in Group I (65%) and 8 of 14 patients with concealed conduction in Group II (57%). The difference in freedom of arrhythmia in patients with the concealed conduction in Group I and Group II did not reach the statistical significance (log-rank test =0.75; p=0.39). Thus, the elimination of concealed conduction revealed using the adenosine triphosphate test does not improve the late RFCA outcome.

To study the contribution of elimination of concealed conduction from pulmonary veins to the effectiveness of catheter ablation in the post-operation period, 134 patients with atrial fibrillation were examined.

Key words: atrial fibrillation, pulmonary veins, left atrium, radiofrequency catheter ablation, concealed conduction, adenosine triphosphate.


Up-to-date potentialities of study of atrial structural remodleing using late gadolinium enhancement cardiac magnetic resonance imaging

O.P. Aparina, O.V. Stukalova, N.A. Mironova, S.P. Golitsyn

Potentialities and limitations are considered of study of atrial structural remodeling with the aid of late gadolinium enhancement cardiac magnetic resonance imaging, as well as application of the technique for study of the influence of the left atrial fibrosis on the clinical course of atrial fibrillation and the outcome of its treatment.

Key word: atrial fibrillation, atrial structural remodeling, left atrial fibrosis, late gadolinium enhancement cardiac magnetic resonance imaging, radiofrequency catheter ablation.


Topographic anatomy of atrio-ventricular node in patients with persistent left upper vena cava

K.V. Davtyan, V.S. Churilina, M.I. Firstova, G.Yu. Simonyan

The results are given of assessment and treatment of a patient with a combination of atrio-ventricular nodal reciprocal tachycardia with persistent left superior vena cava; the algorithm is suggested of gradual assessment of the atrio-ventricular junction structures, which permits one to conduct the successful ablation of slow pathways and to avoid complications.

Key words: atrio-ventricular nodal reciprocal tachycardia, persistent left vena cava, coronary sinus, electrophysiological study, radiofrequency ablation.


Guide to practitioners

Potentialities of ecg holter monitoring in examination of patients with tachycardias

M.M. Medvedev, A.E. Rivin, M.M. Berman, A.A. Savelyev, Yu.V. Shubik

The results of Holter monitoring of a 86‑­year-old patient are given, which permit one to assess the electrophysiological mechanism of paroxysmal tachycardia with narrow QRS complexes; peculiar features of anterograde and retrograde conduction are considered.

Key words: antio-ventricular junction, paroxysmal reciprocal atrio-ventricular nodal tachycardia, Holter monitoring, electrophysiological study, inter-atrial conduction, radiofrequency catheter ablation.



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