Annaly aritmologii

64-68

Authors: Bockeria L.A., Tetvadze I.V., Malenkov D.A., Sanakoev M.K.

Atrial fibrillation (AF) is the most common arrhythmia observed in patients with hypertrophic cardiomyopathy (HCM). Development of AF in patients with HCM is associated with worsening of signs and symptoms and progression of heart failure. In this article a case report of successful surgical treatment of HOCM and AF is presented. Preoperative examination was performed according to protocol approved in our clinic: electrocardiography, ECG Holter monitoring, echocardiography, chest X-ray, cardiac MRI with gadolinium enhancement, cardiac CT-angiography, heart catheterization and EP study. After median sternotomy intraoperative epicardial atrial mapping was performed. Surgical procedure included septal myectomy from the right ventricle and epicardial modification of cryo-maze procedure. At discharge there were no episodes of AF according to ECG Holter monitoring data. According to echocardiography LOVT peak gradient was 25 mm Hg.

79-87

Authors: Bockeria L.A., Bockeria O.L., Bazarsadaeva T.S., Salia N.T., Donakanyan S.A., Biniashvili M.B., Taskina V.Yu.

Objective. Examination of the distal blood flow at a regional (middle cerebral artery) and tissular (nail fold vessels) levels of patients with idiopathic atrial fibrillation before surgical treatment with the estimation of relationship between hemodynamic parameters and arrhythmia characteristics such as its form and duration. Material and methods. Study design: open cross-sectional non-randomized study. 102 patients with idiopathic atrial fibrillation (experimental group) and 48 healthy persons (control group) were included in to the study. The blood flow in the middle cerebral artery was studied with ultrasonograph «Vivid 7 Dimension» (GE Healthcare, USA) and «iE33» (Philips, Netherlands), and in the nail fold vessels – with the help of device «Minimax-Doppler-K» (Russia). Mean blood flow velocity and pulsatility index were evaluated. During the analysis of hemodynamic parameters the patients of the experimental group were divided into subgroups, taking into consideration following factors: cardiac rate (atrial fibrillation with fast and normal ventricular rate, sinus rhythm), duration of atrial fibrillation (more or less than 5 years), age of patients (over or under 50 years old). The data received were processed statistically with the help of Statistica 8.0 software. Results. In patients of experimental group with atrial fibrillation with fast ventricular response, duration of atrial fibrillation more than 5 years and at the age over 50 years old values of mean blood flow and pulsatility index differed significantly compared to the standard parameters at the level of nail fold vessels.The difference of the specified parameters compared to standard values, taken as 100 %, was 15 % to 30 %. In patients with normal ventricular response during atrial fibrillation, with sinus rhythm, duration of atrial fibrillation less than 5 years and age under 50 years old the difference between tested parameters of blood flow at the level of nail fold vessels and standard values was non-significant. The measured parameters of blood flow at the level of middle cerebral artery in patients of the experimental group did not differ significantly from the control of any other sub-groups, considering cardiac rhythm, duration of arrhythmia and age of the patients. Conclusion. Idiopathic atrial fibrillation is associated with the abnormalities of microcirculation, but not at the regional level in the middle cerebral artery. Abnormalities of tissular blood flow are significant in patients with fast ventricular rate, duration of the disease over 5 years and age over 50 years old. Obviously, for the prediction of hemodynamic stroke in patients with atrial fibrillation it is useful to estimate the tissular blood flow at the level of microvessels of nail fold.

94-101

Authors: Bockeria L.A., Bockeria O.L., Bazarsadaeva T.S., Salia N.T., Donakanyan S.A., Biniashvili M.B., Taskina V.Yu.

Objective. Examination of the state of vasodilating endothelial function in the final link of the vascular tree of the patients with essential atrial fibrillation with estimation of dependence of the received results on peculiarities of arrhythmia signs (its form and term) and age factor. Materials and methods. Study design: open single-step non-randomized study. 102 patients with essential atrial fibrillation (primary group) and 48 healthy persons (control group) were under medical supervision. A functional test with compression of brachial artery and ultrasonic dopplerographic test of blood flow in nail fold vessels into the phase of post-compression hyperemia with the help of device «Minimax-Doppler-K» was used for estimation of NO-dependent vasodilating function of endothelium. During the analysis of hemodynamic parameters the patients of the primary group were divided into subgroups, taking into consideration the factors, which reflected: cardiac rate peculiarities (tachysystolic or normosystolic forms of atrial fibrillation, sinus rhythm associated with antiarrythmic treatment); term of atrial fibrillation (more or less than 5 years); age of patients (over or under 50). The data received were processed statistically with application of «STATISTICA 8.0» software. Relative risk (RR) parameter was determined for estimation of the impact of analyzed signs of atrial fibrillation and age of the patients on probability of endothelial dysfunction progression. Results. Among all the patients with essential atrial fibrillation, 41.2 % had endothelial dysfunction at the level of tissual microvessels of nail fold. The significant (р < 0.05) increase of the relative risk of weakening of vasodilating function of endothelium were favoured by: tachysystolitic (RR = 4.3) and normosystolitic (RR = 2.4) forms of atrial fibrillation; term of disease over 5 years (RR = 2.8); age of patients over 50 years (RR = 1,8). Conclusion. Essential atrial fibrillation is associated with increase of probability of weakening of NO-dependent vasodilating endothelial function at the level of tissual microvessels. The frequency of such abnormality significantly increases in the patients with tachysystolitic and (less) normosystolitic forms of atrial fibrillation, term of disease over 5 years and age over 50 years. Obviously, it seems appropriate not only to specify the presence of blood clots in the left atrium, but to estimate the vasodilating function of endothelium at the level of microvessels of nail fold at indication of probability of ischaemic stroke progression in patients with atrial fibrillation.

111-120

Authors: Bockeria L.A., Filatov A.G., Kovalev A.S.

Objective. Qualitative detection of substrate in various forms of atrial fibrillation (AF) with its quantitative evaluation and analysis of the effectiveness of radiofrequency ablation of the substrate-forming parts of atrial myocardium based on long-term postoperative results. Material and methods. From 2009 to 2013 ninety five (95) patients underwent electroanatomical mapping procedure for the determination of the areas with fragmented activity, their properties and radiofrequency ablation. They were divided into 3 groups according to the form of AF: paroxysmal – Group 1 (n=34), persistent – Group 2 (n=30), and long-standing persistent (n=31). Patients were divided into 3 subgroups to evaluate the effectiveness of interventional procedures: subgroup A – extended antral pulmonary veins isolation (n=32), subgroup B – extended antral pulmonary veins isolation and targeted radiofrequency ablation of complex fragmented electrograms (n=31); subgroup C – extended antral pulmonary veins isolation, linear radiofrequency «box lesion» and enhanced additional radiofrequency ablation of complex fragmented electrograms (n=32). Results. Changes in baseline electrophysiological intervals were recorded only in patients of group 1 during antegrade atrioventricular node conduction before and after ablation (241.43 ± 37.6 ms and 312.14 ± 108.57 ms, respectively). Analysis of correlation between the total area of fragmented activity and the total surface area of the LA showed that in paroxysmal AF ratio was 11.18 % (10.2 ± 2.01 cm2 to 91.21 ± 35.83 cm2), in persistent AF – 14.74 % (22.59 ± 10.21 cm2 to 153.25 ± 39.28 cm2), in long-standing persistent AF – 18.85 % (34.99 ± 26.76 cm2 to 185.62 ± 47.43 cm2). The total percentage for all categories of patients was 15.67 % (p = 0.001). The effectiveness of intervention treatment for patients of all groups was 15.6 % (subgroup A), 35.5 % (subgroup B) and 56.3 % (subgroup C). The overall effictiveness was 35.8 % in combination with anti-arrhythmic therapy. Conclusion. Electroanatomical mapping procedure can be used in all patients with AF. Areas of complex fragmented electrograms should be characterized as a functional substrate, allowing visualization of slow conduction sites. Thus, we can recommend to take them into consideration at the selection of treatment modality and predicting the effectiveness of maintenance of sinus rhythm.