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.

5-9

Authors: Revishvili A.Sh., Tumanyan M.R., Matsonashvili G.R., Trunina I.I., Levchenko E.G.

Pediatric electrophysiology, especially in infants, is the most difficult area of clinical arrhythmology. For the last two decades radiofrequency catheter ablation (RFCA) in pediatric patients has been dramatically advanced. Due to this progress the complication rate has been decreased and success rate has been improved. In cases, when arrhythmia can’t be controlled with drugs and becomes life-threatening (takes incessant character, sings of heart failure develop) RFCA is considered to be the method of choice. The most common cause of tachyarrhythmias in children is an accessory pathway (AP). Elimination of AP at an early age can be technically challenging due to small body surface area, limitation of invasion and proved high rate of complications if a patient weighs less than 15 kgs. There are no published data on the long-term effects of RFCA on coronary arteries and myocardial function. Although animal studies showed RF lesion can expand with time and may affect coronary perfusion. A combination of congenital heart disease and incessant tachyarrhythmia is even more difficult to treat. In this article we present a case report of successful RFCA of AP in 4-months-old patient with corrected transposition of great arteries, Ebstein's like modification of tricuspid «arterial» valve, heart failure NYHA II and intraoperatively revealed thrombosis of femoral veins.

15-22

Authors: Chernova A.A., Nikulina S.Yu., Tret’yakova S.S., Voyevoda M.I., Maksimov V.N., Chernov V.N.

Aim. To study the association between polymorphic allelic variants of the alpha-2В-adrenoreceptor gene (ADRA2B), endothelial nitric oxide synthase gene (NOS3), connexin protein gene 40 (Cx40), cardiac myosin heavy chain gene (MYH6), and voltage-gated sodium channels gene (SCN5A) and development of the idiopathic sick sinus syndrome. Methods. 14 probands with primary symptoms of sick sinus syndrome and their 110 relatives of the I–III degree kinship were examined. At the Berzon City Clinical Hospital 20 all participants underwent a clinical and instrumental examonation that entailed the clinical examination, electrocardiography, atropine test, echocardioscopy, bicycle ergometry, left atrial transesophageal pacing, 24-hour ECG (holter) monitoring. In addition, all the examined people underwent molecular genetic analysis of polymorphic allelic variants ADRA2B, NOS3, Cx40, MYH6, SCN5A using PCR in Novosibirsk Scientific Research Institute of Cytology and Genetics. The data was statistically processed on an IBM PC using the Statistica 7.0 software package. Results. Homozygous genotype in a rarer DD allele ADRA2B gene was found to dominate in sick sinus syndrome patients (28 %) compared to participants in the control group (8.99 %). Heterozygous genotype of the 4a/4b gene NOS3 was found to significantly dominate in sick sinus syndrome patients (41.18 %) compared to participants in the control group (25.39 %). Heterozygous genotype 44G >A of the Cx40 gene was found to significantly prevail in sick sinus syndrome (45.07 %) compared to participants in the control group (29.44 %). None of the investigated samples revealed polymorphism 2161C > T (Arg721Trp) of MYH6 gene. Homozygous genotype in rarer allele of (GG) gene SCN5A was found to prevail in primary sick sinus syndrome patients (4.29 %) compared to the absence of this genotype in the control group (0 %). The distribution of ADRA2B, NOS3, Cx40, SCN5A gene genotype in patients with latent sick sinus syndrome was proved to be consistent with that of the genotypes of the above genes in the general population of primary sick sinus syndrome patients. The allelic variants of the above genes were not found to be associated with ompensated sick sinus syndrome. Conclusion. The genetic predictors of idiopathic sick sinus syndrome are heterozygous genotypes 44 GA and 4a/4b genes Cx 40 and NOS3 as well as homozygous genotypes in rare allele DD and GG genes ADRA2B and SCN5A. Polymorphic allelic variant 2161C > T (Arg721Trp) of MYH6 gene was not revealed in the examined cohort of Krasnoyarsk population. The distribution of the genotypes of the investigated genes in latent sick sinus syndrome patients was found to be consistent with that of the genotypes in the general population of primary sick sinus syndrome patients.

31-39

Authors: Bockeria O.L., Ispir’yan A.Yu.

Cases of sudden cardiac death (SCD) in young athletes during physical exercises are rare. According to the data of prospective population study performed in Veneto (Italy), incidence of SCD is 2.3 cases per year (2.6 among men and 1.1 among women) per 100,000 athletes aged 12 to 35 years for all reasons. Out of them 2.1 cases of SCD were caused by cardiovascular diseases. Coronary artery disease is the most frequent cause of SCD in athletes aged over 35 years. Also there are a number of other pathologies manifested by SCD: hypertrophic cardiomyopathy (HCM), arrhythmogenic cardiomyopaphy/right ventricular dysplasia, congenital abnormalities of coronary arteries, commotio cordis, myocarditis, spontaneous rupture or dissection of ascending aorta, Wolff–Parkinson–White syndrome, Brugada syndrome, catecholaminergic ventricular tachycardia. It is known that in the USA HCM is the main cause of sudden cardiac arrest which accounts for a third of all deaths of athletes during competition. It is also thought that the cause of sudden cardiac arrest in athletes with HCM is the ventricular arrhythmias, in majority of cases caused by dysplastic changes in myocardium. In young athletes suddenly dying from arrhythmogenic cardiomyopathy/right ventricular dysplasia right ventricular dilation and massive fibrous fatty changes of muscles are revealed, significantly increasing the risk of development of life-threatening ventricular arrhythmias. Coronary artery, abnormally originated from aorta, creates the sharp angle with aortic wall. It is thought that fatal myocardium ischemia is caused by aortic root expansion due to physical exercises that constricts the damaged vessel, narrowing its lumen. SCD due to nonpenetrating commotio thoracis in the absence of structural damage to ribs, sternum and heart is known as commotio cordis accompanied by the reflex heart arrest. When detecting one of the above mentioned cardiovascular pathologies one should be guided by recommendations of 36th Bethesda conference regarding the future participation of an athlete in competitions or his/her withdrawal from them. Sports organizations, athletes, coaches, educational institutions and doctors should cooperate and aid each other in organization, development and taking measures for detecting cardiovascular diseases and prevention of SCD in athletes.

46-51

Authors: Bockeria L.A., Bockeria O.L., Melikulov A.Kh., Biniashvili M.B., Temirbulatov I.A.

Heart failure is a complex of signs and symptoms appearing as a result of structural or functional disorders of heart that lead to inhibition of pump function. In newborns it's the heart failure causes death in 90 % of cases. Children with the isolated right ventricular apex cardiac pacing systems are exposed to risk of left ventricular failure due to myocardial dissynchrony caused by chronic pacing of right ventricle. In these patients cardiac resynchronization therapy is used as it favors the improvement of myocardial contractile function, increasing of ejection fraction and synchronous contraction of the left ventricular myocardium. These effects in turn contribute to clinical improvement. In children over 10 kg an endocardial approach is preferable. This method in some cases allows to avoid thoracotomy and general anesthesia. However, in unsuccessful cases or lead dislocation from the coronary sinus (accounts for up to 9 %) combined or isolated surgical approaches are used. The former approach is characterized by the left ventricular lead positioned epicardially and other leads are implanted endocardially. The latter approach allows to implant all three pacing leads (atrial, right ventricular and left ventricular leads) epicardially during standard operation.