RU2381006C1 - Method for reduction of regular form of auricular fluttering - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: electrocardiogram is recorded with determining f-f wave frequency and following transesophageal electrocardiostimulation. The transesophageal electrocardiostimulation is ensured with initial stimulation frequency at the rate 10 pulse/min that exceeds the f-f wave frequency of auricular fluttering of duration 3-5 s, with the following discreteness 10 pulses/min to develop a non-uniform atrioventricular execution. Then stimulation is continued with discreteness 10 pulse/min and duration 20-30 s to reduce arrhythmia and development of auricular fibrillation.

EFFECT: method allows improving accuracy of determining the minimally effective electrocardiostimulation frequency for reduction of the regular form of auricular fluttering.

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Description

The invention relates to medicine, namely to cardiology, in particular to methods of using transesophageal electrocardiostimulation (CPEX) for stopping the regular form of atrial flutter (TP).

Currently, atrial stimulation, in particular CPEKS (Kushakovsky M.S. Cardiac arrhythmias. - L .: Medicine, 1993) is used to stop TP. When conducting CPEKS in patients with a regular form of TP, it is rather difficult to judge by the data of the electrocardiogram (ECG) whether the stimulation is effective or not.

An analogue of the proposed solution is also the method of stopping or converting TP to atrial fibrillation (AF) by using various types of super-frequent pacemaker (salvo and slow-growing or slowly decreasing cardiac pacing) (Clinical Cardiology. Translated from English by V.N.Khirmanov. - 2- e edition, revised and enlarged. - M .; St. Petersburg: "BINOM Publishing House" - "Nevsky Dialect", 2002. - 672 p .; Shlevkov N., Yang A., Schrickel JW et al. Role of high frequency atrial pacing for the termination of acute atrial fibrillation and atypical atrial flutter. // Pacing. Clin. Electrophysiol. - 2007. - Vol.30, No. 3. - P. 322-332).

Based on the closest technical nature, as a prototype, we have chosen a method for determining the effective frequency of CPEX for stopping the regular form of TP (after recording an electrocardiogram (ECG) and determining the frequency of waves ff TP) when the stimulation frequency is 15-25% higher than the frequency of waves ff TP (Kushakovsky M .S. Heart Arrhythmias: A Guide for Physicians. - St. Petersburg: LLC "Publishing House Foliant", 2004. - 672 p.).

The disadvantage of analogue and prototype is the lack of accuracy in determining the minimum effective frequency of pacing for stopping the regular form of TP.

The objective of the invention is to increase the efficiency of stopping the regular form of TP.

The technical result of the invention is to increase the accuracy of determining the minimum effective frequency of pacing for stopping the regular form of TP.

The technical result is achieved by the fact that a patient with a regular form of TP conduct an ECG study, then determine the frequency of waves f-f TP. Subsequently, CPEX is performed with an initial stimulation frequency at a frequency of 10 pulses / min, exceeding the frequency of atrial flutter waves ff for 3-5 seconds with a subsequent discreteness of 10 pulses / min until the development of uneven atrioventricular conduction, and after determining the minimum frequency of stimulation that causes the development uneven atrioventricular conduction, continue stimulation with a resolution of 10 pulses / min and a duration of 20-30 s until relief of arrhythmia and the development of atrial fibrillation.

Salient features of the proposed method are the following with the development of uneven atrioventricular conduction during CPECS for stopping the regular form of TP, the frequency of pacing is defined as minimally effective.

The method is as follows. An ECG test is performed for a patient with a regular form of TP. Then determine the frequency of waves f-f TP, and if necessary, to determine the frequency of waves f-f TP conduct registration of transesophageal ECG leads. Further, CPEX is performed with an initial stimulation frequency of 10 pulses / min, exceeding the frequency of f-f TP waves, with a subsequent discreteness of 10 pulses / min and with the development of uneven atrioventricular conduction, the frequency of pacing is determined to be minimally effective. After determining the minimum frequency of stimulation, at which the development of uneven atrioventricular conduction is observed, stimulation is continued with a resolution of 10 pulses / min and a duration of 20-30 s until the arrhythmia is stopped and atrial fibrillation develops.

Salient features of the proposed method are: transesophageal pacemaker performed with an initial frequency of stimulation, at a frequency of 10 pulses / min, exceeding the frequency of waves ff atrial flutter, lasting 3-5 seconds with a subsequent resolution of 10 pulses / min until the development of uneven atrioventricular conduction, then continue the stimulation with a resolution of 10 pulses / min and a duration of 20-30 s until the arrest of arrhythmia and the development of atrial fibrillation.

Currently, it is known that TP is based on “macro reentry”, which develops in the area of the cavotricuspid isthmus (isthmus) located in the right atrium between the inferior vena cava and the tricuspid valve ring, in which the “re-entry” wave circulation is observed around the lower vena cava (Kushakovsky M.S. Heart arrhythmias: A guide for doctors. - St. Petersburg: Hippocrates, 1992. - 544 p.). To stop type I TP using cardiac stimulation according to different authors, it is necessary to have a site of non-excitable tissue located between the moving front of the circular wave and its “tail” (the so-called “excitable window or gap”), and the penetration of the stimulus is facilitated if the re-entry loop quite large (Kushakovsky M.S. Arrhythmias of the heart: A guide for doctors. - St. Petersburg: LLC "Publishing House Foliant", 2004.-672 p .; Atrial fibrillation / Edited by S. A. Boytsov. - St. Petersburg: "ELBI_SPb", 2001 .-- 335 s.). To stop TP, it is necessary to increase the frequency of stimulation in comparison with the time of re-entry in a circle, which increases the likelihood of the stimulus penetrating into the area of non-excitable tissue of the re-entry loop due to shortening of the refractory period of the cells, and when it penetrates into the area of excitable tissue, it can cause new waves of re-entry, which causes the development of AF (Kushakovsky M.S. Cardiac arrhythmias: A guide for doctors. - St. Petersburg: Publishing House Foliant, 2004. - 672 p .; Atrial fibrillation / Edited by S.A. Boytsova. - SPb .: “ELBI _SPb ", 2001. - 335 p.). The effectiveness of CPEKS when it is used to stop TP in patients with coronary artery disease is affected, on the one hand, by the distance between the electrodes and their area, pulse duration and stimulation current strength, and, on the other hand, by the electrophysiological properties of the atrial myocardium (Kushakovsky M.S. Cardiac arrhythmias: A guide for doctors. - St. Petersburg: Foliant Publishing House LLC, 2004. - 672 p.; Atrial fibrillation / Edited by S.A. Boytsova. - St. Petersburg: ELBI_SPb, 2001. - 335 p.). When conducting CPEX in patients with regular TA, it is rather difficult to judge by ECG whether the stimulation is effective or not. Using the proposed method, an indicator of effective CPEKS during CPEKS in the overdrive pacing mode with a regular form of TP is the appearance or exacerbation of uneven atrioventricular conduction. The appearance of uneven atrioventricular conduction in patients with a regular form of TP during CPECS can be associated with an increase in the arrival of impulses through the atrioventricular node from the right atrium as a result of TP, as well as during the excitation of the left atrium during CPEX or when competitive impulses appear due to activation of the left atrium stimulation (Kushakovsky MS Heart arrhythmias: a Guide for doctors. - St. Petersburg: Hippocrates, 1992. - 544 p.).

We give examples of a specific implementation of the method.

Example 1

I / b No. 1326. Patient A., 56 years old, was admitted to a day hospital on 05/14/2004 in the direction of a local doctor regarding IHD: angina pectoris, periodic “interruptions” in the work of the heart. From the anamnesis it is known that the patient suffers from coronary heart disease: angina pectoris of functional class II over the past 4-5 years. He constantly takes nitrong, aspirin at a dose of 300-400 mg per day, metoprolol at a dose of 25-50 mg per day. In the last 3-4 months, I began to notice the appearance of interruptions in the work of the heart. When registering an ECG performed on an outpatient basis on May 14, 2002, a regular form of TP was revealed.

According to the clinical and instrumental examination, the patient’s condition was regarded as coronary heart disease in a hospital: stable angina pectoris of functional class II, data for the presence of “fresh” focal myocardial changes were not detected. The patient was continued with nitrogom therapy at 6.4 mg per day, aspirin at a dose of 300 mg per day, enalopril (ednit) at a dose of 5 mg per day, and warfarin at a dose of 5 mg until an international normalized ratio (MHO) of 2.8 was reached units

05/19/2002, the patient in the hospital was registered ECG simultaneously in 12 standard leads using the computer complex "Polyspectrum-rhythm" (Neurosoft firm, Ivanovo) and registration of transesophageal leads of the ECG. On a standard ECG and when registering transesophageal ECG leads, a regular form of TP was detected with a ventricular contraction rate of 130 beats per minute, f-f wave frequency of 260 beats per minute (see Figure 1). Figure 1 presents the ECG of patient A., 55 years old. TP with 2: 1. ECG recording speed of 50 mm / s. Vp - transesophageal ECG leads, III - the third standard ECG lead; f-f - TP waves. The ventricular rate is 130 beats per minute, the f-f wave frequency is 260 per minute; R - R wave of the QRS complex.

Then, a CPEX was performed with an initial stimulation frequency 10 impulses / min higher than the f-f TP wave frequency, followed by 10 impulses / min and before the development of uneven atrioventricular conduction (see Figure 2). Figure 2 presents the ECG of patient A., 55 years old. TP with 2: 1. ECG recording speed 25 mm / s. II - the second standard assignment of an ECG. The frequency of ventricular contractions is 130 beats per minute; R - R wave of the QRS complex. After superfrequent stimulation using SPECS (St) in the overdrive pacing mode with a frequency of 293 cpm / min, which is 12.7% higher than the frequency of the ff waves, the appearance of uneven excitation is observed, and when the stimulation ceases, the initial electrocardiogram - TP with the conduct of 2: 1. The arrow indicates the continuation of ECG registration.

As can be seen from the ECG pattern, the ventricular rate is 130 beats per minute. After superfrequent stimulation using SPECS (St) in the overdrive pacing mode with a frequency of 293 cpm / min, which is 12.7% higher than the frequency of the ff waves, the appearance of uneven excitation is observed, and when the stimulation ceases, the initial electrocardiogram - TP with the conduct of 2: 1.

Subsequently, after superfrequent stimulation using CPEX with a frequency of 310 pulses / min, which is 19.23% more than the frequency of f-f waves, a regular sinus rhythm with a ventricular contraction rate of 75 beats per minute is recorded (see Fig. 3). In figure 3. presented ECG patient A., 55 years old. Stopping TP with the help of NPEX. ECG recording speed of 50 mm / s. II - the second standard assignment of an ECG. After superfrequent stimulation using CPEX with a frequency of 310 cpm, which is 19.23% more than the frequency of f-f waves, a regular sinus rhythm with a ventricular rate of 75 beats per minute is recorded immediately after the last electrical stimulus (St); P is the P wave of the sinus rhythm, R is the R wave of the QRS complex.

This example shows that after determining the minimum effective frequency of CPEX (determined by the development of uneven conduction along the atrioventricular connection with the initial regular form of TP), when the frequency is exceeded by 5.5% of the determined uneven conduction along the atrioventricular connection (see above), stopping is noted regular form of TP.

Example 2

And / b No. 22345. Patient K., 67 years old, was admitted to the hospital on December 21, 2006, under the direction of an ambulance doctor regarding NES: angina pectoris II functional class. Paroxysm of atrial flutter of unknown prescription. From the anamnesis it is known that the patient suffers from coronary heart disease: angina pectoris of functional class II over the past 3 years. Constantly takes nitrosorbide, antiplatelet agents. When registering an ECG in a clinic, TP was accidentally detected for the first time. Hospitalization in hospital.

In a hospital, according to clinical and instrumental examination, the patient's condition was regarded as coronary heart disease: angina pectoris of functional class II, data for the presence of "fresh" focal myocardial changes were not detected. The patient was continued with nitrosorbide therapy at a dose of 30 mg per day, aspirin at a dose of 300 mg per day, renitec at a dose of 5 mg per day, and warfarin at a dose of 5 mg was also prescribed.

When registering an ECG at the same time in 12 standard leads, including registration of transesophageal leads of an ECG, a regular form of TP was detected with a ventricular contraction rate of 150 beats per minute (wave frequency f-f TP - 300 per second). Then, CPEX was performed with an initial stimulation frequency 10 impulses per minute higher than the f-f TP wave frequency, followed by 10 impulses per minute and before the development of uneven atrioventricular conduction (upon reaching MHO 2.6 units). After superfrequent stimulation using SPECS (St) in overdrive pacing mode with a frequency of 320 cpm, which is 6.67% higher than the frequency of the ff waves, the appearance of uneven excitation was observed, and when the stimulation ceased, the initial electrocardiogram - TP with re-recording 2: 1.

Subsequently, after super-frequent stimulation using CPEX with a frequency of 343 pulses / min, which is 14.33% higher than the frequency of the f-f waves, the regular sinus rhythm was restored with a ventricular rate of 68 beats per minute.

This example shows that after determining the minimum effective frequency of CPECS (determined by the development of uneven conduction along the atrioventricular connection with the initial regular form of TP) when the stimulation frequency is exceeded by 7.66% of the uneven conduction determined by the development of the atriovenric tricular connection (see above ) marked relief of the regular form of TP.

Example 3

I / b No. 2698. Patient S., 60 years old, was admitted to the hospital on September 21, 2002, under the direction of a polyclinic doctor for coronary artery disease: arrhythmic form. The first identified attack of TP. From the anamnesis it is known that the patient previously considered himself practically healthy.

In the hospital, according to clinical and instrumental examination, the patient's condition was regarded as coronary heart disease: arrhythmic form. First identified TP. Data for the presence of "fresh" focal myocardial changes were not detected. The patient was started therapy with warfarin at a dose of 5 mg per day, aspirin at a dose of 300 mg per day, zoocore 20 mg per day, a polarizing mixture.

On the third day of the patient’s stay in the hospital, when MHO reached 2.5 units in the hospital, the ECG was re-recorded simultaneously in 12 standard leads for 60 minutes using the Polyspectrum-Rhythm computer complex (Neurosoft, Ivanovo), and a regular form of TP was detected with a ventricular contraction rate of 150 beats per minute (wave frequency ff TP - 300 per second). Then, CPEX was performed with an initial stimulation frequency 10 impulses per minute higher than the f-f TP wave frequency, followed by 10 impulses per minute and before the development of uneven atrioventricular conduction. After superfrequent stimulation using SPECS (St) in overdrive pacing mode with a frequency of 320 cpm, which is 6.67% higher than the frequency of the ff waves, the appearance of uneven excitation was observed, and when the stimulation ceased, the initial electrocardiogram - TP with re-recording 2: 1.

Subsequently, after super-frequent stimulation using CPEX with a frequency of 343 pulses / min, which is 14.33% higher than the frequency of the f-f waves, the regular sinus rhythm was restored with a ventricular rate of 68 beats per minute.

This example shows that after determining the minimum effective frequency of CPEX (determined by the development of uneven conduction along the atrioventricular connection with the initial regular form of TP) when the stimulation frequency is exceeded by 7.73% of the uneven conduction determined by the development of the atrioventricular connection (see above), relief of the regular form of TP.

Example 4

I / b No. 12976. Patient R., 68 years old, was admitted to the hospital on November 26, 2005, under the direction of a local doctor regarding IHD: angina pectoris, paroxysm of atrial flutter

2: 1. From the anamnesis it is known that the patient suffers from ischemic heart disease: angina pectoris functional class for the past 6 years. Constantly takes monochinqua at a dose of 50 mg per day, aspirin at a dose of 300-400 mg per day, enalapril (renitec) at a dose of 20 mg per day. In the last 2-3 months I began to notice the appearance of interruptions in the work of the heart. At registration of an ECG performed on an outpatient basis on November 25, 2005, atrial flutter was detected 2: 1.

According to the clinical and instrumental examination, the patient’s condition was regarded as coronary heart disease in a hospital: stable angina pectoris of functional class II, data for the presence of “fresh” focal myocardial changes were not detected. The patient was continued with monocinque therapy at a dose of 50 mg per day, aspirin at a dose of 300-400 mg per day, enalapril (renitec) at a dose of 20 mg per day, and warfarin at a dose of 5 mg was also prescribed.

On the fourth day of the patient’s stay in the hospital, when MHO reached 2.7 units, the ECG was re-recorded simultaneously in 12 standard leads for 60 minutes using the Polyspectrum-Rhythm computer complex (Neurosoft firm, Ivanovo) , and a regular form of TP was detected with a ventricular contraction rate of 145 beats per minute (wave frequency ff TP - 290 per second). Then, CPEX was performed with an initial stimulation frequency of 15% higher than the f-f TP wave frequency of 334 imp / min. Arrhythmia did not stop. In the future, a five-time CPEX was performed with a frequency exceeding the frequency of f-f TP waves by 17%, 20%, 25%, 30%, 35%, respectively. In the sixth CPEX procedure, at a stimulation frequency exceeding the f-f TP wave frequency by 35%, TP turned into AF, and its duration was 10 hours and then the sinus rhythm was restored. Subsequently, the arrhythmia recurred on the second day and it was stopped after determining the uneven conduct of the atrioventricular connection with the initial regular form of TP when the stimulation frequency was exceeded by 6.37% of the developmental uneven conductivity of the atrioventricular connection (see above) or when the frequency was exceeded stimulation by 11%, exceeding the frequency of waves ff regular forms of TP.

This example shows that when the stimulation frequency is 33% and 11% higher than the f-f wave frequency of the regular TP form, the regular form of TP is stopped. It should be noted that TP was stopped when the stimulation frequency was exceeded by 6.37% of the uneven conduction in the atrioventricular connection determined by the development (see above).

232 patients with coronary artery disease complicated by a regular form of TA were observed. All patients underwent prolonged-action nitrate therapy, antiplatelet agents, angiotensin-converting enzyme inhibitors (renitec, enalapril, enap), warfarin to achieve the target MHO values (from 2 to 3). Antiarrhythmic drugs were not prescribed. All patients underwent ECG recording, including, if necessary, recording of transesophageal leads, with subsequent determination of the wave frequency f-f TP. In 133 (57.33%) patients, relief of the regular form of TP was performed according to the proposed method, in the remaining 99 (42.67%) - according to the prototype. The effectiveness of stopping the regular form of TP with the help of CPEKS was considered effective in restoring the sinus rhythm immediately after the cessation of stimulation and ineffective in transforming TP after PEPEKS into AF. Statistical analysis of the results is carried out on a computer.

The results of the study are presented in table 1. As can be seen from the table, using the proposed method, it is possible to more efficiently (on average 1.65 times) use NPEX for stopping the regular form of TP in comparison with the prototype.

Thus, the claimed method improves the accuracy of determining the minimum effective frequency of pacing for stopping the regular form of TP, which, in turn, increases the efficiency of stopping the regular form of TP in comparison with the prototype.

Table 1 Comparison of the effectiveness of using CPEX for the treatment of regular forms of TP using the proposed method and the prototype method Patient groups The proposed method Prototype ΔM Efficiency of using NPEX cupping of regular TP form * 122 (91.73%) 46 (46.46%) +1.65 times Note: * - restoration of the sinus rhythm immediately after cessation of CPEX, ΔM - comparative efficiency in comparison with the prototype.

Claims (1)

A method of stopping the regular form of atrial flutter, which consists in recording an electrocardiogram and determining the wave frequency ff followed by transesophageal electrocardiostimulation, characterized in that transesophageal electrocardiostimulation is performed with an initial stimulation frequency at a frequency of 10 pulses / min, exceeding the frequency of waves ff of atrial flutter 3-5 s, with a subsequent discreteness of 10 pulses / min until the development of uneven atrioventricular conduction, then continue the stimulation with discretization Tew 10 pulses / min and a duration of 20-30 s to stop arrhythmias and the development of atrial fibrillation.

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