RU2437688C1 - Method of treating chronic atrial fibrillation from transvenous endocardial approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardiology, and may be used in treating chronic atrial fibrillation. Left atrial RF isolation lines are created by the Labirinth-III layout. In addition, a left atrial auricle is isolated, while a roof and an upper portion of an anterior wall of the left atrium are jointed with the isolated auricle along the anterior wall and a mitral annulus. The damage line continuity is inspected with application of radio-frequency energy by recording of atrial potential amplitude loss. Collectors are stimulated with inspecting their electrical isolation.

EFFECT: method allows providing higher clinical effectiveness in patients suffering chronic atrial fibrillation and ensuring sinus rhythm recovery and maintenance in patients with left atrial volume exceeding 120 ml.

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Description

The invention relates to medicine, namely to cardiology, and can be used in the treatment of persistent atrial fibrillation.

There is a method of transvenous endocardial treatment of atrial fibrillation (AF), which consists in the electrical isolation of each pulmonary vein, by applying radio frequency energy along the border of the connection of the pulmonary vein with the atrium, the insulation is controlled by a circular electrode-catheter placed in the pulmonary vein [1].

The disadvantage of this method is that AF can be eliminated only when the triggering mechanism, namely, fast ectopic activity, is in the pulmonary veins, while there is no effect on the substrate of arrhythmia (atrial myocardium).

There is also a method using non-fluoroscopic techniques, based on a modification of the procedure "Labyrinth-III" [2], but in the endocardial version [3]. The method consists in isolating the pulmonary veins, the posterior wall of the left atrium and connecting a line of damage to the isolated collector of the left pulmonary veins and the mitral valve ring.

This method is the closest to the proposed technical essence and the achieved result and is selected as a prototype.

The disadvantage of the prototype method is the inability to apply it in patients with a constant form of AF and a left atrial volume of more than 120 ml. Therefore, patients with a constant form of atrial fibrillation and large sizes of the left atrium were prescribed anticoagulant therapy and rhythm frequency control.

The purpose of the invention is to increase the effectiveness of treatment of patients with a constant form of atrial fibrillation, including patients with a left atrial volume of more than 150 ml, by creating additional lines of radiofrequency damage in the left atrium.

The goal is achieved by the following solution: continuously apply radio frequency energy, form lines of electrical insulation. The continuity of damage lines is monitored during the application of radio frequency energy by recording a decrease in the amplitude of the atrial potential. Connect the insulation of the collectors of the right and left pulmonary veins. An isolated left collector of pulmonary veins in the lower part of the left atrium is connected to the mitral valve ring. An isolated ear is connected along the anterior wall of the left atrium to the mitral valve ring. The roof of the left atrium is isolated. Stimulate isolated areas in the left atrium, checking their electrical isolation.

New in the proposed method is the additional isolation of the left atrial ear, roof of the left atrium and the upper part of the anterior wall of the left atrium, which allows to reduce the mass of the atrial myocardium and thereby reduce the likelihood of developing and maintaining atrial fibrillation.

The essential features characterizing the invention showed in the inventive combination new properties that are not explicitly derived from the prior art in this field and are not obvious to a specialist.

An identical set of features was not found in the study of patent and medical literature.

This invention can be used in practical health care to improve the quality of treatment of patients with persistent atrial fibrillation.

Based on the foregoing, the present invention should be considered relevant to the conditions of patentability "novelty", "inventive step", "industrial applicability".

The invention will be clear from the following description and the accompanying drawings.

Figure 1 shows a diagram of the application of lines of radio frequency damage to the left atrium, rear view.

1 - the left superior pulmonary vein,

2 - the left lower pulmonary vein,

3 - the ear of the left atrium,

4 - the right superior pulmonary vein,

5 - the right lower pulmonary vein,

6 - line of radio frequency damage, isolating the right collector of the pulmonary veins,

7 - line of radio frequency damage, isolating the left collector of pulmonary veins,

8 - line radiofrequency ablation connecting the right and left collectors of the drug along the upper part of the posterior wall of the left atrium,

9 - line radio frequency damage connecting the right and left collectors of the drug along the lower part of the posterior wall of the left atrium,

10 is a line of radio frequency damage connecting the insulated left collector to the mitral valve ring.

Figure 2. shows a diagram of the application of lines of radio frequency damage to the left atrium, front view.

1 - the left superior pulmonary vein,

2 - the left lower pulmonary vein,

3 - the ear of the left atrium,

4 - the right superior pulmonary vein,

5 - the right lower pulmonary vein,

6 - line of radio frequency damage, isolating the right collector of the pulmonary veins,

11 is a line of radio frequency damage that isolates the ear of the left atrium,

12 is a line of radio frequency damage, isolating the roof of the left atrium along the front wall,

13 is a line of radio frequency damage connecting the isolated ear to the mitral valve ring,

14 - mitral valve ring.

The method is as follows.

The patient is taken to an x-ray operating room. Give medical sedation. According to the Seldinger method, the right femoral vein is punctured three times, into which the introducers are placed, through which catheter electrodes, including NaviStar CoolFlow, are passed into the heart cavity. The esophagus is intubated. Where is the ultrasonic sensor placed? Under the control of ultrasound, the atrial septum is punctured. A NaviStar CoolFlow electrode is passed through the puncture site. Carry out heparinization. Then, electroanatomical reconstruction of the left atrium is performed using the CARTO non-fluoroscopic system (Biosense Webster, USA). The mouths of the left upper 1 (Figure 1), left lower 2 (Figure 1), right upper 4 (Figure 1), right lower 5 (Figure 1) pulmonary veins, mitral valve ring 14 (Figure 2) are identified and marked. ), the ear of the left atrium 3 (Fig.1, 2). Radio frequency energy is applied using the radio frequency destructor "Electropulse RF-100TI" (LLC Electropulse, Tomsk) or the like, with temperature control - 50 ° C and a maximum power of 45 watts. Irrigation is carried out with a CoolFlow Pump (Biosense Webster, USA) or the like, at a rate of 17 ml / min. Pointwise formation of radio frequency damage lines is carried out by continuous application of radio frequency energy. The time of energy deposition at each point is 20-30 s until the atrial potential decreases.

At the initial stage, damage lines are created according to the “Labyrinth III” scheme: radiofrequency destruction begins along the posterior wall of the left atrium from the place where the upper pole of the left upper pulmonary vein flows into the mouth 1 (Figure 1), depart from it by 1 cm, go down along the back walls to the confluence of the lower pole of the mouth of the lower left pulmonary vein into the left atrium 2 (Figure 1). Then they go to the antero-lateral part of the left atrium, bypass the lower pole of the inflow of the left lower pulmonary vein and rise up along the anterolateral part of the left pulmonary vein collector, follow to the start of the line, thereby creating a continuous line of radiofrequency damage around the pulmonary vein collector 7 ( Figure 1, 2). Pass to isolation of the right collector of pulmonary veins. Start along the back wall of the left atrium from the place where the upper pole of the mouth of the right superior pulmonary vein 4 flows (Figure 1), deviate from it by 1 cm, go down along the back wall to the place of the lower pole of the mouth of the right lower pulmonary vein 5 (Figure 1 ) Then they go to the anterolateral part of the right collector, bend around the mouth of the lower right pulmonary vein 5 (Figure 2) and rise up along the anterolateral part of the right collector of the pulmonary veins, follow to the beginning of the line, thereby creating a continuous line of radiofrequency damage around the collector of the right pulmonary veins 6 (Figs. 1, 2). Then the electrode is installed at the beginning of the line that insulates the left collector 7 (Figure 1), and follow the back wall to the beginning of the line that insulates the right collector 6 (Figure 1), thereby creating a horizontal line of damage at the border of the back wall and the roof of the left atrium 8 (Figure 1). Then install the electrode at the line that isolates the left collector 7 (Figure 1), located at the confluence of the lower pole of the lower left pulmonary vein 2 (Figure 1) and follows the line that isolates the right collector of the pulmonary veins 6 (Figure 1) and is located at the lower pole of the mouth of the right lower pulmonary vein 5 (Figure 1), thereby forming a horizontal line of damage at the border of the posterior wall and the bottom of the left atrium, thereby completing the isolation of the posterior wall of the left atrium 9 (Figure 1). Then, the electrode is installed on the line insulating the left collector 7 (Fig. 1), located at the lower pole of the mouth of the mouth of the left inferior pulmonary vein 2 (Fig. 1), and follows down to the mitral valve ring, thereby creating a line of radiofrequency damage on the left isthmus of the heart 10 (Figure 1), which is the final stage in creating the scheme "Labyrinth III", then carry out an additional stage - go to the isolation of the left atrium ear, roof and upper part of the anterior wall. The electrode is installed on the middle part of the line that isolates the left pulmonary vein collector along the anterior-lateral part of the left atrium, and are directed anteriorly, go around the place where the left atrial ear falls into, then follow the front wall and rise up to the roof of the left atrium, then along the roof of the left atrium to the line isolating the left collector of pulmonary veins, thereby isolating the ear of the left atrium 11 (Figure 2). Then the electrode is installed on the line isolating the left atrial ear 11 (Figure 2), on its middle part along the front wall of the left atrium, and follow the line isolating the right pulmonary vein collector 6 (Figure 2) along the border of the front wall and the roof of the left atria, which leads to isolation of the roof of the left atrium 12 (Figure 2). After that, the electrode is installed on the line that insulates the roof along the front wall 12 (Figure 2), and follow down to the mitral valve ring 14 (Figure 2), thereby isolating the front-lateral part of the atrial myocardium adjacent to the mitral valve 13 (Fig. 2). After the formation of all lines, diagnostic stimulation of isolated areas in the left atrium is performed. If there is conduct from an isolated area, its insulation is repeated until its complete electrical isolation.

After the formation of all lines and the monitoring of their usefulness, the electrodes from the heart are removed. If necessary, conduct electropulse therapy to restore sinus rhythm. Introducers are removed, hemostasis is performed and an aseptic sticker is applied.

EXAMPLE. Patient P., 53 years old, was treated at the Department of Surgical Treatment of Heart Rhythm Disorders and Pacemakers, Research Institute of Cardiology SB RAMS from January 28, 2009 to February 25, 2009 with a diagnosis of

Basics: Stage II arterial hypertension. The constant form of atrial fibrillation, atrial flutter type I. NK II A. FC II.

Background: Stage II obesity. Dyslipidemia.

From the data of the anamnesis it was revealed that the patient had paroxysms of AF more than 7 years ago. Preventive antiarrhythmic therapy was ineffective. For the past 2 years, the patient has had a persistent form of atrial fibrillation. Examination: ECG recorded atrial fibrillation; according to computed tomography with contrast, the volume of the left atrium was 195.4 ml.

Due to the patient having a constant form of atrial fibrillation and a large volume of the left atrium, an electrophysiological study and radiofrequency modification in the left atrium were performed on February 16, 2009 according to the scheme described above. The postoperative period was uneventful. The patient was discharged at a sinus rhythm. After 2 months, the patient is re-hospitalized for follow-up examination. The patient did not note the presence of arrhythmia. During daily monitoring of ECG rhythm disturbances were not registered. Conducting a transthoracic and transesophageal ultrasound examination of the pathology did not reveal. Also, the patient is re-examined six months after the operation, arrhythmia is not detected.

The method was tested in 25 patients with an atrial volume of more than 150 ml. All patients are alive. Complications in the early and late postoperative period were not observed. After 2 months after surgery, patients canceled prophylactic antiarrhythmic therapy. During follow-up in 3 patients, during daily ECG monitoring, short arrhythmia paroxysms were documented that stopped on their own.

The proposed method allows to increase the effectiveness of treatment of patients with a constant form of atrial fibrillation and to ensure the restoration and maintenance of the sinus rhythm of the heart in patients with a left atrial volume of more than 150 ml.

Information sources

Claims (1)

A method of treating a permanent form of atrial fibrillation with transvenous endocardial access, which consists in endocardial creation of radiofrequency lines of the left atrial myocardium according to the Labyrinth-III scheme, characterized in that the left atrial ear is additionally isolated, the roof and upper part of the left anterior atrial wall are connected, an isolated ear is connected along the front wall with the mitral valve ring, and the continuity of damage lines is monitored during the application of radio frequency energy by reg deduction of decrease in the amplitude of the atrial potential, and then conduct electrical stimulation of isolated sections of the atrial myocardium.