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CARDIOLOGY AND CARDIO SURGERY
INVENTION
Patent of the Russian Federation RU2171632

METHOD OF DIAGNOSTICS OF THE DIASTOLIC RESOURCE OF THE LEFT VENTRICULAR MYOCARDIUM

METHOD OF DIAGNOSTICS OF THE DIASTOLIC RESOURCE OF THE LEFT VENTRICULAR MYOCARDIUM

The name of the inventor: Petrova EB; Lukushkina EF; Kosonogov A.Ya.
The name of the patent holder: Nizhny Novgorod State Medical Academy
Address for correspondence: 603005, Nizhny Novgorod, ul. Mitina, 10/1, NGMA
Date of commencement of the patent: 1999.07.19

The invention relates to medicine, cardiology. The dopler echocardiographic spectrum of the transmittal flow is recorded from the apical position in a 4-chamber projection, placing a control volume at the level of the mitral valve ring. Simultaneously, the ECG is recorded. The rate of fast and atrial filling of their ratio E / A is assessed. They give a physical load, re-register the blood flow rates of filling the left ventricle into the phase of fast and atrial filling. In children with transverse heart blockages, the speed of the fast filling phase remains practically unchanged, the atrial filling phase velocity decreases. The ratio of the rates of filling of the left ventricle into the phase of rapid filling and the phase of atrial filling before and after physical exertion serves as an indicator of the diastolic reserve of the left ventricular myocardium. The method makes it possible to characterize early diastolic disturbances - a decrease in the diastolic reserve of the left ventricular myocardium with transverse blockades in children and at the earliest possible time allows the implantation of an artificial pacemaker.

DESCRIPTION OF THE INVENTION

The invention relates to medicine, namely, pediatric cardiology, and can be used in examining patients with transverse cardiac blockades in conditions of cardiac (arrhythmological) centers for the dynamic monitoring of children with rhythm disturbances and for departments of surgical treatment of rhythm disturbances.

Pediatric arrhythmology is a fairly new section of pediatric cardiology, this is explained by the characteristics of the child's organism, long-term possible compensation, but at the same time leading to early disability.

Treatment of patients with bradisystolic arrhythmias is a complex task, as it requires consistent tactics of patient management. Currently, the definition of indications for surgical treatment, namely the implantation of an artificial pacemaker (ECS) is widely discussed by pediatricians and cardiac surgeons. In 1993, a working group led by Academician LA Bokeria presented and published indications for the implantation of EKS in adults and children with the only reference that children need more accurate diagnosis of clinical symptoms using modern diagnostic methods. Doppler echocardiography is one such technique. Currently, only one of the Doppler echocardiographic criteria is indicated in the guidelines, namely the presence of myogenic dilatation and the reduction of the ejection fraction of less than 50%.

According to the literature, it is known that violations of diastolic function of the left ventricle occur at the stage of latent heart failure, often precede the appearance of a systolic function and can have prognostic value. The works of foreign authors indicate the development of diastolic heart failure with preserved systolic function. Therefore, it is necessary to consider diastolic disturbances as one of the additional criteria for implantation of ECS.

A method for diagnosing diastolic left ventricular myocardial dysfunction with clinical manifestations of heart failure in adults is already well known and widely used in practice. It consists in the following: remove the dopler echocardiographic spectrum of the transmitral flow from the apical position in a 4-chamber projection, record the control volume at the level of the mitral ring And the following transmittal flow rates are assessed: rapid flow rate (E), atrial fill flow rate (A), acceleration time of the fast filling phase acceleration (Dte), ratio of these parameters and time of isovolume relaxation.

There are several types of diastolic dysfunction: the first, in which most of the blood enters the atrial filling phase. This type of filling can be registered in healthy people of advanced age, can occur in people with hypertension, angina, myocardial infarction, etc. The ratio of the blood flow velocity to the fast filling phase to the blood flow velocity in the atrial filling phase E / A becomes <1.

In the second type, the transmittal flow acquires a pseudo normal form, which is associated with an increase in the peak E speed and a significant decrease in the peak A, with E / A >> 1, a decrease in isometric relaxation time and a slowing-down time in the fast filling phase. Reduction of the diastolic reserve of the left ventricle in adults is judged if the ratio of the above rates before and after exercise is less than 2.45.

As a prototype for assessing the diastolic reserve of left ventricular myocardium, the method of assessing the diastolic reserve of left ventricular myocardium in patients with coronary heart disease was chosen to compare the effectiveness of drug therapy of drugs of different groups. The disadvantage of this method is that it concerns patients already with signs of heart failure in ischemic heart disease and is used for a comparative evaluation of therapeutic treatment. In addition, the use of this method in cardiac surgery for the treatment of rhythm disturbance has not yet been properly applied.

It is therefore an object of the present invention to improve the diagnosis of the diastolic reserve of the left ventricular myocardium in children with transverse heart blockages for timely surgical correction and thereby improve the quality of life of children.

The task is solved by a method for diagnosing a diastolic reserve of the left ventricular myocardium, including the registration of the doppler echocardiographic spectrum of the rates of the blood flow of the left ventricle at rest and after physical exertion, the assessment of the blood flow velocity in the fast filling phase and in the atrial filling phase in which, in accordance with the invention, in children With transverse blockade of the heart with a decrease in the values ​​of the rate in the atrial filling phase after the load, the decrease in the diastolic reserve of the left ventricular myocardium is judged and the indications of the artificial pacemaker are determined. The choice of assessment of diastolic reserve of the left ventricle in children with transverse heart blockages, the parameter of the blood flow velocity in the atrial filling phase is justified by the results of processing of statistical echocardiographic indices of children with transverse blockades that did not have obvious clinical manifestations of diastolic left ventricular dysfunction. Regular for this group of children was a decrease in the rate of blood flow to the atrial filling phase after a sample with physical exertion. The initial values ​​of blood flow velocities are individual for each child in the atrial filling phase and the rates after the load.

The authors believe that the sign introduced into the formula is very significant, because, in combination with other characteristics, it provides a solution to the task, namely, to improve the quality of life of children with transverse heart blockages that do not show clinical signs of the disease by implanting ECS. The authors are of the opinion that at an early age in children the functional state of the myocardium remains safe and for him more sparing with small consequences is the implantation of ECS at earlier stages of the disease.

In the sources of information available to authors, no information was found on the diagnosis of diastolic reserve in children with transverse heart blockages by reducing the values ​​of blood flow velocity in the atrial filling phase after carrying out a sample with physical exertion.

The method according to the invention is carried out as follows. The patient in the position on the left flank in the 4-chamber projection with the cursor position at the level of the mitral valve ring is removed by the transmittal flow in parallel with the recording of the electrocardiogram (since in transverse blockades against the background of atrial-ventricular asynchronism, not every P-tooth is hemodynamic atrial contraction) The following indicators: the speed of the blood flow of rapid filling, the time of falling acceleration of this phase, the speed of blood flow of atrial filling, the time of isovolumeic relaxation. Then give a physical load, namely 20 sit-ups in 30 seconds, and remove the above-mentioned indicators. The following changes occur: the fast filling phase practically does not change its characteristics, and the atrial filling phase decreases in speed, thus the E / A ratio changes and becomes >> 1, while the isovolume relaxation time increases somewhat, although it remains within the limits The norm is 70 ms and the acceleration fall time is 145 ms.

The positive effect of these changes is that early diastolic disturbances precede systolic disturbances and are recorded with the left functional ventricular myocardium preserved, which is favorable for ECS implantation and manifests itself as a low stimulation threshold. Thus, the evaluation of the diastolic reserve of left ventricular myocardium can be attributed to one of the dopler echocardiographic indications for implantation of ECS in children with transverse heart blockages, which allows improving the quality of life of patients at the earliest possible time.

Below are examples of case histories of children who, with the help of the proposed method, clarified the degree of hemodynamic disorders and carried out at an earlier time the implantation of an artificial pacemaker.

EXAMPLE 1 Molev Nikolai Aleksandrovich, born in 1986, is 9 years old. He was in the cardiosurgical department of the First Grad Clinical Hospital from 04/01/1966 to 10/04/96 N the medical history of 1899/268. Diagnosis: Postmiocarditis cardiosclerosis. Complete atrioventricular block. NK II and Art. Has been sick since the age of 3, when myocarditis developed after a viral infection. Subsequently, as a complication of myocarditis, violations of atrioventricular conduction began to be recorded. Dynamic observation marked an aggravation of atrioventricular blockade to III century, the periodic appearance of signs of heart failure - shortness of breath when exercising, fatigue, lagging behind in peers in physical development. Periodically, the liver is enlarged. According to the Holter monitoring, the bradycardia reaches 28-34 per min, with a load of max. 46 per min. In the dynamics of an increase in the heart cavities according to EchoCG. The diastolic reserve was assessed by recording the transmittal flux on photographic paper and the following indicators were obtained: up to the loading, the rapid filling rate E was 0.89 m / s, the atrial filling rate 0.59 m / s, the acceleration fall time was 140 ms, the isovolume relaxation time - 65 ms. After a load of E-0.9 m / s, A - 0.4 m / s, the acceleration fall time was 145 ms, the time of isovolume relaxation 62 ms diastolic reserve was 0.4. Based on the symptoms listed above, a decision has been made about the need for implantation of ECS. On 2.04.96, the implantation of the RELAY 294-03 SN 214413, operating in the DDDR mode, was performed. Postoperative period without complications. Currently, the child is on dispensary supervision. Physical development corresponds to the age norm, adequate two-chamber stimulation with an atrioventricular delay of 125 ms, the chambers of the heart correspond to the age norm.

EXAMPLE 2 . Goryunkova Yana Ruslanovna, 10.02.93, 4 years old. Was in the clinic on treatment from 21.05.97 to 10.06.97. Diagnosis: congenital atrioventricular blockade III st. N of the medical history 3115/397. The patient has frequent ARI. When the girl was examined at the CSTO, a full AV blockade was revealed at the age of 3 years. According to holter monitoring, the heart rate is reduced to 32 per min, an increase in the heart cavity compared with the age norms. In dynamics, despite ongoing treatment, there is an increase in bradycardia to 28-30 per min. , With frequent pauses at night to a heart rate of 19 per min, according to the EchoTM, an increase in the left ventricular cavity, mitral valve prolapse with regurgitation of I-II st. When carrying out a sample with physical activity, signs of a diastolic reserve decrease. Based on the foregoing, the patient performed an implantation of TRILOGY DR + SN 000216131 on May 29, 1997. A smooth postoperative period. Currently he is on dispensary observation 1 time in 6 months without clinical and echocardiographic abnormalities. In total, due to the proposed method of diagnosis, 15 patients with transverse blockades were implanted with EKS. All children are on dispensary observation for 5 years with good clinical and echocardiographic results.

INFORMATION SOURCES

1. Belenkov Yu. N. Dynamics of diastolic reserve of left ventricular myocardium in patients with chronic heart failure, // Cardiology - 1996 - N 6, - c. 3-8, publishing house Mediosphere - a prototype.

2. Korytnikov K.I. Impulse doppler echocardiography in assessing the diastolic function of the left ventricle with ischemic heart disease, Soviet medicine - 1990 - N 1, - c. 28-31. Publishing house Moscow.

3. Ageev F.T., Jahangirov T.Sh., Perevez Ghani, V.Yu. Marev, N.N. Belenkov, // Possibilities of ultrasound doppler echocardiography in the evaluation of diastolic heart function disorders in patients with chronic heart failure. // Cardiology 1994, - N 11-12, p. 12-17, ed. Moscow.

4. Dougherty AH, Naccarelli GV, Gray EL et al. / / Ibid. - 1984 - Vol. 54.-P. 778-772.

5. Souffer Jc, Caasch WH // Prigr cardijvasc. Dis. - 1990.- Vol. 32. - P. 319-332.

CLAIM

A method for diagnosing a diastolic reserve of left ventricular myocardium, including the registration of the doppler echocardiographic spectrum of the transmitral flow at rest and after physical exertion, assessment of the blood flow velocity in the fast filling phase and in the atrial filling phase, characterized in that in children with transverse cardiac blockade, The phase of atrial filling at constant speed in the fast filling phase after exercise is judged to reduce the diastolic reserve of left ventricular myocardium and determine the indication for the implantation of an artificial pacemaker driver.

print version
Date of publication 05.04.2007gg