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#1
09.09.2005, 10:54
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ЧП ЭХО-КС
Коллеги, такой вопрос. Каково отношение к транспищеводной ЭХО-КС в вопросе восстановления мерцательной аритмии. Можно ли восстанавливать пароксизм давностью более 2-х суток без месячной антикоагулянтной подготовки, имея данные об отсутствии тромбов в полостях? Существуют ли работы по сравнению результатов тактик: подготовка антикоагулянтами – ЭИТ и ЧПЭХО-КС - отсутствие тромбов –ЭИТ?
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#2
09.09.2005, 11:15
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...Можно ли восстанавливать пароксизм давностью более 2-х суток без месячной антикоагулянтной подготовки, имея данные об отсутствии тромбов в полостях?...
Если мне не изменяет память, то в последнем Guidelines по мерцательной аритмии описана именно такая последовательность. А именно, возможность проведения ЧП-ЭхоКГ при пароксизмах давностью более 2х суток и при отсутствие тромбов в предсердии (и особенно в ушке левого, которое плохо визуализируется при трансторакальном исследовании) восстановление ритма без предварительной антикоагулянтной подготовки. [Ссылки доступны только зарегистрированным пользователям ] Или я не понял суть вопроса?
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), т.к. использовал русский перевод на кардиосайте.|
#4
09.09.2005, 23:40
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Например, такое.
Europace. 2000 Apr;2(2):119-26. Related Articles, Links Early cardioversion of atrial fibrillation and atrial flutter guided by transoesophageal echocardiography: a single centre 8.5-year experience. Corrado G, Santarone M, Beretta S, Tadeo G, Tagliagambe LM, Foglia-Manzillo G, Spata M, Miglierina E, Acquati F, Santarone M. Unita Operativa di Cardiologia, Ospedale Valduce Como, Italy. [Ссылки доступны только зарегистрированным пользователям ] AIMS: To analyse the safety and impact on maintenance of sinus rhythm of transoesophageal echocardiographically guided early cardioversion associated with short-term anticoagulation in a large series of patients with atrial fibrillation and atrial flutter. METHODS AND RESULTS: Patients who were candidates for cardioversion were eligible for inclusion if they had atrial fibrillation or atrial flutter lasting longer than 2 days or of unknown duration. Patients received short-term anticoagulation with warfarin or heparin and underwent transthoracic echocardiography followed by transoesophageal echocardiography. Early cardioversion was performed if no thrombus was seen on the transoesophageal study. Warfarin was maintained for 1 month after cardioversion. In patients with atrial thrombi, cardioversion was deferred and prolonged anticoagulation was prescribed. The study population included 183 patients. One hundred and sixty nine patients without atrial thrombi underwent early cardioversion. Fourteen patients with atrial thrombi (7.6%) underwent a second transoesophageal echocardiogram after a median of 4 weeks of oral warfarin, and cardioversion was performed if clot regression was documented. No patient in our study population had a clinical thromboembolic event at 1 month follow-up (95% C.I. 0-0.016). The immediate success rate of cardioversion was better among patients with atrial fibrillation < 4 weeks duration compared with patients with atrial fibrillation of longer or of unknown duration: 96.6% vs 85%, respectively (P = 0.014). At 1 month follow-up, the percentage of arrhythmia relapses in patients with initially successful cardioversion was similar in the two groups (29% vs 26%, P = ns); thus the initial better outcome in patients with recent-onset arrhythmia was not lost. CONCLUSION: Transoesophageal echocardiography-guided early cardioversion in concert with short-term anticoagulation is safe. This approach permits abbreviation of the overall duration of atrial fibrillation and has a better impact on the maintenance of sinus rhythm for patients in whom the duration of atrial fibrillation is < 4 weeks. Такое... Eur Heart J. 2000 May;21(10):837-47. Transoesophageal echocardiography-guided cardioversion of atrial fibrillation or flutter. Selection of a low-risk group for immediate cardioversion. Roijer A, Eskilsson J, Olsson B. Department of Cardiology, University Hospital, Lund, Sweden. AIMS: Despite exclusion of left atrial thrombi by transoesophageal echocardiography, cardioversion-related thromboembolism has been reported in atrial fibrillation or flutter. To define a low-risk group for cardioversion without previous anticoagulation, patients were selected for immediate cardioversion if there were no thrombi, no echo spontaneous contrast and the outflow velocity of the left atrial appendage was greater than 0.25 m. s(-1)on transoesophageal echocardiography. METHODS AND RESULTS: Two hundred and forty-two consecutive patients referred for cardioversion of atrial fibrillation or flutter with a duration of more than 2 days and no anticoagulation therapy were examined with transoesophageal echocardiography. After the transoesophageal echocardiography examination, patients who were eligible for immediate cardioversion were anticoagulated with low molecular weight heparin (dalteparin) subcutaneously, together with warfarin prior to cardioversion. Dalteparin treatment was continued until the patient had reached therapeutic prothrombin values. Based on the transoesophageal echocardiographic findings the patients were divided into two groups: immediate cardioversion, group A, with a mean age of 62+/-13 years (n=162); or conventional warfarin treatment before cardioversion, group B, with a mean age of 67+/-10 years (P<0.05) (n=80). In group A, lone atrial fibrillation or flutter was more common (53%; 95% CI: 45-61) compared to group B (34%; 95% CI: 23-44, P<0.05), while heart disease was more common in group B (45%; 95% CI: 34-56) compared to group A (31%; 95% CI: 24-39, P<0.05). Echocardiography revealed thrombi in 5% (95% CI: 2.6-8) of the patients, left atrial size was larger, fractional shortening lower, and a higher proportion had impaired left ventricular function in group B. No thromboembolic event occurred at or after cardioversion in any of the patients; however, before planned cardioversion one transitory ischaemic attack, one lethal stroke and one cardiac death occurred in three of the patients with thrombi despite warfarin therapy. One-month follow-up maintenance of sinus rhythm was 75% in group A compared to 45% in group B (P<0.01). CONCLUSION: After using our transoesophageal echocardiographic exclusion criteria (no thrombi, no spontaneous echo contrast and left atrial appendage outflow velocity > or = 25 m. s(-1)) cardioversion can safely be performed in 2/3 of patients with atrial fibrillation or flutter without previous anticoagulation therapy. These patients maintained sinus rhythm significantly better after 1 month compared to patients with prolonged warfarin therapy before cardioversion. Copyright 2000 А самое большое было, по-моему, ACUTE. Но не помню, где оно опубликовано. Мы, кстати, активно ЧП-Эхо пользуемся для этого. Достиг целевого МНО (дней за 7), затем - ЧП-Эхо, затем - кардиоверсия и еще на 4 недели варфарин.
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#5
10.09.2005, 06:29
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Цитата:
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#6
10.09.2005, 07:33
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Не предусмотрено, уважаемый Евгений Иванович!
По московским стандартам человек с мерцалкой должен в больнице провести не меньше 6 дней. А целевого МНО, как правило, за 7 дней достигают. Но, в принципе, предложенная Вами схема вполне нормальная, думаю, можно и так. Вопрос, а в какой дозе гепарин или НМГ?
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#7
12.09.2005, 11:04
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Цитата:
 , уважаемый Михаил Юрьевич. (скажем НМГ 1 мг\кг 2 р\д). Буржуи то сами как делали? И еще, Вы упомянули о неких московских стандартах, нет ли их где в электронном виде ?
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#8
12.09.2005, 22:08
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T. BARTEL, R. ERBEL. Transoesophageal echocardiography for immediate and safe cardioversion in patients with atrial fibrillation. European Heart Journal (2001) 22, 2041–2044
[Ссылки доступны только зарегистрированным пользователям ] The Assessment of Cardioversion Using Transoesophageal Echocardiography (ACUTE) multi centre study.
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#9
13.09.2005, 18:02
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Уважаемый Игорь, спасибо за ссылочку!
Уважаемый Евгений Иванович, боюсь, что в электронном виде их особо нигде нет. Мы как-то искали, нашли только 2000 или 2001 года.
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Линейный вид
