Trembling of auricles – a takhiaritmiya with correct frequent (to 200 — 400 in 1 min.) a rhythm of auricles. Trembling of auricles is shown by heartbeat paroxysms duration from several seconds to several days, arterial hypotension, dizziness, consciousness loss. For identification of trembling of auricles clinical examination, the ECG in 12 assignments, holterovsky monitoring, a chrespishchevodny electrocardiography, a ritmografiya, ultrasonography of heart, EFI is conducted. For treatment of trembling of auricles medicamentous therapy, a radio-frequency ablyation and predserdny EX-is used.
Trembling of auricles
Trembling of auricles – the supraventrikulyarny tachycardia which is characterized by excessively frequent, but regular predserdny rhythm. Along with blinking (fibrillation) of auricles (frequent, but irregular, chaotic activity of auricles), trembling belongs to kinds of vibrating arrhythmia. Blinking and trembling of auricles are closely connected among themselves and can alternate, mutually replacing each other. In cardiology trembling of auricles meets considerably less than blinking (0,09% against 2-4% in the general population) and usually proceeds in the form of paroxysms. Trembling of auricles develops at men more often 60 years are more senior.
Reasons of trembling of auricles
In most cases trembling of auricles arises against the background of organic diseases of heart. As the reasons of this type of arrhythmia rheumatic heart diseases, IBS (an atherosclerotic cardiosclerosis, a sharp myocardial infarction), a cardiomyopathy, miokardiodistrofiya, myocarditis can serve, perikardit, a hypertension, SSSU, a WPW syndrome. Trembling of auricles can complicate a current of the early postoperative period after cardiac interventions concerning congenital heart diseases, aortocoronary shunting.
Trembling of auricles occurs also at patients with HOBL, emphysema of lungs, a thrombembolia of a pulmonary artery. At pulmonary heart the terminal stage of heart failure sometimes is followed by trembling of auricles. As the risk factors of trembling of auricles which are not connected with heart pathology diabetes, a thyrotoxicosis, a syndrome sleepy , alcoholic, medicinal, etc. intoxications, a gipokaliyemiya can act.
If the predserdny takhiaritmiya develops at almost healthy person without the visible reasons, speak about idiopathic trembling of auricles. The role of genetic predisposition to emergence of blinking and trembling of auricles is not excluded.
Pathogenesis of trembling of auricles
The basis of pathogenesis of trembling of auricles is made by the macro-re-entry mechanism – repeated repeated excitement of a myocardium. The typical paroxysm of trembling of auricles is caused by circulation of a big pravopredserdny circle of re-entry which is in front limited by a ring of the trikuspidalny valve, and behind - an evstakhiyevy crest and hollow veins. The trigger factors necessary for induction of arrhythmia, short episodes of fibrillation of auricles or predserdny ekstrasistola can act. At the same time the high frequency of depolarization of an auricle is noted (about 300 . in min.).
As the AV-knot is not able to pass impulses of such frequency, only a half of predserdny impulses is, as a rule, carried out to a ventricle (block 2:1) therefore ventricles are reduced with a frequency about 150 . in a minute. Much less often blocks arise in the ratio 3:1, 4:1 or 5:1. If the coefficient of carrying out changes, the ventricular rhythm becomes irregular that is followed by spasmodic increase or reduction of ChSS. Extremely dangerous ratio of predserdno-ventricular carrying out is the coefficient 1:1 which is shown sharp increase in ChSS to 250 — 300 . in min., decrease in warm emission and loss of consciousness.
Classification of trembling of auricles
Allocate typical (classical) and atypical options of trembling of auricles. At classical option of trembling of auricles circulation of a wave of excitement happens in the right auricle on a typical circle; at the same time the frequency of tremblings 240-340 develops in min. Typical trembling of auricles is istmuszavisimy, i.e. gives in to knocking over and restoration of a sinusovy rhythm by means of a krioablyation, a radio-frequency ablyation, chrespishchevodny electrocardiostimulation in the field of a kavo-trikuspidalny isthmus (istmus) as most vulnerable link of a loop of macro-re-entry.
Depending on an orientation of circulation of a wave of excitement distinguish two kinds of classical trembling of auricles: counterclockwise – a wave of excitement circulates around the trikuspidalny valve counterclockwise (90% of cases) and clockwise - a wave of excitement circulates in macro-re-entry loop clockwise (10% of cases).
Atypical (istmusnezavisimy) trembling of auricles is characterized by circulation of a wave of excitement in the left or right auricle, but not on a typical circle that is followed by emergence of waves with a frequency of tremblings of 340-440 a minute. Taking into account the place of formation of a circle of macro-re-entry distinguish pravopredserdny (mnozhestvennotsiklovy and verkhnepetlevy) and levopredserdny istmusnezavisimy tremblings of auricles. Atypical trembling of auricles cannot be stopped by means of ChPEKS in view of lack of a zone of slow carrying out.
From the point of view of a clinical current distinguish for the first time the developed trembling of auricles, a paroksizmalny, persistiruyushchy and constant form. The Paroksizmalny form lasts less than 7 days and is stopped independently. The Persistiruyushchy form of trembling of auricles has duration more than 7 days, at the same time independent restoration of a sinusovy rhythm is impossible. Speak about a constant form of trembling of auricles in case medicamentous or electric therapy did not bring desirable effect or it was not carried out.
Pathogenetic value of trembling of auricles is defined by ChSS on which expressiveness of clinical symptomatology depends. Takhisistoliya brings to diastolic, and then to both systolic sokratitelny dysfunction of a myocardium of the left ventricle and development of chronic heart failure. When trembling auricles decrease in a coronary blood-groove which can reach 60% takes place.
Symptoms of trembling of auricles
The clinic for the first time of the developed or paroksizmalny trembling of auricles is characterized by sudden attacks of heartbeat which are followed by the general weakness, decrease in physical endurance, discomfort and pressure in a thorax, stenocardia, short wind, arterial hypotension, dizziness. Frequency of paroxysms of trembling of auricles varies from one in a year to several in day. Attacks can arise under the influence of physical activity, hot weather, an emotional stress, plentiful drink, alcohol intake and disorder of intestines. At high pulse rate quite often there are presinkopalny or sinkopalny states.
Even the asymptomatic course of trembling of auricles is followed by high risk of development of complications: ventricular takhiaritmiya, fibrillation of ventricles, system tromboemboliya (stroke, heart attack of a kidney, TELA, sharp occlusion of mezenterialny vessels, occlusion of vessels of extremities), heart failure, cardiac arrest.
Diagnostics of trembling of auricles
Clinical inspection of the patient with trembling of auricles reveals speeded up, but rhythmical pulse. However at carrying out coefficient 4:1 pulses can make 75-85 . in min., and at continuous change of coefficient the rhythm of heart becomes nepravilyyony. The rhythmical and frequent pulsation of cervical veins corresponding to a rhythm of auricles and exceeding arterial pulse in 2 and more times is the Patognomonichny sign of trembling of auricles.
Registration of the ECG in 12 assignments finds frequent (to 200-450 in min.) the regular, predserdny waves of F having the sawtooth form; lack of teeth P; correct ventricular rhythm; not changed ventricular complexes to which a certain quantity of predserdny waves precedes (4:1, 3:1, 2:1 etc.). Test with massage of a carotid sine strengthens AV-blockade therefore predserdny waves become more expressed.
By means of daily monitoring of the ECG pulse rate at different times is estimated days, and paroxysms of trembling of auricles are fixed. When performing ultrasonography hearts (transthoracic EhoKG) are investigated the sizes of cavities of heart, sokratitelny function of a myocardium, a condition of heart valves. Performance of chrespishchevodny EhoKG allows to reveal blood clots in auricles.
Biochemical blood test is appointed for detection of the reasons of trembling of auricles and can include definition of electrolytes, hormones of a thyroid gland, rheumatologic tests etc. For specification of the diagnosis of trembling of auricles and differential diagnostics with other types of takhiaritmiya carrying out an electrophysiological research of heart can be required.
Treatment of trembling of auricles
Medical actions when trembling auricles are directed to knocking over of paroxysms, restoration of a normal sinusovy rhythm, prevention of future episodes of frustration. Beta-blockers (for example, , etc.), locks of calcic channels (verapamil, diltiazy), potassium medicines, warm glycosides, antiarrhytmic medicines are applied to medicinal therapy of trembling of auricles (, , a sotalola a hydrochloride). For decrease in tromboembolichesky risk performing antikoagulyantny therapy is shown (heparin intravenously, hypodermically; ).
For knocking over of typical paroxysms of trembling of auricles method of the choice is carrying out chrespishchevodny electrocardiostimulation. At a sharp vascular collapse, stenocardia, brain ischemia, increase of heart failure the electric cardioversion is shown by categories of low power (from 20-25 J). Efficiency of electropulse therapy increases against the background of performing medicinal antiarrhytmic therapy.
Recidivous and constant forms of trembling of auricles are indications for a radio-frequency ablyation or a krioablyation of the center of macro-re-entry. Efficiency of a kateterny ablyation when trembling auricles exceeds 95%, the risk of development of complications makes less than 1,5%. RChA of AV knot and implantation EX-is shown to patients with SSSU and paroxysms of trembling of auricles.
Forecast and profilaktiak of trembling of auricles
Trembling of auricles is characterized by resistance to antiarhythmic drug treatment, firmness of paroxysms, tendency to a retsidivirovaniye. A recurrence of trembling can turn into blinking of auricles. The long course of trembling of auricles contributes to development of tromboembolichesky complications and heart failure.
Patients with trembling of auricles need observation of the cardiologist-aritmologa, consultation of the heart surgeon for the solution of a question of expediency of surgical destruction of the aritmogenny center. Prevention of trembling of auricles demands treatment of primary diseases, decrease in level of a stress and uneasiness, the termination of the use of caffeine, nicotine, alcohol, some medicines.