Актуальность. Вегетативный контроль сердца осуществляется через нейрокардиальную ось, включающую рефлексы на трех уровнях сердечной деятельности: центральном (высшие структуры переднего мозга, ствол мозга и спинной мозг), внутригрудном экстракардиальном (звездчатые и дорсальные корешковые ганглии) и внутрисердечном. Нейромодуляция автономной нервной системы (аблация ганглионарных сплетений, эпикардиальное введение препаратов для временной нейротоксичности, подпороговая стимуляция блуждающего нерва, блокада звездчатого ганглия, стимуляция барорецепторов, стимуляция спинного мозга, денервация нервных волокон почечных и легочных артерий) представляет собой новый терапевтический метод лечения нарушений ритма сердца и сердечно-сосудистой патологии. До 30 % пациентов, перенесших открытое кардиохирургическое вмешательство, сталкиваются с развитием фибрилляции предсердий, которая связана с повышенной заболеваемостью и смертностью в отдаленном периоде наблюдения. Цель. Оценить эффективность и безопасность различных методик нейромодуляции автономной нервной системы для профилактики послеоперационной фибрилляции предсердий по данным клинических и экспериментальных исследований. Заключение. Методики нейромодуляции автономной нервной системы продемонстрировали высокую эффективность и безопасность для профилактики послеоперационной фибрилляции предсердий. Поступила в редакцию 21 августа 2023 г. Исправлена 16 октября 2023 г. Принята к печати 31 октября 2023 г. Финансирование Исследование выполнено при финансовой поддержке гранта Российского научного фонда, проект № 22-25-00672. Конфликт интересов Авторы заявляют об отсутствии конфликта интересов. Вклад авторов Концепция и дизайн работы: В.В. Шабанов, А.Г. Филиппенко, В.В. Белобородов Написание статьи: В.В. Шабанов, А.Г. Филиппенко, Т.У. Халхожаев, В.И. Муртазин Исправление статьи: В.В. Шабанов Утверждение окончательного варианта статьи: все авторы

Introduction: Despite the advancement interventional methods for treating atrial fibrillation, the effectiveness of catheter ablation remains poor, especially in patients with persistent and long-persistent atrial fibrillation. Thus, experts continue to explore new treatments for this arrhythmia. The issue of experimental studies investigating the association between spinal cord stimulation and atrial fibrillation is mainly attributed to the lack of optimal algorithms for spinal cord stimulation in animal experiments. Therefore, it is important to develop adequate algorithms for spinal cord stimulation in the chronic model of atrial fibrillation.Objective: To evaluate the impact of spinal cord stimulation on the model of atrial fibrillation in mini-pigs.Methods: In a series of experiments, 6 (100%) successful implantations of electrodes and pacemakers, and spinal cord stimulation electrodes were performed. The electrodes were used to stimulate the atria, creating a model of atrial fibrillation, while the spinal cord stimulation was carried out using an electrode implanted into the spinal canal. During the experiment, an electrophysiological study was performed using an implanted pacemaker. The inducibility of atrial fibrillation was assessed before and after the experiment using various spinal cord stimulation algorithms.Results: There were no complications associated with surgery or stimulation of the atria and spinal cord. Spinal stimulation had a modeling effect on the autonomic nervous system, significantly changing the average heart rate, Wenckebach point, and effective refractory period. When comparing spinal stimulation algorithms, algorithm 1 was found to significantly reduce the atrial fibrillation inducibility.Conclusion: Spinal cord stimulation had a modeling effect on the autonomic nervous system, significantly changing the average heart rate, Wenckebach point, and effective refractory period. Inducibility of atrial fibrillation decreases with changes in the spinal pacing algorithm. Received 15 September 2023. Revised 30 October 2023. Accepted 31 October 2023. Funding: The study was supported by Russian Science Foundation (project No. 22-25-00672). Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.G. Filippenko, V.V. Shabanov, V.I. MurtazinData collection and analysis: A.G. Filippenko, T.U. Khalkhoghaev, V.V. BeloborodovStatistical analysis: A.G. Filippenko, V.V. ShabanovDrafting the article: A.G. Filippenko, V.V. BeloborodovCritical revision of the article: V.V. ShabanovFinal approval of the version to be published: V.V. Shabanov, A.G. Filippenko, V.V. Beloborodov, T.U. Khalkhoghaev, V.I. Murtazin

Background: Refractory angina pectoris significantly reduces the length and quality of life. One of the methods to control symptoms and improve the quality of life of patients with refractory angina pectoris is spinal cord stimulation.Objective: To evaluate the effectiveness of spinal cord stimulation in controlling anginal pain in the long-term period over a long follow-up (>7 years).Methods: We retrospectively studied treatment results of 9 patients (6 men and 3 women) in the long-term follow-up from October 2012 to November 2022. Anginal pain and patients' quality of life were assessed using the visual analog scale and the Seattle Angina Questionnaire, respectively.Results: The mean follow-up was 7.33 ± 1.11 years. In the long-term postoperative period, regression of pain according to the visual analog scale was 52.3% (P = .0025). The Seattle Angina Questionnaire showed an improvement of the quality of life by 52.2% (P = .0993).Conclusion: Spinal cord stimulation allows to make control of chronic anginal pain more efficient, improve patients’ length and quality of life, and reduce the frequency and severity of disability. Received 8 December 2022. Revised 17 July 2023. Accepted 18 July 2023. Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Актуальность. Несмотря на стремительное развитие интервенционных методов лечения фибрилляции предсердий, эффективность катетерных технологий остается невысокой, особенно у пациентов с персистирующей и длительно персистирующей формами. Это заставляет ученых продолжать поиски новых методов лечения. Проблема экспериментальных исследований влияния спинальной стимуляции на фибрилляцию предсердий главным образом обусловлена отсутствием оптимальных алгоритмов стимуляции спинного мозга в эксперименте у животных с хронической моделью патологии. Это определяет актуальность разработки таких алгоритмов в эксперименте. Цель. Оценить влияние спинальной стимуляции на хроническую модель фибрилляции предсердий у мини-свиней породы минисибс. Методы. Выполнили 6 (100 %) имплантаций электродов и электрокардиостимуляторов для создания модели хронической фибрилляции предсердий, а также электродов для стимуляции спинного мозга. С помощью электродов осуществляли стимуляцию предсердий, создавая хроническую модель фибрилляции предсердий. Параллельно выполняли стимуляцию спинного мозга через имплантированный в спинномозговой канал электрод. В ходе эксперимента проводили электрофизиологическое исследование при помощи имплантированного электрокардиостимулятора и оценивали индуцируемость фибрилляции предсердий до и после спинальной стимуляции при различных ее алгоритмах. Результаты. Осложнений, связанных с оперативным вмешательством или стимуляцией предсердий и спинного мозга, не выявили. Стимуляция спинного мозга продемонстрировала значимые изменения средней частоты сердечных сокращений, точки Венкебаха и эффективного рефрактерного периода. При сравнении алгоритмов спинальной стимуляции между собой алгоритм 1 значимо снижал индуцибельность фибрилляции предсердий. Заключение. Стимуляция спинного мозга оказывает моделирующее влияние на автономную нервную систему, значимо меняя базовую частоту сердечных сокращений, точку Венкебаха и эффективный рефрактерный период. Индуцибельность фибрилляции предсердий снижается при изменении алгоритма спинальной стимуляции. Поступила в редакцию 15 сентября 2023 г. Исправлена 30 октября 2023 г. Принята к печати 31 октября 2023 г. Финансирование Исследование выполнено при финансовой поддержке гранта Российского научного фонда, проект № 22-25-00672. Конфликт интересов Авторы заявляют об отсутствии конфликта интересов. Вклад авторов Концепция и дизайн работы: А.Г. Филиппенко, В.В. Шабанов, В.И. Муртазин Сбор и анализ данных: А.Г. Филиппенко, Т.У. Халхожаев, В.В. Белобородов Статистическая обработка данных: А.Г. Филиппенко, В.В. Шабанов Написание статьи: А.Г. Филиппенко, В.В. Белобородов Исправление статьи: В.В. Шабанов Утверждение окончательного варианта статьи: все авторы

Objective: To evaluate the model of atrial fibrillation (AF) in mini-pigs with endocardial approach implantation of CRT-P using bi-electrodes pacing through RV/LV connectors.Methods: All surgical interventions were minimally invasive and conducted under general anaesthesia. CRT-P was implanted endocardially, using X-ray. First electrode was fixed in the right atrial appendage. The second one — in the interatrial septum or the right atrial free wall. Both of them were connected with CRT-P through RV/LV. Bi-electrode atrial stimulation was realized during a week with a basic heart rate of 150 bpm and a delay between electrodes of 80 ms (mean 450 bpm), which corresponds to the heart rate (HR) of AF. Electrophysiological study was performed during the experiment to analyze the cardiac conduction system. AF inducibility was evaluated before and after stimulation.Results: A series of experiments demonstrated that there were no complications following the device and electrodes implantation. There was a non-sustained paroxysm of AF before permanent pacing in one of three pigs. After pacing we noted a tendency to increase the baseline HR (average frequency from 94 ± 4 to 98 ± 6 bpm). Non-sustained paroxysm of AF was induced in all cases. The sustained AF with 92 min burden was induced in one pig.Conclusion: Endocardial bi-electrode atrial pacing in mini-pigs has proven to be safe. This AF model improves AF inducibility and can be considered as an alternative to epicardial stimulation for experiments employing AF models. Received 4 December 2022. Revised 17 January 2023. Accepted 18 January 2023. Funding: The study was supported by Russian Science Foundation (project No. 22-25-00672). Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: V.V. Beloborodov, D.V. Losik, E.V. FisherData collection and analysis: E.V. Fisher, V.V. Beloborodov, D.V. Losik, A.G. FilippenkoDrafting the article: D.V. Losik, E.V. Fisher, V.I. Murtazin, V.V. BeloborodovCritical revision of the article: A.B. Romanov, D.V. Losik, V.V. Shabanov, I.L. MikheenkoFinal approval of the version to be published: D.V. Losik, V.V. Beloborodov, E.V. Fisher, V.I. Murtazin, A.G. Filippenko, I.L. Mikheenko, V.V. Shabanov, A.B. Romanov

Цель. Изучить метод индуцируемости модели фибрилляции предсердий у мини-свиней минисибс при помощи эндокардиальной имплантации электродов в правое предсердие и постоянной стимуляции с двух электродов при помощи ресинхронизирующего бивентрикулярного устройства. Методы. Разработку модели осуществляли на свиньях породы минисибс весом 76,7 ± 3,5 кг в условиях экспериментальной рентгеноперационной. Все оперативные вмешательства были малоинвазивными и выполнялись в условиях общей анестезии. Один электрод фиксировали в область ушка правого предсердия; второй — в область межпредсердной перегородки или свободную стенку правого предсердия. Оба электрода коммутировали с ресинхронизирующим бивентрикулярным устройством в разъемы для правожелудочкового и левожелудочкового электродов. С помощью двух электродов осуществляли стимуляцию предсердий с базовой частотой сердечных сокращений 150 уд/мин и задержкой между стимулами двух электродов 80 мс в течение недели. В ходе эксперимента проводили электрофизиологическое исследование при помощи имплантированного устройства и оценивали индуцируемость фибрилляции предсердий до и после эксперимента. Результаты. Серия экспериментальных работ продемонстрировала отсутствие осложнений при имплантации электродов и устройства. Исходно базовая средняя частота сердечных сокращений составила 94 уд/мин, эффективный рефрактерный период правого предсердия в среднем составил 307 мс. У одной из трех мини-свиней индуцировали неустойчивый пароксизм фибрилляции предсердий до постоянной стимуляции. После постоянной стимуляции предсердий в течение недели со средней частотой сердечных сокращений 450 уд/мин отметили увеличение базовой частоты сердечных сокращений (средняя — от 94 до 98 уд/мин), у всех субъектов эксперимента индуцировали неустойчивые пароксизмы фибрилляции предсердий, в одном случае — устойчивый пароксизм продолжительностью 92 мин. Заключение. Эндокардиальная стимуляция предсердий у мини-свиней минисибс безопасна. Модель фибрилляции при помощи стимуляции предсердий с двух электродов со средней частотой сердечных сокращений 450 уд/мин увеличивает индуцируемость и может быть рассмотрена как альтернатива эпикардиальной стимуляции для экспериментальных работ с применением моделей фибрилляции предсердий. Поступила в редакцию 4 декабря 2022 г. Исправлена 17 января 2023 г. Принята к печати 18 января 2023 г. Финансирование Исследование выполнено при финансовой поддержке гранта Российского научного фонда, проект № 22-25-00672. Конфликт интересов Авторы заявляют об отсутствии конфликта интересов. Вклад авторов Концепция и дизайн: В.В. Белобородов, Д.В. Лосик, Е.В. Фишер Сбор и анализ данных: Е.В. Фишер, В.В. Белобородов, Д.В. Лосик, А.Г. Филиппенко Написание статьи: Д.В. Лосик, Е.В. Фишер, В.И. Муртазин, В.В. Белобородов Исправление статьи: А.Б. Романов, Д.В. Лосик, В.В. Шабанов, И.Л. Михеенко Утверждение окончательного варианта статьи: все авторы

Introduction: Autonomic control of the heart is exerted by the neurocardiac axis, which comprises reflexes at three levels of cardiac activity: central (higher structures of the forebrain, brainstem, and spinal cord), intrathoracic extracardiac (stellate and dorsal root ganglia), and intracardiac. Neuromodulation of the autonomic nervous system (ANS) (ganglion plexus ablation, epicardial drug infusion for temporary neurotoxicity, low-level vagus nerve stimulation, stellate ganglion blockade, baroreceptor stimulation, spinal cord stimulation, renal and pulmonary artery nerve fiber denervation) is a new therapeutic approach for managing heart rhythm disorders and cardiovascular pathologies. Atrial fibrillation (AF) occurs in up to 30% of patients after open cardiac surgery and is associated with increased morbidity and mortality in the long-term follow-up. Objective: To evaluate the safety and efficacy of the different neuromodulation approaches for preventing postoperative atrial fibrillation (POAF) in clinical and experimental settings.Conclusion: ANS neuromodulation techniques have demonstrated high efficacy and safety for preventing POAF. Received 21 August 2023. Revised 16 October 2023. Accepted 31 October 2023. Funding: The study was supported by Russian Science Foundation (project No. 22-25-00672). Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: V.V. Shabanov, A.G. Filippenko, V.V. BeloborodovDrafting the article: V.V. Shabanov, A.G. Filippenko, T.U. Khalkhoghaev, V.I. MurtazinCritical revision of the article: V.V. ShabanovFinal approval of the version to be published: V.V. Shabanov, V.V. Beloborodov, T.U. Khalkhoghaev, V.I. Murtazin, A.G. Filippenko

Background. Critical limb ischemia is defined as persistent ischemic pain attributed to a variety of severely compromised blood flow to affected extremities. The treatment of non-reconstructable critical limb ischemia is still challenging; the amputation rate was 9.3%, and mortality rate was 23.2% within 24 months. Spinal cord stimulation (SCS) has become an alternative clinical practice for the treatment of intractable pain of the extremities.Aim. To determine whether high-frequency spinal cord stimulation (SCS) is better than low-frequency SCS for pain relief in chronic limb-threatening ischemia treatment.Methods. Throughout enrollment 56 patients were examined, of whom 6 rejected to participate in the study. The participants were randomly allocated to high-frequency (HF) or low frequency (LF)-SCS groups of 25 patients each by an external statistician, using an online tool. The patients were examined by a neurosurgeon and a vascular surgeon to assess pain intensity by visual analog scale, quality of life by short-form-36 health survey (SF-36), and functional status by walking impairment questionnaire in 3 and 12 months. Tissue perfusion by transcutaneous oxygen tension measurement was also measured in 12 months.Results. Intention-to-treat analysis demonstrated comparative advantage of HF-SCS over LF-SCS in 3 months with mean visual analog scale score 2.8 [95% CI, 2.4; 3.2] and 3.3 [95% CI, 3.0; 3.6] respectively (p = 0.031). Clinical superiority of HF-SCS persisted at 12 months follow up (p<0.001). HF-SCS produces significantly greater pain relief by walking impairment questionnaire in 3 (p<0.001) and 12 months (p = 0.009). Accordingly, general and mental health domains of SF-36 were significantly better in HF-SCS in 12 months. Despite a tendency toward better resting oxygen pressure in HF-SCS group, there was no intergroup difference by transcutaneous oxygen tension (p = 0.076).Conclusion. High-frequency spinal cord stimulation imposes better pain relief, life quality and functional activity in patients with chronic limb-threatening ischemia in short-term follow up.

OBJECTIVE:To analyze the results of sphenopalatine ganglion stimulation in treatment of chronic headache.MATERIALS AND METHODS:Medical histories of patients who underwent sphenopalatine ganglion stimulation in 4 clinical centers have been analyzed. The analysis included the type of pain and its characteristics, methods of surgery, CT, MRI, radiography before and after surgery. The follow-up data of patients with implanted pulse generators was collected in an outpatient clinic or by telephone review.RESULTS:The study included 15 patients with chronic refractory headache, including 14 with cluster headache and one female patient with features of trigeminal autonomic cephalgia without a clear definition of the type of pain. Trial stimulation was performed in 10 patients to determine analgesic effect. Among them stimulation was favorable in 7 cases, and 6 of them underwent pulse generator implantation. In total, 11 (73%) patients underwent implantation with a follow-up from 1 to 60 months. Among them only 6 (54%) patients use stimulation, the remaining 5 (46%) cases had device-related complications (migration, infection of system). Cluster headache has a significant improvement in long-term follow-up.CONCLUSIONS:Sphenopalatine ganglion stimulation may have high potential in the treatment of chronic drug-resistant cluster headache. The complication rate demonstrates that operative technique should be improved.

AIM To study the clinical dynamics in the long-term period after spinal cord stimulation (SCS) in patients with chronic pain syndrome and critical lower limb ischemia (CLLI) and to identify factors affecting the prognosis of SCS. MATERIAL AND METHODS The clinical dynamics was analyzed in 48 patients with pain syndrome and CLLI 1 year after SCS. Microcirculatory blood flow (MBF) was studied in the affected foot by laser-doppler flowmetry (LDF) (Perfusion Units (PU)) and transcutaneous oximetry (TcpO2, mmHg.) using an occlusive test before and after SCS. The factors associated with negative clinical dynamics 1 year after SCS were determined. RESULTS In 74% of cases, SCS contributes to the improvement of clinical status (reduction of pain syndrome, increase in motor activity, healing of ulcers). After SCS, according to LDF and TcpO2, the authors observed an increase in MBF and tissue metabolism - from 1.3 (0.7-2.8) to 6.2 (3.8-8.7) PU and from 14.5 (7.5-22.1) to 41.1 (26.4-57.6) mmHg, respectively with normalization of the MBF reserve during the occlusion test. Negative clinical dynamics after SCS is associated with high comorbidity, TcO2 <10 mmHg and the duration of pain. CONCLUSION SCS contributes to the improvement of the clinical status of patients with chronic pain syndrome and CLLI. The negative dynamics is associated with high comorbidity, TcrO2 <10 mmHg and the duration of pain.

Background. Several previous studies have demonstrated that spinal cord stimulation (SCS) can reduce the amputation rate in patients with critical lower limb ischemia (CLLI) and improve blood circulation parameters of the lower limbs. However, there is a lack of studies on the long-term effects of SCS on the quality of life (QoL) of patients with CLLI. Aim. The present study aimed to assess QoL changes in patients with CLLI after SCS system implantation in the long run (i.e., 30–60 months).Methods. This study included 38 patients with CLLI (10 females, 28 males; age range: 39–83 years) who underwent surgery in 2012–2016. QoL was analyzed using the SF-36 questionnaire before and 30–60 months after SCS. The mortality and amputation rates and amputation levels of the patients were also analyzed. The SF-36 questionnaire scores were normalized according to the data of the respective sex and age groups in the general Russian population. The obtained scores were analyzed in their dynamics and compared with the scores of the general population.Results. The preoperative scores of three of four physical well-being QoL parameters of the patients significantly reduced compared with the scores of the general population (p < 0.001). However, the scores of mental well-being QoL parameters were close to those of the general population. The total physical well-being score reduced (37.9 ± 9.2 points), whereas the total mental well-being score was within the medium range (48.1 ± 8.3 points). At 30–60 months after SCS system implantation, 5 patients or their representatives were unavailable, 12 died, 3 underwent amputation at the tibial level, and 16 showed preserved support function of the legs (2 of these patients underwent toe amputation). SCS system failure was noted in 3 patients. Patients with preserved support function of the legs completed the SF-36 questionnaire at 30–60 months after SCS system implantation. All QoL parameter scores showed increases, and the total postoperative physical well-being score of these patients was close to that of the general population (46.3 ± 10.6 points, p = 0.050 compared with the preoperative score). However, the total mental well-being score of the patients was higher than that of the general population (57.9 ± 3.8 points, p = 0.041). Conclusion. SCS does not reduce the mortality rate in patients with CLLI compared with conservative therapy. However, it reduces the amputation rate in patients who survive. Significant positive changes in QoL persist for a long time after SCS system implantation in most patients.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

The aim - to assess the state of peripheral perfusion in patients with critical lower limb ischemia (CLLI) before and during the longterm period after spinal cord stimulation (SCS). Material and methods. Microcirculatory blood flow (MBF) of the lower limbs (LL) was studied in 42 patients with CLLI by transcutaneous oximetry (ТсрО 2 , mmHg) and laser doppler flowmehy (Perfusion Units (PU)). Results. Prior to SCS we observed a reduction in peripheral perfusion and a disturbance the function of MBF in the form of a paradoxical reaction of blood flow during the orthostatic test (OT). After SCS, we observed an increase in tissue metabolism and MBF from 10.5 (6.4-16.0) mmHg and 1.0 (0.5-1.9) PU to 39.5 (15.0-57.0) mmHg and 5.7 (2.3-9.6) PU respectively, with an improvement in MBF function as an adequate response in OT. Conclusions. With CLLI, we detected a decrease in peripheral perfusion and breaking mechanisms of adaptation of MBF during OT. After SCS there is an increase the level of peripheral perfusion and improvement in the function of MBF.

Critical limb ischemia (CLI) is a state of substantial reduction of blood flow in the extremities, mostly due to severe obstruction of the arteries. In lower limbs, it produces severe pain after even a short distance walk (intermittent claudication) and/or skin ulcers or sores. Surgical revascularization is a “golden standard” in CLI therapy, but it is contraindicated or not accessible for a large proportion of patients, while the medical prognosis is poor for conservative therapy. This situation stimulated the development of alternative approaches, including spinal cord stimulation (SCS) and various methods of “indirect” revascularization. In this paper, the authors give a short description of the latest approaches and a detailed review of the SCS method, while paying special attention to the studies that demonstrate not only a palliative effect of SCS (pain reduction), but also clinically significant changes in the indicators of lower limb muscles blood supply. CLI is characterized with a "vicious circle": pain causes reduced mobility and changes in the preferred limb position, which in turn lead to edema triggering an increase of ischemia and further elevation of pain. The clinical effects of SCS in CLI patients are related both with pain relief leading to a break of this vicious circle, and with the direct vasodilatory effects of the stimulation itself. There are several possible biological mechanisms of these actions, but most probably the therapeutic actions of SCS arise from their combination. Examination of different opinions about the appropriateness of spinal cord stimulation in patients with CLI, including those related to the economic efficiency of the method, leads to the conclusion that the evidence on these issues is currently insufficient. The reviewed data demonstrate the need for further development of the CLI treatment methods and high urgency of this problem.Received 6 April 2017. Accepted 23 April 2017.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflict of interest.

Представлен клинический случай установки вентрикулоатриального шунта у 10-месячного пациента с тяжелой сопутствующей патологией – спаечной болезнью после многократных оперативных вмешательств по поводу неспецифического язвенного колита. При установке вентрикулоатриального шунта выявлены анатомические особенности строения внутренней югулярной вены. В послеоперационном периоде, по данным клинико-неврологического и инструментального исследования, отмечалась положительная динамика пациента.