Vo
lu
m
e
5,
Fe
br
ua
ry
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
PLANIMETRIC ECG INDICATORS IN CHILDREN WITH PREMATURE
VENTRICULAR EXCITATION BY THE TYPE OF CLC SYNDROME, CLC
PHENOMENON AND MAHAIM
Abdurakhmonov I.T., Kutlikova G.M., Atakhonova N.S., Aripova N.K.
Kukon University, Andijon Branch
Abstract:
In the syndrome of premature ventricular excitation (PVE) of the heart, part of the
ventricular myocardium or the entire myocardium is activated by impulses conducted
through accessory pathways (AP), and patients sooner or later develop tachyarrhythmic
attacks, which under certain conditions are transformed into atrial and ventricular fibrillation,
posing a threat to the patient's life.
Manifestations of PVE are rare - from 0.15 to 3.1% of the general population, including 9%
of the total number of children with cardiac arrhythmias. This disease manifests itself in
different forms - from constant clinical and electrophysiological manifestations in the
manifest form to the absence of any subjective and objective symptoms in the latent form.
Key words:
arrhythmia, accessory pathways, pre-excitation of the ventricles of the heart,
planimetry, children.
Introduction
. The problem of cardiac arrhythmias and complications associated with them
has become especially relevant in pediatrics in recent years [3, 5, 9, 10]. There are a number
of heart diseases, such as premature ventricular excitation syndrome (PVS), these cardiac
arrhythmias are based on re-entry mechanisms caused by the presence of the AP impulse,
the ECG expression of which are varieties of PVS (syndromes and phenomena: WPW, CLC,
Mahaima-Levi). There is no reliable data in the literature on the prevalence of arrhythmias
caused by AP in children [5, 6, 7]. Unlike adults, in children, rhythm disturbances associated
with AP are often asymptomatic and, in 40.0 - 60.0%, are an accidental finding. Active
detection and examination of children with arrhythmias due to the presence of AP would be
of great theoretical and practical importance, since accumulation of scientific material
allows us to determine risk groups for life-threatening arrhythmias, show their characteristic
clinical and electrocardiographic criteria, concentrate the efforts of doctors in managing sick
children, and determine the focus of preventive programs.
Objective of the study: To study the planimetric parameters of P, the QRS complex and ST–
T in standard leads and precordial leads. To study and identify the most significant
amplitude–interval parameters of electrocardiography for the manifestation and stabilization
of premature ventricular excitation.
Material and methods of the study: 1,733 children aged 7–14 years (827 girls, 906 boys)
were examined. They were selected from the general population of schoolchildren (17,330
children) by simple randomization (A–girls, B–boys), which formed the basis of a 10%
sample (Dvoyrin V.V., Klimenkov A.A. 1985). The survey program was carried out in two
stages. Stage I was conducted according to the following program: standard survey,
objective examination of children and standard survey of parents (Rose questionnaire) for
detection of attacks of tachyarrhythmia or its equivalents (feeling of heartbeat, pain, sinking,
Vo
lu
m
e
5,
Fe
br
ua
ry
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
interruptions in the heart area, dizziness, "darkening", "goosebumps" before the eyes, etc.);
study of blood pressure (three times), pulse counting; anthropometric studies and assessment
of puberty of the examined children; Electrocardiography (in 12 standard leads). Planimetric
method of quantitative analysis of ECG was conducted according to the recommendation of
Stomboltsyan R.G. and R.V., Mikhaelyants (method. recommendations Yerevan, 1981). In
this case, planimetric indicators of P, QRS complex and ST-T in standard leads and
precordial leads were studied separately (Fig. 1).
The area of the initial and final parts of the ventricular complex of the ECG were
calculated separately according to the method: the area was conditionally considered
positive (+) if the curve comprising it was above the isoline, negative (–) if it was below this
line. The initial part of the QRS complex consists of the algebraic sum of the area of the
Q, R, S waves, and the final part - ST-T - of the algebraic sum of the areas of the ST-T
interval and the T wave. Results and discussion. The planimetric area of the QRS
complex in sick children with CLC syndrome (Table 1) is increased in many ECG leads, in
sick children with CLC syndrome aged 7-10 years it is increased in six leads (50.0%): AVR,
AVL and V1-V4, and in sick children aged 11-14 years in five (41.7%) I, AVR, V1-V3. In
CLC syndrome, the decrease in ST–T area by the number of ECG leads was pronounced at
the age of 7–10 years (58.3%) and 11–14 years (75%).
Table 1.
Vo
lu
m
e
5,
Fe
br
ua
ry
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
These changes were expressed by a decrease in the ST-T area in leads I, II, III, AVF and
V4-V6 in sick children aged 7-10 years and in leads I, III, AVL, V3-V6 in children aged 11-
14 years.
In sick children with the CLC phenomenon (Table 2), an increase in the QRS area was
detected in five ECG leads, more pronounced in the right precordial leads V1-V4. In these
leads, the SPR for the QRS area was also increased. At the same time, in contrast to the CLC
syndrome, with the CLC phenomenon, a decrease in the ST-T area was observed in the
largest number of leads (66.7%) in sick children aged 7-10 years - I, II, III, AVF, V2-V5,
than in children aged 11-14 years (33.3%).
Table 2.
We have shown that the relationships of the QRS areas (r=0.560, r=0.574, r=0.509)
and ST–T (r=0.606, r=0.591, r=0.597) closely correlate with the ECG intervals P–Q and
QRS in leads V6. When studying the planimetric indices of QRS and ST–T in sick children
with the Mahaim phenomenon (Table 3), we found smaller changes, i.e. an increase in the
Vo
lu
m
e
5,
Fe
br
ua
ry
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
QRS area was rarely detected in 25% and 33.3% of cases by the number of ECG leads at the
age of 7–10 and 11–14 years. They were expressed only in leads V4–V6 at the age of 11–14
years. It should be noted that if in other groups of sick children with PVZ (WPW, CLC
syndromes and phenomena) the number of leads by low values of the QRS area is not
exceeded in 33.3% of cases, then with the Mahaim phenomenon, a low QRS area was found
more often at the age of 11–14 years (66.7%).
Table 3.
A distinctive feature of the Mahaim phenomenon was also a more frequent increase in the
ST–T area in both age groups (41.7% each) than in children in other groups with PVS (from
16.7 to 25%). The ST–T complex is significantly increased in leads V3–V6 due to giant T
waves and reversion of the ST–T interval. As a result, the SPR increased to 103.8% (V4)
and 202.4% (V6). In sick children with Mahaim phenomena, the area of the QRS
complex positively correlates more with the P–Q interval in lead V6 (r=0.466) than with the
ST–T area. The QRS of the de– and repolarization phase (Fig. 2) in sick children with CLC
syndrome aged 7–10 years is increased in leads V2–V5 compared to their healthy peers.
With age (11–14 years), this indicator decreased in leads V1–V4 or was unchanged. In the
CLC phenomenon at the age of 7–10 years, as well as in the CS syndrome, it is increased in
leads V1–V5), and at the age of 11–14 years, only in leads V2–V3. CS in the Mahaim
phenomenon in children aged 7–10 years did not differ significantly from that of healthy
children in leads V1–V5, and in V6 it was reduced. In sick children with the Mahaim
phenomenon at the age of 11–14 years, a significant decrease in CS was detected in leads
V1–V2. It should be noted that in the syndrome, the CLC phenomenon and the Mahaim
phenomenon, the direction of the CS is the same as in healthy children, only the conduction
of the impulse through the accessory pathways or the AV node is accelerated, and therefore
an initial high activation of one of the ventricles is detected in leads V1–V2 (the syndrome
and the CLC phenomenon at the age of 7–10 years) or a slowdown in the conduction of the
impulse along the other (the syndrome and the CLC phenomenon at the age of 11–14 years,
Vo
lu
m
e
5,
Fe
br
ua
ry
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
the Mahaim phenomenon). These conditions create mechanisms of asynchronous de– and
repolarization and can be the cause of Microre–entry, longitudinal dissociation and
summation of excitation impulses at the level of Purkinje cells and contractile myocardium
[6, 8].
As an objective method characterizing the relationship between the processes of ventricular
de- and repolarization, we studied the integral values of the QRS and ST–T complex,
their vectors (Ĥ) axis (Â), as well as the divergence angle (ÂQRS–ÂST–T) in the frontal and
horizontal plane. The results of such an analysis of the ECG of children with PVS are given
in Tables 4 and 5.
Vo
lu
m
e
5,
Fe
br
ua
ry
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
Как видно из данных таблицы 4 и 5, у больных детей с ПВЖ по типу WPW, CLC and
Mahaim, the integral values of the HQRS vector are reduced, and the HST–T vector is
reduced by CLC compared to healthy children of the same age. The absence of changes in
the ventricular gradient vector HG in many sick children with PVG indicates that the ST–T
changes are due to primary changes in the QRS complex, i.e. due to impaired impulse
conduction along additional conduction pathways. The unusual impulse conduction leads to
a multidirectional change in the ÂQRS and ST–T angles in the horizontal plane, which is
expressed in the WPW syndrome and phenomenon and CLC, as the Mahaim phenomenon.
Thus, the main parameters of the ventricular complex of the ECG (QRS and ST–T) of sick
children by amplitude-interval values, planimetric parameters of the ECG of sick children
with PVG are characterized by a violation of the synchronicity of the phases of de– and
repolarization of the ventricles by the area of the QRS and ST–T complex, ECG, the
expression of which are "peaks" and "dips". In sick children with PVG aged 7–10 years, an
increase in repolarization shifts is observed without a change in the ventricular gradient,
which leads to electrical instability of the ventricular myocardium. With age (by 11–14
years), such electrical instability leads to changes in the ventricular myocardium
(hypertrophy, hyperfunction), and from that the ventricular gradient in most cases of PVG is
changed. Conclusion
1. The main structure of the PVS is the syndrome (29.3%), the CLC phenomenon (24.4%)
and the WPW phenomenon (20.7%), than the Mahaim phenomenon (14.6%) and the WPW
syndrome (11.0%).
2. In assessing the severity of atrial damage in children with PVS, in addition to the
amplitude-architectonic characteristics of the P wave, an important place is occupied by
additional indicators of atrial electrical activity: the triangle coefficient (mm / sec), the
strength of the ratio of the area of the right and left atrium in lead V1 (SSPLP, mm /
sec), the time of internal deviation of the right and left atrium (TIRD, TILD, sec), the rate of
rise of P (mm / 0.01 sec) angle , ,
as well as planimetric indicators of P, (mV • ms)
the angle of divergence of the vector ÂP and ÂQRS, in the frontal and horizontal planes.
Vo
lu
m
e
5,
Fe
br
ua
ry
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
3. Sick children with PVG have features in the indices of electrical activity and stability of
the heart: in the CLC type, the period of electrical stability of the heart (T–P). In sick
children with PVG, the "ventricular excitation phase" (Q–T1), the period of early
repolarization (ST–T), the vulnerability index (RR•QT/RR) are significantly shortened, and
the prematurity index (RR/QT) is increased.
4. Sick children with PVG reliably often have ECG signs indicating the predominance of the
right ventricle (low indices R1, V5, V6, deep S, V5, V6), immaturity of the left ventricular
myocardium - low QRS, ST–T, (mV, m sec) their vectors HQRS, HST–T, HG (Ashman
units), angles ÂP–ÂQRS and ÂQRS–ÂST–T. In this case, the value of the vector and angle
of the ventricular gradient (ÂG, ĤG), ECG syndromes of ventricular repolarization [(Tv1 –
Tv6)] and de- and repolarization of the right ventricle [(Rv1) – (Tv1)] have important
diagnostic information.
References:
1.
Ахматова Ш.А. Сравнительная характеристика клинико-диагностических
признаков патологии сердца у новорожденных. Дис. ... магистра. Казань 2014: 80.
2.
Балыкова Л.А., Назарова А.Н Лечение аритмий сердца у детей // Практическая
медицина. – 2010. – № 5. – С. 30–36.
3.
Крутова А.В. и соавт. Особенности течения и прогноз нарушений сердечного
ритма и проводимости у детей первого года жизни // Педиатрия. Журнал имени Г.Н.
Сперанского. 2015. № 2. – С. 13–18.
4.
Диагностика и лечение особенностей ритма и проводимости сердца у детей. /
Под редакцией М.А. Школьниковой, Д.Ф. Егоров - СПб: Человек, 2012 - 432 С.
5.
Задионченко В.С., Шехян Г.Г., Снеткова А.А., Щекота А.М., Ялымов А.А. Роль
дополнительных проводящих путей сердца в предвозбуждении желудочков.
Справочник поликлинического врача. 2012 - №6-С. 46-49.
6.
Нагорная
Н.В.,
Пшеничная
Е.В.,
Паршин
С.А.
Неинвазивное
электрофизиологическое исследование — современный метод диагностики
нарушений ритма сердца и проводимости у детей // Здоровье ребенка. — 2012. — №
3(38). — С. 71-76.
7.
Школьникова М.А. Жизнеугрожаемые аритмии у детей. // -М. «Медицина». –
1999. –230 стр.
8.
Колбасова Е.В. Факторы риска пароксизмальной тахикардии у детей с
асимптоматичным WPW-синдромом //Анналы аритмологии. — 2011. — № 2
(Прилож.). — С. 39.
9.
Бурак Т.Я. Особенности оценки результатов нагрузочных проб при синдроме
WPW. Вестник аритмологии. — 2010. — № 59. — С. 78-80.
10.
Школьникова М.А., Миклашевич И.М., Калинина Л.А. Нормативные
показатели ЭКГ у детей и подростков. — М.: Ассоциация детских кардиологов России,
2010. — 232 с.
