经皮穿刺介入肺静脉射频消融治疗阵发性房颤的应用解剖

目的　探讨肺静脉起源性房颤的解剖学机制 ,为经肺静脉射频消融治疗阵发性房颤提供应用解剖学资料。　方法　在 38例心标本上观察了肺静脉壁肌层的结构和形态 ,并用组织学和透射电镜等方法确定肺静脉壁外层缠绕肌的来源和性质。　结果　自肺静脉口向远端的肺静脉壁肌层的外层有心房肌缠绕 ,其出现率为87 8% ;心房肌缠绕的形态可分为括约肌型、“U”型和交叉型 ;缠绕肺静脉的心房肌中有一些可能是起博细胞 (P细胞 )。　结论　肺静脉壁肌层的外层有心房肌缠绕 ,其中有一些可能是P细胞。这些结果为阐明房颤发生的机制以及在临床射频消融术中 ,寻找肺静脉口、确定消融的位置和深度等提供了部分解剖学依据     

心房颤动致犬肺静脉肌袖缝隙连接蛋白40表达降低

目的探讨心房颤动时犬肺静脉肌袖缝隙连接蛋白40和43(Cx40,Cx43)基因及蛋白表达的变化及其意义。方法17只杂种犬随机分为心房颤动组(11只)和对照组(6只),房颤组经颈外静脉将电极置入右心耳快速起搏(400次/分)8周复制房颤模型,开胸取右上肺静脉近心房1cm内组织,用荧光实时定量PCR及Western blot技术检测缝隙连接蛋白40和43(Cx40,Cx43)mRNA及蛋白的表达量。结果房颤组和对照组犬肺静脉肌袖组织Cx40和Cx43的mRNA表达无显著性差异,房颤组Cx40蛋白表达明显低于对照组(P<0.05),Cx43蛋白表达无显著性差异。结论房颤可使肺静脉肌袖Cx40蛋白表达降低,缝隙连接发生重构,从而促进房颤的维持和稳定。     

山羊心上、下腔静脉心肌袖的组织学及亚微结构特征

目的:探讨山羊心上、下腔静脉肌袖的组织学构造,为研究上、下腔静脉肌袖与局灶性房颤的关系提供形态学基础。方法:取新鲜山羊上下腔静脉的肌袖组织,常规组织切片,光镜和电镜观察及细胞计量。结果:心肌袖纤维位于上下腔静脉外膜下,是血管中膜的一部分。与右心房交界处的心肌袖较厚,随着向远端的延伸,肌袖组织逐渐变薄。肌纤维有纵行、环行和斜行3种走行形式。在腔静脉同一周径上的不同区域肌袖分布不均一。腔静脉心肌袖的细胞特征与心房心肌细胞无明显差异,但心肌细胞之间闰盘不典型,一般为直线型。结论:心肌袖细胞与心房心肌细胞之间无明显差异,提示肌袖与心房肌具有同源性。     

老龄心房颤动犬模型肺静脉肌袖细胞起搏电流在异丙肾上腺素作用下的变化

背景：心房颤动是老年人常见的心律失常疾病,有研究表明肺静脉肌袖细胞起搏电流能增加快速心律失常特别是心房颤动发生的风险。 目的：观察异丙肾上腺素对老龄犬肺静脉肌袖细胞起搏电流的作用。 方法：选择14只老龄健康犬,7只快速起搏10周制备心房颤动模型,其余未经快速起搏处理的犬作对照。分离各组肺静脉肌袖细胞,利用全细胞膜片钳在电压钳模式下记录起搏电流。 结果与结论：在0.1~10.0 μmol/L的浓度范围内异丙肾上腺素均使细胞膜起搏电流电流升高,且作用呈现出浓度依赖性,半数有效量为1.7 μmol/L (95%可信区间为1.2~2.6 μmol/L)。房颤组肺静脉肌袖细胞给予1.0 μmol/L异丙肾上腺素时,起搏电流显著增加,在-120 mV的测试电位时,使其电流密度升高(P < 0.01)。1.0 μmol/L异丙肾上腺素使房颤组肺静脉肌袖细胞起搏电流的稳态激活曲线向正方向移动,使半激活电压下降,更接近静息电位,同时也使激活曲线斜率(P < 0.01)。结果证实,异丙肾上腺素可能通过升高肺静脉肌袖细胞起搏电流促进心房颤动的发生。     

山羊肺静脉心肌袖解剖学观测

目的观察山羊肺静脉心肌袖的形态特征,为异位房颤动物模型提供形态资料。方法解剖30例山羊肺静脉,充分暴露心肌袖,进行形态学观测。结果30例羊心均出现肺静脉心肌袖,其中斜形47.6%,环形40.9%,纵形11.5%。右上、右下、左下、左上肌袖厚度分别为0.46±0.14mm、0.35±0.16mm、0.35±0.11mm、0.37±0.13mm,长度分别为10.75±3.15mm、9.46±2.20mm、11.41±2.87mm、9.20±2.88mm。结论30例山羊肺静脉心肌袖出现率为100%,可能与局灶性房颤的发生有关。     

血清BNP浓度与肺静脉消融术后房颤复发关系的研究

目的:研究房颤患者经肺静脉消融后房颤复发与血清脑利钠肽(BNP)之间的关系。方法:采用化学免疫荧光检测法检测68例左室射血分数正常的房颤患者(阵发性房颤48例,持续性房颤20例)消融前血清BNP浓度,两组患者均于术后3个月接受72hHolter监测以观察房颤复发。结果:消融前阵发性房颤组血清BNP浓度低持续性房颤组(81.40±15.20pg/mlvs142.5±32.60pg/ml,P0.05),阵发性房颤消融术后复发房颤10例(20.9%),其血清BNP浓度较未复发者增高(144.30±20.41pg/mlvs68.5±25.30pg/ml,P0.05).持续性房颤消融术后9例(45.00%)复发房颤,其血清BNP浓度(193.35±30.25pg/ml)显著高于未复发者及阵发性房颤复发者。结论:房颤患者消融术前血清BNP浓度同肺静脉消融术后房颤复发有关;血清BNP浓度可能对提高房颤消融成功有积极意义。     

风湿性瓣膜病合并心房颤动的导管消融治疗

目的评价风湿性瓣膜病合并心房颤动（房颤）经导管射频消融的安全性和疗效。方法57例风湿性瓣膜病合并房颤患者，其中男性34例，女性23例，年龄39～65岁，平均年龄47．6岁（标准差16．7岁），轻度二尖瓣狭窄4例，二尖瓣球囊扩张术后2例，二尖瓣置换术后17例，二尖瓣、主动脉瓣置换术后34例（其中8例同时行三尖瓣成形术），左心房内径（45．6±7．1）mm，阵发性房颤3例，持续性房颤54例，房颤病程（2．1±1．7）年。术前均经食管超声心动图排除左心房血栓。采用CARTO三维系统引导环肺静脉消融电隔离术．附加二尖瓣峡部、三尖瓣峡部线性消融及左心房碎裂电位消融以改良基质。术后定期随访Holter、ECG及UCG。结果57例患者均顺利完成消融术。操作时间（184±26）min，X线透视时间（25±14）min。环肺静脉消融使左肺静脉电隔离49例（86．0％）、右肺静脉电隔离52例（91．2％）。其余病例结合肺静脉节段性消融实现电隔离。持续性房颤消融恢复窦性心律9例，其中3例环肺静脉消融终止，6例碎裂电位消融终止；持续性房颤转为不典型房扑4例,消融未能终止，转为典型房扑2例，三尖瓣峡部消融恢复窦性心律。消融结束未恢复窦性心律者,均行直流电复律成功转复。术后1个月1例阵发性房颤和10例持续性房颤因复发再次消融。随访时间（7±4）个月，45例（78．9％）患者维持窦性心律。无明显并发症。结论CARTO系统引导环肺静脉消融电隔离结合基质改良治疗瓣膜性心脏病合并的房颤在有经验的治疗中心安全有效。     

冷冻球囊消融治疗阵发性心房颤动短期随访研究

目的研究冷冻球囊消融治疗阵发性心房颤动(房颤)围术期并发症,并分析房颤早期复发的预测因素。方法选择2014年3月至2016年12月于武汉大学人民医院心内科接受冷冻球囊消融治疗阵发性房颤患者30例,其中男性14例,女性16例;年龄52~70岁,平均年龄60.5岁。行冷冻球囊消融治疗。分析围术期发生的并发症。随访冷冻球囊消融术后早期(3个月内)房颤复发的情况,并分析复发的预测因素。结果 30例患者均成功完成手术,无严重并发症发生。术中发生迷走神经反射2例(6.7%),1例于左上肺静脉冷冻复温后发生,1例于左下肺静脉冷冻复温后发生。无心包积液、膈神经麻痹等事件发生。术后随访3个月,其中7例(23.3%)患者在术后早期复发房颤,研究显示左心房内径是房颤患者行冷冻球囊消融术后早期复发的预测因素。结论冷冻球囊消融治疗阵发性房颤成功率高,围术期及近期随访安全性良好。左心房内径是阵发性房颤患者冷冻球囊消融术后早期复发的预测因素。     

多层螺旋CT肺静脉成像在房颤射频消融术中的应用价值

目的:探讨多层螺旋CT(MSCT)肺静脉成像对房颤射频消融治疗的指导意义。方法:回顾分析34例经导管射频消融治疗的房颤患者,术前行MSCT肺静脉增强扫描,术中行选择性肺静脉造影(CPV)。MSCT重建肺静脉-左心房图像,观察肺静脉的解剖类型,测量各支肺静脉的口径,并与术中CPV结果比较。所有患者均采用环肺静脉线性消融术,其中14例术前MSCT原始图像数据整合入Carto系统。结果:MSCT共识别肺静脉136根,其中22例为标准型肺静脉解剖(64.7%),5例为有单独开口的右副肺静脉(14.7%),6例为左肺静脉共同开口(17.6%),还有1例混合变异(3.0%)。CPV仅识别肺静脉130根。MSCT及CPV对各支肺静脉直径的测量无显著差异,(P0.05)。20例传统Carto系统标测及14例Carto-Merge技术指导下的环肺静脉消融术平均手术时间分别为(190.46±35.13)min和(162.63±33.74)min(P0.05)。结论:MSCT肺静脉成像可以替代CPV评估肺静脉,其显示肺静脉-左心房区域解剖学细节的能力优于CPV;Carto-Merge技术融合MSCT重建图像指导房颤射频消融手术,有利于保证环肺静脉线性消融的连续性,并有效缩短手术时间。     

心脏瓣膜病手术同期射频消融治疗房颤的疗效分析

目的探讨心内直视术同期行双极射频消融改良迷宫术治疗心脏瓣膜病合并心房颤动的临床疗效和预后。方法选取60例因心脏瓣膜病合并房颤接受单纯瓣膜置换术的患者和75例接受瓣膜置换术同期行双极射频消融改良迷宫术的患者作为研究对象,比较2种不同治疗方式的围术期技术特征、术后不同时间节点的房颤转复率等临床效果。结果 2组患者的瓣膜置换术式和瓣膜类型差异无统计学意义(P0.05),但观察组的体外循环时间和主动脉阻断时间长于对照组,差异具有统计学意义(P0.05)。观察组患者术后3个月、6个月、1年的房颤转复率均显著优于对照组,差异具有统计学意义(P0.05)。结论心内直视术同期行双极射频消融改良迷宫术治疗心脏瓣膜病合并心房颤动具有较好的短期临床效果。     

The myocardial sleeves of the pulmonary veins: potential implications for atrial fibrillation

Atrial fibrillation (AF) is the most common abnormal heart rhythm and contributes to cardiac morbidity and mortality. Electrophysiological studies with pacing have shown that AF is initiated by ectopic beats localized in the pulmonary vein (PV) walls. The aim of this work was to look for some anatomical or histological particularities to explain these ectopic beats. Ten autopsied hearts were examined (6 males, 4 females). The myocardium was studied from the left atrium to the PV. Histological sections were made from 39 PVs. Myocardial cells were localized to PV between 9 and 38 mm from the PV-atrial junction. The sleeve was composed of circularly and longitudinally oriented bundles of cardiomyocytes. The peripheral end of the myocardial sleeve was irregular. The longest myocardial sleeves were found in the superior veins and were longitudinally oriented. At the PV-atrial junction, the circular bundles were not often circumferential. PV myocardial architecture confirmed the possibility of initiating AF. This fact is important for therapeutic radiofrequency ablation and explains why PV disconnection is essential.     

Strong desmin immunoreactivity in the myocardial sleeves around pulmonary veins,superior caval vein and coronary sinus supports the presumed arrhythmogenicity of these regions

Myocardial sleeve around human pulmonary veins plays a critical role in the pathomechanism of atrial fibrillation. Besides the well-known arrhythmogenicity of these veins, there is evidence that myocardial extensions into caval veins and coronary sinus may exhibit similar features. However, studies investigating histologic properties of these structures are limited. We aimed to investigate the immunoreactivity of myocardial sleeves for intermediate filament desmin, which was reported to be more abundant in Purkinje fibers than in ventricular working cardiomyocytes. Sections of 16 human (15 adult and 1 fetal) hearts were investigated. Specimens of atrial and ventricular myocardium, sinoatrial and atrioventricular nodes, pulmonary veins, superior caval vein and coronary sinus were stained with anti-desmin monoclonal antibody. Intensity of desmin immunoreactivity in different areas was quantified by the ImageJ program. Strong desmin labeling was detected at the pacemaker and conduction system as well as in the myocardial sleeves around pulmonary veins, superior caval vein, and coronary sinus of adult hearts irrespective of sex, age, and medical history. In the fetal heart, prominent desmin labeling was observed at the sinoatrial nodal region and in the myocardial extensions around the superior caval vein. Contrarily, atrial and ventricular working myocardium exhibited low desmin immunoreactivity in both adults and fetuses. These differences were confirmed by immunohistochemical quantitative analysis. In conclusion, this study indicates that desmin is abundant in the conduction system and venous myocardial sleeves of human hearts.     

Irreversible intrapulmonary vascular changes after pulmonary vein stenosis complicating catheter ablation for atrial fibrillation.

BACKGROUND: Pulmonary vein stenosis is a recognized complication of catheter ablation of arrhythmias emanating from the pulmonary vein; however, there is little information on secondary effects of pulmonary vein stenosis on lung tissue. METHODS AND RESULTS: A 55-year-old man with a history of paroxysmal atrial fibrillation refractory to antiarrhythmic medication had radiofrequency ablation in April 2003 and July 2003. Although these procedures were successful in resolving the patient's arrhythmia, they were complicated by the development of pulmonary vein stenosis of all four veins and pulmonary hypertension requiring patch annuloplasty of the pulmonary veins in October 2003. The patient was referred to our center for pulmonary vein stent placement in December 2003, June 2004, and August 2004, each time for recurrent hemoptysis. Due to persistent hemoptysis over the next several months, the patient underwent left lower lung lobectomy in September 2005. Microscopic examination of the lung showed marked medial thickening and intimal hyperplasia of large and small pulmonary veins and arteries, as well as focal organizing thrombi in the small arteries. The lung tissue showed extensive hemosiderin deposition indicative of prior hemorrhage. CONCLUSION: Chronic pulmonary vein stenosis after radiofrequency ablation of atrial fibrillation results in irreversible venous and arterial morphologic changes throughout the lung, including areas both close to, and remote from, the site of catheter ablation. Because there are persistent pathological changes remote from the ablation site causing the pulmonary hypertension, stenting the site of ablation to reopen large pulmonary veins may not be effective in treating the pulmonary hypertension.     

Microanatomy of Human Left Ventricular Coronary Veins

We describe analyses of the microanatomy of major left ventricular veins, including their relationship to the myocardium. Immediately following fixation of six fresh human hearts, anterior interventricular veins (AIV), left marginal veins (LMV), posterior veins of the left ventricle (PVLV), and posterior interventricular veins (PIV) were sectioned in ～5 mm intervals perpendicular to the veins' length from base to apex. Slides were prepared, digitized, and analyzed; measurements were made of each vein's wall thickness, circumference, distance between vein wall and myocardium, and distance between vein wall and closest artery. For analyses, based on the length of each vein, slides were grouped into three regions: basal (top third), mid (middle third), and apical (bottom third). Vein wall thicknesses and circumferences were significantly smaller (P < 0.05) in apical than basal regions in all veins. Vein wall thicknesses were significantly larger in the AIV and PIV than in the LMV and PVLV (P < 0.05). The AIV was significantly farther away (1.81–2.99 mm) from the myocardium than the other three veins (P < 0.05). Left ventricular venous microanatomy was quantified and analyzed. Variation in venous microanatomy, including distance between vein walls and excitable myocardium, could impact therapies involving the coronary venous system. Anat Rec, 2009. © 2008 Wiley‐Liss, Inc.     

完全性肺静脉异位连接的解剖分型及临床意义

目的：探讨完全性肺静脉异位连接（total anomalous pulmonary venous connection,TAPVC．）的解剖分型及其临床意义。方法：46例TAPVC患者按照Darling分型方法分型，并将心上型和心内型各分为2个亚形。将全组病例分成梗阻型和非梗阻型。对照术前患者的临床症状及体征及术后疗效。结果：46例TAPVC中心上型25例，肺静脉总干经垂直静脉连接于上腔静脉23例，肺静脉总干直接开口于右侧上腔静脉2例；心内型17例，肺静脉总干开口于冠状静脉窦11例，开口于右心房6例；心下型4例。肺静脉总干通过垂直静脉连接于肝门静脉。肺静脉回流梗阻7例，均依据解剖分型选择手术治疗。死亡4例，余康复出院。结论：TAPVC的解剖分型对其临床诊断及治疗有较高的价值。     

Nkx2.5‐negative myocardium of the posterior heart field and its correlation with podoplanin expression in cells from the developing cardiac pacemaking and conduction system

Recent advances in the study of cardiac development have shown the relevance of addition of myocardium to the primary myocardial heart tube. In wild‐type mouse embryos (E9.5–15.5), we have studied the myocardium at the venous pole of the heart using immunohistochemistry and 3D reconstructions of expression patterns of MLC‐2a, Nkx2.5, and podoplanin, a novel coelomic and myocardial marker. Podoplanin‐positive coelomic epithelium was continuous with adjacent podoplanin‐ and MLC‐2a‐positive myocardium that formed a conspicuous band along the left cardinal vein extending through the base of the atrial septum to the posterior myocardium of the atrioventricular canal, the atrioventricular nodal region, and the His‐Purkinje system. Later on, podoplanin expression was also found in the myocardium surrounding the pulmonary vein. On the right side, podoplanin‐positive cells were seen along the right cardinal vein, which during development persisted in the sinoatrial node and part of the venous valves. In the MLC‐2a‐ and podoplanin‐positive myocardium, Nkx2.5 expression was absent in the sinoatrial node and the wall of the cardinal veins. There was a mosaic positivity in the wall of the common pulmonary vein and the atrioventricular conduction system as opposed to the overall Nkx2.5 expression seen in the chamber myocardium. We conclude that we have found podoplanin as a marker that links a novel Nkx2.5‐negative sinus venosus myocardial area, which we refer to as the posterior heart field, with the cardiac conduction system. Anat Rec, 290:115–122, 2007. © 2006 Wiley‐Liss, Inc.     

Myocardial sleeves of pulmonary veins and atrial fibrillation: a postmortem histopathological study of 100 subjects

Atrial fibrillation (AF) is triggered by ectopic beats originating from extensions of the left atrial myocardium over the pulmonary veins (PVs), so-called myocardial sleeves. A total of 100 hearts (393 PVs) obtained at autopsy were studied. Of these, 50 were from patients with chronic AF and 50 from controls in sinus rhythm. Out of a total of 393 PVs studied, a sleeve was present in 349 PVs (88.8%). The myocardial sleeves frequently harboured senile atrial amyloid and scarring. These two changes were evaluated semi-quantitatively (grade 0–3). Amyloidosis was found in 68% of all hearts and in 55% of all sleeves. It was more frequent in patients with AF (58.5%) than in those without (51.7%), however, without statistical significance (p values 0.948, 0.306, 0.166 and 1). Scarring was present in all 349 sleeves studied. It was significantly more severe in patients with AF (average grade 2.44) than in those without (average grade 2.00) (p values <0.001, <0.1, <0.05 and <0.01). In conclusion, amyloidosis and particularly scarring of the myocardial sleeves of the pulmonary veins, appear to be common in the elderly population as an arrhythmogenic substrate for AF.     

Structural identification and characterization of arteries and veins in the placental stem villi

The vascular wall structure in the human full-term placental villi of normal pregnancy was studied by means of light and electron microscopy with an improved technique of perfusion fixation and tissue preparation. We observed 81 sections of stem villi that showed cross-sectional profiles of paired vessels in their center. Both vascular walls contained a large amount of extracellular matrix and no elastic lamina between smooth muscle cells of the media, making identification of the artery and the vein quite difficult at first sight. We then noted that the density of the smooth muscle cell population was always considerably higher in one than the other, and identified the former as artery and the latter as vein on the basis of their connection with larger arteries and veins running on the chorionic plate. Between the paired vessels, the artery had a smaller caliber than the vein, and the ratio of venous to arterial caliber was distributed from 1.0 to 2.5. The thickness of media was usually thicker in the vein than in the artery. Clusters of elastic fibers were found occasionally in the media of arteries and veins, and basement membrane-like materials were associated frequently with the elastic fibers and were distributed widely in the media as well as in the adventitia. In the veins, the smooth muscle cells of the most superficial part of the media contained well-developed rough endoplasmic reticulum and Golgi apparatus, indicating differentiation to secrete extracellular matrices. The present study revealed the difference of wall structure between arteries and veins in the placental stem villi for the first time at the ultrastructural level, and suggested differentiation of venous smooth muscle cells, possibly by some influence from the luminal side.