PULMONER VENLER VE ATRİAL FİBRİLASYON

Öz

Atrial fibrilasyon (AF), adult yaşlarda yüksek morbidite ve mortaliteye yol açan en sık görülen kalp ritm bozukluğudur. Pulmoner venlerin (PVs) belli şartlarda AF ye neden olabileceğinin tespit edimesini takiben bu durumun nasıl oluştuğunu araştırmaya yönelik bir çok çalışma yapılmıştır. Torasik venler, özellikle PVs elektriksel aktiviteye sahiptir ve bir çok çalışmaya konu olmuştur. PV lerin aritmojenik etkiye yol açması ile ilgili bir çok mekanizma ileri sürülmüştür. PV'lerin kolaylıkla indüklenebilir kardiyomyositler içermesi artmış otomatisite, trigger aktivite başlatma ve mikroentrant çevrim oluşmasına neden olur. Farmakolojik tedavinin çoğu zaman başarısız olması girişimsel tedavilere ilgiyi artırmıştır. Ablasyon teknikleri AF tedavi yönetiminde giderek artan sıklıkta kullanılmaktadır.

Anahtar Kelimeler

• Aritmiler, Kardiyak, Atrial fibrilasyon, Ablasyon Teknikleri, Pulmoner venler

PULMONARY VEINS AND ATRIAL FIBRILLATION

Abstract

Atrial fibrillation (AF) is the most frequent heart rhythm disorder in the adult population, which leads to high morbidity and mortality. The detection that the PVs could be responsible for AF undercertain circumstances has been followed by much research to determine how this can ocur. Thoracic veins, especially the PVs, are electrically active and have been the subject of several studies. Several mechanisms for PV arrhythmogenicity have been proposed. The PVs contained cardiomyocytes with easily inducible arrhythmogenic activity due to the enhanced automaticity, induction of triggered activity, and genesis of microreentrant circuits. The failure of most of the time on pharmacologic treatments has increased interest in interventional treatments. The ablative techniques in managing of AF have be en used with increasing frequency.

Keywords

• Arrhythmias, Cardiac, Atrial Fibrillation, Ablation Techniques, Pulmonary Veins

Kaynakça

1. 1. Brand FN, Abbott RD, Kannel WB, Wolf PA. Characteristics and prognosis of lone atrial fibrillation. 30-y ear follow-up in the Framingham Study. J Am Med Assoc 1985; 254: 3449-53.
2. 2. Levy S, Maarek M, Coumel P, et al. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Circulation 1999; 99: 3028-35.
3. 3. Cheung W. Electrical activity of the pulmonary vein and its interact›on w›th the right atrium in the gu›nea-pig. J Physiol 1980; 314: 445-56.
4. 4. Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339: 659-666. Landmark report that first identified and demonstrated that ectopic beats originating from the pulmonary veins initiate clinical atrial fibrillation.
5. 5. Chen SA, Hsieh MH, Tai TC, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins. Circulation 1999; 100: 1879-86.
6. 6. Pappone C, Rosanio S, Oreto G, et al. Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach. Circulation 2000; 102: 2619-28.
7. 7. Oral H, Knight BP, Tada H, et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002; 105: 1077-81.
8. 8. Hirose M, Laurita KR. Calcium-mediated triggered activity is an underlying cellular mechanism of ectopy originating from the pulmonary vein in dogs. Am J Physiol Heart Circ Physiol 2007; 292: H1861-H1867.

9. 9. Patterson E, Po S, Scherlag BJ, Lazzara R. Triggered firing in pulmonary veins initiated by in vitro autonomic nerve stimulation. Heart Rhythm 2005; 2: 624-31.
10. 10. Chou C-C, Nihei M, Zhou S, et al. Intracellular calcium dynamics and anisotropic reentry in isolated canine pulmonary veins and left atrium. Circulation 2005;111: 2889-97.
11. 11. Arora R, Verheule S, Scott L, et al. Arrhythmogenic substrate of the pulmonary veins assessed by high-resolution optical mapping. Circulation 2003;107: 1816-21.
12. 12. Rutger J. Hassink, H. Thomas Aretz, Jeremy Ruskin, David Keane, Morphology of Atrial Myocardium in Human Pulmonary Veins A Postmortem Analysis in Patients With and Without Atrial Fibrillation J Am Coll Cardiol 2003; 42: 1108-14.
13. 13. Jais P, Haissaguerre M, Shah DC, et al. A focal source of atrialfibrillation treated by discrete radio frequency ablation. Circulation 1997; 95: 572-6.
14. 14. Haissaguerre M, Jais P, Shah DC, et al. Electrophysiological end pointfor catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci. Circulation 2000; 101: 1409-17.
15. 15. Seol CA, Kim J, Kim WT, et al. Simulation of spontaneous action potentials of cardiomyocytes in pulmonary veins of rabbits. Prog Biophys Mol Biol 2008; 96: 132-51.
16. 16. Jais P, Haissaguerre M, Shah DC, et al. A focal source of atrialfibrillation treated by discrete radio frequency ablation. Circulation 1997; 95: 572-6.
17. 17. Ehrlich JR, Cha TJ, Zhang L, et al. Cellular electrophysiology of canine pulmonary vein cardiomyocytes: action potential and ionic current properties. J Physiol 2003; 551: 801-13.
18. 18. Coumel P, Attuel P, Lavallee J, Flammang D, Leclercq JF, Slama R. The atrial arrhythmia syndrome o f vagal origin. Arch Mal Coeur Vaiss 1978; 71: 645-56.
19. 19. Tan AY, Chen P-S, Chen LS, Fishbein MC. Autonomic nerves in pulmonary veins. Heart Rhythm 2007; 4: 57-60.
20. 20. Morel E, Meyronet D, Thivolet-Bejuy F, Chevalier P. Identification and distribution of interstitial Cajal cells in human pulmonary veins. Heart Rhythm 2008; 5: 1063-7.
21. 21. Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 1999; 100: 1879-86.
22. 22. Blom NA, Gittenberger-de Groot AC, DeRuiter MC, et al. Development of the cardiac conduction tissue in human embryos using HNK-1 antigen expression: possible relevance for understanding of abnormal atrial automaticity. Circulation 1999; 99: 800-6.
23. 23. Haissaguerre M, Jais P, Shah DC, et al. Electrophysiological end pointfor catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci. Circulation 2000; 101: 1409-17.
24. 24. Chen YJ, Chen SA, Chen YC, et al. Effects of rapid atrial pacing on the arrhythmogenic activity of single cardiomyocytes from pulmonary veins: implication in initiation of atrial fibrillation. Circulation 2001; 104: 2849 -54.
25. 25. Jais P, Hocini M, Macle L, et al. Distinctive electrophysiological properties of pulmonary veins in patients with atrial fibrillation. Circulation 2002; 106: 2479-85.
26. 26. Kumagai K, Ogawa M, Noguchi H, Yasuda T, Nakashima H & Saku K. Electrophysiologic properties of pulmonary veins assessed using a multielectrode basket catheter. J Am Coll Cardiol 2004; 43: 2281-9.
27. 27. Lin WS, Prakash VS, Tai CT, Hsieh MH, Tsai CF, Yu WC, et al. Pulmonary vein morphology in patients with paroxysmal atrial fibrillation initiated by ectopic beats originating from the pulmonary veins: implications for catheter ablation. Circulation 2000; 101: 1274-81.
28. 28. Herweg B, Sichrovsk, T, Polosajian L, Rozenshtein A & Steinberg JS. Hypertension and hypertensive heart disease are associated with increased ostial pulmonary vein diameter. J Cardiovasc Electrophysiol 2005; 16: 2-5.
29. 29. Pan NH, Tsao HM, Chang NC, Chen YJ & Chen SA. Aging dilates atrium and pulmonary veins: implications for the genesis of atrial fibrillation. Chest 2008; 133: 190-6.
30. 30. Chang SL, Chen YC, Chen YJ, Wangcharoen, W, Lee SH, Lin CI, et al. Mechanoelectrical feedback regulates the arrhythmogenic activity of pulmonary veins. Heart 2007; 93: 82-8.
31. 31. Seol CA., Kim WT, Ha JM, Choe H, Jang YJ, Youm JB, et al. Stretchactivated currents in cardiomyocytes isolated from rabbit pulmonary veins. Prog Biophys Mol Biol 2008; 97: 217-31.
32. 32. Maruyama T, Kishikawa T, Ito H, Kaji Y, Sasaki Y & Ishihara Y. Augmentation of pulmonary vein backflow velocity during left atrial contraction: a novel phenomenon responsible for progression of atrial fibrillation in hypertensive patients. Cardiology 2008; 109: 33-40. Cardiovasc Electrophysiol 16: 2-5.
33. 33. Chiu YT, Wu TJ, Wei HJ, Cheng CC, Lin NN, Chen YT, et al. Increased extracellular collagen matrix in myocardial sleeves of pulmonary veins: an additional mechanism facilitating repetitive rapid activities in chronic pacinginduced sustained atrial fibrillation. J Cardiovasc Electrophysiol 2005; 16: 753-9.
34. 34. Tabata T, Thomas JD & Klein AL. Pulmonary venous flow by Doppler echocardiography: revisited 12 years later. J Am Coll Cardiol 2003; 41: 1243-50.
35. 35. Tsao HM, Yu WC, Cheng HC, Wu MH, Tai CT, Lin WS, et al. Pulmonary vein dilation in patients with atrial fibrillation: detection by magnetic resonance imaging. J Cardiovasc Electrophysiol 2001; 12(7): 809-13.
36. 36. Chen SA, Chen YJ, Yeh HI, Tai CT, Chen YC, Lin CI.Pathophysiology of the pulmonary vein as an atrial fibrillation initiator. Pacing Clin Electrophysiol 2003; 26: 1576-82.
37. 37. Blom NA, Gittenberger-de Groot AC, DeRuiter MC, Poelmann RE, Mentink MM, Ottenkamp J. Development of the cardiac conduction tissue in human embryos using HNK-1 antigen expression: possible relevance for understanding of abnormal atrial automaticity. Circulation 1999; 99: 800-6.
38. 38. Arora R, Verheule S, Scott L, et al. Arrhythmogenic substrate of the pulmonary veins assessed by high-resolution optical mapping. Circulation 2003; 107: 1816-21.
39. 39. Eva Hertervig, Ole Kongstad, Erik Ljungstrom, Bertil Olsson, and Shiwen Yuan Pulmonary vein potentials in patients with and without atrial fibrillation Europace 2008; 10: 692-7l.
40. 40. Coumel P. Paroxysmal atrial fibrillation: a disorder of autonomic tone? Eur Heart J 1994; 15: 916.
41. 41. Oral H, Chugh A, Scharf C, et al. Pulmonary vein isolation for vagotonic, adrenergic, and random episodes of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2004; 15: 402-8.
42. 42. Pappone C, Santinelli V, Manguso F, et al. Pulmonary vein denervation enhances longterm benefit AFter circumferential ablation for paroxysmal atrial fibrillation. Circulation 2004; 109: 327-34.
43. 43. Lemola K, Chartier D, Yeh YH, et al. Pulmonary vein region ablation in experimental vagal atrial fibrillation: role of pulmonary veins versus autonomic ganglia. Circulation 2008; 117: 470-7.
44. 44. Armour JA, Murphy DA, Yuan BX, Macdonald S & Hopkins DA. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec 1997; 247: 289.
45. 45. Tan AY, Li H, Wachsmann-Hogiu S, Chen LS, Chen PS & Fishbein MC. Autonomic innervation and segmental muscular disconnections at the human pulmonary vein–atrial junction: implications for catheter ablation of atrial–pulmonary vein junction. J Am Coll Cardiol 2006; 48: 132-43.
46. 46. Tan AY, Zhou S, Jung BC, Ogawa M, Chen LS, Fishbein MC, et al. Ectopicatrial arrhythmias arising from canine thoracic veins during in-vivo stellate ganglia stimulation. Am J Physiol Heart Circ Physiol 2008; 259: 691-8.
47. 47. Oral H, Chugh A, Scharf C, Hall B, Che ung P, Veerareddy S, et al. Pulmonary vein isolation for vagotonic, adrenergic,and random episodes of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2004; 15(4): 402-6.
48. 48. Chen SA, Chen YJ, Yeh HI, Tai CT, Chen YC, Lin CI.Pathophysiology of the pulmonary vein as an atrial fibrillation initiator. Pacing Clin Electrophysiol 2003; 26: 1576-82.
49. 49. Oral H, Ozaydin M, Chugh A, Scharf C, Tada H, Hall B, et al. Role of the coronary sinus in maintenance of atrial fibrillation. J Cardiovasc Electrophysiol 2003;14(12): 1329-36.
50. 50 Lin YJ, Tai CT, Kao T, Tso HW, Higa S, Tsao HM, et al. Frequency analysis in different types of paroxysmal atrial fibrillation. J Am Coll Cardiol 2006; 47(7): 1401-7.
51. 51. Chen YC, Chen SA, Chen YJ, Chang MS, Chan P, Lin CI.Effects of thyroid hormone on the arrhythmogenic activityof pulmonary vein cardiomyocytes. J Am Coll Cardiol 2002; 39(2): 366-72.
52. 52. Jais P, Haissaguerre M, Shah DC, et al. A focal source of atrial fibrillation treated by discrete radio frequency ablation. Circulation 1997; 95: 572-6.
53. 53. Vickas V Patel. Novel insights into the cellular basis of atrial fibrillation. Expert Rev Cardiovasc Ther 2010; 8(7): 907-16.
54. 54. Blom NA, Gittenberger-de Groot AC, DeRuiter MC, Poelmann RE, Mentink MM, Ottenkamp J. Development of the cardiac conduction tissue in human embryos using HNK-1 antigen expression: possible relevance for understanding of abnormal atrial automaticity. Circulation 1999; 99: 800-6.
55. 55. Masani F. Node-like cells in the myocardial layer of the pulmonary vein of rats: an ultrastructural study. J Anat 1986; 145: 133-42.
56. 56. Perez-Lugones A, McMahon JT, Ratliff NB, Saliba WI, Schweikert RA, Marrouche NF, et al. Evidence of specialized conduction cells in human pulmonary veins of patients with atrial fibrillation. J Cardiovasc Electrophysiol 2003; 14(8): 803-9.
57. 57. Roux N, Havet E & Mertl P. The myocardial sleeves of the pulmonary veins:potential implications for atrial fibrillation. Surg Radiol Anat 2004; 26: 285-9.
58. 58. Mueller-Hoecker J, Beitinger F, Fernandez B, Bahlmann O, Assmann G, Troidl C, et al. Of rodents and humans: a light microscopic and ultrastructural study on cardiomyocytes in pulmonary veins. Int J Med Sci 2008; 5: 152-8.
59. 59. Verheule S, Wilson EE, Arora R, et al. Tissue structure and connexin expression of canine pulmonary veins. Cardiovasc Res 2002; 55: 727-38.
60. 60. Narayan SM, Kazi D, Krummen DE, et al. Repolarization and activation restitution near human pulmonary veins and atrial fibrillation initiation: a mechanism for the initiation of atrial fibrillation by premature beats. J Am Coll Cardiol 2008; 52: 1222-30.
61. 61. Lutomsky BA, Rostock T, Koops A, Steven D, Müllerleile K, Servatius H, et al. Catheter ablation of paroxysmal atrial fibrillation improves cardiac function: a prospective study on the impact of atrial fibrillation ablation on left ventricularfunction assessed by magnetic resonance imaging. Europace 2008; 10: 593-9.
62. 62. Okuyama Y, Miyauchi Y, Park AM, Hamabe A, Zhou S, Hayashi H, et al. High resolution mapping of the pulmonary vein and the vein of Marshall during induced atrial fibrillation and atrial tachycardia in a canine model of pacinginduced congestive heart failure. J Am Coll Cardiol 2003; 42: 348-60.
63. 63. Sun Q, Tang M, Pu J & Zhang S. Pulmonary venous structural remodeling in a canine model of chronic atrial dilation due to mitral regurgitation. Can J Cardiol 2003; 24: 305-8.
64. 64. Wetzel U, Boldt A, Lauschke J, Weigl J, Schirdewahn P, Dorszewski A, et al. Expression of connexins 40 and 43 in human left atrium in atrial fibrillation of different aetiologies. Heart 2005; 91: 166-70.
65. 65. Chen YC, Chen SA, Chen YJ, Chang MS, Chan P & Lin CI. Effects of thyroid hormone on the arrhythmogenic activity of pulmonary vein cardiomyocytes. J Am Coll Cardiol 2002; 39: 366-72.
66. 66. Siyamek Neragi-Miandoaba, Shoshana Weinerb, David J. Sugarbaker Incidence of atrial fibrillation AFter extrapleural pneumonectomy vs. pleurec tomy in patients with malignant pleural mesothelioma Interactive Cardio Vascular and Thoracic Surgery 2008; 7: 1039-43.
67. 67. Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 1999; 100: 1879-86.
68. 68. Patterson E, Lazzara R, Szabo B, et al. Sodium-calcium exchange initiated by the Ca2_ transient: an arrhythmia trigger within pulmonary veins. J Am Coll Cardiol 2006; 47: 1196-206.
69. 69. Patterson E, Po SS, Scherlag BJ, et al. Triggered firing in pulmonary veins initiated by in vitro autonomic nerve stimulation. Heart Rhythm 2005; 2: 624-31.
70. 70. Chen SA, Hsieh MH, Tai CT, Tsai CF, Prakash VS, Yu WC, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonaryveins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 1999; 100: 1879-86.
71. 71. Chen YJ, Chen YC, Tai CT, Yeh HI, Lin CI & Chen SA. Angiotensin II and angiotensin II receptor blocker modulate the arrhythmogenic activity of pulmonaryveins. Br J Pharmacol 2006; 147: 12-22.
72. 72. Chen YJ, Chen YC, Wongcharoen W, Lin CI, & Chen SA. Effect of K201, anovel antiarrhythmic drug on calcium handling and arrhythmogenic activity of pulmonary vein cardiomyocytes. Br J Pharmacol 2008; 153: 915-25.
73. 73. Sicouri S, Glass A, Belardinelli L & Antzelevitch C. Antiarrhythmic effects of ranolazine in canine pulmonary vein sleeve preparations. Heart Rhythm 2008; 5: 1019-26.
74. 74. Rostock T, Servatius H, Risius T, Ventura R, Weiss C, Meinertz T, et al. Impact of amiodarone on electrophysiologic properties of pulmonary veins in patients with paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2005; 16: 39-44.
75. 75. Tojo H, Kumagai K, Noguchi H, Ogawa M, Yasuda T, Nakashima H, et al. Hybrid therapy with pilsicainide and pulmonary vein isolation for atrial fibrillation. Circ J 2005; 69: 1503-7.
76. 76. Haissaguerre M, Shah DC, Jaïs P, Hocini M, Yamane T, Deisenhofer I, et al. Electrophysiological breakthroughs from the left atrium to the pulmonary veins. Circulation 2000; 102: 2463-5.
77. 77. Oral H, Knight BP, Tada H, Ozaydin M, Chugh A, Hassan S, et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002; 105: 1077-81.
78. 78. Tojo H, Kumagai K, Noguchi H, Ogawa M, Yasuda T, Nakashima H, et al. Hybrid therapy with pilsicainide and pulmonary vein isolation for atrial fibrillation. Circ J 2005; 69: 1503-7.