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Maesen B, Verheule S, Zeemering S, La Meir M, Nijs J, Lumeij S, Lau DH, Granier M, Crijns HJ, Maessen JG, Dhein S, Schotten U. Endomysial fibrosis, rather than overall connective tissue content, is the main determinant of conduction disturbances in human atrial fibrillation. Europace 2022; 24:1015-1024. [PMID: 35348667 PMCID: PMC9282911 DOI: 10.1093/europace/euac026] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/15/2022] [Indexed: 12/20/2022] Open
Abstract
Aims Although in persistent atrial fibrillation (AF) a complex AF substrate characterized by a high incidence of conduction block has been reported, relatively little is known about AF complexity in paroxysmal AF (pAF). Also, the relative contribution of various aspects of structural alterations to conduction disturbances is not clear. In particular, the contribution of endomysial fibrosis to conduction disturbances during progression of AF has not been studied yet. Methods and results During cardiac surgery, epicardial high-density mapping was performed in patients with acutely induced (aAF, n = 11), pAF (n = 12), and longstanding persistent AF (persAF, n = 9) on the right atrial (RA) wall, the posterior left atrial wall (pLA) and the LA appendage (LAA). In RA appendages, overall and endomysial (myocyte-to-myocyte distances) fibrosis and connexin 43 (Cx43) distribution were quantified. Unipolar AF electrogram analysis showed a more complex pattern with a larger number of narrower waves, more breakthroughs and a higher fractionation index (FI) in persAF compared with aAF and pAF, with no differences between aAF and pAF. The FI was consistently higher at the pLA compared with the RA. Structurally, Cx43 lateralization increased with AF progression (aAF = 7.5 ± 8.9%, pAF = 24.7 ± 11.1%, persAF = 35.1 ± 11.4%, P < 0.001). Endomysial but not overall fibrosis correlated with AF complexity (r = 0.57, P = 0.001; r = 0.23, P = 0.20; respectively). Conclusions Atrial fibrillation complexity is highly variable in patients with pAF, but not significantly higher than in patients with acutely induced AF, while in patients with persistent AF complexity is higher. Among the structural alterations studied, endomysial fibrosis, but not overall fibrosis, is the strongest determinant of AF complexity.
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Affiliation(s)
- Bart Maesen
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Sander Verheule
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Physiology, Maastricht University, Universiteitssingel 50, PO Box 616, 6200MD Maastricht, The Netherlands
| | - Stef Zeemering
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Physiology, Maastricht University, Universiteitssingel 50, PO Box 616, 6200MD Maastricht, The Netherlands
| | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussels, Brussels, Belgium
| | - Jan Nijs
- Department of Cardiac Surgery, UZ Brussels, Brussels, Belgium
| | - Stijn Lumeij
- Department of Physiology, Maastricht University, Universiteitssingel 50, PO Box 616, 6200MD Maastricht, The Netherlands
| | - Dennis H Lau
- Department of Physiology, Maastricht University, Universiteitssingel 50, PO Box 616, 6200MD Maastricht, The Netherlands
| | - Mathieu Granier
- Department of Physiology, Maastricht University, Universiteitssingel 50, PO Box 616, 6200MD Maastricht, The Netherlands
| | - Harry Jgm Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Stefan Dhein
- Department of Cardiac Surgery, Clinic for Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Physiology, Maastricht University, Universiteitssingel 50, PO Box 616, 6200MD Maastricht, The Netherlands
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Buja LM, Zhao B, Segura A, Lelenwa L, McDonald M, Michaud K. Cardiovascular pathology: guide to practice and training. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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3
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Buja LM, Schoen FJ. The pathology of cardiovascular interventions and devices for coronary artery disease, vascular disease, heart failure, and arrhythmias. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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4
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Kalpana SR, Shenthar J, Padmanabhan D, Rai MK, Singh A, Banavalikar B, Kalyani RN, Kamalapurkar G. A histological study of the atria in patients with isolated rheumatic mitral regurgitation with and without atrial fibrillation. J Cardiovasc Electrophysiol 2021; 33:32-39. [PMID: 34741568 DOI: 10.1111/jce.15286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/09/2021] [Accepted: 09/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is a high incidence of atrial fibrillation (AF) in patients with isolated rheumatic mitral regurgitation (MR). The histopathologic changes in the atria of patients with isolated rheumatic MR with and without AF are unknown. OBJECTIVES We aimed to determine the histological findings in patients with isolated severe rheumatic MR with and without AF. METHODS Patients with severe isolated rheumatic MR undergoing valve replacement surgeries underwent endocardial biopsies from right atrial appendage, left atrial appendage, right free wall, left free wall, left posterior wall, and mitral valve. Group I consisted of patients in sinus rhythm (SR), and Group II included patients with AF. We analyzed and compared these 10 histological features in the biopsies of patients in Groups I and II. RESULTS Of the 25 patients, 12 were in Group I and 13 in Group II. In Group I, patients had severe myocyte hypertrophy (60% vs. 18%, p = .04) that was significantly more in the right atrium (22.7% vs. 11.4%, p = .059). Interstitial adipose tissue deposition was more common in Group I (30% vs. 25%, p = .06). Interstitial fibrosis was evenly distributed at all sites without significant difference between the two groups. Group II patients had a higher prevalence and severity of vacuolar degeneration (91% vs. 60%, p = .09). CONCLUSIONS Patients with isolated severe rheumatic MR and AF have more vacuolar degeneration in the atrial tissue. Patients with SR have myocyte hypertrophy and interstitial adipose tissue deposition. Interstitial fibrosis is uniformly distributed in patients in SR and AF.
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Affiliation(s)
- Saligrama R Kalpana
- Department of Pathology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Jayaprakash Shenthar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Deepak Padmanabhan
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Maneesh K Rai
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Ankit Singh
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Bharatraj Banavalikar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Ravikumar N Kalyani
- Department of Cardiothoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Giridhar Kamalapurkar
- Department of Cardiothoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
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5
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van Schie MS, Starreveld R, Bogers AJJC, de Groot NMS. Sinus rhythm voltage fingerprinting in patients with mitral valve disease using a high-density epicardial mapping approach. Europace 2021; 23:469-478. [PMID: 33432326 PMCID: PMC7947572 DOI: 10.1093/europace/euaa336] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/06/2020] [Indexed: 12/03/2022] Open
Abstract
Aims Unipolar voltage (UV) mapping is increasingly used for guiding ablative therapy of atrial fibrillation (AF) as unipolar electrograms (U-EGMs) are independent of electrode orientation and atrial wavefront direction. This study was aimed at constructing individual, high-resolution sinus rhythm (SR) UV fingerprints to identify low-voltage areas and study the effect of AF episodes in patients with mitral valve disease (MVD). Methods and results Intra-operative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium, Bachmann’s bundle (BB), and pulmonary vein area was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). In all patients, there were considerable regional variations in voltages. UVs at BB were lower in patients with PAF compared with those without [no AF: 4.94 (3.56–5.98) mV, PAF: 3.30 (2.25–4.57) mV, P = 0.006]. A larger number of low-voltage potentials were recorded at BB in the PAF group [no AF: 2.13 (0.52–7.68) %, PAF: 12.86 (3.18–23.59) %, P = 0.001]. In addition, areas with low-voltage potentials were present in all patients, yet we did not find any predilection sites for low-voltage potentials to occur. Conclusion Even in SR, advanced atrial remodelling in MVD patients shows marked inter-individual and regional variation. Low UVs are even present during SR in patients without a history of AF indicating that low UVs should carefully be used as target sites for ablative therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
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6
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van Schie MS, Starreveld R, Roos-Serote MC, Taverne YJHJ, van Schaagen FRN, Bogers AJJC, de Groot NMS. Classification of sinus rhythm single potential morphology in patients with mitral valve disease. Europace 2021; 22:1509-1519. [PMID: 33033830 PMCID: PMC7544534 DOI: 10.1093/europace/euaa130] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/24/2020] [Accepted: 04/28/2020] [Indexed: 12/31/2022] Open
Abstract
Aims The morphology of unipolar single potentials (SPs) contains information on intra-atrial conduction disorders and possibly the substrate underlying atrial fibrillation (AF). This study examined the impact of AF episodes on features of SP morphology during sinus rhythm (SR) in patients with mitral valve disease. Methods and results Intraoperative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium (RA, LA), Bachmann’s bundle (BB), and pulmonary vein area (PVA) was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). Unipolar SPs were classified according to their differences in relative R- and S-wave amplitude ratios. A clear predominance of S-waves was observed at BB and the RA in both the no AF and PAF groups (BB 88.8% vs. 85.9%, RA 92.1% vs. 85.1%, respectively). Potential voltages at the RA, BB, and PVA were significantly lower in the PAF group (P < 0.001 for each) and were mainly determined by the size of the S-waves amplitudes. The largest difference in S-wave amplitudes was found at BB; the S-wave amplitude was lower in the PAF group [4.08 (2.45–6.13) mV vs. 2.94 (1.40–4.75) mV; P < 0.001]. In addition, conduction velocity (CV) at BB was lower as well [0.97 (0.70–1.21) m/s vs. 0.89 (0.62–1.16) m/s, P < 0.001]. Conclusion Though excitation of the atria during SR is heterogeneously disrupted, a history of AF is characterized by decreased SP amplitudes at BB due to loss of S-wave amplitudes and decreased CV. This suggests that SP morphology could provide additional information on wavefront propagation.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Maarten C Roos-Serote
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
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Pichler Sekulic S, Sekulic M. Case Report: Acute Thrombotic Angiopathy of Atrial Appendage Epicardial Veins: A Seemingly Innocuous Finding Portending a Fatal Outcome. Front Cardiovasc Med 2021; 8:621632. [PMID: 33791344 PMCID: PMC8006332 DOI: 10.3389/fcvm.2021.621632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/09/2021] [Indexed: 11/15/2022] Open
Abstract
Thrombotic angiopathy is a pathologic description to describe endothelial injury, and with sufficient and sustained injury can lead to exposure of underlying tissue factor and the deposition of associated fibrin material. We present briefly a case of an 87-year-old woman with mitral valve regurgitation and atrial fibrillation undergoing mitral valve annuloplasty, Cox-maze procedure, and excision of the left atrial appendage. Pathologic examination of the excised atrial appendage revealed commonly encountered cardiomyocyte hypertrophy and endocardial fibroelastosis, however also showed a non-occlusive, acute thrombotic angiopathy involving epicardial veins. The surgical and immediate post-operative course was unremarkable; however, 3 weeks after discharge, the patient would develop a fatal pulmonary embolism. While fibrin thrombosis developing within the atrial appendage chamber is a recognized concern in the setting of atrial fibrillation, the significance of an acute thrombotic angiopathy involving epicardial veins of the atrial appendage is less clear although in the presented case was the sole potential harbinger of a subsequent fatal thrombotic event.
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Affiliation(s)
- Simona Pichler Sekulic
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
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8
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Legere SA, Haidl ID, Castonguay MC, Brunt KR, Légaré JF, Marshall JS. Increased mast cell density is associated with decreased fibrosis in human atrial tissue. J Mol Cell Cardiol 2020; 149:15-26. [PMID: 32931784 DOI: 10.1016/j.yjmcc.2020.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/29/2020] [Accepted: 09/02/2020] [Indexed: 12/31/2022]
Abstract
Fibrotic remodelling of the atria is poorly understood and can be regulated by myocardial immune cell populations after injury. Mast cells are resident immune sentinel cells present in the heart that respond to tissue damage and have been linked to fibrosis in other settings. The role of cardiac mast cells in fibrotic remodelling in response to human myocardial injury is controversial. In this study, we sought to determine the association between mast cells, atrial fibrosis, and outcomes in a heterogeneous population of cardiac surgical patients, including a substantial proportion of coronary artery bypass grafting patients. Atrial appendage from patients was assessed for collagen and mast cell density by histology and by droplet digital polymerase chain reaction (ddPCR) for mast cell associated transcripts. Clinical variables and outcomes were also followed. Mast cells were detected in human atrial tissue at varying densities. Histological and ddPCR assessment of mast cells in atrial tissue were closely correlated. Patients with high mast cell density had less fibrosis and lower severity of heart failure classification or incidence mortality than patients with low mast cell content. Analysis of a homogeneous population of coronary artery bypass graft patients yielded similar observations. Therefore, evidence from this study suggests that increased atrial mast cell populations are associated with decreased clinical cardiac fibrotic remodelling and improved outcomes, in cardiac surgery patients.
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Affiliation(s)
- Stephanie A Legere
- Dalhousie University, Department of Microbiology and Immunology, Halifax, NS, Canada; Dalhousie Human Immunology and Inflammation Group, Dalhousie University, Halifax, NS, Canada; IMPART Investigator Team Canada, Canada
| | - Ian D Haidl
- Dalhousie University, Department of Microbiology and Immunology, Halifax, NS, Canada; Dalhousie Human Immunology and Inflammation Group, Dalhousie University, Halifax, NS, Canada
| | - Mathieu C Castonguay
- Department of Pathology and Laboratory Medicine, QEII Health Sciences Centre, Halifax, NS, Canada
| | - Keith R Brunt
- Dalhousie Medicine New Brunswick, Department of Pharmacology, Saint John, NB, Canada; New Brunswick Heart Centre, Saint John, NB, Canada; IMPART Investigator Team Canada, Canada
| | - Jean-François Légaré
- Dalhousie Human Immunology and Inflammation Group, Dalhousie University, Halifax, NS, Canada; Dalhousie Medicine New Brunswick, Department of Pharmacology, Saint John, NB, Canada; New Brunswick Heart Centre, Saint John, NB, Canada; IMPART Investigator Team Canada, Canada
| | - Jean S Marshall
- Dalhousie University, Department of Microbiology and Immunology, Halifax, NS, Canada; Dalhousie Human Immunology and Inflammation Group, Dalhousie University, Halifax, NS, Canada; IMPART Investigator Team Canada, Canada.
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9
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Fayyaz AU, Bois MC, Dasari S, Padmanabhan D, Vrana JA, Stulak JM, Edwards WD, Kurtin PJ, Asirvatham SJ, Grogan M, Maleszewski JJ. Amyloidosis in surgically resected atrial appendages: a study of 345 consecutive cases with clinical implications. Mod Pathol 2020; 33:764-774. [PMID: 31723241 DOI: 10.1038/s41379-019-0407-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/04/2019] [Accepted: 10/05/2019] [Indexed: 11/09/2022]
Abstract
Histomorphologic parameters of atrial appendages removed during the Cox-Maze procedure have been shown to correlate with recurrence of atrial fibrillation. While amyloid deposition has been noted within atrial appendages, the incidence and significance remains incompletely understood. More accurate amyloid typing methodologies and targeted pharmacotherapeutics have recently been developed, prompting pathologists to provide more detailed information about the type of amyloid identified in such samples. This study sought to fully characterize the morphologic characteristics of atrial amyloid as well as its incidence and clinical significance. Tissue archives were queried for atrial appendages removed during the cardiac surgeries (2010-2014). Patient demographics, imaging features, and salient clinical findings were recorded. Pattern and extent of amyloid deposition were recorded. Typing of the amyloid protein, when present, was performed on a subset of cases by laser capture microdissection with mass spectrometry-based proteomic analysis. A total of 383 atrial appendages from 345 consecutive patients were included in the study (mean age, 69 years; range, 26-92 years). Amyloid was present in 46% of patients. A linear relationship was observed between age and presence of atrial amyloidosis. Women were more likely to have atrial amyloidosis. Two distinct morphologies of amyloid were observed: filamentous and nonfilamentous, and correlated perfectly with amyloid type (filamentous = AANF-type amyloid; nonfilamentous = ATTR-type amyloid). Filamentous deposits were observed in 91% of those with amyloid. Amyloid was more likely to be found in the left atrial appendage than the right. Patients with atrial amyloid, irrespective of type, were more likely to have experienced stroke or TIA and more likely to have atrial arrhythmia preoperatively. Postoperatively, those with atrial amyloid are more likely to experience recurrence of arrhythmia than those who did not have atrial amyloid. Understanding the morphologic characteristics of AANF-type amyloid will allow for identification by the light microscopy and obviates the need for expensive ancillary typing techniques. The finding of nonfilamentous amyloid, should still prompt confirmation of amyloid type so that targeted therapy may be employed.
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Affiliation(s)
- Ahmed U Fayyaz
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Melanie C Bois
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Julie A Vrana
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - William D Edwards
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul J Kurtin
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph J Maleszewski
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA. .,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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Vatnikov YA, Rudenko AA, Usha BV, Kulikov EV, Notina EA, Bykova IA, Khairova NI, Bondareva IV, Grishin VN, Zharov AN. Left ventricular myocardial remodeling in dogs with mitral valve endocardiosis. Vet World 2019; 13:731-738. [PMID: 32546918 PMCID: PMC7245723 DOI: 10.14202/vetworld.2020.731-738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/06/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND AIM Left ventricular myocardial remodeling could play an important role in the progression of chronic heart failure (CHF) syndrome in dogs with mitral valve endocardiosis. The aim of this study was to evaluate the left ventricular myocardial remodeling in dogs with mitral valve endocardiosis and to study the dependence of the incidence of this pathological phenomenon on the functional class (FC) of progression of the CHF syndrome. MATERIALS AND METHODS A total of 108 afflicted dogs and 36 clinically healthy dogs were examined using transthoracic echocardiography. The following structural and geometric parameters of the left ventricular remodeling were evaluated: Myocardial mass and its index, sphericity index at the end of systole and diastole, end-systolic and end-diastolic relative wall thickness, and integral remodeling index. RESULTS In all clinically healthy dogs, a normal type of the left ventricular chamber geometry was revealed, whereas, in dogs with mitral valve endocardiosis, the normal geometry of the left ventricle occurred in 56.4%, eccentric hypertrophy in 24.1%, concentric remodeling in 10.2%, and concentric hypertrophy in 9.3% of the cases. In patients with endocardiosis, there was no dilatation type of cardiac remodeling observed. CONCLUSION When compared to the clinically healthy animals, the dogs with mitral valve endocardiosis presented with indicators of structural and geometric remodeling, such as increased myocardial mass, myocardial mass index, and sphericity index at the end of systole and diastole, as well as relatively reduced integral systolic index of remodeling and systolic relative thickness of the walls of the heart. The parameters of the left ventricular myocardial remodeling correlated significantly with the FC of CHF syndrome.
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Affiliation(s)
- Yury A. Vatnikov
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Andrey A. Rudenko
- Department of Veterinary Medicine, Moscow State University of Food Production, 125080 Moscow, Russia
| | - Boris V. Usha
- Department of Veterinary Medicine, Moscow State University of Food Production, 125080 Moscow, Russia
| | - Evgeny V. Kulikov
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Elena A. Notina
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Irina A. Bykova
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Nadiya I. Khairova
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Irina V. Bondareva
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Victor N. Grishin
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Andrey N. Zharov
- Department of Veterinary Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
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11
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Nery PB, Al Dawood W, Nair GM, Redpath CJ, Sadek MM, Chen L, Green MS, Wells G, Birnie DH. Characterization of Low-Voltage Areas in Patients With Atrial Fibrillation: Insights From High-Density Intracardiac Mapping. Can J Cardiol 2018; 34:1033-1040. [PMID: 30056843 DOI: 10.1016/j.cjca.2018.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/21/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND There is limited data on the scar burden in patients with atrial fibrillation (AF). In this study, we sought to evaluate the presence and extent of an abnormal left atrial (LA) substrate in patients with paroxysmal or persistent AF. METHODS Consecutive patients who underwent initial AF catheter ablation were prospectively enrolled. Endocardial voltage mapping was acquired in sinus rhythm using multipolar mapping catheters. Automated software was used to ensure homogeneous data collection. Assessment of low-voltage area (LVA) was performed by a reviewer blinded to clinical details. RESULTS One hundred and four patients were prospectively enrolled; 69 had paroxysmal and 35 persistent AF. The mean LA volume was 159 ± 48 mL, and the average number of LA points collected was 1308 ± 1065. Atrial LVAs were present in 23 of 69 (33%) subjects with paroxysmal and 20 of 35 (57%) with persistent AF (P = 0.02). Amongst 43 of 104 patients with scar, the average extent of LVA was 19.4 ± 21.6 cm2 and the mean percentage area was 7.6 ± 8.8%. Univariate analysis showed that age, LA volume, and persistent AF were associated with the presence of LVA. Multivariable analysis showed that age (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.00-1.11; P = 0.046) and LA volume (OR 1.02; 95% CI 1.01-1.04; P < 0.001) remained predictors of LVA. AF classification (persistent vs paroxysmal) was not a predictor of an abnormal atrial substrate (OR 1.34; 95% CI 0.4-3.9; P = 0.56). CONCLUSIONS There is wide variability in the presence and extent of LVA in patients with paroxysmal or persistent AF. Age and LA volume were predictors of LVA. There was no correlation between AF classification and the presence of LVA.
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Affiliation(s)
- Pablo B Nery
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Wafa Al Dawood
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Girish M Nair
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Calum J Redpath
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mouhannad M Sadek
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Li Chen
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martin S Green
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George Wells
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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12
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Shenthar J, Kalpana SR, Prabhu MA, Rai MK, Nagashetty RK, Kamlapurkar G. Histopathological Study of Left and Right Atria in Isolated Rheumatic Mitral Stenosis With and Without Atrial Fibrillation. J Cardiovasc Electrophysiol 2016; 27:1047-54. [PMID: 27256970 DOI: 10.1111/jce.13024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 05/21/2016] [Accepted: 05/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mitral stenosis (MS) has the highest incidence of atrial fibrillation (AF) in chronic rheumatic valvular disease. There are very few studies in isolated MS comparing histopathological changes in patients with sinus rhythm (SR) and AF. OBJECTIVES To analyze the histological changes associated with isolated MS and compare between changes in AF and SR. METHODS This was a prospective study in patients undergoing valve replacement surgery for symptomatic isolated MS who were divided into 2 groups, Group I AF (n = 13) and Group II SR (n = 10). Intra-operative biopsies performed from 5 different sites from both atria were analyzed for 10 histopathologic changes commonly associated with AF. RESULTS On multivariate analysis, myocytolysis (odds ratio [OR]: 1.48, P = 0.05) was found to be associated with AF, whereas myocyte hypertrophy (OR: 0.21, P = 0.003), and glycogen deposition (OR: 0.43, P = 0.002) was associated with SR. Interstitial fibrosis the commonest change was uniformly distributed across both atria irrespective of the rhythm. CONCLUSION In rheumatic MS, SR is associated with myocyte hypertrophy whereas AF is associated with myocytolysis. Endocardial inflammation is more common in left atrial appendage irrespective of rhythm. Interstitial fibrosis is seen in >90% of patients distributed in both the atria and is independent of the rhythm. Amyloid and Aschoff bodies are uncommon and the rest of the changes are uniformly distributed across both the atria.
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Affiliation(s)
- Jayaprakash Shenthar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India.
| | | | - Mukund A Prabhu
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Maneesh K Rai
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Ravikumar Kalyani Nagashetty
- Department of Cardiothoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Giridhar Kamlapurkar
- Department of Cardiothoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
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13
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Cardiac pathology in Irish wolfhounds with heart disease. J Vet Cardiol 2016; 18:57-70. [DOI: 10.1016/j.jvc.2015.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 10/04/2015] [Accepted: 10/07/2015] [Indexed: 11/15/2022]
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14
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Buja L, Schoen F. The Pathology of Cardiovascular Interventions and Devices for Coronary Artery Disease, Vascular Disease, Heart Failure, and Arrhythmias. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00032-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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15
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Tsai FC, Chang GJ, Hsu YJ, Lin YM, Lee YS, Chen WJ, Kuo CT, Yeh YH. Proinflammatory gene expression in patients undergoing mitral valve surgery and maze ablation for atrial fibrillation. J Thorac Cardiovasc Surg 2015; 151:1673-1682.e5. [PMID: 26774166 DOI: 10.1016/j.jtcvs.2015.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 11/27/2015] [Accepted: 12/05/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE It is difficult to achieve rhythm control in patients with long-standing persistent atrial fibrillation (AF). The radiofrequency maze procedure is an effective means in curing AF with a variable recurrence rate depending on patient characteristics and AF duration. In these patients, the characteristics of the atrial substrate have not been well investigated. Because the inflammatory process has been shown to be important in the pathogenesis of AF, we sought to characterize the proinflammatory gene expression in left atria obtained from patients with AF undergoing mitral valve surgery combined with the maze procedure to distinguish the changes associated with AF and its recurrence after the surgical ablation. METHODS Left atrial appendages from 35 patients receiving mitral valve surgery were used for study. Ten patients had sinus rhythm (SR) and 25 patients had persistent AF for more than 1 year and underwent the maze procedure. Among the AF patients, 13 patients remained in SR (AF-SR) and 12 patients had recurrent AF during the 1-year clinical follow-up (AF-AF). The nCounter Human Inflammation Array (NanoString Technologies, Seattle, Wash) was used for evaluating proinflammatory gene expression. Quantitative polymerase chain reaction, Western blot, and immunohistochemistry were applied for studying messenger RNA and protein expression. RESULTS Of 144 expressed proinflammatory genes, the inflammation array analysis revealed that 32 genes were differentially expressed between AF (including AF-SR and AF-AF) and SR. Thirteen genes were differentially expressed between AF-SR and AF-AF. The array and quantitative polymerase chain reaction produced parallel results in analyzing the expression of particular genes. Concordant with the gene expression difference between AF and SR patients, rapid pacing increased the expressions of SHC1, RHOA, PDGFA, and TRAF2 in HL-1 myocytes, implicating a causative effect of tachyarrhythmia on these genes. Compared with AF-SR, AF-AF expressed more intense oxidative stress, upregulations of collagen, transforming growth factor beta 1, and intranuclear nuclear factor of activated T-cells. Regression analysis showed that increased left atrial diameter was associated with the expression of RHOA and STAT1. CONCLUSIONS Differential expression profiles of proflammatory genes were presented between SR and AF and between maintained SR and recurrent AF after the maze procedure. The identified inflammatory molecules associated with AF and failed surgical ablation may provide clues for developing new potential therapeutic targets to improve AF rhythm control.
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Affiliation(s)
- Feng-Chun Tsai
- Division of Cardiac Surgery, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Gwo-Jyh Chang
- Graduate Institute of Clinical Medical Sciences, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Min Lin
- School of Dentistry, National Yang-Ming University, Taipei, Taiwan
| | - Yun-Shien Lee
- Department of Biotechnology, Ming-Chuan University, Taoyuan, Taiwan
| | - Wei-Jan Chen
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Tai Kuo
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Division, Chang-Gung Memorial Hospital, Chang-Gung University College of Medicine, Taoyuan, Taiwan.
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16
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Anatomical Basis for the Cardiac Interventional Electrophysiologist. BIOMED RESEARCH INTERNATIONAL 2015; 2015:547364. [PMID: 26665006 PMCID: PMC4668306 DOI: 10.1155/2015/547364] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/28/2015] [Indexed: 12/11/2022]
Abstract
The establishment of radiofrequency catheter ablation techniques as the mainstay in the treatment of tachycardia has renewed new interest in cardiac anatomy. The interventional arrhythmologist has drawn attention not only to the gross anatomic details of the heart but also to architectural and histological characteristics of various cardiac regions that are relevant to the development or recurrence of tachyarrhythmias and procedural related complications of catheter ablation. In this review, therefore, we discuss some anatomic landmarks commonly used in catheter ablations including the terminal crest, sinus node region, Koch's triangle, cavotricuspid isthmus, Eustachian ridge and valve, pulmonary venous orifices, venoatrial junctions, and ventricular outflow tracts. We also discuss the anatomical features of important structures in the vicinity of the atria and pulmonary veins, such as the esophagus and phrenic nerves. This paper provides basic anatomic information to improve understanding of the mapping and ablative procedures for cardiac interventional electrophysiologists.
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17
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van Oosten EM, Boag AH, Cunningham K, Veinot J, Hamilton A, Petsikas D, Payne D, Hopman WM, Redfearn DP, Song W, Lamothe S, Zhang S, Baranchuk A. The histology of human right atrial tissue in patients with high-risk Obstructive Sleep Apnea and underlying cardiovascular disease: A pilot study. IJC HEART & VASCULATURE 2015; 6:71-75. [PMID: 28785630 PMCID: PMC5497175 DOI: 10.1016/j.ijcha.2015.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 01/10/2015] [Accepted: 01/13/2015] [Indexed: 11/06/2022]
Abstract
Background Obstructive Sleep Apnea (OSA) results in intermittent hypoxia leading to atrial remodeling, which, among other things, facilitates development of atrial fibrillation. While much data exists on the macrostructural changes in cardiac physiology induced by OSA, there is a lack of studies looking for histologic changes in human atrial tissue induced by OSA which might lead to the observed macrostructural changes. Methods A case control study was performed. Patients undergoing coronary artery bypass grafting (CABG) were evaluated for OSA and categorized as high-risk or low-risk. The right atrial tissue samples were obtained during CABG and both microscopic histological analysis and Sirius Red staining were performed. Results 18 patients undergoing CABG were included; 10 high-risk OSA and 8 low-risk OSA in evenly matched populations. No statistically significant difference between the two groups was observed in amount of myocytolysis (p = 0.181), nuclear hypertrophy (p = 0.671), myocardial inflammation (p = n/a), amyloid deposition (p = n/a), or presence of thrombi (p = n/a), as measured through routine H&E staining. As well, no statistically significant difference in interstitial and epicardial collagen was observed, as measured by Sirius Red staining (for total tissue: p = 0.619: for myocardium: p = 0.776). Conclusions In this pilot study there were no observable histological differences in human right atrial tissue from individuals at high- and low-risk for OSA. Further investigation would be required for more definitive results.
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Affiliation(s)
- Erik M van Oosten
- Queens University, Department of Medicine, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada
| | - Alexander H Boag
- Queens University, Department of Pathology, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada
| | - Kris Cunningham
- Queens University, Department of Pathology, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada
| | - John Veinot
- University of Ottawa, Department of Medicine, 451 Smyth Rd, Ottawa, Ontario K1H 8M5, Canada
| | - Andrew Hamilton
- Queens University, Department of Medicine, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada.,Department of Cardiac Surgery, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada
| | - Dimitri Petsikas
- Queens University, Department of Medicine, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada.,Department of Cardiac Surgery, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada
| | - Darrin Payne
- Queens University, Department of Medicine, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada.,Department of Cardiac Surgery, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada
| | - Wilma M Hopman
- Cardiology Department, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada
| | - Damian P Redfearn
- Queens University, Department of Medicine, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada.,Cardiology Department, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada
| | - WonJu Song
- Department of Biomedical and Molecular Sciences, Botterell Hall, 18 Stuart Street, Kingston, Ontario K7L 3N6, Canada
| | - Shawn Lamothe
- Department of Biomedical and Molecular Sciences, Botterell Hall, 18 Stuart Street, Kingston, Ontario K7L 3N6, Canada
| | - Shetuan Zhang
- Department of Biomedical and Molecular Sciences, Botterell Hall, 18 Stuart Street, Kingston, Ontario K7L 3N6, Canada
| | - Adrian Baranchuk
- Queens University, Department of Medicine, 15 Arch Street, Kingston, Ontario K7L 3N6, Canada.,Cardiology Department, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada
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18
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Kwak JG, Seo JW, Oh SS, Lee SY, Ham EK, Kim WH, Kim SJ, Bae EJ, Lim C, Lee CH, Lee C. Histopathologic analysis of atrial tissue in patients with atrial fibrillation: comparison between patients with atrial septal defect and patients with mitral valvular heart disease. Cardiovasc Pathol 2014; 23:185-92. [PMID: 24746709 DOI: 10.1016/j.carpath.2014.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 01/18/2014] [Accepted: 01/21/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) in adult patients with atrial septal defect (ASD) accompanies an enlarged right atrium (RA) with a less enlarged left atrium (LA), which is the opposite situation in patients with AF and mitral valvular disease. This study was to compare the histopathological change in the atrium of patients with AF of two different etiologies: ASD and mitral disease. METHODS Twenty-four patients were enrolled. Group 1 included patients with ASD (8), Group 2 included patients with ASD with AF (6), and Group 3 included patients with mitral disease with AF (10). Preoperative atrial volumes were measured. Atrial tissues were obtained during surgical procedures and stained with periodic acid-Schiff, smooth muscle actin, Sirius red, and Masson's trichrome to detect histopathologic changes compatible with AF. The severity of histopathological changes was represented with "positivity" and "strong positivity" after analyzing digitalized images of the staining. We investigated the relationship between the degree of atrial dilatation and severity of histopathological changes according to the groups and tissues. RESULTS Group 2 and Group 3 patients showed a tendency toward an enlarged RA volume and enlarged LA volume, respectively, compared with each others. However, in the histopathologic analysis, "positivity" and "strong positivity" showed no significant positive correlations with the degree of atrial volume in special staining. CONCLUSIONS A similar degree of histopathologic changes was observed in both atria in patients with AF (Group 2 and 3) regardless of the degree of dilatation of atrial volume and disease entities.
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Affiliation(s)
- Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hostpial, Bucheon, Republic of Korea
| | - Jeong-Wook Seo
- Department of Pathology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sam Se Oh
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hostpial, Bucheon, Republic of Korea
| | - Sang Yun Lee
- Department of Pediatrics, Sejong General Hospital, Bucheon, Republic of Korea
| | - Eui Keun Ham
- Department of Pathology, Sejong General Hospital, Bucheon, Republic of Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea.
| | - Soo-Jin Kim
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine, Konkuk University, Seoul, Republic of Korea
| | - Eun Jung Bae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Cheoung Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hostpial, Bucheon, Republic of Korea
| | - Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hostpial, Bucheon, Republic of Korea
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