Vol. 24 No. 3 (2020)
HEART RHYTHM DISORDERS

Clinical effectiveness of catheter treatment for atrial fibrillation depending on the dynamics of histological changes in the myocardium

PDF (Русский)
  • A. Shelemehov,
  • R. Batalov,
  • Yu. Rogovskaya,
  • S. Usenkov,
  • E. Archakov,
  • A. Gusakova,
  • M. Rebenkova
A. Shelemehov
Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
Bio
R. Batalov
Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
Yu. Rogovskaya
Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
S. Usenkov
Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
E. Archakov
Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
A. Gusakova
Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
M. Rebenkova
Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk
DOI: https://doi.org/10.21688/1681-3472-2020-3-90-106

Published 2020-09-30

Keywords

  • atrial fibrillation,
  • efficiency,
  • endomyocardial biopsy,
  • myocarditis,
  • radiofrequency ablation

How to Cite

Shelemehov, A., Batalov, R., Rogovskaya, Y., Usenkov, S., Archakov, E., Gusakova, A., & Rebenkova, M. (2020). Clinical effectiveness of catheter treatment for atrial fibrillation depending on the dynamics of histological changes in the myocardium. Patologiya Krovoobrashcheniya I Kardiokhirurgiya, 24(3), 90–106. https://doi.org/10.21688/1681-3472-2020-3-90-106

Copyright (c) 2020 Shelemehov A.E., Batalov R.E., Rogovskaya Yu.V., Usenkov S.Yu., Archakov E.A., Gusakova A.M., Rebenkova M.S.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Abstract

Background. Atrial fibrillation (AF) is combined with an inflammatory process that occurs in the myocardium. Diagnosis of histological changes, including inflammatory changes, in the myocardium is a complex task in the field of modern medicine. The only reliable way of determining the inflammatory changes in the myocardium is endomyocardial biopsy (EMB). As per our literature review, there are no data on the effect of histological changes in the myocardium on the efficacy of interventional treatment for AF. Moreover, assessing the dynamics of EMB results allows us to approach the treatment of patients in greater detail, thereby lowering the risk of the development and progression of serious cardiac pathologies, particularly AF.
Aim. To study the effectiveness of catheter treatment for ‘idiopathic’ AF, depending on the dynamics of histological changes in the myocardium.
Methods. We enrolled 48 patients with an ‘idiopathic’ form of AF; the median patient age was 39.0 y (33.5–48.0 y). Of these, 42 (87.5 %) were men and 6 (12.5 %) were women. The median duration of arrhythmic history was 4.0 y (2.0–7.0 y). All the patients underwent radiofrequency isolation of the pulmonary veins (Rcil) and EMB from the right ventricle. Histological tests, using the criteria of Cristina Basso, and immunohistochemical (IHC) tests were performed to determine the antigens of the following viruses: herpes simplex virus (HSV) types 1, 2 and 6, enterovirus (EV), Epstein-Barr, adenovirus and parvovirus (PV). After 6 mon, EMB, histological and IHC studies were repeated. Depending on the clinical form of AF, the patients are divided into the following three groups: group 1—paroxysmal form [21 (43.7 %) patients], group 2—persistent [13 (27.1 %) patients], group 3—long-term persistent [14 (29.2 %) patients]. Based on the results of the observation and evaluation of effectiveness, all the groups were divided into the following three subgroups: a—absence of AF during 12 mon of observation, b—early arrhythmia recurrences were registered during the first 3 mon of observation, c—presence of late arrhythmia recurrence after 3 mon of observation.
Results. According to the histological criteria for active lymphocytic myocarditis identified in the subgroups, there were 5 patients (35.7 %) in 1a, 2 (50 %) in 1b, 6 (75 %) in 2a, 2 (66,7 %) in 2b, 7 (70 %) in 3a, 2 (66.7 %) in 3b, and 1 (100 %) in 3c. The rest of the patients showed signs of lymphocytic infiltration. After 6 mon, only in group 2a, there was a significant reduction in the number of patients with active lymphocytic myocarditis (p < 0.05). All the patients showed fibrotic changes and expression of HSV 6 and EV antigens of varying severity; this persisted till after 6 mon. The overall effectiveness of the surgical treatment was 66.7 % for paroxysmal, 61.5 % for persistent and 71.4 % for long-term persistent forms of AF during 12 mon of follow-up.
Conclusion. Patients with ‘idiopathic’ AF show inflammatory changes in the myocardium, and 48.7 % met the criteria for myocarditis. All the patients showed the expression of viral antigens and the development of fibrosis that met the criteria for post-inflammatory changes. A repeat study that was conducted after 6 mon showed no significant dynamics of inflammatory and fibrotic changes. Despite the presence of inflammatory changes in the myocardium, the effectiveness of catheter treatment was 66.7 % for paroxysmal, 61.5 % for persistent and 71.4 % for long-term persistent forms of AF.

Received 29 April 2020. Revised 1 June 2020. Accepted 3 June 2020.

Funding: The study did not have sponsorship.

Conflict of interest: Authors declare no conflict of interest.

Author contributions
Conception and design: A.E. Shelemekhov, R.E. Batalov
Data collection and analysis: A.E. Shelemekhov, Yu.V. Rogovskaya, S.Yu. Usenkov, E.A. Archakov, M.S. Rebenkova
Drafting the article: A.E. Shelemekhov
Statistical analysis: A.E. Shelemekhov, A.M. Gusakova
Critical revision of the article: R.E. Batalov, Yu.V. Rogovskaya, A.M. Gusakova
Final approval of the version to be published: A.E. Shelemehov, R.E. Batalov, Yu.V. Rogovskaya, S.Yu. Usenkov, E.A. Archakov, A.M. Gusakova, M.S. Rebenkova

PDF (Русский)

References

  1. Kirchof P., Benussi S., Kotecha D., Ahlsson A., Atar D., Casadei B., Castella M., Diener H.-C., Heidbuchel H., Hendriks J., Hindricks G., Manolis A.S., Oldgren J., Popescu B.A., Schotten U., Van Putte B., Vardas P., ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893-2962. PMID: 27567408. https://doi.org/10.1093/eurheartj/ehw210
  2. Wazni O.M., Marrouche N.F., Martin D.O., Verma A., Bhargava M., Saliba W., Bash D., Schweikert R., Brachmann J., Gunther J., Gutleben K., Pisano E., Potenza D., Fanelli R., Raviele A., Themistoclakis S., Rossillo A., Bonso A., Natale A. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA. 2005;293(21):2634-40. PMID: 15928285. https://doi.org/10.1001/jama.293.21.2634
  3. Ревишвили А.Ш., Нардая Ш.Г., Рзаев Ф.Г., Мустапаева З.В., Котанова Е.С. Электрофизиологические и клинические предикторы эффективности радиочастотной аблации легочных вен и левого предсердия у пациентов с персистирующей формой фибрилляции предсердий. Анналы аритмологии. 2014;11(1):46-53. [Revishvili A.Sh., Nardaya S.G., Rzayev F.G., Mustapaeva Z.V., Katanova E.S. Electrophysiological and clinical predictors of effectiveness of radiofrequency ablation in the pulmonary veins and left atrium in patients with persistent form of atrial fibrillation. Annals of Arrhythmology. 2014;11(1):46-53. (In Russ.)] https://doi.org/10.15275/annaritmol.2014.1.6
  4. Ардашев А.В., Желяков Е.Г., Долгушина Е.А., Рыбаченко М.С., Мангутов Д.А., Конев А.В., Волошко С.В., Врублевский О.Ю., Крючко М.В., Ливенцева Э.Н. Радиочастотная катетерная аблация хронической формы фибрилляции предсердий методом изоляции легочных вен и анатомической модификации субстрата аритмии. Кардиология. 2009;49(1):39-46. [Ardashev A.V., Zhelyakov E.G., Dolgushina E.A., Rybachenko M.S., Mangutov D.A., Konev A.V., Voloshko S.V., Vrublevsky O.Yu., Kryuchko M.V., Liventseva E.N. Radiofrequency catheter ablation of chronic atrial fibrillation by pulmonary vein isolation and anatomical modification of the arrhythmia substrate. Cardiology. 2009;49(1):39-46. (In Russ.)]
  5. Calkins H., Kuck K.H., Cappato R., Brugada J., Camm A.J., Chen S.-A., Crijns H.J.G., Damiano R.J.Jr., Davies D.W., DiMarco J., Edgerton J., Ellenbogen K., Ezekowitz M.D., Haines D.E., Haissaguerre M., Hindricks G., Iesaka Y., Jackman W., Jalife J., Jais P., Kalman J., Keane D., Kim Y.-H., Kirchhof P., Klein G., Kottkamp H., Kumagai K., Lindsay B.D., Mansour M., Marchlinski F.E., McCarthy P.M., Mont J.L., Morady F., Nademanee K., Nakagawa H., Natale A., Nattel S., Packer D.L., Pappone C., Prystowsky E.N., Raviele A., Reddy V., Ruskin J.N., Shemin R.J., Tsao H.-M., Wilber D., Ad N., Cummings J., Gillinov A.M., Heidbuchel H., January C., Lip G., Markowitz S., Nair M., Ovsyshcher I.E., Pak H.-N., Tsuchiya T., Shah D., Siong T.W., Vardas P.E. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Europace. 2012;4:528-606.
  6. Kim M.N., Lee J.J., Kim S.-A., Kim Y.H., Choi J.I., Park S.-M., Park S.W., Kim Y.-H., Shim W.-J. The difference of predictors for recurrence after catheter ablation of non-paroxismal atrial fibrillation according to follow-up period. Int Heart J. 2014;55(4):312-318. PMID: 24898595. https://doi.org/10.1536/ihj.13-370
  7. Akoum N., Daccarett M., McGann C., Segerson N., Vergara G., Kuppahally S., Badger T., Burgon N., Haslam T., Kholmovski E., Macleod R., Marrouche N. Atrial fibrosis helps select the appropriate patient and strategy in catheter ablation of atrial fibrillation: a DE-MRI guided approach. J Cardiovasc Electrophysiol. 2011;22(1):16-22. PMID: 20807271, PMCID: PMC3133570. https://doi.org/10.1111/j.1540-8167.2010.01876.x
  8. Wyse D.G., Van Gelder I.C., Ellinor P.T., Go A.S., Kalman J.M., Narayan S.M., Nattel S., Schotten U., Rienstra M. Lone atrial fibrillation: does it exist? J Am Coll Cardiol. 2014;63(17):1715-1723. PMID: 24530673, PMCID: PMC4008692. https://doi.org/10.1016/j.jacc.2014.01.023
  9. Благова О.В., Недоступ А.В. Современные маски миокардита (от клинических синдромов к диагнозу). Российский кардиологический журнал. 2014;19(5):13-22. [Blagova O.V., Nedostup A.V. Contemporary masks of the myocarditis (from clinical signs to diagnosis). Russian Journal of Cardiology. 2014;19(5):13-22. (In Russ.)] https://doi.org/10.15829/1560-4071-2014-5-13-22
  10. Носкова М.В. Воспаление и инфекция – нераспознанные причины возникновения фибрилляции предсердий. Анналы аритмологии. 2006;3(2):47-52. [Noskova M.V. Inflammation and infection are unrecognized causes of atrial fibrillation. Annals of Arrhythmology. 2006;3(2):47-52. (In Russ.)]
  11. Терещенко С.Н., Арутюнов Г.П., Гиляревский С.Р., Жиров И.В., Зыков К.А., Масенко В.П., Нарусов О.Ю., Насонова С.Н., Наумов В.Г., Осмоловская Ю.Ф., Самко А.Н., Сафиуллина А.А., Скворцов А.А., Стукалова О.В., Сычёв А.В., Шария М.А., Шевченко А.О. Миокардиты: клинические рекомендации. М.; 2016. 57 с. [Tereshchenko S.N., Arutyunov G.P., Gilyarevskyi R.S., Zhirov I.V., Zykov K.A., Masenko V.P., Narusov O.Yu., Nasonova S.N., Naumov V.G., Osmolovskaya Yu.F., Samko A.N., Safiullina A.A., Skvortsov A.A., Stukalova O.V., Sychov A.V., Shariya M.A., Shevchenko A.O. Myocarditis: clinical guidelines. Moscow; 2016. 57 p. (In Russ.)]
  12. Mitrofanova L.B., Orshanskaya V., Ho S.Y., Platonov P.G. Histological evidence of inflammatory reaction associated with fibrosis in the atrial and ventricular walls in a case-control study of patients with history of atrial fibrillation. Europace. 2016;18(suppl 4):iv156-iv162. PMID: 28011843. https://doi.org/10.1093/europace/euw361
  13. Maisch B., Bültman B., Factor S., Gröne H.-J., Hufnagel G., Kawamura K., Kühl U., Olsen E.J., Pankuweit S., Virmani R., McKenna W., Richardson P.J., Thiene G., Schultheiß H.-P., Sekiguchi M. World Heart Federation consensus conferences definition of inflammatory cardiomyopathy (myocarditis): report from two expert committees on histology and viral cardiomyopathy. Heartbeat. 1999;4:3-4.
  14. Митрофанова Л.Е., Карев В.Е. Миокардиты (стандарты морфологической диагностики при аутопсии и эндомиокардиальной биопсии). Библиотека патологоанатома. 2010;115:52. [Mitrofanova L.Ye., Karev V.Ye. Myocarditis (standards for morphological diagnostics during autopsy and endomyocardial biopsy). Pathologist Library. 2010;115:52. (In Russ.)]
  15. Митрофанова Л.Б. Роль эндомиокардиальной биопсии в диагностике воспалительных заболеваний миокарда. Российский кардиологический журнал. 2016;21(1):73-79. [Mitrofanova L.B. The role of endomyocardial biopsy in diagnostics of inflammatory myocardium diseases. Russian Journal of Cardiology. 2016;21(1):73-79. (In Russ.)] https://doi.org/10.15829/1560-4071-2016-1-73-79
  16. Basso C., Calabrese F., Angelini A., Carturan E., Thiene G. Classification and histological, immunohistochemical, and molecular diagnosis of inflammatory myocardial disease. Heart Fail Rev. 2013;18(6):673-681. PIMD: 23096264. https://doi.org/10.1007/s10741-012-9355-6
  17. Caforio A.L., Pankuweit S., Arbustini E., Basso C., Gimeno-Blanes J., Felix S.B., Fu M., Heliö T., Heymans S., Jahns R., Klingel K., Linhart A., Maisch B., McKenna W., Mogensen J., Pinto Y.M., Ristic A., Schultheiss H.-P., Seggewiss H., Tavazzi L., Thiene G., Yilmaz A., Charron P., Elliott P.M., European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34(33):2636-2648. PMID: 23824828. https://doi.org/10.1093/eurheartj/eht210
  18. Calkins H., Reynolds M.R., Spector P., Sondhi M., Xu Y., Martin A., Williams C.J., Sledge I. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol. 2009;2(4):349-361. PMID: 19808490. https://doi.org/10.1161/CIRCEP.108.824789
  19. Noheria A., Kumar A., Wylie J.V. Jr., Josephson M.E. Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation: a systematic review. Arch Intern Med. 2008;168(6):581-586. PMID: 18362249. https://doi.org/10.1001/archinte.168.6.581
  20. Nair G.M., Nery P.B., Diwakaramenon S., Healey J.S., Connolly S.J., Morillo C.A. A systematic review of randomized trials comparing radiofrequency ablation with antiarrhythmic medications in patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2009;20(2): 138-144. PMID: 18775040. https://doi.org/10.1111/j.1540-8167.2008.01285.x
  21. Parkash R., Tang A.S.L., Sapp J.L., Wells G. Approach to the catheter ablation technique of paroxysmal and persistent atrial fibrillation: a meta-analysis of the randomized controlled trials. J Cardiovasc Electrophysiol. 2011;22(7):729-738. PMID: 21332861. https://doi.org/10.1111/j.1540-8167.2011.02010.x
  22. Sekiguchi M., Take M. World survey of catheter biopsy of the heart. In: Sekiguchi M., Olsen E.G.J., eds. Cardiomyopathy: clinical, pathological and theoretical aspects. Baltimore: University Park Press; 1980:217-225.
  23. Rogovskaya Y., Botalov R., Ryabov V. Histopathologic, Immunohistochemical Features and Profile of Viral Antigens in Patients with Myocarditis. Advanced Materials Research. 2015;1085:447-452. https://doi.org/10.4028/www.scientific.net/AMR.1085.447
  24. Mahfoud F., Gärtner B., Kindermann M., Ukena C., Gadomski K., Klingel K., Kandolf R., Böhm M., Kindermann I. Virus serology in patients with suspected myocarditis: utility or futility? Eur Heart J. 2011;32(7):897-903. PMID: 21217143. https://doi.org/10.1093/eurheartj/ehq493
  25. Баталов Р.Е., Роговская Ю.В., Рябов В.В., Татарский Р.Б., Сазонова С.И., Хлынин М.С., Попов С.В., Карпов Р.С. Идиопатическая форма фибрилляции предсердий, воспаление и клинические результаты радиочастотной аблации. Российский кардиологический журнал. 2014;19(12):7-12. [Batalov R.E., Rogovskaya Yu.V., Ryabov V.V., Tatarsky R.B., Sazonova S.I., Khlynin M.S., Popov S.V., Karpov R.S. Idiopathic form of atrial fibrillation, inflammation and clinical results of radiofrequency ablation. Russian Journal of Cardiology. 2014;19(12):7-12. (In Russ.)] https://doi.org/10.15829/1560-4071-2014-12-7-12