Department of Cuore e Grossi Vasi A. Reale, polo pontino, University La Sapienza, Rome, Italy.
Eur Rev Med Pharmacol Sci. 2009 Nov-Dec;13(6):431-42.
Some of theories try to explain the insurgence of atrial fibrillation (AF) in patients with acute articular rheumatism (AAR). These theories remind the close relation between AF and left atrium, or with valvular vitium degree, or monophasic action potential and histological cardiac structure. In 15 years of work in the academic Department of Heart and Big Vessels in Rome, the Authors studied 243 patients with mitral valvular disease post AAR before and after surgical manoeuvres.
Patients were divided in order to monitor atrium and ventricle morphological and functional modifications of the valve according to cardiac rhythm. Patients classification was based on surgical therapy adopted, kind of mitral disease and cardiac rhythm. An histological examination was performed, only in patients treated with valvular replacement. During the operation an histological examination in an atrial tissue fragment was performed. 243 patients with mitral valvular disease post AAR with indication in valvular adjustment were studied. The whole population was treated with mitral transcutaneous valvuloplasty (Group B--130 patients) or with mitral valve replacement surgery (Group A--113 patients). These two groups were divided: in Gr.A in Gr.A1 and Gr.A2, and Gr.B in Gr.B1 and Gr.B2, according to cardiac rhythm (sinus rhythm iSR, AF). These subgroups were also divided in Gr.A1SR, Gr.A1AF; Gr.A2SR, Gr.A2AF; Gr.A3SR, Gr.A3AF, according to mitralic disease's kind (stenosis, stenosis/regurgitation, regurgitation). A complex screening were exerted to all patients using echocardio-doppler technology. Morphological parameters of atrium and ventricle, and functional parameters of mitral valve, aorta and tricuspid were evaluated. In Gr.A group patients during the operation were execute a bioptic sampling from left atrium and a consecutive histological valuation.
In Gr.A1 mitral valve area (MtVA) arises smaller (p<0.01) in the group with AF, than those in SR. On the contrary, in subgroups of population of Gr.B there isn't statistic disagreement (p>0.05). Left atrium volume arises elder in patients in AF than in patients in SR (p<0.01), either in patients of subgroups Gr.A1, Gr.A2 or in patients of the whole Gr.B before and after valvuloplasty. In the whole population Gr.B, either Gr.BRS or Gr.BFA, left and right atrial volumes decrease eloquently (p<0.01) after valvoplasty. There's no linear relationship (Pearson r<0.5) between the different subgroups of Gr.A (Gr.A1, Gr.A2, Gr.A3) and those of Gr.B according to mitral valve area (MtVA), volume and left atrial area. Left atrial biopsy shows in patients of SR a normal atrial tissue in the 48% of cases and lightly altered in remaining 52%. On the contrary in patients of AF there are strong anomalies in the 100% of cases.
According to histological view, atrial volumes variations and valvular area variations before and after surgical treatment, and according also to their comparisons in different groups, authors could assume that insurgence of AF and its chronicization could be an expression of a strong atrial myocardial histological alteration. Furthermore while starting moment of AF genesis is characterized by histological alterations of atrial myocardium (expression of rheumatic chronic disease), its chronicization hands to anatomic-volumetric progressive deterioration of the atrial dysfunction.
一些理论试图解释急性关节炎风湿症（AAR）患者心房颤动（AF）的发作。这些理论提醒人们密切关注 AF 与左心房之间的关系，或者与瓣膜病变程度、单相动作电位和组织学心脏结构之间的关系。在罗马心脏和大血管学术系工作的 15 年中，作者研究了 243 例 AAR 后二尖瓣病变患者手术前后的左心房和心室形态及功能改变。
根据心律失常监测患者的瓣膜心房和心室形态及功能改变。根据手术治疗、二尖瓣病变和心律失常对患者进行分类。仅对接受瓣膜置换的患者进行组织学检查。在手术过程中，对心房组织的一个片段进行了组织学检查。研究了 243 例 AAR 后二尖瓣病变患者，这些患者均有瓣膜调整指征。所有患者均接受经皮二尖瓣成形术（B 组-130 例）或二尖瓣置换术（A 组-113 例）治疗。根据心律失常（窦性节律 iSR、AF）将两组患者分为 A 组和 B 组：A 组在 A1 组和 A2 组，B 组在 B1 组和 B2 组。根据二尖瓣病变的类型（狭窄、狭窄/反流、反流），这些亚组又分为 A1SR、A1AF、A2SR、A2AF、A3SR、A3AF。所有患者均采用超声心动图技术进行综合筛查。评估心房和心室的形态学参数，以及二尖瓣、主动脉和三尖瓣的功能参数。在 A 组患者中，在手术过程中从左心房进行活组织取样，并进行连续的组织学评估。
在 A1 组中，AF 患者的二尖瓣瓣口面积（MtVA）明显小于 SR 患者（p<0.01）。相反，在 B 组人群的亚组中没有统计学差异（p>0.05）。AF 患者的左心房容积大于 SR 患者（p<0.01），无论是 A1 组、A2 组还是整个 B 组患者，在成形术前后。在整个 B 组患者中，无论是 BRS 还是 BFA，左、右心房容积在成形术后明显减少（p<0.01）。根据二尖瓣瓣口面积（MtVA）、容积和左心房面积，A 组（A1、A2、A3）的不同亚组与 B 组之间没有线性关系（Pearson r<0.5）。左心房活检显示，SR 患者中有 48%的心房组织正常，52%的患者有轻微改变。相反，在 AF 患者中，100%的患者都有明显的异常。
根据组织学观点、手术前后的心房容积变化和瓣口面积变化，以及它们在不同组之间的比较，作者可以假设 AF 的发作及其慢性化可能是心房心肌组织学改变的表现。此外，当 AF 发生的起始时刻以心房心肌组织的组织学改变为特征（风湿性慢性疾病的表现）时，其慢性化则导致心房功能的进行性解剖-容积恶化。
