Nerve Supply of the Human Pulmonary Veins: An Anatomical Study

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Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Prevention and Reversal of Atrial Fibrillation Inducibility.

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Nerve Supply of the Human Pulmonary Veins: An Anatomical Study Raimundas Vaitkevicius, MD, Inga Saburkina, MD, PhD, Kristina Rysevaite, Inga Vaitkeviciene, MD, Neringa Pauziene, PhD, Remigijus Zaliunas, MD, Patrick Schauerte, MD, José Jalife, MD, FHRS, Dainius H. Pauza, PhD Heart Rhythm Volume 6, Issue 2, Pages 221-228 (February 2009) DOI: 10.1016/j.hrthm.2008.10.027 Copyright © 2009 Heart Rhythm Society Terms and Conditions

Figure 1 Anterior view of the pressure-inflated left superior PV stained for AChE shows the subdivision of a PV into 3 fragments: root, transit, and extrapericardial zones. Dotted line, limits of the cardiac hilum; solid black arrows, myocardial sleeves into the transit zone of the PV; white arrows, pericardial remains. AChE = acetylcholinesterase; PV = pulmonary vein. Heart Rhythm 2009 6, 221-228DOI: (10.1016/j.hrthm.2008.10.027) Copyright © 2009 Heart Rhythm Society Terms and Conditions

Figure 2 Pathways of epicardial nerves extending to human PVs. Drawings of left lateral (A) and right lateral (B) views of pressure-inflated human atria shows routes of nerves (gray arrows) extending to the PVs from distinct epicardial ganglionated subplexuses (black arrows) indicated in capital letters as abbreviations. Dotted line, limits of the cardiac hilum. The numbers at the base of the direction arrows show the percentage of the examined preparations in which the drawn nerve pathways were identified. DRA = dorsal right atrial subplexus; IVC = inferior vena cava; LD = left dorsal subplexus; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; MD = middle dorsal subplexus; PV = pulmonary vein; RIPV = right inferior pulmonary vein; RSPV =right superior pulmonary vein; SVC = superior vena cava. Heart Rhythm 2009 6, 221-228DOI: (10.1016/j.hrthm.2008.10.027) Copyright © 2009 Heart Rhythm Society Terms and Conditions

Figure 3 Left lateral view of the left PVs of an 18-year-old man showing the AChE-stained epicardial ganglionated nerves extending to the anterior surface of the PV roots from the LD. Boxed areas in A are enlarged as B and C to illustrate the relationship between epicardial nerves and myocardial sleeves of the LSPV. Dotted line limits the cardiac hilum; black arrowheads, some epicardial ganglia; black solid arrows, some myocardial sleeves; white arrows, pericardial remains. LD = left dorsal subplexus; NF = nerve fold (ligament of Marshall) location; OTrV = orifice of tributaries of pulmonary vein; LSPV = left superior pulmonary vein; LIPV = left inferior pulmonary vein; PV = pulmonary vein. Heart Rhythm 2009 6, 221-228DOI: (10.1016/j.hrthm.2008.10.027) Copyright © 2009 Heart Rhythm Society Terms and Conditions

Figure 4 Anatomical relationships of nerves on PVs with epicardial ganglionated nerve subplexuses. A: Macrophotograph of inferior surface of left PVs showing the course of epicardial ganglionated nerves extending from the middle and left dorsal neural subplexuses to the PV roots. B: Macrophotograph of anterior surface of RSPV illustrating the ganglionated nerves interconnected with the DRA. The oblong boxed area is enlarged in the bottom left corner; the square boxed area is enlarged in the bottom right corner and shows the appearance of epicardiac ganglion located on the PVs roots. Dotted line, limits of the cardiac hilum; black arrowheads, epicardial ganglia; black solid arrows, myocardial sleeves stained histochemically for AChE; white arrows, pericardial remains; white thin arrows, ganglionic neurons. AChE = acetylcholinesterase; DRA = dorsal right atrial subplexus; LD = left dorsal subplexus; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; OTrV = orifice of tributaries of pulmonary vein; PV = pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein. Heart Rhythm 2009 6, 221-228DOI: (10.1016/j.hrthm.2008.10.027) Copyright © 2009 Heart Rhythm Society Terms and Conditions

Figure 5 Distribution of ganglia on PVs. A: Histogram illustrating the total neural ganglion area distribution along the walls of PVs, in zones shown in Figure 1. The differences between the total ganglion areas in each zone were statistically significant at P < .01. B: Histogram showing the total ganglion area on the anterior, posterior, superior, and inferior surfaces of each of 4 PVs. Means of total ganglion area were significantly different between all surfaces of every PV at P < .01. C: Histogram showing the total compact receptor area on the anterior, posterior, superior, and inferior surfaces of 4 PVs. A = anterior; I = inferior; P = posterior; PV = pulmonary vein; S = superior; E-P = extrapericardial zone. Heart Rhythm 2009 6, 221-228DOI: (10.1016/j.hrthm.2008.10.027) Copyright © 2009 Heart Rhythm Society Terms and Conditions

Figure 6 Macrophotographs of human PVs illustrate the subendothelial neural structures: nerves (A, B) and endothelial nerve endings (B-D). A: The endothelium was cut using a microscissor to make a clear window for the observation of nerves situated beneath the endothelium that was intensely stained for AChE. Boxed area in C is enlarged as D to show morphology of compact nerve endings. Dotted line, receptor fields; dashed line, diffuse nerve endings; triplets of black arrowheads, afferent nerve fibers that ramified in the receptor field; white solid arrows, endothelium, black arrows, myocardium; angled arrows, compact receptor fields scattered around the orifice of tributary veins. AChE = acetylcholinesterase; PV = pulmonary vein; TrV = tributary vein. Heart Rhythm 2009 6, 221-228DOI: (10.1016/j.hrthm.2008.10.027) Copyright © 2009 Heart Rhythm Society Terms and Conditions

Figure 7 Nerve fibers between myocardial cells in the human PVs. Microphotograph of the longitudinally sectioned wall of PV showing the neural meshwork adjacent to cardiomyocytes at the root of PV. The solid black arrow points to the myocardial nerve, the black arrowheads indicate some AChE-positive nerve terminals associated with cardiac myocytes, the white ones indicate varicosities along nerve terminals. AChE = acetylcholinesterase; PV = pulmonary vein. Heart Rhythm 2009 6, 221-228DOI: (10.1016/j.hrthm.2008.10.027) Copyright © 2009 Heart Rhythm Society Terms and Conditions