Clinical Presentation, Investigation, and Management of Pulmonary Vein Stenosis Complicating Ablation for Atrial Fibrillation

Abstract

Background-Although segmental or circumferential ablation is effective in eliminating pulmonary vein (PV)-mediated atrial fibrillation (AF), this procedure may be complicated by the occurrence of PV stenosis. Methods and Results-To establish the clinical presentation, diagnostic manifestations, and interventional management of PV stenosis, 23 patients with stenosis of 34 veins complicating ablation of AF were evaluated. Each patient became symptomatic 103Ϯ100 days after undergoing ablation. In 8 veins, the ablation producing the PV stenosis was a repeated procedure for continued AF. Nineteen patients presented with dyspnea on exertion, 7 with dyspnea at rest, 9 with cough, and 6 with chest pain. On multirow spiral computed tomography examination, the narrowest lumen of the affected PVs measured 3Ϯ2 mm compared with 13Ϯ3 mm at baseline (PՅ0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4Ϯ3% of total perfusion compared with 22Ϯ10% in unaffected segments. At percutaneous intervention, these veins showed 80Ϯ13% stenosis, with a mean gradient of 12Ϯ5 mm Hg. This was significantly reduced to a residual stenosis of 9Ϯ8% (PՅ0.001) and a residual gradient of 3Ϯ4 mm Hg (PՅ0.001).Twenty veins were treated with balloon dilatation alone, whereas 14 veins were stented with standard 10-mm-diameter bare-metal stents. Although the symptomatic response was nearly immediate and impressive, 14 patients developed in-stent or in-segment restenosis, requiring repeated interventions in 13. Conclusions-Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AF. Nevertheless, alternative treatment methods will be required to decrease recurrent in-stent or in-segment restenosis. (Circulation. 2005;111:546-554.)

Catheter Ablation of Lone Atrial Fibrillation

“…Rather well balanced distribution in stenosis of left superior (32%), left inferior (26%) and right superior PV (35%) was noticed while involvement of right inferior PV occurred less frequently (6%) [171]. A repeated ablation procedure was responsible for 26% of all cases of PV stenosis.…”

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

“…1142,1143,1144,1145,1155,1156 Thus, follow-up strategies and intensity should be based on symptoms. Patients with restenosis usually report an increase of complaints existing prior to the intervention.…”

Pulmonary-Vein Stenosis Can Mimic Massive Pulmonary Embolism After Radiofrequency Ablation for Atrial Fibrillation

“…CTPA is more sensitive for differentiation because it shows the positions of vein stenosis and pulmonary embolus separately. [2][3][4]13 However, with our patient the massive filling defect on CTPA misled the clinicians and radiologists to the misdiagnosis of pulmonary embolism. Actually, pulmonary-vein stenosis triggers pulmonary congestion, increases the capillary wedge pressure, and ultimately slows the pulmonary arterial flow.…”

“…7,9 Also, V /Q mismatch or perfusion defect of a certain lobe on V /Q scan occurs in 80% of pulmonary-vein-stenosis patients, and a higher percentage in pulmonary-embolism patients. [10][11][12][13][14] Thus, it is hard to distinguish between pulmonary-vein stenosis and pulmonary embolism based on symptoms and V /Q scan. CTPA is more sensitive for differentiation because it shows the positions of vein stenosis and pulmonary embolus separately.…”

“…13,21 Complete pulmonary-vein occlusion may lead to pulmonaryvein thrombosis or even infarction, with substantial venous congestion in the affected lobe. 22 Symptoms of pulmonary-vein thrombosis usually arise several months after radiofrequency-catheter ablation, and are less acute than those of pulmonary-artery embolism.…”