Natural course of acquired pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation—Is routine follow‐up imaging indicated or not?

Abstract

Introduction Thermal injury during radiofrequency ablation (RFA) of atrial fibrillation (AF) can lead to pulmonary vein stenosis (PVS). The aim of the present study was to analyze the natural course of RFA‐induced PVS with regard to the grade of stenosis, clinical symptoms, and mortality during long‐term follow‐up. Methods and Results All patients with follow‐up imaging for radiofrequency‐induced untreated PVS were retrospectively assessed. From 2004 to 2017, the total rate of PVS following AF ablation in our center was 0.78% (87 of 11 103). Thirty‐eight patients with a total of 54 untreated PVS underwent follow‐up including imaging scan. The mean degree of stenosis at the time of diagnosis was 57% ± 27% vs 45% ± 35% (P = .05) after a mean follow‐up of 43 ± 31 months. There was a shift in severity of the PVS: 18 of 54 (33%) vs 16 of 54 (30%) severe PVS, 19 of 54 (35%) vs 10 of 54 (18%) moderate PVS, and 17 of 54 (32%) vs 28 of 54 (52%) mild PVS (P = .0001). The mean symptom score decreased significantly during follow‐up (1.8 ± 1.0 vs 0.4 ± 0.5, P = .0001). Each of the four patients with progression of PVS underwent another pulmonary vein isolation for AF recurrence following pulmonary vein reconduction during follow‐up period. Conclusion This study showed a spontaneous reduction in stenosis grade and symptoms of PVS over a 3.5‐year follow‐up. Consequently, routine follow‐up imaging of PVS seems not to be necessary. However, additional RF energy delivery to stenotic pulmonary veins should be avoided if possible. In case of conduction recovery, the ablation line should be done wide‐antrally and follow‐up imaging of PVS is recommended.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…These risks are rare but include PV stenosis and stiff LA syndrome. 8,9,17 Many of the randomized clinical trials, which have demonstrated superiority of catheter ablation over antiarrhythmic drug therapy, included repeat ablation procedures as part of their prospective study designs. 1,10,11,18 Randomized data also suggest that repeat ablation is superior to antiarrhythmic drug therapy for the treatment of recurrent AF after first ablation.…”

Role of advanced imaging with cardiac computed tomography and MRI in atrial and ventricular ablation

“…Oesophageal injury can be visualized with both CCT [26] and CMR with LGE [27]. Similarly, patients with suspected pulmonary vein stenosis can be imaged via CCT or CMR [28].…”

The importance of antral pulmonary vein isolation during visually‐guided laser balloon ablation

“…The latter may require PV angioplasty and large diameter bare‐metal stent placement with a substantial number of patients developing in‐stent restenosis 2 . By contrast, moderate PV stenosis is unlikely to progress over time putting into question the need for routine follow‐up imaging in asymptomatic patients 3 …”

“…2 By contrast, moderate PV stenosis is unlikely to progress over time putting into question the need for routine follow-up imaging in asymptomatic patients. 3 Balloon technologies are designed to target the antral portion of the PV ostium. Selecting a sufficiently large balloon-to-PV ratio should mitigate the risk of inadvertent energy delivery inside the PV ostium.…”