Pulmonary Vein Stenosis After Radiofrequency Ablation of Atrial Fibrillation

Abstract

Background-Pulmonary vein (PV) stenosis is a complication of ablation for atrial fibrillation. The impact of different ablation strategies on the incidence of PV stenosis and its functional characterization has not been described. Methods and Results-PV isolation was performed in 608 patients. An electroanatomic approach was used in 71 and circular mapping in 537 (distal isolation, 25; ostial isolation based on PV angiography, 102; guided by intracardiac echocardiography, 140; with energy delivery based on visualization of microbubbles, 270). Severe (Ն70%) narrowing was detected in 21 patients (3.4%), and moderate (50% to 69%) and mild (Ͻ50%) narrowing occurred in 27 (4.4%) and 47 (7.7%), respectively. Severe stenosis occurred in 15.5%, 20%, 2.9%, 1.4%, and 0%, respectively. Development of symptoms was correlated with involvement of Ͼ1 PV with severe narrowing (Pϭ0.01), whereas all patients with mild and moderate narrowing were asymptomatic. In the latter group, lung perfusion (V/Q) scans were normal in all but 4 patients. All patients with severe stenosis had abnormal perfusion scans. Conclusions-V/Q scans are useful to assess the functional significance of PV stenosis. Mild and moderate degrees of PV narrowing are not associated with development of symptoms and seem to have no or minimal detrimental effect on pulmonary flow. The incidence of severe PV stenosis seems to be declining with better imaging techniques to ensure ostial isolation and to guide power titration. Mild narrowing 3 months after ablation does not preclude future development of severe stenosis and should be assessed with repeat imaging studies. (Circulation. 2003;108:3102-3107.)

Incidence and Factors Associated With the Occurrence of Pulmonary Vein Narrowing After Cryoballoon Ablation

“…In previous studies that were performed during the initial AF ablation era, the prevalence of PV stenosis was reported to be 3% to 42%. [4][5][6][7][8] Since then, the prevalence has decreased to 0.3% as the ablation site has shifted toward the left atrium (LA) 9 and with the optimization of radiofrequency energy and technical improvements that have been achieved by confirming the catheter position with a 3-dimensional electroanatomical mapping system. Although most cases of PV stenosis are asymptomatic, severe PV stenosis can progress to complete occlusion with potentially life-threatening symptoms of segmental pulmonary hypertension or venous infarction of the corresponding lobe.…”

A review of the safety aspects of radio frequency ablation

“…Progression of stenosis was variable. Saad et al reported 8.8% progression mainly in first 3 months and regression in 10.4% [38].…”

“…In 2002, Arentz et al showed 28% incidence of PVS, which in later studies declined to 0.1–1.3% [22], [35], [36] and only 0.29% needed intervention [37]. This decreasing incidence was due to changing ablation site from pulmonary vein lumen to antrum, reducing power of ablation and adopting additional imaging modalities to better delineate the ostial anatomy [38], [39]. Dong et al showed that encircling individual veins carried more risk compared to encircling ipsilateral pairs [40].…”

“…MR imaging was also equally useful as CT scanning [23]. Functional assessment with V/Q scan helped in identifying asymptomatic patients with severe stenosis [38], [39]. Progression of stenosis was variable.…”

Atrial Fibrillation Device Therapy Considerations in Design of Clinical Trials

“…Delivery of energy within the PVs themselves led to unacceptable rates of PV stenosis. 23,24 As a result, various approaches have been used to, in effect, isolate the PVs. While other trigger areas exist, many are approaching focal ablations by targeting tissue around the orifices of the PVs.…”