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Guber K, Ranard LS, Ng V, Hahn RT, Sommer R, Vahl TP. An Unusual Cause of Shortness of Breath: Pulmonary Vein Stenosis After Surgical Mitral Valve Replacement. JACC Case Rep 2022; 4:533-537. [PMID: 35573843 PMCID: PMC9091516 DOI: 10.1016/j.jaccas.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/19/2022] [Accepted: 01/28/2022] [Indexed: 12/03/2022]
Abstract
A 79-year-old man with prior bioprosthetic mitral valve replacement presented with progressive shortness of breath and was found to have right upper pulmonary vein stenosis and paravalvular leak diagnosed with the use of multimodal imaging. The patient underwent balloon angioplasty, stenting of the pulmonary vein, and paravalvular leak closure with ultimate resolution of symptoms. (Level of Difficulty: Intermediate.).
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Key Words
- AF, atrial fibrillation
- CCTA, cardiac computed tomographic angiography
- CT, computed tomography
- DOE, dyspnea on exertion
- PV, pulmonary vein
- PVL, paravalvular leak
- PVS, pulmonary vein stenosis
- RUPV, right upper pulmonary vein
- TEE, transesophageal echocardiography
- TTE, transthoracic echocardiography
- V/Q, ventilation-perfusion
- iatrogenic complication
- paravalvular leak
- pulmonary vein stenosis
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Affiliation(s)
- Kenneth Guber
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Lauren S Ranard
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vivian Ng
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert Sommer
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Torsten P Vahl
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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Abstract
PURPOSE OF REVIEW Pulmonary vein stenosis (PVS) is a rare entity that until the last 2 decades was seen primarily in infants and children. Percutaneous and surgical interventions have limited success due to relentless restenosis, and mortality remains high. In adults, acquired PVS following ablation for atrial fibrillation has emerged as a new syndrome. This work will review these two entities with emphasis on current treatment. RECENT FINDINGS Greater emphasis on understanding and addressing the mechanism of restenosis for congenital PVS has led to the use of drug-eluting stents (DES) and systemic drug therapy to target neo-intimal growth. Frequent reinterventions are positively affecting outcomes. Longer-term outcomes of percutaneous treatment for acquired PVS are emerging. Treatment of congenital PVS continues to be plagued by restenosis. DES show promise, but frequent reinterventions are required. Larger upstream vein diameter predicts success for congenital and acquired PVS interventions. Efforts to induce/maintain vessel growth are important for future treatment strategies.
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Affiliation(s)
- Patcharapong Suntharos
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
| | - Lourdes R Prieto
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
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Clinical outcomes after the endovascular treatments of pulmonary vein stenosis in patients with congenital heart disease. Cardiol Young 2019; 29:1057-1065. [PMID: 31287033 DOI: 10.1017/s1047951119001495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pulmonary vein stenosis (PVS) is a condition with challenging treatment and leads to severe cardiac failure and pulmonary hypertension. Despite aggressive surgical or catheter-based intervention, the prognosis of PVS is unsatisfactory. This study aimed to assess the prognosis and to establish appropriate treatment strategies. METHODS We retrospectively reviewed endovascular treatments for PVS (2001-2017) from the clinical database at the Okayama University Hospital. RESULTS A total of 24 patients underwent PVS associated with total anomalous pulmonary venous connection and 7 patients underwent isolated congenital PVS. In total, 53 stenotic pulmonary veins were subjected to endovascular treatments; 40 of them were stented by hybrid (29) and percutaneous procedures (11) (bare-metal stent, n = 34; drug-eluting stent, n = 9). Stent size of hybrid stenting was larger than percutaneous stenting. Median follow-up duration from the onset of PVS was 24 months (4-134 months). Survival rate was 71 and 49% at 1 and 5 years, respectively. There was no statistically significant difference between stent placement and survival; however, patients who underwent bare-metal stent implantation had statistically better survival than those who underwent drug-eluting stent implantation or balloon angioplasty. Early onset of stenosis, timing of stenting, and small vessel diameter of pulmonary vein before stenting were considered as risk factors for in-stent restenosis. Freedom from re-intervention was 50 and 26% at 1 and 2 years. CONCLUSIONS To improve survival and stent patency, implantation of large stent is important. However, re-intervention after stenting is also significant to obtain good outcome.
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Tehrani S, Lipkin D. Angioplasty of acquired pulmonary vein stenosis using covered stent. Catheter Cardiovasc Interv 2013; 82:E617-20. [PMID: 23592594 DOI: 10.1002/ccd.24942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 02/20/2013] [Accepted: 04/07/2013] [Indexed: 11/07/2022]
Abstract
One of the most serious complications post-catheter ablation of atrial fibrillation is the development of pulmonary vein stenosis. Controversy currently exists about the optimal treatment approach. The use of balloons and larger stents (~10 mm) results in more optimal outcome than just balloon angioplasty alone; however, even with stent implantation, recurrent restenosis may occur in 30 to 50% of patients. We report the case of a 28-year-old man who developed recurrent left inferior pulmonary vein stenosis following radiofrequency ablation for atrial fibrillation. This was initially stented with good result but soon after developed restenosis and required balloon angioplasty. Following the third episode of restenosis, stenting of the pulmonary vein was performed using a covered stent. The pulmonary vein has remained patent for the last 5 years.
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Affiliation(s)
- Shana Tehrani
- Department of Cardiology, The Wellington Hospital, St. John's Wood, London, NW8 9LE, UK; Hatter Cardiovascular Institute, Institute of Cardiovascular Research, University College London, London, WC1E 6HX, UK
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Balasubramanian S, Marshall AC, Gauvreau K, Peng LF, Nugent AW, Lock JE, McElhinney DB. Outcomes After Stent Implantation for the Treatment of Congenital and Postoperative Pulmonary Vein Stenosis in Children. Circ Cardiovasc Interv 2012; 5:109-17. [DOI: 10.1161/circinterventions.111.964189] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sowmya Balasubramanian
- From the Department of Cardiology, Children's Hospital Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Harvard Medical School, Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA (L.F.P.); and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.W.N.)
| | - Audrey C. Marshall
- From the Department of Cardiology, Children's Hospital Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Harvard Medical School, Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA (L.F.P.); and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.W.N.)
| | - Kimberlee Gauvreau
- From the Department of Cardiology, Children's Hospital Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Harvard Medical School, Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA (L.F.P.); and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.W.N.)
| | - Lynn F. Peng
- From the Department of Cardiology, Children's Hospital Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Harvard Medical School, Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA (L.F.P.); and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.W.N.)
| | - Alan W. Nugent
- From the Department of Cardiology, Children's Hospital Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Harvard Medical School, Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA (L.F.P.); and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.W.N.)
| | - James E. Lock
- From the Department of Cardiology, Children's Hospital Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Harvard Medical School, Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA (L.F.P.); and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.W.N.)
| | - Doff B. McElhinney
- From the Department of Cardiology, Children's Hospital Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Harvard Medical School, Boston, MA (S.B., A.C.M., K.G., J.E.L., D.B.M.); the Department of Pediatrics, Lucille Packard Children's Hospital at Stanford, Palo Alto, CA (L.F.P.); and the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.W.N.)
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Bingler MA, Darst JR, Fagan TE. Cryo-balloon angioplasty for pulmonary vein stenosis in pediatric patients. Pediatr Cardiol 2012; 33:109-14. [PMID: 21892648 DOI: 10.1007/s00246-011-0099-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 08/19/2011] [Indexed: 10/17/2022]
Abstract
This study sought to determine the safety and effectiveness of cryo-balloon angioplasty (CbA) for pulmonary vein stenosis (PVS) in pediatric patients. Current therapy options for PVS are less than satisfactory due to recurrent progressive restenosis and neointimal proliferation. Catheterization database, hospital records, imaging studies, and pathologic specimens were reviewed for procedural-related and outcomes data in all patients who underwent pulmonary vein (PV) CbA using the Boston Scientific PolarCath Peripheral Dilation System between August 2006 and June 2009. Thirteen patients (19 PVs; median age 13 months [range 3.5 months to 18.5 years] and weight 7.9 kg [range 3.8 to 47.7]) underwent CbA. Mean PVS diameter after CbA increased from 2.19 (± 0.6) to 3.77 (± 1.1) mm (p < 0.001). Mean gradient decreased from 14 (± 7.4) to 4.89 (± 3.2) mm Hg (p < 0.001). Mean stenosis-to-normal vein diameter ratio increased from 0.52 (± 0.15) to 0.89 (± 0.33) (p < 0.001). Eight patients underwent repeat catheterization a mean of 5.6 months (± 3.66) later. Improved PVS diameter was maintained in 2 PVs. Four veins had restenosis but maintained diameters greater than that before initial CbA. In 11 PVs, the diameter decreased from 4.28 (± 1.14) to 2.53 (± 0.9) mm (p = 0.001). Mean gradient increased from 3.55 (± 3.0) to 14.63 (± 9.6) mm Hg (p = 0.011). All vessels underwent repeat intervention with acute relief of PVS. Stroke occurred within 24 h of CbA in 1 patient. CbA of PVS is safe and results in acute relief of stenosis. However, CbA appears minimally effective as the sole therapy in maintaining long-term relief of PVS.
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Tan J, Rivandi AH, Sawhney N, Feld G, Karimi A. Congenital narrowing of a pulmonary vein: slit-like pulmonary vein ostium. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 36:e150-2. [PMID: 21627669 DOI: 10.1111/j.1540-8159.2011.03123.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 01/26/2011] [Accepted: 02/01/2011] [Indexed: 11/30/2022]
Abstract
We report the case of a 60-year-old female with a history of refractory paroxysmal atrial fibrillation. Preablation contrast enhanced pulmonary vein computed tomography (CT) scan demonstrated a slit-like narrowing of the left inferior pulmonary vein ostium. The narrowing measured approximately 3 mm, with poststenotic dilation. The patient had no prior history of ablation. The patient subsequently underwent segmental antral isolation of all four pulmonary veins and cavo-tricuspid isthmus ablation with bidirectional block. The diagnosis of preexisting congenital pulmonary vein stenosis had an impact on the type of ablation procedure performed (antral rather than ostial) and will affect the interpretation of postablation CT scans.
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Affiliation(s)
- Jessica Tan
- Departments of Radiology and Cardiology, UCSD, University of California, San Diego, CA 92103, USA
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Hickey EJ, Caldarone CA. Surgical management of post-repair pulmonary vein stenosis. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2011; 14:101-108. [PMID: 21444056 DOI: 10.1053/j.pcsu.2011.01.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Obstructed pulmonary venous drainage - either in association with total anomalous pulmonary venous drainage, congenital stenosis, or post-repair stenosis - is associated with poor outcome. Post-repair stenosis typically involves fibrotic scar tissue extending from the site of anastomosis. "Sutureless" repair techniques avoid direct left atrial-pulmonary vein suture lines by instead reconstituting atrial tissue to posterior pericardium. Hence, the repair leaves widely decompressed pulmonary veins in the posterior mediastinum draining directly into the left atrium as a 'controlled bleed.' In our experience, late outcomes are significantly more favorable with sutureless repair techniques versus conventional pulmonary vein surgery. Therefore, after these encouraging results, we have now extended the application of this repair strategy to all scenarios of pulmonary vein surgery, including primary repair of unobstructed total anomalous pulmonary venous connection. The sutureless repair is versatile and facile. In particular, complex geometry of multiple decompressed veins can be easily accommodated by wide left atrial-pericardial suture lines. Common pitfalls can be avoided by mobilizing and protecting the phrenic pedicle and preserving the integrity of the areolar connective tissue and pleuro-parietal membrane. Overall, sutureless repair of anomalous or stenotic pulmonary veins appears safe and effective. Furthermore, in patients known to be at high risk of recurrent stenosis, sutureless techniques appear to offer improved freedom from recurrent stenosis.
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Affiliation(s)
- Edward J Hickey
- Division of Cardiovascular Surgery and Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Canada
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