Pulmonary vein narrowing after pulsed field versus thermal ablation

AIMS

When it occurs, pulmonary vein (PV) stenosis after atrial fibrillation (AF) ablation is associated with significant morbidity. Even mild-to-moderate PV narrowing may have long-term implications. Unlike thermal ablation energies, such as radiofrequency (RF) or cryothermy, pulsed field ablation (PFA) is a non-thermal modality associated with less fibrotic proliferation. Herein, we compared the effects of PFA vs. thermal ablation on PV narrowing after AF ablation.

METHODS AND RESULTS

ADVENT was a multi-centre, randomized, single-blind study comparing PFA (pentaspline catheter) with thermal ablation-force-sensing RF or cryoballoon (CB)-to treat drug-refractory paroxysmal AF. Pulmonary vein diameter and aggregate cross-sectional area were obtained by baseline and 3-month imaging. The pre-specified, formally tested, secondary safety endpoint compared a measure of PV narrowing between PFA vs. thermal groups, with superiority defined by posterior probability > 0.975. Among subjects randomized to PFA (n = 305) or thermal ablation (n = 302), 259 PFA and 255 thermal ablation (137 RF and 118 CB) subjects had complete baseline and 3-month PV imaging. No subject had significant (≥70%) PV stenosis. Change in aggregate PV cross-sectional area was less with PFA (-0.9%) than thermal ablation (-12%, posterior probability > 0.999)-primarily driven by the RF sub-cohort (-19.5%) vs. CB sub-cohort (-3.3%). Almost half of all PFA PV diameters did not decrease, but the majority (80%) of RF PVs decreased, regardless of PV anatomic location.

CONCLUSION

In this first randomized comparison of PFA vs. thermal ablation, PFA resulted in less PV narrowing-thereby underscoring the qualitatively differential and favourable impact of PFA on PV tissue.

Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: Insights From the ADVICE Trial

BACKGROUND

Pulmonary vein (PV) stenosis is a complication of atrial fibrillation (AF) ablation. The incidence of PV stenosis after routine post-ablation imaging remains unclear and is limited to single-centre studies. Our objective was to determine the incidence and predictors of PV stenosis following circumferential radiofrequency ablation in the multicentre Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) trial.

METHODS

Patients with symptomatic AF underwent circumferential radiofrequency ablation in one of 13 trial centres. Computed tomographic (CTA) or magnetic resonance (MRA) angiography was performed before ablation and 90 days after ablation. Two blinded reviewers measured PV diameters and areas. PVs with stenosis were classified as severe (> 70%), moderate (50%-70%), or mild (< 50%). Predictors of PV stenosis were identified by means of multivariable logistic regression.

RESULTS

A total of 197 patients (median age 59.5 years, 29.4% women) were included in this substudy. PV stenosis was identified in 41 patients (20.8%) and 47 (8.2%) of 573 ablated PVs. PV stenosis was classified as mild in 42 PVs (7.3%) and moderate in 5 PVs (0.9%). No PVs had severe stenosis. Both cross-sectional area and diameter yielded similar classifications for severity of PV stenosis. Diabetes was associated with a statistically significant increased risk of PV stenosis (OR 4.91, 95% CI 1.45-16.66).

CONCLUSIONS

In the first systematic multicentre evaluation of post-ablation PV stenosis, no patient acquired severe PV stenosis. Although the results are encouraging for the safety of AF ablation, 20.8% of patients had mild or moderate PV stenosis, in which the long-term effects are unknown.

Management Of Pulmonary Vein Stenosis Following Catheter Ablation Of Atrial Fibrillation

There is limited literature available regarding PV (pulmonary vein) stenosis management. Starting from its incidence, subsequent follow up using imaging technologies to monitor the success and the way of managing different groups pose varied opinions. However, with newer technological advancements and better understanding of mechanism of the atrial fibrillation ablation, the incidence of PV stenosis secondary to catheter ablation is declining. This paper highlights the current trends and future of management of PV stenosis secondary to catheter ablation for atrial fibrillation.

Complications from catheter ablation of atrial fibrillation: a systematic review

Atrial fibrillation (AF) is the most common arrhythmia requiring treatment that is encountered in clinical practice. Recent advances in the understanding of underlying mechanisms of AF have led to the increased use of catheter ablation (CA) as a treatment modality for paroxysmal, persistent, or long-standing persistent AF in patients with symptomatic AF despite treatment with antiarrhythmic medications. Because of the complexity in technique and anatomic location of the ablation sites, it is not surprising that CA of AF is associated with a greater risk of procedural complications compared with simpler cardiac ablation procedures. Major and minor complications, including life-threatening complications, have been described and quantified. This systematic review describes the potential risks of CA that have been reported over a period and provides insights into the evolving strategies to minimize these complications, thus making CA techniques safer and potentially more efficacious for AF.

Transesophageal echocardiography for the diagnosis of pulmonary vein stenosis after catheter ablation of atrial fibrillation: a systematic review

AIMS

Pulmonary vein (PV) stenosis is a potentially serious complication of catheter ablation of atrial fibrillation (AF). The optimal method for diagnosis of PV stenosis has not been established. We undertook a systematic review of the literature to investigate the diagnostic performance of transesophageal echocardiography (TEE) for the detection of PV stenosis after catheter ablation of AF.

METHODS

We searched MEDLINE and EMBASE databases for studies evaluating the diagnostic performance of TEE for the detection of PV stenosis after catheter ablation of AF, compared to a reference standard of PV angiography, magnetic resonance imaging (MRI), or computed tomography (CT). Study quality was assessed using the QUADAS tool.

RESULTS

A total of seven studies that included 344 patients (1,344 PVs) met the selection criteria. Of these, three studies used PV angiography as the reference standard, while MRI and CT were used in two studies each. Compared to PV angiography, TEE had sensitivity between 82% and 100% and specificity between 98% and 100%. Compared to MRI, TEE sensitivity was 100% in both studies, while the specificity ranged between 98% and 99%. Compared to CT, TEE had sensitivity between 86% and 100% and specificity of 95%. Quality of the reviewed studies was somewhat limited by the retrospective design in most of the studies.

CONCLUSIONS

TEE has a high sensitivity and specificity in detecting PV stenosis. Given its wide availability and favorable side effect profile, these data suggest that TEE is very useful tool for the diagnosis of PV stenosis after catheter ablation of AF.

Acquired pulmonary vein stenosis: one problem, two mechanisms

Until the last decade, acquired pulmonary vein (PV) stenosis in the adult population was a rare finding, caused by neoplasm or inflammatory conditions such as sarcoidosis or fibrosing mediastinitis. With the increased use of catheter-based ablation for the treatment of atrial fibrillation, PV stenosis is increasingly recognized as a complication of this procedure. Additionally, PV stenosis has been described as a rare complication of cardiac surgery. This report describes two cases of PV stenosis, one acquired as a result of multiple left atrial ablation procedures and the other after surgical cannulation of the right upper PV.

The State of the Art in Pulmonary Vein Stenosis -Diagnosis & Treatment

Pulmonary vein stenosis is a rare but serious complication of pulmonary vein isolation to treat atrial fibrillation. Pulmonary vein angioplasty/stenting has emerged as the treatment of choice for significantly stenotic veins. Guidelines for post ablation evaluation of the pulmonary veins, including the timing and method of surveillance for possible stenosis, the criteria for intervention, the technical aspects of intervention, and finally the surveillance post intervention, are still being developed. The relatively high rate of restenosis after intervention in a subset of patients remains a great challenge. A better understanding of the pathophysiology underlying this syndrome is needed to appropriately answer many of the remaining questions. The goal of this manuscript is to describe what has been learned about this complication and its treatment from a relatively large experience in a single institution over the past decade, and provide a comprehensive review of the existing literature in order to shed as much light on the subject as is possible, while at the same time exposing the areas that need further study.

How to identify and treat patient with pulmonary vein stenosis post atrial fibrillation ablation

PURPOSE OF REVIEW

The diagnosis of pulmonary vein stenosis, following catheter ablation of atrial fibrillation, potentially carries significant morbidity for affected patients. It is important that physicians remain aware of the entity and have an understanding of how to treat such patients. There has been controversy in how to assess patients following atrial fibrillation ablation, and how to treat asymptomatic patients with pulmonary vein stenosis. This article reviews the recently published data.

RECENT FINDINGS

The reported incidence of pulmonary vein stenosis is decreasing. Nonetheless, it may not be found if not sought, as even patients with severe pulmonary vein stenosis may be asymptomatic. Also, patients with symptoms may be misdiagnosed if pulmonary vein stenosis is not included in the differential diagnosis. Computed tomography (CT) and MRI have been shown to be the diagnostic modalities of choice. The treatment options for severe pulmonary vein stenosis and occlusion are primarily that of pulmonary vein angioplasty with or without stenting. Despite the observed rate of restenosis, patients derive benefit from pulmonary vein angioplasty.

SUMMARY

The best imaging modalities to assess for pulmonary vein stenosis are CT and MRI. Early intervention in symptomatic patients with severe pulmonary vein stenosis is warranted; in asymptomatic patients, the data suggest that such patients will also derive benefit.