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Matsumoto S, Suzuki M, Matsubayashi S, Tsukada A, Kusaba Y, Katsuno T, Iikura M, Izumi S, Takeda Y, Hojo M, Sugiyama H. Refractory Hemoptysis Caused by Severe Pulmonary Vein Stenosis after Multiple Catheter Ablations. Intern Med 2021; 60:3279-3284. [PMID: 34657907 PMCID: PMC8580755 DOI: 10.2169/internalmedicine.6513-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/14/2021] [Indexed: 12/27/2022] Open
Abstract
We herein report a 48-year-old man with a history of chronic atrial fibrillation (AF) and repeated hemoptysis after radiofrequency ablation. Contrast tomography showed soft tissue thickening of the left hilar region and left pulmonary vein stenosis. We performed bronchial artery embolization, but the hemoptysis did not disappear, and AF was not controlled. We performed left lung lobectomy and maze procedures since we considered surgical removal necessary as radical treatment. After the surgery, hemoptysis and atrial fibrillation did not recur. Refractory hemoptysis after catheter ablation is rare, but occasionally occurs in patients with severe pulmonary vein stenosis.
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Affiliation(s)
- Shuichiro Matsumoto
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Manabu Suzuki
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Sachi Matsubayashi
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Akinari Tsukada
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Yusaku Kusaba
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Takashi Katsuno
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Motoyasu Iikura
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Shinyu Izumi
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Yuichiro Takeda
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Masayuki Hojo
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
| | - Haruhito Sugiyama
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan
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Scanavacca MI. How to prevent, recognize and manage complications of AF ablation? Rev Port Cardiol 2017; 36 Suppl 1:43-49. [PMID: 29126890 DOI: 10.1016/j.repc.2017.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 09/02/2017] [Indexed: 11/16/2022] Open
Abstract
Ablation of atrial fibrillation (AF) is one of most complex procedures in electrophysiology. Many technical improvements have been incorporated lately in order to improve clinical results and reducing risks. Currently, cardiac tamponade, stroke, PV stenosis, phrenic palsy and atrial esophageal fistula are still recognized as the major risks of AF ablation, although their managements have been much better established. The aim of this article is to review recent data in how to avoid, to identify and to treat such complications.
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Affiliation(s)
- Mauricio I Scanavacca
- Instituto do Coração (InCor), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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3
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How to prevent, recognize and manage complications of AF ablation? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Narui R, Tokuda M, Matsushima M, Isogai R, Tokutake K, Yokoyama K, Hioki M, Ito K, Tanigawa SI, Yamashita S, Inada K, Shibayama K, Matsuo S, Miyanaga S, Sugimoto K, Yoshimura M, Yamane T. Incidence and Factors Associated With the Occurrence of Pulmonary Vein Narrowing After Cryoballoon Ablation. Circ Arrhythm Electrophysiol 2017. [DOI: 10.1161/circep.116.004588] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryohsuke Narui
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Michifumi Tokuda
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Matsushima
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Ryota Isogai
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Tokutake
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Yokoyama
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Mika Hioki
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Keiichi Ito
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Shin-ichi Tanigawa
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Seigo Yamashita
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Keiichi Inada
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Kenri Shibayama
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Seiichiro Matsuo
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Satoru Miyanaga
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Sugimoto
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Michihiro Yoshimura
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
| | - Teiichi Yamane
- From the Department of Cardiology (R.N., M.T., R.I., K.T., K.Y., M.H., K.Ito, S.T., S.Y., K.Inada, K.Shibayama, S.Matsuo, S.Miyanaga, K.Sugimoto, M.Y., T.Y.) and Division of Clinical Epidemiology (M.M.), The Jikei University School of Medicine, Tokyo, Japan
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5
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Romantowski J, Kuziemski K, Janowicz A, Siemińska A, Szurowska E, Jassem E. Recurrent haemoptysis as a symptom of severe pulmonary vein stenosis-a rare complication of catheter ablation in atrial fibrillation. Respirol Case Rep 2017; 5:e00212. [PMID: 28096996 PMCID: PMC5221469 DOI: 10.1002/rcr2.212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/04/2016] [Accepted: 11/06/2016] [Indexed: 11/11/2022] Open
Abstract
A pulmonary vein stenosis is a known adverse event of catheter ablation in atrial fibrillation. However, it should be considered due to high frequency of such procedures. Haemoptysis, a symptom of severe stenosis, is often misdiagnosed as other different diseases. We present a case report of a 52‐year‐old patient with recurrent haemoptysis, dyspnoea, and fatigue, which turned out to be complication after catheter ablation. Successful treatment with drug‐eluting stent (DES) was implemented with vast clinical improvement and follow‐up.
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Affiliation(s)
- Jan Romantowski
- Department of Pneumonology and Allergology Medical University of Gdańsk Gdańsk Pomorskie Poland
| | - Krzysztof Kuziemski
- Department of Pneumonology and Allergology Medical University of Gdańsk Gdańsk Pomorskie Poland
| | - Alicja Janowicz
- Department of Pneumonology and Allergology Medical University of Gdańsk Gdańsk Pomorskie Poland
| | - Alicja Siemińska
- Department of Pneumonology and Allergology Medical University of Gdańsk Gdańsk Pomorskie Poland
| | - Edyta Szurowska
- Department of Radiology Medical University of Gdańsk Gdańsk Pomorskie Poland
| | - Ewa Jassem
- Department of Pneumonology and Allergology Medical University of Gdańsk Gdańsk Pomorskie Poland
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6
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Farooki AM, Bazick-Cuschieri H, Gordon EK, Lee JC, Cantu EC, Augoustides JG. CASE 7--2014 Rescue therapy with early extracorporeal membrane oxygenation for primary graft dysfunction after bilateral lung transplantation. J Cardiothorac Vasc Anesth 2014; 28:1126-32. [PMID: 23999325 PMCID: PMC3969394 DOI: 10.1053/j.jvca.2013.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Ali M Farooki
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
| | | | - Emily K Gordon
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
| | | | - Edward C Cantu
- Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.AMF was a cardiac anesthesia fellow
| | - John G Augoustides
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
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7
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Kumar N, Aksoy I, Pison L, Timmermans C, Maessen J, Crijns H. Management Of Pulmonary Vein Stenosis Following Catheter Ablation Of Atrial Fibrillation. J Atr Fibrillation 2014; 7:1060. [PMID: 27957081 DOI: 10.4022/jafib.1060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/14/2014] [Accepted: 06/11/2014] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Jos Maessen
- Department of cardiac surgery, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht,the Netherlands
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8
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Pulmonary venous stenosis on ventilation-perfusion scintigraphy: a correlation with dynamic magnetic resonance pulmonary angiography. Clin Nucl Med 2014; 39:292-4. [PMID: 24445274 DOI: 10.1097/rlu.0000000000000344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A case of pulmonary vein stenosis as a result of prior atrial fibrillation focus procedures for atrial fibrillation, correlated with magnetic resonance (MR) pulmonary angiography, is presented. Restricted flow to the right lung in similar quantities measured by nuclear medicine and MR techniques is observed, with perfusion scintigraphy demonstrating decreased but not absent flow to the right lung and left lower lobe and with MRI demonstrating restriction of flow through the right and left lower pulmonary veins. The sharp differences in venous outflow can be seen by MR, whereas their effects are visible by scintigraphy.
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9
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von Bary C, Weber S, Dornia C, Eissnert C, Fellner C, Latzin P, Fredersdorf S, Stadler S, Hamer OW. Evaluation of Pulmonary Vein Stenosis After Pulmonary Vein Isolation Using a Novel Circular Mapping and Ablation Catheter (PVAC). Circ Arrhythm Electrophysiol 2011; 4:630-6. [DOI: 10.1161/circep.111.963397] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christian von Bary
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Stefan Weber
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Christian Dornia
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Christoph Eissnert
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Claudia Fellner
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Philipp Latzin
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Sabine Fredersdorf
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Stefan Stadler
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
| | - Okka W. Hamer
- From the Klinik und Poliklinik für Innere Medizin II (C.v.B., S.W., C.E., S.F., S.S.) and Institut für Röntgendiagnostik (C.D., C.F., O.W.H.), University Medical Center Regensburg, Regensburg, Germany; and Division of Respiratory Medicine, Inselspital, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (P.L.)
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Sorgente A, Chierchia GB, de Asmundis C, Sarkozy A, Capulzini L, Brugada P. Complications of atrial fibrillation ablation: when prevention is better than cure. Europace 2011; 13:1526-32. [PMID: 21784748 DOI: 10.1093/europace/eur209] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
As atrial fibrillation ablation is becoming increasingly popular in many cardiac electrophysiological laboratories around the world, preventing, avoiding, or treating procedure-related complications is of utmost importance. In our review of the literature regarding this issue, we addressed in detail all the potential collateral and undesired effects associated to this intervention.
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Sohns C, Vollmann D, Luethje L, Dorenkamp M, Seegers J, Schmitto JD, Zabel M, Obenauer S. MDCT in the diagnostic algorithm in patients with symptomatic atrial fibrillation. World J Radiol 2011; 3:41-6. [PMID: 21390192 PMCID: PMC3051109 DOI: 10.4329/wjr.v3.i2.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 01/22/2011] [Accepted: 01/25/2011] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common supraventricular arrhythmia and a major cause of morbidity. Arrhythmogenic foci originating within the pulmonary veins (PVs) are an important cause of both paroxysmal and persistent AF. A variety of endovascular and surgical techniques have been used to electrically isolate the PV from the left atrium. Pulmonary venography for localization of the PV ostium can be difficult to perform during the ablation procedure. While the anatomy of the PV is patient-specific, non-invasive imaging techniques may provide useful diagnostic information prior to the intended intervention. In this context, multidetector computed tomography (MDCT) visualization of the left atrial and PV anatomy prior to left atrial ablation and PV isolation is becoming increasingly important. MDCT imaging provides pre-procedural information on the left atrial anatomy, including atrial size and venous attachments, and it may identify potential post-procedural complications, such as pulmonary vein stenosis or cardiac perforations. Here, we review the relevant literature and present the current “state-of-the-art” of left atrial anatomy, PV ostia as well as the clinical aspects of refractory AF, MDCT imaging protocols and procedural aspects of PV ablation.
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12
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Lee DH, Oh YS, Shin WS, Kim JH, Choi YS, Jang SW, Park CS, Youn HJ, Lee MY, Chung WS, Seung KB, Rho TH, Kim JH, Choi KB. A transthoracic echocardiographic follow-up study after catheter ablation of atrial fibrillation: can we detect pulmonary vein stenosis by transthoracic echocardiography? Korean Circ J 2010; 40:442-7. [PMID: 20967145 PMCID: PMC2957642 DOI: 10.4070/kcj.2010.40.9.442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 03/15/2010] [Accepted: 03/30/2010] [Indexed: 12/30/2022] Open
Abstract
Background and Objectives While pulmonary vein isolation (PVI) is an effective curative procedure for patients with atrial fibrillation (AF), pulmonary vein (PV) stenosis is a potential complication which may lead to symptoms that are often unrecognized. The aim of this study was to compare differences between ablation sites in pulmonary venous flow (PVF) measured by transthoracic Doppler echocardiography (TTE) before and after PVI. Subjects and Methods One hundred five patients (M : F=64 : 41; mean age 56±10 years) with paroxysmal AF (n=78) or chronic, persistent AF (n=27) were enrolled. PVI strategies consisted of ostial ablation (n=75; OA group) and antral ablation using an electroanatomic mapping system (n=30; AA group). The ostial diameter was estimated by magnetic resonance imaging (MRI) in patients with PVF ≥110 cm/sec by TTE after PVI. Results No patient complained of PV stenosis-related symptoms. Changes in mean peak right PV systolic (-6.7±28.1 vs. 10.9±25.9 cm/sec, p=0.038) and diastolic (-4.1±17.0 vs. 9.9±25.9 cm/sec, p=0.021) flow velocities were lower in the AA group than in the OA group. Although the change in mean peak systolic flow velocity of the left PV before and after PVI in the AA group was significantly lower than the change in the OA group (-13.4±25.1 vs. 9.2±22.3 cm/sec, p=0.016), there was no difference in peak diastolic flow velocity. Two patients in the OA group had high PVF velocities (118 cm/sec and 133 cm/sec) on TTE, and their maximum PV stenoses measured by MRI were 62.5% and 50.0%, respectively. Conclusion PV stenosis after PVI could be detected by TTE, and PVI by antral ablation using an electroanatomic mapping system might be safer and more useful for the prevention of PV stenosis.
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Affiliation(s)
- Dong-Hyeon Lee
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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13
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Yamaji H, Hina K, Kawamura H, Murakami T, Murakami M, Yamamoto K, Hirohata A, Miyoshi T, Hirohata S, Kusachi S. Prone position is essential for detection of pulmonary vein pseudostenosis by enhanced multidetector computed tomography in patients who undergo pulmonary vein isolation. Circ J 2009; 72:1460-4. [PMID: 18724022 DOI: 10.1253/circj.cj-08-0055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pulmonary vein (PV) stenosis is a major complication of PV isolation (PVI) by catheter ablation, so in the present study the optimal position for detecting PV stenosis on enhanced multidetector computed tomography (MDCT) image acquisition was determined. METHODS AND RESULTS The 64-slice enhanced MDCT was carried out before and after PVI in 116 consecutive patients with atrial fibrillation while they were in the prone position, as well as while supine. The supine position MDCT image showed >50% diameter stenosis of the PV in 11 (9%) patients before PVI (% diameter stenosis: mean 55+/-4%, range 51-65%). Greater than 50% diameter stenosis was seen in the left inferior PV in all 11 patients. The prone position attenuated the PV stenosis findings in the MDCT images in all 11 patients (mean 9+/-6%, range 2-18%). Stenosis visualized on images acquired in the supine position was, therefore, concluded to be pseudostenosis caused by descending aorta compression. At 3 months after PVI, no significant changes in PV diameter were observed in these 11 patients. CONCLUSION The present study demonstrated that the prone position is essential for eliminating PV pseudostenosis observed on supine-position enhanced MDCT images. The results also indicate that preexisting PV organic stenosis is rare.
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Affiliation(s)
- Hirosuke Yamaji
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
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Hauser TH, Peters DC, Wylie JV, Manning WJ. Evaluating the left atrium by magnetic resonance imaging. Europace 2009; 10 Suppl 3:iii22-7. [PMID: 18955395 DOI: 10.1093/europace/eun223] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The emergence of catheter based ablation therapy for the prevention of recurrent atrial fibrillation has increased interest in the anatomy of the left atrium and pulmonary veins. In this article, we review the magnetic resonance imaging method of imaging the left atrium and the pulmonary veins, normal and variant anatomy, and the utility of imaging before and after atrial fibrillation ablation.
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Affiliation(s)
- Thomas H Hauser
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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15
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Takahashi A, Kuwahara T, Takahashi Y. Complications in the catheter ablation of atrial fibrillation: incidence and management. Circ J 2009; 73:221-6. [PMID: 19129678 DOI: 10.1253/circj.cj-08-1097] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Radiofrequency catheter ablation is widely performed as an effective treatment for recurrent, drug-resistant atrial fibrillation (AF). Recently, various types of ablation strategies, such as extensive encircling pulmonary vein (PV) isolation, linear ablation and complex fractionated electrogram-guided ablation, have been used to achieve a high efficacy for all types of AF. However, several complications (thromboembolic events, PV stenosis and atrio-esophageal fistula etc) with an incidence of 3.9-6%, have been reported. It is important to understand the incidence, prevention and management of complications in order to develop safe ablation strategies.
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16
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Vivier PH, Perot G, Bertrand D, Dacher JN, Roques S. Une suspicion d’embolie pulmonaire. Rev Med Interne 2008; 29:498-9. [PMID: 17628233 DOI: 10.1016/j.revmed.2007.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Accepted: 06/11/2007] [Indexed: 10/23/2022]
Affiliation(s)
- P-H Vivier
- Service de radiologie centrale, CHU Charles-Nicolle de Rouen, 1, rue de Germont, 76031 Rouen cedex, France.
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17
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Stojanovska J, Cronin P. Computed Tomography Imaging of Left Atrium and Pulmonary Veins for Radiofrequency Ablation of Atrial Fibrillation. Semin Roentgenol 2008; 43:154-66. [DOI: 10.1053/j.ro.2008.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Okumura Y, Watanabe I, Ohkubo K, Yamada T, Kawauchi K, Takagi Y, Ashino S, Kofune M, Kofune T, Hashimoto K, Shindo A, Sugimura H, Nakai T, Kunimoto S, Saito S, Hirayama A. Full-motion two- and three-dimensional pulmonary vein imaging by intracardiac echocardiography after pulmonary vein isolation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:409-17. [PMID: 18373758 DOI: 10.1111/j.1540-8159.2008.01009.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The pulmonary veins (PVs) are topographically complex and motile, so angiographic visualization of the PVs anatomy is limited. An imaging technique that accurately portrays the pulmonary vein (PV) anatomy would be valuable during and after catheter ablation procedures. PURPOSE We investigated whether three-dimensional (3D) intracardiac echocardiography (ICE) can visualize radiofrequency (RF)-induced tissue changes after PV isolation. METHODS We performed 3D ICE studies with a 9F, 9-MHz ICE catheter after segmental or extended PV isolation. The ICE catheter was placed 3-4 cm inside the PV ostium and mounted onto a pullback device. Sequential two-dimensional (2D) images of the full length of the vein were obtained in 0.3 mm steps with cardiac and respiratory cycle gating. Each image was fed into a computer, and the aggregate data set was reconstructed into a 3D, full-motion image. RF lesion location and lesion size were studied on 67 pullback images from 29 patients. RESULTS The 2D and 3D reconstruction was possible for 27 left superior PVs, 13 left inferior PVs, 26 right superior PVs, and one right inferior PV. The ablation site was identified 3-7 mm inside the PV ostium, and a 1/2 - 4/5 circumferential area was ablated with no clinically relevant stenosis. No significant differences were found on the ablated area or ablation site between segmental and extensive PV isolation. CONCLUSION The 2D and 3D ICE of the PVs provides detailed anatomical information of the proximal PVs, and RF-induced tissue changes in the PV wall can be visualized by ICE.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Natale A, Raviele A, Arentz T, Calkins H, Chen SA, Haïssaguerre M, Hindricks G, Ho Y, Kuck KH, Marchlinski F, Napolitano C, Packer D, Pappone C, Prystowsky EN, Schilling R, Shah D, Themistoclakis S, Verma A. Venice Chart international consensus document on atrial fibrillation ablation. J Cardiovasc Electrophysiol 2007; 18:560-80. [PMID: 17456138 DOI: 10.1111/j.1540-8167.2007.00816.x] [Citation(s) in RCA: 291] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrea Natale
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, USA
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20
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Schneider C, Ernst S, Malisius R, Bahlmann E, Lampe F, Broemel T, Krause K, Boczor S, Antz M, Kuck KH. Transesophageal echocardiography: A follow-up tool after catheter ablation of atrial fibrillation and interventional therapy of pulmonary vein stenosis and occlusion. J Interv Card Electrophysiol 2007; 18:195-205. [PMID: 17458690 DOI: 10.1007/s10840-007-9085-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 01/29/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pulmonary vein stenosis (PVS) has been described as a complication after primary catheter ablation of atrial fibrillation (Afib). The purpose of this study was to evaluate the utility of transesophageal echocardiography (TEE) as follow-up tool after catheter ablation of Afib and interventional therapy of PVS and pulmonary vein occlusion (PVO). METHODS We report on 28 patients with stenosis (PVS) of 33 pulmonary veins (PVs) and total PVO of 4 veins complicating ablation of Afib assessed by angiography and/or magnetic resonance imaging (MRI). Subsequently, transseptal PV angiograms were performed, followed by recanalization of three totally occluded PVs and balloon dilatation of seven severe PVS (in four cases combined with PV stenting). PVs were analyzed by multiplane TEE in an intraindividual comparison of preablation/preintervention and follow-up measurements of mean and peak flow velocity, velocity time integrals, and diameters. RESULTS Of a total of 28 patients, 14 had mild PVS (n = 14), 9 had moderate PVS (n = 10), 6 had severe PVS (n = 8), and 4 patients showed totally occluded PVs (n = 4). In multivariate analysis flow velocities and vessel diameters showed significant differences (mild, moderate, and severe PVS and PVO; p = 0.001). Interventional benefits of balloon dilatation (n = 10) and stent implantation (n = 4), as well as in-stent restenosis could be detected (p = 0.014). In all recanalized vessels TEE showed reestablished flow. In occluded PVs no flow was detectable. The TEE vessel diameters correlated with angiography data (r = 0.87) and computed tomography/MRI (r = 0.90). CONCLUSIONS TEE can be used as a follow-up tool after interventional therapy in patients after catheter ablation and acquired PVS/PVO. Restenosis/in-stent restenosis can be identified by analyzing the vessel diameters and blood flow characteristics.
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Affiliation(s)
- Carsten Schneider
- Department of Cardiology, St. Georg Hospital, Lohmühlenstrasse 5, Hamburg, Germany.
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21
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Yang HM, Lai CK, Patel J, Moore J, Chen PS, Shivkumar K, Fishbein MC. Irreversible intrapulmonary vascular changes after pulmonary vein stenosis complicating catheter ablation for atrial fibrillation. Cardiovasc Pathol 2007; 16:51-5. [PMID: 17218215 DOI: 10.1016/j.carpath.2006.07.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Revised: 07/11/2006] [Accepted: 07/20/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Pulmonary vein stenosis is a recognized complication of catheter ablation of arrhythmias emanating from the pulmonary vein; however, there is little information on secondary effects of pulmonary vein stenosis on lung tissue. METHODS AND RESULTS A 55-year-old man with a history of paroxysmal atrial fibrillation refractory to antiarrhythmic medication had radiofrequency ablation in April 2003 and July 2003. Although these procedures were successful in resolving the patient's arrhythmia, they were complicated by the development of pulmonary vein stenosis of all four veins and pulmonary hypertension requiring patch annuloplasty of the pulmonary veins in October 2003. The patient was referred to our center for pulmonary vein stent placement in December 2003, June 2004, and August 2004, each time for recurrent hemoptysis. Due to persistent hemoptysis over the next several months, the patient underwent left lower lung lobectomy in September 2005. Microscopic examination of the lung showed marked medial thickening and intimal hyperplasia of large and small pulmonary veins and arteries, as well as focal organizing thrombi in the small arteries. The lung tissue showed extensive hemosiderin deposition indicative of prior hemorrhage. CONCLUSION Chronic pulmonary vein stenosis after radiofrequency ablation of atrial fibrillation results in irreversible venous and arterial morphologic changes throughout the lung, including areas both close to, and remote from, the site of catheter ablation. Because there are persistent pathological changes remote from the ablation site causing the pulmonary hypertension, stenting the site of ablation to reopen large pulmonary veins may not be effective in treating the pulmonary hypertension.
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Affiliation(s)
- Hui-Min Yang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, CA 90095, USA
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22
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Iesaka Y, Otomo K, Nagata Y, Uno K. Catheter Ablation Therapy for Atrial Fibrillation Current Advancements in Strategies. Circ J 2007; 71 Suppl A:A82-9. [PMID: 17587745 DOI: 10.1253/circj.71.a82] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Curing atrial fibrillation (AF) by catheter ablation has significantly improved patient morbidity and mortality. The circumferential pulmonary vein isolation technique is established as the principal procedure, with a high cure rate and acceptable safety, for paroxysmal AF, but new adjunctive ablation strategies targeting the AF substrates and sources for long-standing persistent/chronic AF have been developed. These new techniques include linear ablation, complex fractionated atrial electrogram guided ablation, dominant frequency map-guided ablation, ganglionated plexi ablation and disconnection of the coronary sinus and superior vena cava to ablate the AF substrates and sources. The long-term usefulness of the established technique and these innovative adjunctive approaches for the treatment of AF remains to be investigated.
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Affiliation(s)
- Yoshito Iesaka
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Japan.
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23
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IESAKA YOSHITO. Complications of Catheter Ablation of Atrial Fibrillation: Cause, Prevention and Management. J Cardiovasc Electrophysiol 2006. [DOI: 10.1111/j.1540-8167.2006.00629.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Kelly S, Bicknell SG, Sharma S. Left Atrial Wall Hematoma After Radiofrequency Ablation for Atrial Fibrillation. AJR Am J Roentgenol 2006; 186:1317-9. [PMID: 16632725 DOI: 10.2214/ajr.05.0102] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Sarah Kelly
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
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26
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Anselme F, Gahide G, Savouré A, Gerbaud E, Mabru M, Cribier A, Dacher JN. MR evaluation of pulmonary vein diameter reduction after radiofrequency catheter ablation of atrial fibrillation. Eur Radiol 2006; 16:2505-11. [PMID: 16639495 DOI: 10.1007/s00330-006-0252-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Revised: 01/04/2006] [Accepted: 03/10/2006] [Indexed: 11/26/2022]
Abstract
Fifty consecutive patients aged 52+/-12 years suffering from drug refractory atrial fibrillation (AF) underwent baseline and post-ablation MR angiography (MRA) at a mean follow-up of 4+/-3.5 months. Pulmonary vein (PV) disconnection was performed with a maximum energy delivery of 30 W. MRA allowed a two-plane measurement of each PV ostium. After ablation, no significant stenosis was observed, and only 1/194 (0.5%) and 3/194 (2%) PVs had a diameter reduction of 31-40% in the coronal and axial planes, respectively. There was a significant overall post-procedural PV narrowing of 4.9% in the coronal plane and 6.5% in the axial plane (P=ns between both planes). MRA is an efficient technique that can be used in pre- and postoperative evaluation of AF patients. Using a maximal power delivery limited to 30 W, no significant PV stenosis was observed at mid-term follow-up. Late PV anatomical assessment is needed to confirm these results on long-term follow-up.
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Affiliation(s)
- Frédéric Anselme
- Department of Cardiology, Rouen University Hospital, Rouen, France
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27
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Gerstenfeld EP, Sauer W, Callans DJ, Dixit S, Lin D, Russo AM, Beldner S, McKernan M, Marchlinski FE. Predictors of success after selective pulmonary vein isolation of arrhythmogenic pulmonary veins for treatment of atrial fibrillation. Heart Rhythm 2006; 3:165-70. [PMID: 16443531 DOI: 10.1016/j.hrthm.2005.10.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2005] [Accepted: 10/14/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) ablation procedures typically involve isolation of all pulmonary veins (PVs) in addition to adjunctive linear lesions, yet the need for such an extensive ablation strategy in all patients is unclear. OBJECTIVES The purpose of this study was to identify a subgroup of patients undergoing AF ablation with good clinical success after limited PV isolation. METHODS Patients (N = 450) underwent trigger-guided segmental isolation of only arrhythmogenic PVs. We compared clinical characteristics of patients who required isolation of only one or two PVs to those in whom AF ablation required isolating > or = 3 PVs. RESULTS For the group of patients undergoing isolation of < or = 2 PVs, AF freedom without antiarrhythmic drug use was achieved in 56 (58%) of 97 patients, and AF control was achieved in 66 (68%) of 97 patients after a single procedure. After additional procedures, 77 (79%) of 97 patients achieved complete AF freedom without antiarrhythmic drugs, and 82 (85%) of 97 patients achieved AF control. Younger age (odds ratio [OR] 1.05; confidence interval [CI] 1.01,1.09) and lack of persistent AF (OR 3.27; CI 1.0, 10.7) were each independent predictors of freedom from AF. In patients younger than 50 years with paroxysmal AF undergoing isolation of < or = 2 PVs (n = 44), AF freedom without antiarrhythmic drugs was achieved in 32 (73%) of 44 after a single ablation procedure. CONCLUSION Targeted PV isolation has a good long-term (18-month) success rate in patients younger than 50 years with paroxysmal AF and < or = 2 PVs triggering AF.
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Affiliation(s)
- Edward P Gerstenfeld
- University of Pennsylvania Health System, Philadelphia, Pennsylvania 19104, USA.
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28
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Macedo R, Schmidt A, Rochitte CE, Lima JAC, Bluemke DA. MRI to assess arrhythmia and cardiomyopathies. J Magn Reson Imaging 2006; 24:1197-206. [PMID: 17083108 DOI: 10.1002/jmri.20739] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) is highly precise for morphological and functional analyses of the myocardium, and has been used to assess different types of cardiomyopathies. Its ability to characterize tissue, especially with gadolinium (Gd) delayed-enhancement techniques, has shown promising results for the diagnosis of arrhythmogenic cardiomyopathies. In this review we discuss the background and potential of this approach, as well as its usefulness for assessing arrhythmias and cardiomyopathies.
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Affiliation(s)
- Robson Macedo
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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29
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Packer DL, Keelan P, Munger TM, Breen JF, Asirvatham S, Peterson LA, Monahan KH, Hauser MF, Chandrasekaran K, Sinak LJ, Holmes DR. Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation. Circulation 2005; 111:546-54. [PMID: 15699274 DOI: 10.1161/01.cir.0000154541.58478.36] [Citation(s) in RCA: 229] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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 103+/-100 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 3+/-2 mm compared with 13+/-3 mm at baseline (P< or =0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4+/-3% of total perfusion compared with 22+/-10% in unaffected segments. At percutaneous intervention, these veins showed 80+/-13% stenosis, with a mean gradient of 12+/-5 mm Hg. This was significantly reduced to a residual stenosis of 9+/-8% (P< or =0.001) and a residual gradient of 3+/-4 mm Hg (P< or =0.001). 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.
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Affiliation(s)
- Douglas L Packer
- Division of Cardiac Electrophysiology/Cardiology, Department of Internal Medicine, Mayo Clinic and Foundation, Saint Mary's Hospital Complex, Rochester, Minn 55902, USA.
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30
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Burgstahler C, Trabold T, Kuettner A, Kopp AF, Mewis C, Kuehlkamp V, Claussen CD, Schroeder S. Visualization of pulmonary vein stenosis after radio frequency ablation using multi-slice computed tomography: initial clinical experience in 33 patients. Int J Cardiol 2005; 102:287-91. [PMID: 15982498 DOI: 10.1016/j.ijcard.2004.05.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2004] [Revised: 04/13/2004] [Accepted: 05/05/2004] [Indexed: 11/20/2022]
Abstract
PURPOSE Radio frequency ablation (RFA) of the pulmonary veins (PV) is an established technique for treatment of atrial fibrillation (AF). However, stenoses within the treated areas are well known complications. Thus, a reliable non-invasive diagnosis of PV stenosis would be an important step forward in the care of these patients (pts). Aim of the present study was the diagnostic accuracy of new multi-slice detected computed tomography (MSCT) in visualization of PV and in detecting PV stenosis. MATERIAL AND METHODS A total of 33 pts (17 male, 16 female, mean age 57+/-10.2 years [40-71]) were included. Retrospectively ECG-gated CT angiography (CTA) was performed within 1 day to a maximum of 380 days after RFA with a MSCT scanner. Interpretation of the scan was performed on conventional contrast enhanced axial slices and on 3D volume rendering images (maximum intensity projection: MIP, multi-planar reconstruction: MPR). Lesion severity was determined on a semi-quantitative scale (mild: <20%, intermediate: 20-50%, severe >50%) and compared to conventional angiography which had been performed at the beginning and at the end of RFA. RESULTS MSCTA was applied without any complications, and all treated pulmonary veins (n=73) could be visualized. Diagnostic image quality was obtained in all examinations. A significant stenosis was detected by conventional angiography in 26/73 (36%) PV (2/73 (3%) severe, 14/73 (19%) intermediate, 10/73 (14%) mild). Using MSCTA, only 13 stenosis in 73 treated PV could be visualized (1/73 (1%) severe, 6/73 (8%) intermediate, 6/73 (8%) mild). CONCLUSIONS Multi-slice-detector CT is able to visualize PV and to detect PV stenoses. However, stenosis severity seems to be underestimated and not all lesions could be accurately detected. Larger studies have to be performed to further assess the diagnostic accuracy and clinical reliability of this new non-invasive method and to focus on the incidence of PV stenosis following RFA especially in long-time follow up.
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Affiliation(s)
- Christof Burgstahler
- Department of Internal Medicine, Division of Cardiology, Eberhard-Karls-University Tuebingen, Otfried-Mueller-Str. 10, 72076 Tuebingen, Germany
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López-Candales A, Kaczorowski D, Pellegrini R. An unusual clinical presentation resembling superior vena cava syndrome post heart surgery. Cardiovasc Ultrasound 2005; 3:31. [PMID: 16202133 PMCID: PMC1262735 DOI: 10.1186/1476-7120-3-31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Accepted: 10/03/2005] [Indexed: 11/17/2022] Open
Abstract
Background An unusual sequence of post operative events heralded by hemodynamic deterioration followed by dyspnea and rapidly progressive dilatation of superficial neck and facial veins, resembling a superior vena cava syndrome, two days post surgical resection of filamentous aortic valve masses, closure of a patent foramen ovale, and performance of a modified Maze procedure for atrial fibrillation in a patient that presented with transient neurologic findings is presented. Case Presentation Although both clinical findings and hemodynamic derangements completely resolved following tricuspid valve repair aimed to correct the new onset severe tricuspid regurgitation noted post operatively; a clear mechanism was not readily obvious and diagnostic testing data somewhat conflictive. We present a careful retrospective examination of all clinical data and review possible clinical entities that could have been implicated in this particular case and recognize that transesophageal echocardiographic findings were most useful in identifying the best course of action. Conclusion After reviewing all clinical data and despite the inconclusive nature of test results; the retrospective examination of transesophageal echocardiographic findings proved to be most useful in identifying the best course of action. We postulate that in our case, resolution of the suspected pulmonary embolism with anticoagulation and reestablishment of a normal right ventricular geometry with tricuspid valve repair worked in unison in restoring normal hemodynamics and resolving both dyspnea and venous dilatation.
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Affiliation(s)
- Angel López-Candales
- Cardiothoracic Division, Department of Surgery and the Cardiovascular Institute*, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Cardiothoracic Division, Department of Surgery and the Cardiovascular Institute*, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ronald Pellegrini
- Cardiothoracic Division, Department of Surgery and the Cardiovascular Institute*, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Vaseghi M, Cesario DA, Valderrabano M, Boyle NG, Ratib O, Finn JP, Wiener I, Shivkumar K. Impedance monitoring during catheter ablation of atrial fibrillation. Heart Rhythm 2005; 2:914-20. [PMID: 16171742 DOI: 10.1016/j.hrthm.2005.06.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Accepted: 06/11/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Delivery of radiofrequency energy in proximity of a pulmonary vein can cause vein stenosis. A sudden decrease in impedance as the catheter is moved from the vein into the left atrium (LA) has been used to define the pulmonary vein-LA transition during ablation procedures. OBJECTIVES The purpose of this study was to define the variables affecting impedance measurement. METHODS In vitro analysis of impedance was performed in a saline bath using sheaths and a plastic stereolithographic model of the LA. Impedance was continuously monitored during a calibrated pullback from the pulmonary vein into the LA in 37 veins of 10 patients referred for catheter ablation. Location of the catheter was confirmed by the following imaging modalities: intracardiac echocardiography, contrast venography, electroanatomic mapping, and computed tomography/magnetic resonance imaging (offline) in all patients. RESULTS Larger cross-sectional areas containing the catheter correlated with lower impedance in an exponential manner both with respect to sheath size (R(2) = 0.99) and in the stereolithographic model (R(2) = 0.91). In vivo, the impedance in the pulmonary veins decreased in an exponential manner as the catheter was pulled back into the LA. However, impedance at the vein orifice was not significantly higher than the LA. A defined cutoff value for defining the pulmonary vein-LA transition could not be identified. CONCLUSION The primary determinant of impedance is the cross-sectional area of the space containing the catheter. Impedance monitoring alone does not guarantee a catheter tip position outside the pulmonary vein. Intraprocedural imaging confirmation should be considered to avoid radiofrequency application within pulmonary veins.
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Affiliation(s)
- Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
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Dong J, Vasamreddy CR, Jayam V, Dalal D, Dickfeld T, Eldadah Z, Meininger G, Halperin HR, Berger R, Bluemke DA, Calkins H. Incidence and Predictors of Pulmonary Vein Stenosis Following Catheter Ablation of Atrial Fibrillation Using the Anatomic Pulmonary Vein Ablation Approach: Results from Paired Magnetic Resonance Imaging. J Cardiovasc Electrophysiol 2005; 16:845-52. [PMID: 16101625 DOI: 10.1111/j.1540-8167.2005.40680.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There are currently no studies systematically evaluating pulmonary vein (PV) stenosis following catheter ablation of atrial fibrillation (AF) using the anatomic PV ablation approach. METHODS AND RESULTS Forty-one patients with AF underwent anatomic PV ablation under the guidance of a three-dimensional electroanatomic mapping system. Gadolinium-enhanced magnetic resonance (MR) imaging was performed in all patients prior to and 8-10 weeks after ablation procedures for screening of PV stenosis. A PV stenosis was defined as a detectable (> or =3 mm) narrowing in PV diameter. The severity of stenosis was categorized as mild (<50% stenosis), moderate (50-70%), or severe (>70%). A total 157 PVs were analyzed. A detectable PV narrowing was observed in 60 of 157 PVs (38%). The severity of stenosis was mild in 54 PVs (34%), moderate in five PVs (3.2%), and severe in one PV (0.6%). All mild PV stenoses displayed a concentric pattern. Moderate or severe PV stenosis was only observed in patients with an individual encircling lesion set. Multivariable analysis identified individual encircling lesion set and larger PV size as the independent predictors of detectable PV narrowing. All patients with PV stenosis were asymptomatic and none required treatment. CONCLUSIONS The results of this study demonstrate that detectable PV narrowing occurs in 38% of PVs following anatomic PV ablation. Moderate or severe PV stenosis occurs in 3.8% of PVs. The high incidence of mild stenosis likely reflects reverse remodeling rather than pathological PV stenosis. The probability of moderate or severe PV stenosis appears to be related to creation of individual encircling rather than encircling in pairs lesion.
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Affiliation(s)
- Jun Dong
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Jin Y, Ross DL, Thomas SP. Pulmonary Vein Stenosis and Remodeling After Electrical Isolation for Treatment of Atrial Fibrillation:. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:1362-70. [PMID: 15511245 DOI: 10.1111/j.1540-8159.2004.00640.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Asymptomatic pulmonary vein (PV) stenosis after PV electrical isolation for atrial fibrillation has been reported in several studies and may be due to dynamic factors. The purpose of this study was to determine if PV stenosis progresses after the initial procedure. Consecutive patients (n = 26) requiring repeat procedures for atrial fibrillation recurrence were studied (mean age 55 +/- 12 years). Segmental PV potential-guided ostial ablation was performed with transvenous catheters. Biplane angiographic images were obtained before and after each procedure (52 procedures). Stenoses were found in 14 (16%) of 87 targeted veins immediately after the initial procedures. After 129 +/- 94 days no new stenoses were found at the second procedure. PV stenoses were unchanged in 8 previously stenosed veins, slightly deteriorated in 1 vein, improved in 2 veins, and fully resolved in 3 veins. No patients had symptoms attributable to PV stenosis. PV stenosis occurred in 6 (9%) of 68 additional veins at the second procedure. No baseline or procedural characteristics predicted stenosis. Progression of PV stenosis is uncommon in the medium term. Complete or partial resolution of PV stenosis occurs in approximately one third of cases. Absence of PV stenosis after an initial procedure does not ensure PV stenosis will not occur with further ablation in the same vein.
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Affiliation(s)
- Yuanzhe Jin
- Department of Cardiology, Westmead Hospital, Westmead Private Hospital and University of Sydney, Westmead, Australia
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Cronin P, Sneider MB, Kazerooni EA, Kelly AM, Scharf C, Oral H, Morady F. MDCT of the Left Atrium and Pulmonary Veins in Planning Radiofrequency Ablation for Atrial Fibrillation: A How-To Guide. AJR Am J Roentgenol 2004; 183:767-78. [PMID: 15333369 DOI: 10.2214/ajr.183.3.1830767] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Paul Cronin
- Department of Radiology, Division of Thoracic Radiology, University of Michigan Health Systems, B1 132F Taubman Center, 1500 E Medical Center Dr., TC 2910, Ann Arbor, MI 48109, USA.
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Thomas SP, Boyd AC, Aggarwal G, Jin Y, Ross DL. Percutaneous pulmonary vein isolation for treatment of atrial fibrillation. Intern Med J 2004; 34:453-7. [PMID: 15317542 DOI: 10.1111/j.1445-5994.2004.00648.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transvenous catheter ablation for the treatment of atrial fibrillation is an evolving technique. AIM The purpose of this study was to identify subgroups of patients most likely to benefit from pulmonary vein electrical isolation. METHODS Patients with symptomatic atrial fibrillation resistant to pharmacological therapy were studied. Mapping-guided segmental application of radio-frequency energy was used to electrically isolate the pulmonary veins in 74 patients. Ischaemic or dilated cardiomyopathy was present in 34% of patients. Atrial fibrillation had been present for a mean time (+/- standard deviation) of 6.6 +/- 6.1 years. It was paroxysmal in 53 patients (72%). RESULTS The mean number of procedures was 1.6/patient. After 6 +/- 6 months, 73% of patients (54/74) were in sinus rhythm. Thirteen of those in sinus rhythm were using anti-arrhythmic medications (25%). Recurrence of atrial fibrillation soon after pulmonary vein isolation occurred in 50%. Patients with persistent/permanent atrial fibrillation were less likely to be in sinus rhythm at follow up (11/21 (52%) vs 43/53 (81%); P = 0.01). However, the rate of early recurrence was similar in the intermittent and the persistent/permanent groups (26/53 (49%) vs 11/21(52%), respectively; P-value not significant). Patients with persistent atrial fibrillation were more likely to experience a recurrence of atrial fibril-lation (89%; P = 0.04). No other baseline factors predicted procedural success. Cardiac tamponade occurred in two patients and moderate pulmonary vein stenosis (>50% diameter narrowing) occurred in three patients. CONCLUSIONS Pulmonary vein isolation is an effective curative treatment for a broad group of patients with atrial fibrillation. However, the procedure is only suitable for patients with problematic atrial fibrillation resistant to other therapies because of the small risk of serious complications.
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Affiliation(s)
- S P Thomas
- Department of Cardiology, Westmead Hospital and Westmead Private Hospital, Sydney, New South Wales, Australia.
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Kluge A, Dill T, Ekinci O, Hansel J, Hamm C, Pitschner HF, Bachmann G. Decreased Pulmonary Perfusion in Pulmonary Vein Stenosis After Radiofrequency Ablation. Chest 2004; 126:428-37. [PMID: 15302728 DOI: 10.1378/chest.126.2.428] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
STUDY OBJECTIVES The functional impact of pulmonary vein (PV) stenosis on pulmonary perfusion after radiofrequency ablation (RFA) for atrial fibrillation (AF) has not been systematically evaluated previously. Therefore, we correlated magnetic resonance (MR) pulmonary perfusion imaging with single-photon emission CT (SPECT) perfusion and with the degree of PV stenosis (PVS) apparent on MR angiography (MRA) after RF ablation. SETTING Joint radiology-cardiology collaborative magnetic resonance unit at the Kerckhoff Heart Center. DESIGN AND PATIENTS This was a cohort study of 110 patients who were routinely examined by MRA after RFA for AF, whereby 51 patients with a PV diameter reduction of > 25% or with clinical symptoms (ie, dyspnea and cough) were enrolled into the study. Patients were examined at follow-up by MR perfusion imaging and MRA, and the results were compared to those from patients who underwent SPECT scanning and from a control group of 26 untreated patients. Twelve patients underwent PVS dilatation as well as 22 sequential follow-up examinations. METHODS Pulmonary perfusion was evaluated using a dynamic contrast-enhanced three-dimensional MR perfusion sequence (1.5 T, 2.5-s temporal resolution, and 0.05 cm spatial resolution), and high-resolution, contrast-enhanced MRA was performed to measure PV diameter. PV dilatation was performed using an angioplasty catheter that was 8 to 10 mm in diameter. RESULTS The localization and extent of perfusion defects measured by MRI or SPECT scanning were precisely matched. MR perfusion imaging detected 20 of 21 perfusion defects (sensitivity, 95.2%; specificity, 100%). PVSs and perfusion deficits correlated closely and showed the following threshold: perfusion decreased substantially in PVs <or= 6 mm in diameter (21 of 25 areas; 84.0%) compared to 2 of 180 areas (1.1%) with PVs > 6 mm in diameter. After PVS dilatation, perfusion was restored partially after weeks, and complete normalization was seen in 4 of 12 patients (33%). CONCLUSIONS PVSs caused severe perfusion deficits, which were reliably demonstrated by MR perfusion imaging. Clinical symptoms correlated better with MR perfusion than they did with MRA. The combination with MRA to assess underlying PVS allowed a "one-stop-shopping" MRI procedure to be carried out. The results led to alterations of RFA techniques, and therefore MRA and MR perfusion imaging may be beneficial in patient follow-up and in evaluating new ablation techniques.
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Affiliation(s)
- Alexander Kluge
- Department of Diagnostic Radiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, Germany.
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Pürerfellner H, Aichinger J, Martinek M, Nesser HJ, Cihal R, Gschwendtner M, Dierneder J. Incidence, management, and outcome in significant pulmonary vein stenosis complicating ablation for atrial fibrillation. Am J Cardiol 2004; 93:1428-31, A10. [PMID: 15165933 DOI: 10.1016/j.amjcard.2004.02.049] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2003] [Revised: 02/16/2004] [Accepted: 02/16/2004] [Indexed: 10/26/2022]
Abstract
This study summarizes our results in diagnosing and treating pulmonary vein stenosis complicating ablation for atrial fibrillation in 6 of 92 patients. Patients with significant pulmonary vein narrowing underwent either dilatation or dilatation plus stenting. Pulmonary vein intervention produced a favorable clinical course over the following 7 +/- 2 months despite significant restenosis in 2 patients.
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Affiliation(s)
- Helmut Pürerfellner
- Department of Internal Medicine II, Elisabethinen Academic Teaching Hospital, University of Innsbruck, Fadingerstrasse 1, A-4010 Linz, Austria.
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Abstract
The past several years have witnessed a significant growth in the number of institutions offering catheter ablation for atrial fibrillation (AF). This growth has been a result of a better understanding of pathophysiology of AF and use of instruments and approaches that made catheter ablation of AF a safe and an effective alternative to the drug therapy. The procedure increasingly is becoming a therapy of choice for a select group of symptomatic, drug-refractory patients without structural heart disease, and it is being offered to a rapidly widening patient pool. This article reviews the procedural aspects and clinical evidence supporting this wider use of AF ablation. In addition, new techniques and technologies for AF ablation and new avenues of research in this area are explored.
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Affiliation(s)
- Bohuslav Finta
- Division of Cardiology, William Beaumont Hospital, Northpointe Heart Center, 27901 Woodward Avenue, Suite 300, Berkley, MI 48072-0921, USA
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Vasamreddy CR, Jayam V, Lickfett L, Nasir K, Bradley DJ, Eldadah Z, Dickfeld T, Donahue K, Halperin HS, Berger R, Calkins H. Technique and Results of Pulmonary Vein Angiography in Patients Undergoing Catheter Ablation of Atrial Fibrillation. J Cardiovasc Electrophysiol 2004; 15:21-6. [PMID: 15028068 DOI: 10.1046/j.1540-8167.2004.03352.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Delineation of pulmonary vein (PV) anatomy is an integral part of the PV isolation procedure. The aims of the present study were to (1) describe the technique of selective PV angiography, (2) show the typical fluoroscopic locations and appearance of the PVs, and (3) compare the ostial diameters of PVs measured by angiography and magnetic resonance imaging (MRI). METHODS AND RESULTS Twenty consecutive patients undergoing a PV isolation procedure underwent selective PV angiography using a deflectable 8-French lumened catheter (Naviport, Cardima). The left superior PV (LSPV) runs upward and away from the spine in the right anterior oblique (RAO) projection and upward and toward the spine in the left anterior oblique (LAO) projection. The opposite is true for the right superior PV (RSPV). The left inferior PV (LIPV) has a bull's-eye appearance in the RAO projection, and the right inferior PV (RIPV) has a bull's-eye appearance in the LAO projection due to their end-on trajectories. The LIPV in the LAO projection and the RIPV in the RAO projection run horizontally toward the spine. An excellent correlation was noted in PV ostial size as assessed by angiography and MRI (r(2) < 0.90, P < 0.0001). CONCLUSION This study describes the technique and results of PV angiography and fluoroscopy. The study also demonstrates good correlation of PV ostial diameters by contrast venography and MRI. PV angiography can be used as an alternate to MRI or computed tomographic imaging, particularly when these tests are unavailable or are contraindicated in the patient.
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Ghaye B, Szapiro D, Dacher JN, Rodriguez LM, Timmermans C, Devillers D, Dondelinger RF. Percutaneous Ablation for Atrial Fibrillation: The Role of Cross-sectional Imaging. Radiographics 2003; 23 Spec No:S19-33; discussion S48-50. [PMID: 14557499 DOI: 10.1148/rg.23si035513] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Percutaneous ablation is a well-established technique for treating cardiac arrhythmia by removing or isolating tissue at the site of the abnormal impulse formation. Various forms of energy for ablation procedures may be delivered via a catheter with fluoroscopic guidance. The procedures most commonly performed are radiofrequency ablation and cryotherapy. Atrial fibrillation, the most frequently occurring supraventricular tachyarrhythmia, may be initiated by ectopic beats that originate in the ostia of the pulmonary veins. The clinical efficacy of isolation (or focal ablation) of the pulmonary veins for treatment of atrial fibrillation has been well demonstrated. Pre- and postprocedural examinations with computed tomography (CT) or magnetic resonance (MR) imaging are frequently performed to depict the anatomy and to obtain baseline measurements of the pulmonary veins to enable early detection of complications from ablation. Venous stenosis or thrombosis and pulmonary hypertension may occur after radio-frequency ablation. Familiarity with the appearance of normal anatomic variants at CT and MR imaging and with the normal range of pulmonary vein diameters is essential for preoperative management and early detection of procedure-related complications.
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Affiliation(s)
- Benoit Ghaye
- Department of Medical Imaging, Liège University Hospital, Sart Tilman B 35, B-4000 Liège, Belgium.
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Qureshi AM, Prieto LR, Latson LA, Lane GK, Mesia CI, Radvansky P, White RD, Marrouche NF, Saad EB, Bash DL, Natale A, Rhodes JF. Transcatheter angioplasty for acquired pulmonary vein stenosis after radiofrequency ablation. Circulation 2003; 108:1336-42. [PMID: 12952852 DOI: 10.1161/01.cir.0000086322.21781.6a] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary vein stenosis has recently been recognized as a complication of radiofrequency ablation for atrial fibrillation. This study evaluates the presentation of affected patients and the role of transcatheter therapy for this patient population. METHODS AND RESULTS This study used a retrospective review of data from 19 patients (age, 51+/-13 years) with pulmonary vein stenosis who underwent catheterization and angiography between December 2000 and December 2002. Quantitative perfusion and spiral CT scans were performed for initial diagnosis and follow-up. The median duration between radiofrequency ablation and the reported onset of respiratory symptoms for 18 of 19 patients was 7.5 weeks (0.1 to 48). After the onset of symptoms, all but two patients were initially misdiagnosed with a symptoms-to-diagnosis duration of 16 weeks (2-59). At initial catheterization, 17 of 19 patients had angioplasty in 30 veins with stent placement in 5 vessels when a flap occurred. Overall vessel diameter increased from 2.6+/-1.6 to 6.6+/-2.4 mm (P<0.0001). There were 4 procedure-related adverse events but no long-term sequelae. Immediate follow-up showed improved flow to involved lung segments. At a median follow-up of 43 weeks (2-92), although repeat angioplasty for restenosis was necessary in 8 of 17 patients, 15 of 17 patients currently have no or minimal persistent symptoms. CONCLUSIONS Pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation is often misdiagnosed. Although further follow-up is necessary to determine long-term success, our data indicate better pulmonary vein flow and symptomatic improvement in the majority of patients undergoing dilation of postablation pulmonary vein stenosis.
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Affiliation(s)
- Athar M Qureshi
- Department of Pediatric Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Gerstenfeld EP, Callans DJ, Dixit S, Zado E, Marchlinski FE. Incidence and location of focal atrial fibrillation triggers in patients undergoing repeat pulmonary vein isolation: implications for ablation strategies. J Cardiovasc Electrophysiol 2003; 14:685-90. [PMID: 12930245 DOI: 10.1046/j.1540-8167.2003.03013.x] [Citation(s) in RCA: 162] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The etiology of atrial fibrillation (AF) recurrences after pulmonary vein (PV) isolation is not well described. The aim of this study was to examine the reason for recurrent AF in patients undergoing a repeat attempt at AF trigger ablation. METHODS AND RESULTS Patients with recurrent AF more than 1 month after ablation returned for repeat mapping and ablation. A circular mapping catheter was advanced to each previously targeted PV ostium to determine if the PV was still electrically isolated. Ectopy then was provoked with isoproterenol (up to 20 microg/min), burst pacing, and pacing into AF followed by cardioversion. The location of ectopy triggering atrial premature depolarizations (APDs) or AF was noted. Of 226 patients who underwent ablation of AF triggers, 34 (8 women and 26 men; age 56 +/- 10 years) with recurrent AF returned for a repeat procedure 207 +/- 183 days after the first procedure. There were 84 previously completely isolated PVs in these 34 patients. Thirty-three (39%) of 84 previously isolated PVs were still completely isolated at the time of the second procedure. Fifty-one PVs (61%) had evidence of recovered PV potentials. Fifty triggers of APDs and AF (n = 30) or APDs only (n = 20) were identified in these 34 patients. The majority of triggers [27/50 (54%)] originated from previously targeted PVs. Sixteen triggers [16/50 (32%)] originated from previously nontargeted PVs. CONCLUSION The majority of AF recurrences originate from previously isolated PVs. One third of recurrent triggers originated from PVs that were not targeted during the initial ablation session. Although empiric isolation of all PVs may reduce recurrences, strategies to ensure ostial PV isolation and to prevent recurrent PV conduction after ablation should have the greatest impact on reducing AF recurrence.
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Affiliation(s)
- Edward P Gerstenfeld
- Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Satake S, Tanaka K, Saito S, Tanaka S, Sohara H, Hiroe Y, Miyashita Y, Takahashi S, Murakami M, Watanabe Y. Usefulness of a new radiofrequency thermal balloon catheter for pulmonary vein isolation: a new device for treatment of atrial fibrillation. J Cardiovasc Electrophysiol 2003; 14:609-15. [PMID: 12875422 DOI: 10.1046/j.1540-8167.2003.02577.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A rapidly firing or triggered ectopic focus located within a pulmonary vein (PV) or close to the PV ostium could induce atrial fibrillation (AF). The aim of this study was to evaluate the efficacy and safety of a radiofrequency thermal balloon catheter for isolation of the PV from the left atrium (LA). METHODS AND RESULTS Twenty patients with drug-resistant paroxysmal AF were treated by isolating the superior PVs using an RF thermal balloon catheter. Using a transseptal approach, the balloon, which had an inflated diameter 5 to 10 mm larger than that of the PV ostium, was wedged at the LA-PV junction. It was heated by a very-high-frequency current (13.56 MHZ) applied to the coil electrode inside the balloon for 2 to 3 minutes, and the procedure was repeated up to four times. The balloon center temperature was maintained at 60 degrees to 75 degrees C by regulating generator output. Successful PV isolation was achieved in 19 of the 20 left superior PVs and in all 20 of the right superior PVs and was associated with a decrease in amplitude of the ostial potentials. Total procedure time was 1.8 +/- 0.5 hours, which included 22 +/- 7 minutes of fluoroscopy time. After a follow-up period of 8.1 +/- 0.8 months, 17 patients were free from AF, with 10 not taking any antiarrhythmic drugs and 7 taking the same antiarrhythmic agent as before ablation. Electron beam computed tomography revealed no complications, such as PV stenosis at ablation sites. CONCLUSION The PV and its ostial region can be safely and quickly isolated from the LA by circumferential ablation around the PV ostia using a radiofrequency thermal balloon catheter for treatment of AF.
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Affiliation(s)
- Shutaro Satake
- Cardiology and Catheterization Laboratories, Heart Center, Shonan Kamakura General Hospital, Kamakura, Japan.
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Kato R, Lickfett L, Meininger G, Dickfeld T, Wu R, Juang G, Angkeow P, LaCorte J, Bluemke D, Berger R, Halperin HR, Calkins H. Pulmonary vein anatomy in patients undergoing catheter ablation of atrial fibrillation: lessons learned by use of magnetic resonance imaging. Circulation 2003; 107:2004-10. [PMID: 12681994 DOI: 10.1161/01.cir.0000061951.81767.4e] [Citation(s) in RCA: 392] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study sought to define the technique and results of magnetic resonance imaging (MRI) of pulmonary vein (PV) anatomy before and after catheter ablation of atrial fibrillation (AF). METHODS AND RESULTS Twenty-eight patients with AF underwent ablation. Patients underwent gadolinium-enhanced MRI before and 6 weeks after their procedures. A control group of 27 patients also underwent MRI. Variant PV anatomy was observed in 38% of patients. AF patients had larger PV diameters than control subjects, but no difference was observed in the size of the PV ostia among AF patients. The PV ostia were oblong in shape with an anteroposterior dimension less than the superoinferior dimension. The left PVs had a longer "neck" than the right PVs. A detectable PV narrowing was observed in 24% of veins. The severity of stenosis was severe in 1 vein (1.4%), moderate in 1 vein (1.4%), and mild in 15 veins (21.1%). All patients were asymptomatic, and none required treatment. CONCLUSIONS This study demonstrates that AF patient have larger PVs than control subjects and demonstrates the value of MRI in facilitating AF ablation. The benefits of preprocedural MRI of PVs include the ability to evaluate the number, size, and shape of the PVs. MRI also provides an assessment of the severity of PV stenosis.
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Affiliation(s)
- Ritsushi Kato
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
In 2003, pulmonary venous flow (PVF) evaluation by Doppler echocardiography is being used daily in clinical practice. Twelve years ago, we reviewed the potential uses of PVF in various conditions. Some of its important uses in cardiology have materialized, while others have not and have been supplanted by newer approaches. Current applications of measuring PVF have included: differentiating constrictive pericarditis from restriction, estimation of left ventricular (LV) filling pressures, evaluation of LV diastolic dysfunction and left atrial (LA) function, and grading the severity of mitral regurgitation (MR). However, there have been a number of controversies raised in the use of PVF profiles. Using transthoracic echocardiography, there may be technical issues in measuring the atrial reversal flow velocity. The use of PVF in the evaluation of the severity of MR is not always specific and can be affected by atrial fibrillation (AF) and elevated mean LA pressure. Mitral valvuloplasty and radiofrequency ablation for AF, which are the newer applications of PVF in monitoring invasive procedures, are mentioned. This article reviews the important clinical role of Doppler evaluation of PVF, discusses its limitations and pitfalls, and highlights its newer applications.
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Affiliation(s)
- Tomotsugu Tabata
- Cardiovascular Imaging Center, Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Ohio 44195, USA
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Nattel S, Khairy P, Roy D, Thibault B, Guerra P, Talajic M, Dubuc M. New approaches to atrial fibrillation management: a critical review of a rapidly evolving field. Drugs 2003; 62:2377-97. [PMID: 12396229 DOI: 10.2165/00003495-200262160-00005] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, the prevalence of which is increasing with the aging of the population. Because of its clinical importance and the lack of highly satisfactory management approaches, AF is the subject of active clinical and research efforts. This paper reviews recent and on-going developments in pharmacological and non-drug management of AF. The ideal therapeutic goal for AF is the production and maintenance of sinus rhythm. Comparative studies suggest that available class I and III drugs have comparable and modest efficacy for sinus rhythm maintenance. Amiodarone, with actions of all antiarrhythmic classes, has recently been shown to have clearly superior efficacy compared with other available drugs. Newer agents are in development, but their advantages are as yet unclear and appear limited. A potentially interesting approach is the prescription of drugs upon the occurrence of an attack, rather than on a continuous basis. Recent insights into AF mechanisms may permit therapy to prevent development of the AF substrate. An alternative to sinus rhythm maintenance is a rate control approach, with no attempt to prevent AF. Drugs to effect rate control include digitalis, beta-blockers and calcium channel antagonists. Digitalis has limited value for control of exercise heart rate and for paroxysmal AF, but is particularly well suited for patients with concomitant AF and congestive heart failure. AV-nodal ablation and pacing is an effective alternative for rate control but leaves the patient pacemaker dependent. The relative merits of rate versus rhythm control are being evaluated in ongoing trials, preliminary results of which indicate no statistically significant differences in primary endpoints but highlight the risks of rhythm control therapy. In patients requiring pacemakers, physiological pacing (dual chamber devices or atrial pacing) has an advantage over purely ventricular pacemakers in AF prevention. Newer pacing modalities that produce more synchronised atrial activation, as well as pacemakers that prevent excessive atrial rate swings, show promise in AF prevention and may soon see wider use. The usefulness of automatic atrial defibrillators is presently limited by discomfort during shocks. Targeted destruction of pulmonary vein foci by radiofrequency catheter ablation suppresses paroxysmal AF. Efficacy in persistent AF is lower and still under study. Problems include potential recurrence in other veins and a small but nontrivial risk of pulmonary vein stenosis. Surgical division of the atria into zones with limited electrical connection, the MAZE procedure, is highly effective in AF prevention but is a major intervention that is not applicable to most patients. In conclusion, significant advances are being made in the management of patients with AF but much more work remains to be done.
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Affiliation(s)
- Stanley Nattel
- Department of Medicine and Research Center, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada.
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Villacastín J, Pérez-Castellano N, Moreno J, González R. Left atrial flutter after radiofrequency catheter ablation of focal atrial fibrillation. J Cardiovasc Electrophysiol 2003; 14:417-21. [PMID: 12741717 DOI: 10.1046/j.1540-8167.2003.02418.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report an arrhythmic complication in two patients in whom a procedure directed at isolating one or two pulmonary veins had been performed. The complication was related to pulmonary vein disconnection scars after ablation. Both patients developed new clinical tachycardia (atypical atrial flutter) secondary to a reentrant phenomena in the vicinity of a previously ablated pulmonary vein.
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Affiliation(s)
- Julián Villacastín
- Unidad de Arritmias del Instituto Cardiovascular del Hospital Cliníco San Carlos, Madrid, Spain.
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Feld GK, Yao B, Reu G, Kudaravalli R. Acute and chronic effects of cryoablation of the pulmonary veins in the dog as a potential treatment for focal atrial fibrillation. J Interv Card Electrophysiol 2003; 8:135-40. [PMID: 12766505 DOI: 10.1023/a:1023660901347] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) may be triggered by premature atrial depolarizations originating in the pulmonary veins (PV). Radiofrequency catheter ablation of PV foci may prevent recurrence of AF, but may cause PV stenosis. Therefore, a safer method for ablation of PV foci is needed. This study evaluated the acute and chronic effects of PV ablation using a cryocatheter ablation (CCA) system, which may be less likely to cause PV stenosis. METHODS CCA was performed by freezing for 5 minutes or more in one or more PVs in 10 anesthetized dogs. Pacing threshold and vessel diameter were measured before and after PV cryoablation. All dogs were restudied at 4.0 +/- 1.64 months (range 2-7) in a manner identical to baseline. RESULTS CCA was performed in 27 PVs (range 1-4/dog), with a mean freeze time of 8.62 +/- 5.42 minutes per vein (range 5.23-22.06). Mean temperature for all freezes was -65 +/- 5.3 degrees C. Mean PV diameter was 6.49 +/- 1.73 vs 6.24 +/- 1.83 mm (p = NS) and mean pacing threshold 1.32 +/- 0.75 vs 9.36 +/- 5.93 mA (p <.01), before vs. acutely after ablation. At followup, at the ablation sites PV diameter (7.02 +/- 1.88 mm) was unchanged from baseline, whereas pacing threshold remained elevated (2.54 +/- 1.44 mA, p <.05 vs baseline). There were no acute or long-term complications. CONCLUSIONS; (1) CCA of PVs produced a significant rise in acute and chronic pacing threshold indicating loss of atrial conductivity. (2) CCA of PVs did not cause PV stenosis or other complications. (3) The data suggest that CCA of PVs may be a safe and effective method for treating focal AF.
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Affiliation(s)
- Gregory K Feld
- Department of Medicine, Cardiac Electrophysiology Program, Division of Cardiology, University of California-San Diego, UCSD Medical Center, 200 W. Arbor Drive, San Diego, CA 92103, USA
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Ernst S, Ouyang F, Goya M, Löber F, Schneider C, Hoffmann-Riem M, Schwarz S, Hornig K, Müller KM, Antz M, Kaukel E, Kugler C, Kuck KH. Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease. J Cardiovasc Electrophysiol 2003; 14:366-70. [PMID: 12741706 DOI: 10.1046/j.1540-8167.2003.02334.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Catheter ablation has recently been used for curative treatment of atrial fibrillation. METHODS AND RESULTS Three of 239 patients who underwent ablation close to the pulmonary vein (PV) ostia at our institute developed severe hemoptysis, dyspnea, and pneumonia as early as 1 week and as late as 6 months after the ablation. Because the patients were arrhythmia-free, the treating physician initially attributed the symptoms to new-onset pulmonary disease (e.g., bronchopulmonary neoplasm). After absent PV flow was confirmed by transesophageal echocardiography, transseptal contrast injection depicted a totally occluded PV in all three patients. Successful recanalization, even in chronically occluded Pvs, was performed in all patients. During follow-up, Doppler flow measurements by transesophageal echocardiography demonstrated restenosis in all primarily dilated PV, which led to stent implantation. CONCLUSION PV stenosis/occlusion after catheter ablation of atrial fibrillation occurs in a subset of patients. However, because in-stent restenosis occurred in two patients after 6 to 10 weeks, final interventional strategy for PV stenosis or occlusion remains unclear. To prevent future PV stenosis or occlusion, a decrease in target temperature and energy of radiofrequency current or the use of new energy sources (ultrasound, cryothermia, microwave) seems necessary.
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Affiliation(s)
- Sabine Ernst
- Department of Cardiology, Allgemeines Krankenhaus St. Georg, Hamburg, Germany.
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