Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: An Iatrogenic Problem Larger Than the Primary Problem

Esophageal injury, perforation, and fistula formation following atrial fibrillation ablation

BACKGROUND

Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication.

METHODS

We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review.

RESULTS

A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5-40%, cryoballoon 3-25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention.

CONCLUSIONS

Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications.

Dynamic chest radiography for pulmonary vascular diseases: clinical applications and correlation with other imaging modalities

Dynamic chest radiography (DCR) is a novel functional radiographic imaging technique that can be used to visualize pulmonary perfusion without using contrast media. Although it has many advantages and clinical utility, most radiologists are unfamiliar with this technique because of its novelty. This review aims to (1) explain the basic principles of lung perfusion assessment using DCR, (2) discuss the advantages of DCR over other imaging modalities, and (3) review multiple specific clinical applications of DCR for pulmonary vascular diseases and compare them with other imaging modalities.

Pulmonary vein occlusion: A delayed complication following radiofrequency ablation for atrial fibrillation

This case reports demonstrates the rare but potentially serious complication of pulmonary vein stenosis and subsequent thrombosis diagnosed two years after radiofrequency ablation of the pulmonary veins for atrial fibrillation. Pulmonary vein stenosis can remain asymptomatic until significant occlusion occurs, after which it can present with a variety of symptoms, mimicking a myriad of cardiovascular and pulmonic pathologies. Early diagnosis and treatment rely on consistent follow up using appropriate diagnostic imaging modalities and is paramount in preventing severe complications.

Reduction in Pulmonary Vein Stenosis and Collateral Damage With Pulsed Field Ablation Compared With Radiofrequency Ablation in a Canine Model

BACKGROUND

Pulmonary vein (PV) stenosis is a highly morbid condition that can result after catheter ablation for PV isolation. We hypothesized that pulsed field ablation (PFA) would reduce PV stenosis risk and collateral injury compared with irrigated radiofrequency ablation (IRF).

METHODS

IRF and PFA deliveries were randomized in 8 dogs with 2 superior PVs ablated using one technology and 2 inferior PVs ablated using the other technology. IRF energy (25-30 W) or PFA was delivered (16 pulse trains) at each PV in a proximal and in a distal site. Contrast computed tomography scans were collected at 0, 2, 4, 8, and 12-week (termination) time points to monitor PV cross-sectional area at each PV ablation site.

RESULTS

Maximum average change in normalized cross-sectional area at 4-weeks was -46.1±45.1% post-IRF compared with -5.5±20.5% for PFA (P≤0.001). PFA-treated targets showed significantly fewer vessel restrictions compared with IRF (P≤0.023). Necropsy showed expansive PFA lesions without stenosis in the proximal PV sites, compared with more confined and often incomplete lesions after IRF. At the distal PV sites, only IRF ablations were grossly identified based on focal fibrosis. Mild chronic parenchymal hemorrhage was noted in 3 left superior PV lobes after IRF. Damage to vagus nerves as well as evidence of esophagus dilation occurred at sites associated with IRF. In contrast, no lung, vagal nerve, or esophageal injury was observed at PFA sites.

CONCLUSIONS

PFA significantly reduced risk of PV stenosis compared with IRF postprocedure in a canine model. IRF also caused vagus nerve, esophageal, and lung injury while PFA did not.

Combined pulmonary vein stenosis stenting and left atrial appendage occlusion in a patient with hemoptysis after atrial fibrillation ablation

Background

Pulmonary vein stenosis (PVS) after radiofrequency ablation for non-valvular atrial fibrillation (AF) is an uncommon but serious complication. PVS stenting can rapidly restore pulmonary flow and improve symptoms with long-term low incidence of restenosis. However, high risk of thrombosis remains if AF is recurrent, especially for CHA₂DS₂-VASc > 2.

Case presentation

A 67-year-old man with diabetes, hypertension and a history of stroke underwent radiofrequency pulmonary vein isolation for persistent AF 1 year ago. Six months later he developed recurrent respiratory infection and massive hemoptysis. Computed tomography pulmonary angiography revealed severe left pulmonary vein stenosis. Simultaneous percutaneous PVS stenting and left atrial appendage occlusion were performed to resolve recurrent hemoptysis and prevent stroke. The clinical follow-up indicated a good short and mid-term result with significant improvement of symptoms.

Conclusions

Simultaneous PVS stenting and left atrial appendage occlusion is feasible and effective in patients with recurrence of AF and hemoptysis induced by radiofrequency ablation for AF.

Stent implantation for severe pulmonary vein stenosis or occlusion secondary to atrial fibrillation ablation

BACKGROUND

Catheter interventional treatment of pulmonary vein stenosis or occlusion (PVS/O) following radiofrequency ablation (RFA) for atrial fibrillation (AF) remains a challenging field due to lacking randomized data and there are limited data about stenting.

METHODS

All patients at our center who underwent pulmonary vein stenosis (PVS) stenting for PVS/O induced by RFA were retrospectively assessed. Clinical presentation, anatomic site of stenosis and hemodynamic information, as well as follow-up data, were collected and analyzed.

RESULTS

From January 2010 to June 2018, 56 patients with PVS/O secondary to RFA were treated with 113 stents. Procedural success rate was 95.8%. Pressure gradients significantly reduced (p < 0.001) and vessel caliber markedly increased (p < 0.001) in all the stenotic sites, with immediate symptoms significantly improved. The overall in-stent restenosis (ISR) rate was 21.8% after a median follow-up period of 26 months (interquartile range: 16 to 35.5 months). The incidence of ISR was higher in patients treated with stent diameter ≤ 8 mm than those with stent diameter >8 mm (HR: 3.91; 95% CI 1.74-8.81; p = 0.001).

CONCLUSIONS

PVS stenting is a safe and effective procedure for PVS/O secondary to RFA. Long-term patency and good clinical outcomes are gained after bigger-diameter stent implantation.