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Zakynthinos GE, Dimeas IE, Sinis SI, Tsolaki V, Daniil Z, Gourgoulianis KI. Recurrent Pleuritic Chest Pain, Lobar Consolidation, and Pleural Effusion in a 50-Year-Old Woman. Chest 2022; 162:e37-e41. [DOI: 10.1016/j.chest.2022.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 02/02/2022] [Accepted: 02/23/2022] [Indexed: 10/17/2022] Open
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Assessment and Management of Pulmonary Vein Occlusion After Atrial Fibrillation Ablation. JACC Cardiovasc Interv 2019; 11:1633-1639. [PMID: 30139471 DOI: 10.1016/j.jcin.2018.05.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/03/2018] [Accepted: 05/08/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study sought to evaluate the sensitivity of noninvasive imaging in the assessment of severely stenosed and occluded pulmonary veins, and examine clinical outcomes following percutaneous intervention. BACKGROUND PV stenosis (PVS) is a rare complication of atrial fibrillation ablation, but is associated with significant morbidity. Patients present with nonspecific pulmonary symptoms that can result in delayed diagnosis and progression to PV occlusion. The assessment and management of PV occlusion has rarely been described. METHODS This was a prospective observational study performed from 2000 to 2014. RESULTS Computed tomography identified 124 patients with severe PVS, including 46 patients with at least 1 occluded vein. Patients with PV occlusion more frequently presented with cough (64.1% vs. 32.8%; p = 0.002) and hemoptysis (39.1% vs. 14.1%; p = 0.0015) and were more likely to have pulmonary parenchymal consolidation (77.3% vs. 41.7%; p = 0.0002). Intervention was attempted in 65 occluded veins and a residual microchannel was identified in 22 (34.0%). Balloon angioplasty was performed in 11, and 11 were treated with stenting. Over 3 years the rates of restenosis were similar for patients with PVS and PV occlusion (47.0% vs. 35.0%; p = 0.24). Among patients with PV occlusion, stenting significantly reduced the rate of restenosis (hazard ratio: 3.97; 95% confidence interval: 1.14 to 13.85; p = 0.03). CONCLUSIONS Veins deemed occluded on noninvasive imaging require invasive characterization, as residual microchannels may be present in one-third of patients. In patients with a microchannel, intervention can be performed with either balloon angioplasty or stenting. Recurrence remains a common problem; however, stenting significantly reduces the rate of subsequent restenosis.
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Raeisi-Giglou P, Wazni OM, Saliba WI, Barakat A, Tarakji KG, Rickard J, Cantillon D, Baranowski B, Tchou PJ, Bhargava M, Dresing TJ, Callahan TD, Kanj M, Lindsay BD, Hussein AA. Outcomes and Management of Patients With Severe Pulmonary Vein Stenosis From Prior Atrial Fibrillation Ablation. Circ Arrhythm Electrophysiol 2019; 11:e006001. [PMID: 29752377 DOI: 10.1161/circep.117.006001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 03/12/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary vein (PV) stenosis remains a feared complication of atrial fibrillation ablation. Little is known about outcomes in patients with severe PV stenosis, especially about repeat ablations. METHODS In 10 368 patients undergoing atrial fibrillation ablation (2000-2015), computed tomography scans were obtained 3 to 6 months after ablation. The clinical outcomes in severe PV stenosis were determined. RESULTS Severe PV stenosis was diagnosed in 52 patients (0.5%). This involved mostly the left superior PV (51% of severely stenosed veins). Percutaneous interventions were performed in 43 patients, and complications occurred in 5: 3 PV ruptures, 1 stroke, and 1 phrenic injury. Over a median follow-up of 25 months, 41 (79%) patients remained arrhythmia free. Repeat ablation was performed in 15 patients (7 from the main series and 8 from prior ablation at other institutions); of whom 10 had PV stents in place. Conduction recovery was noted in all but 2 of the stenosed or stented PVs, and areas with recovery were targeted with antral ablation. Lasso entrapment within stents occurred in 2 patients but eventually freed without complications. After redo ablation, preplanned stenting was performed in 3 patients and computed tomographic scans showed progression of concomitant stenoses in 1 patient (moderate to severe). No procedure-related deaths occurred. CONCLUSIONS The incidence of severe PV stenosis is low but remains associated with significant morbidity. In patients with recurrent arrhythmia, conduction recovery at the stenosed or stented veins is common. Care must be taken to ablate antrally to avoid stenosis progression. In patients with prior PV stents, we suggest to avoid using Lasso.
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Affiliation(s)
| | - Oussama M Wazni
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Walid I Saliba
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Amr Barakat
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | | | - John Rickard
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Daniel Cantillon
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Bryan Baranowski
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Patrick J Tchou
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Mandeep Bhargava
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Thomas J Dresing
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Thomas D Callahan
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Mohamed Kanj
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Bruce D Lindsay
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH
| | - Ayman A Hussein
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, OH.
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Padala SK, Ellenbogen KA. Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: An Iatrogenic Problem Larger Than the Primary Problem. Circ Arrhythm Electrophysiol 2019; 11:e006461. [PMID: 29752378 DOI: 10.1161/circep.118.006461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Santosh K Padala
- Section of Electrophysiology, Virginia Commonwealth University, Richmond
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Fender EA, Widmer RJ, Hodge DO, Cooper GM, Monahan KH, Peterson LA, Holmes DR, Packer DL. Severe Pulmonary Vein Stenosis Resulting From Ablation for Atrial Fibrillation. Circulation 2016; 134:1812-1821. [DOI: 10.1161/circulationaha.116.021949] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 10/05/2016] [Indexed: 02/02/2023]
Abstract
Background:
The frequency of pulmonary vein stenosis (PVS) after ablation for atrial fibrillation has decreased, but it remains a highly morbid condition. Although treatment strategies including pulmonary vein dilation and stenting have been described, the long-term impacts of these interventions are unknown. We evaluated the presentation of severe PVS, and examined the risk for restenosis after intervention using either balloon angioplasty (BA) alone or BA with stenting.
Methods:
This was a prospective, observational study of 124 patients with severe PVS evaluated between 2000 and 2014.
Results:
All 124 patients were identified as having severe PVS by computed tomography in 219 veins. One hundred two patients (82%) were symptomatic at diagnosis. The most common symptoms were dyspnea (67%), cough (45%), fatigue (45%), and decreased exercise tolerance (45%). Twenty-seven percent of patients experienced hemoptysis. Ninety-two veins were treated with BA, 86 were treated with stenting, and 41 veins were not treated. A 94% acute procedural success rate was observed and did not differ by initial management. Major procedural complications occurred in 4 of the 113 patients (3.5%) who underwent invasive assessment, and minor complications occurred in 15 patients (13.3%). Overall, 42% of veins developed restenosis including 27% of veins (n=23) treated with stenting and 57% of veins (n=52) treated with BA. The 3-year overall rate of restenosis was 37%, with 49% of BA-treated veins and 25% of stented veins developing restenosis (hazard ratio, 2.77; 95% confidence interval, 1.72–4.45;
P
<0.001). After adjustment for age, CHA2DS2-VASc score, hypertension, and the time period of the study, there was still a significant difference in the risk of restenosis for BA versus stenting (hazard ratio, 2.46; 95% confidence interval, 1.47–4.12;
P
<0.001).
Conclusions:
The diagnosis of PVS is challenging because of nonspecific symptoms and the need for dedicated pulmonary vein imaging. There is no difference in acute success by type of initial intervention; however, stenting significantly reduces the risk of subsequent pulmonary vein restenosis in comparison with BA.
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Affiliation(s)
- Erin A. Fender
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - R. Jay Widmer
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - David O. Hodge
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - George M. Cooper
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - Kristi H. Monahan
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - Laurie A. Peterson
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - David R. Holmes
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
| | - Douglas L. Packer
- From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.)
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Fender EA, Packer DL, Holmes DR. Pulmonary vein stenosis after atrial fibrillation ablation. EUROINTERVENTION 2016; 12 Suppl X:X31-X34. [DOI: 10.4244/eijv12sxa7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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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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Abstract
PURPOSE OF REVIEW The diagnosis of pulmonary vein stenosis, following catheter ablation of atrial fibrillation, potentially carries significant morbidity for affected patients. It is important that physicians remain aware of the entity and have an understanding of how to treat such patients. There has been controversy in how to assess patients following atrial fibrillation ablation, and how to treat asymptomatic patients with pulmonary vein stenosis. This article reviews the recently published data. RECENT FINDINGS The reported incidence of pulmonary vein stenosis is decreasing. Nonetheless, it may not be found if not sought, as even patients with severe pulmonary vein stenosis may be asymptomatic. Also, patients with symptoms may be misdiagnosed if pulmonary vein stenosis is not included in the differential diagnosis. Computed tomography (CT) and MRI have been shown to be the diagnostic modalities of choice. The treatment options for severe pulmonary vein stenosis and occlusion are primarily that of pulmonary vein angioplasty with or without stenting. Despite the observed rate of restenosis, patients derive benefit from pulmonary vein angioplasty. SUMMARY The best imaging modalities to assess for pulmonary vein stenosis are CT and MRI. Early intervention in symptomatic patients with severe pulmonary vein stenosis is warranted; in asymptomatic patients, the data suggest that such patients will also derive benefit.
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Kim JH, Shin SY, Joo HJ, Choi JI, Hong SJ, Pak HN, Kim YH. Percutaneous Pulmonary Vein Angioplasty for the Pulmonary Vein Stenosis After Catheter Ablation of Atrial Fibrillation. Korean Circ J 2008. [DOI: 10.4070/kcj.2008.38.3.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Ji Hoon Kim
- Department of Cardiology and Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Yong Shin
- Department of Cardiology and Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyung Joon Joo
- Department of Cardiology and Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jong Il Choi
- Department of Cardiology and Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Soon Jun Hong
- Department of Cardiology and Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hui-Nam Pak
- Department of Cardiology and Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young-Hoon Kim
- Department of Cardiology and Internal Medicine, Korea University College of Medicine, Seoul, Korea
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