Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome

Comprehensive review of pulmonary vein stenosis post-atrial fibrillation ablation: diagnosis, management, and prognosis

Pulmonary vein stenosis (PVS) can occasionally occur in the follow-up after pulmonary vein isolation (PVI) for atrial fibrillation (AF). During PVI, ablation is performed at the PV ostium or distal part, leading to tissue damage. This damage can result in fibrosis of the necrotic myocardium, proliferation, and thickening of the vascular intima, as well as thrombus formation, further advancing PVS. Mild-to-moderate PVS often remains asymptomatic, but severe PVS can cause symptoms, such as dyspnea, cough, fatigue, decreased exercise tolerance, chest pain, and hemoptysis. These symptoms are due to pulmonary hypertension and pulmonary infarction. Imaging evaluations such as contrast-enhanced computed tomography are essential for diagnosing PVS. Early suspicion and detection are necessary, as underdiagnosis can lead to inappropriate treatment, disease progression, and poor outcomes. The long-term prognosis of PVS remains unclear, particularly regarding the impact of mild-to-moderate PVS over time. PVS treatment focuses on symptom management, with no established definitive solutions. For severe PVS, transcatheter PV angioplasty is performed, though the risk of restenosis remains high. Restenosis and reintervention rates have improved with stent implantation compared with balloon angioplasty. The role of subsequent antiplatelet therapy remains uncertain. Dedicated evaluation is essential for accurate diagnosis and appropriate management to avoid significant long-term impacts on patient outcomes.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Efficacy and safety of Saireito (TJ-114) in patients with atrial fibrillation undergoing catheter ablation procedures: A randomized pilot study

BACKGROUND

Early arrhythmia recurrences commonly occur after atrial fibrillation (AF) ablation because of irritability and inflammation of left atrium. We hypothesized that short-term use of Saireito would be effective in reducing frequent atrial tachyarrhythmias in the early-phase post-ablation.

METHODS

One hundred patients undergoing catheter ablation for symptomatic AF were randomly assigned to either a 30-day use of Saireito or control group. The primary endpoint was total number of episodes of frequent atrial tachyarrhythmias including definite recurrent AF and frequent premature atrial contractions during the 30-day treatment period post-ablation.

RESULTS

Three (6.0%) out of 50 patients treated with Saireito discontinued the drug because of adverse symptoms. The Saireito group was associated with a numerically lower number of episodes of frequent atrial tachyarrhythmias than the control group (3.1 versus 5.2 times, P = 0.17). The mean daily episodes of frequent atrial tachyarrhythmias were significantly fewer in the Saireito group during Day-6 to Day-10 (0.12/day versus 0.27/day, P = 0.03), and during Day-11 to Day-15 (0.08/day versus 0.24/day, P = 0.001). The prevalence of adverse symptoms during the 30-day treatment period was significantly higher in the Saireito group (18.0% versus 2.0%, P = 0.005).

CONCLUSIONS

Thirty-day use of Saireito following AF ablation was associated with a tendency toward reduced number of episodes of frequent atrial tachyarrhythmias during the treatment period, with more pronounced effect in the first two weeks.

Color Doppler Aliasing: Unmasking the Diagnosis of Cardiac Rosai-Dorfman

•Multimodality imaging of cardiac masses is needed for comprehensive evaluation. •Isolated cardiac RDD is reported to occur in 0.1% to 0.2% of cases. •Turbulent pattern of color flow Doppler should raise suspicion for PV stenosis.

Changes in pulmonary vein size and narrowing depend on the cardiac cycle before and after pulmonary vein isolation

Accurate measurement of the pulmonary vein dimension (PVD) is important for determining stenosis and efficacy following pulmonary vein isolation (PVI). Little is known about the quantitative evaluation of the impact of the cardiac cycle on pulmonary vein (PV) morphology before and after PVI. This study aims to investigate variations in the ostial size of the PV during the cardiac cycle before and after PVI and the effect of the cardiac cycle on PV stenosis and reduction rate using cardiac computed tomography (CT). Sixty-eight patients with atrial fibrillation who underwent cardiac CT before and after PVI at our institution between 23 January 2021 and 5 February 2022 were retrospectively analyzed. The maximum and minimum PVD were measured at each segment before and after the PV. Each PV was evaluated according to the PVD reduction rate (ΔPVD), calculated as follows: (1 - post-PVD/pre-PVD) × 100 (%). The average dimension of all PVs at the end-diastolic frame was significantly reduced compared to that at the end-systolic frame before PVI. The average dimensions of the right superior and right inferior PV at the end-diastolic frame were significantly reduced compared with those at the end-systolic frame following PVI. The average reduction rate of dimension-classified stenosis of PVs, except for the left inferior PV at the end-diastolic frame, was significantly reduced compared with that at the end-systolic frame. The cardiac cycle affects PVD assessment, including PV stenosis, after PVI. PVD measurement is recommended to be unified to the end-systolic frame of the cardiac cycle to avoid underestimating PV stenosis before and after PVI, ensuring appropriate management and follow-up.

Global research progress on radiofrequency ablation in cardiology: A bibliometric analysis (2004-2023)

In recent years, significant advancements in radiofrequency ablation technology have notably enhanced arrhythmia treatment in cardiology. Technological advancements and increasing clinical adoption have made radiofrequency ablation a key therapy in improving life quality for patients with conditions like atrial fibrillation (AF). Consequently, there has been a marked increase in research output, underscoring the technology's significance and its potential in cardiology. Aims to comprehensively analyze cardiology's radiofrequency ablation research trends, identifying leading countries and institutions in international collaborations, key researchers' contributions, and evolving research hotspots. The study, based on the Web of Science Core Collection database, reviewed the literatures from 2004 to 2023. CiteSpace 6.2.R7 Basic was used for bibliometric analysis, which examined annual publication trends, international collaboration networks, key authors, leading research institutions, major journals, keyword co-occurrence and clustering trends. Analyzing 3423 relevant articles, this study reveals a consistent growth in cardiology radiofrequency ablation research since 2004. The analysis shows that the United States, Germany, and France hold central roles in the international collaboration network, with leading authors from premier US and European institutions. Keyword cluster analysis identifies "atrial flutter" and "ventricular tachycardia" as current research focal points. Cardiology radiofrequency ablation research shows a growth trend, led by the United States and European countries. Research hotspots are concentrated on the diverse applications of radiofrequency ablation technology and the treatment of AF. Future studies may increasingly focus on technological innovation and the deepening of clinical applications.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Cardiovascular magnetic resonance pulmonary perfusion for functional assessment of pulmonary vein stenosis

BACKGROUND

Cardiovascular magnetic resonance (CMR) imaging allows to combine pulmonary perfusion measurements and pulmonary venous angiography during a single-session examination with both imaging modules representing the basis for accurate diagnosis and therapeutic stratification of pulmonary vein (PV) stenosis. The present study investigated the clinical utility of dynamic pulmonary perfusion imaging integrated into a comprehensive CMR protocol for the evaluation of patients with suspected PV stenosis.

METHODS

162 patients with clinically suspected PV stenosis after catheter ablation of atrial fibrillation underwent a combined single-session CMR examination (cardiac cine imaging, dynamic pulmonary perfusion, and three-dimensional PV angiography). CMR angiography was used for visual grading of PV stenoses; dynamic pulmonary perfusion imaging was evaluated per lung lobe visually and quantitatively.

RESULTS

All PV stenosis ≥90% showed a visible perfusion deficit of the corresponding lung lobe (60/60, 100%) while all PVs with luminal narrowing <50% exhibited normal pulmonary perfusion (680/680, 100%). However, every third 70-89% stenosis showed a normal pulmonary perfusion (10/31, 32%) while every fourth 50-69% PV stenosis was associated with hypoperfusion of the corresponding lung lobe (9/39, 23%). For quantitative pulmonary perfusion measurements, ROC analysis demonstrated high discriminatory power regarding PV stenosis detection with the highest AUC values for time-to-peak enhancement (cut-off value, 8.5 s).

CONCLUSIONS

The combination of CMR angiography and CMR pulmonary perfusion allowed for assessment of the anatomical degree of PV stenosis and its hemodynamic impact on the pulmonary parenchymal level. Thus, the proposed comprehensive CMR protocol provided an efficient diagnostic work-up of patients with suspected PV stenosis.

Pulmonary Vein Angioplasty for Pulmonary Vein Stenosis After Ablation Therapy for Atrial Fibrillation - A Report of 7 Cases

BACKGROUND

Pulmonary vein (PV) stenosis after atrial fibrillation (AF) ablation is rare; however, it remains a serious complication. PV angioplasty is reportedly an effective therapy; however, a dedicated device for PV angioplasty has not been developed, and the detailed procedural methods remain undetermined. This study describes the symptoms, indications, treatment strategies, and long-term outcomes for PV stenosis after AF ablation.

METHODS AND RESULTS

This study retrospectively analyzed 7 patients with PV stenosis after catheter ablation for AF and who had undergone PV angioplasty at our hospital during 2015-2021. PV stenosis occurred in the left superior (5 patients) and left inferior (2 patients) PV. Six patients had hemoptysis, chest pain, and dyspnea. Seven de novo lesions were treated using balloon angioplasty (BA) (3 patients), a bare metal stent (BMS) (3 patients), and a drug-coated balloon (DCB) (1 patient). The restenosis rate was 42.9% (n=3; 2 patients in the BA group and 1 patient in the DCB group). The repeat treatment rate was 28.6% (2 patients in the BA group). Stenting was performed as repeat treatment. One patient with subsequent repeat restenosis development underwent BA. Ten PV angioplasties were performed; there were no major complications.

CONCLUSIONS

Regarding PV angioplasty after ablation therapy for AF, stenting showed superior long-term PV patency than BA alone; therefore, it should be considered as a standard first-line approach.

Applications of multimodality imaging for left atrial catheter ablation

Atrial arrhythmias, including atrial fibrillation and atrial flutter, may be treated through catheter ablation. The process of atrial arrhythmia catheter ablation, which includes patient selection, pre-procedural planning, intra-procedural guidance, and post-procedural assessment, is typically characterized by the use of several imaging modalities to sequentially inform key clinical decisions. Increasingly, advanced imaging modalities are processed via specialized image analysis techniques and combined with intra-procedural electrical measurements to inform treatment approaches. Here, we review the use of multimodality imaging for left atrial ablation procedures. The article first outlines how imaging modalities are routinely used in the peri-ablation period. We then describe how advanced imaging techniques may inform patient selection for ablation and ablation targets themselves. Ongoing research directions for improving catheter ablation outcomes by using imaging combined with advanced analyses for personalization of ablation targets are discussed, together with approaches for their integration in the standard clinical environment. Finally, we describe future research areas with the potential to improve catheter ablation outcomes.

Post-ablation Dyspnea a Case Report to Highlight the Differential Diagnoses

The diagnosis of post-cardiac ablation pericarditis is difficult as it requires the exclusion of the more common causes of chest pain, but in the right setting, non-invasive diagnostic tools are adequate. Here we present the case of a 60-year-old man who underwent atrial fibrillation ablation and subsequently developed severe mid-sternal chest pain and dyspnea one day later without significant electrocardiographic findings, a mildly elevated troponin T, and elevation of the right hemidiaphragm. The patient was managed conservatively. A two-dimensional transthoracic echocardiogram showed no regional wall motion abnormalities, significant transvalvular gradients, but showed minimal pericardial effusion. A sniff test was negative for diaphragmatic paralysis. After the diagnosis, the patient’s symptoms resolved with non-steroidal anti-inflammatory drugs and colchicine. This case of pericarditis after cardiac ablation highlights the possible differential diagnosis when confronted with post-ablation cardiac symptoms. Despite the classic presentation, the electrocardiogram showed no significant ST/PR changes. In the right clinical setting, non-invasive imaging may be appropriate management.

Refractory Hemoptysis Caused by Severe Pulmonary Vein Stenosis after Multiple Catheter Ablations

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.

Anatomical changes in the pulmonary veins and left atrium after cryoballoon ablation

BACKGROUND

The anatomical changes in pulmonary veins (PVs) after cryoballoon ablation (CBA) are unclear. We aimed to determine the morphological changes in the PVs and left atrium (LA) along with the predictive factors for clinical PV stenosis.

METHODS

We analyzed data of 320 PVs from 80 patients who underwent CBA for atrial fibrillation (age: 62 ± 10 years, 59 males). All patients underwent pre- and post-procedural cardiac computed tomography. We defined clinical PV stenosis when the cross-sectional area decreased by more than 50%.

RESULTS

The average ostial PV area and LA volume decreased significantly after CBA (pre- vs post-CBA; 2.4 ± 1.0 cm² vs 2.3±1.1 cm² , P < .001, 75.0 ± 23.2 cm³ vs 70.7 ± 21.9 cm³ , P < .001, respectively). There was a significant correlation between the reduction rates of the PV area and those of LA volume (R = 0.411, P < .001). The larger preoperative PV area and greater reduction in LA volume were associated with advanced PV narrowing. Clinical PV stenosis was observed in six PVs, was more common in females (male vs female; 0.8% vs 4.8%, P = .043), and tended to be more frequent in left PVs (left PVs vs right PVs; 3.1% vs 0.6%: P = .107), irrespective of the LA volume reduction.

CONCLUSIONS

The significant reduction of the ostial PV area occurred after CBA, which correlated with the reduction rate of LA volume. The narrowing of the PV was partly produced by the LA volume reduction. Clinical PV stenosis was more common in females and tended to be more frequent in left PVs.

A Unique Compensatory Mechanism for Total Pulmonary Vein Occlusion Post Atrial Fibrillation Catheter Ablation Visualized by Multimodality Imaging

Pulmonary vein (PV) stenosis is a rare and serious complication of radiofrequency catheter ablation (RFCA) for atrial fibrillation. However, it can be asymptomatic or mildly symptomatic depending on the severity of the stenosis and the development of compensatory mechanisms. This study provides a detailed description and visualization of a unique type of venous collaterals that bypass the PV stenosis and drain directly in the left atrium alleviating PV stenosis sequelae. This study reports a case of a 61-year-old male who presented with mild dyspnea and fatigue 3 years post atrial fibrillation RFCA. After a thorough evaluation of the case, a redo-ablation was planned. As a part of the preablation workup, a transesophageal echocardiography (TEE), a ventilation-perfusion (V/Q) scan of the lungs, and a chest computed tomography angiogram (CTA) were performed. The TEE revealed total obstruction of the left superior PV, with no color Doppler flow detected. It also showed evidence of multiple collateral flows at the os of the left superior PV. The V/Q scan showed a large perfusion defect involving the entire left upper lobe consistent with a compromised left upper PV flow. The CTA with 3D volume rendering revealed the total occlusion of the left superior PV at its ostium. Moreover, the scan confirmed the pulmonary venous drainage via small collateral channels that was suggested by the TEE.

Treatment of Congenital and Acquired Pulmonary Vein Stenosis

PURPOSE OF REVIEW

Pulmonary vein stenosis (PVS) is a rare entity that until the last 2 decades was seen primarily in infants and children. Percutaneous and surgical interventions have limited success due to relentless restenosis, and mortality remains high. In adults, acquired PVS following ablation for atrial fibrillation has emerged as a new syndrome. This work will review these two entities with emphasis on current treatment.

RECENT FINDINGS

Greater emphasis on understanding and addressing the mechanism of restenosis for congenital PVS has led to the use of drug-eluting stents (DES) and systemic drug therapy to target neo-intimal growth. Frequent reinterventions are positively affecting outcomes. Longer-term outcomes of percutaneous treatment for acquired PVS are emerging. Treatment of congenital PVS continues to be plagued by restenosis. DES show promise, but frequent reinterventions are required. Larger upstream vein diameter predicts success for congenital and acquired PVS interventions. Efforts to induce/maintain vessel growth are important for future treatment strategies.

Radiofrequency Catheter Ablation: How to Manage and Prevent Collateral Damage?

Radiofrequency catheter ablation has become the standard of care for the management of various arrhythmias and, in fact, the first-line therapy for many tachyarrhythmias. It entails creating scar tissue in the heart in regions where abnormal impulses form or propagate to restore normal cardiac conduction. As the heart is a complex organ and is surrounded by and related to many other anatomical structures, it is important to avoid the collateral damage that can happen from radiofrequency (RF) ablation on the endocardium as well as on the epicardium. This review explores methods for mitigating or limiting collateral damage during catheter ablation.

Long-term outcome of percutaneous intervention for pulmonary vein stenosis after pulmonary vein isolation procedure

OBJECTIVES

Report long-term outcomes of percutaneous intervention in patients with pulmonary vein stenosis (PVS) after pulmonary vein isolation (PVI) from a single center over 16 years.

BACKGROUND

Outcome reports of percutaneous intervention for PVS resulting from PVI are limited.

METHODS

Retrospective review of all patients with PVS after PVI who underwent percutaneous intervention at the Cleveland Clinic Foundation between January 2000 and December 2016.

RESULTS

A total of 205 patients underwent cardiac catheterization for PVS during the study period. Completely occluded veins which could not be recanalized occurred in six patients. Of the remaining 199 patients, 27 (14%) were lost to follow-up, leaving 172 patients with 276 veins for analysis. Balloon angioplasty was performed in 62 veins and stent implantation in 250 (primary in 214, to treat postdilation restenosis in 36). Re-intervention occurred in 45/62 (73%) balloon-dilated veins and 45/250 (18%) stented veins. Freedom from re-intervention at 1 and 5 years was 90 and 73% following stenting versus 40 and 23% following balloon dilation (p < .001, Hazard ratio (HR) = 5.7). Veins with stent diameter ≥7 mm (n = 231) had greater freedom from re-intervention (95% at 1 year, 79% at 5 years) than veins with stents <7 mm (43% at 1 year, 9% at 5 years), p < .001. There was clear symptomatic improvement after intervention and no procedural mortality.

CONCLUSIONS

Stent implantation at ≥7 mm for PVS after PVI is associated with low rates of re-intervention, in contrast to balloon dilation and stenting with small conventional stents.

Repair of iatrogenic pulmonary vein occlusion with a vascularized atrial flap

Pulmonary vein obstruction is a rare condition, most commonly reported following pulmonary vein catheter ablation for atrial arrhythmia. This novel technique for treatment of pulmonary venous obstruction has the advantage of utilizing an autologous vascularized flap with intact endothelium for reconstruction of the pulmonary vein and to prevent restenosis.

Mimickers of chronic thromboembolic pulmonary hypertension on imaging tests: a review

Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by mechanical obstruction of large pulmonary arteries secondary to one or more episodes of pulmonary embolism. Ventilation perfusion scan is the recommended initial screening test for this condition and typically shows multiple large mismatched perfusion defects. However, not all patients with an abnormal ventilation perfusion scan have CTEPH since there are other conditions that be associated with a positive ventilation perfusion scan. These conditions include in situ thrombosis, pulmonary artery sarcoma, fibrosing mediastinitis, pulmonary vasculitis and sarcoidosis, among others. Although these conditions cannot be distinguished from CTEPH using a ventilation perfusion scan, they have certain characteristic radiological features that can be demonstrated on other imaging techniques such as computed tomography scan and can help in differentiation of these conditions. In this review, we have summarized some key clinical and radiological features that can help differentiate CTEPH from the CTEPH mimics.

Pulmonary Computed Tomography Parenchymal and Vascular Features Diagnostic of Postablation Pulmonary Vein Stenosis

PURPOSE

The purpose of this study was to define the full spectrum of pulmonary computed tomography (CT) changes characteristic of postablation pulmonary vein stenosis (PVS).

MATERIALS AND METHODS

We retrospectively reviewed our pulmonary vein isolation database. PVS was graded as follows: grade 1:<50%, grade 2: 50% to 75%, grade 3: 76% to 99%, and grade 4: total occlusion. CT parenchymal and vascular changes were detected and correlated with clinical course and nuclear scans.

RESULTS

Of 486 patients who underwent pulmonary vein isolation, 56 patients (11%) were symptomatic, prompting referral to CT evaluation. Grades 1, 2, 3, and 4 PVS were documented in 42, 1, 2, and 11 patients, respectively. Apart from PVS, abnormal CT findings were present only in patients with PVS grades 2 to 4. Pulmonary parenchymal changes (consolidation, "ground glass" opacities, interlobular septal thickening, and volume loss) were found in PVS grades 2 to 4. Pulmonary vascular changes (oligemia, "sluggish flow," and collateral mediastinal vessels) were shown in patients with grades 3 to 4 PVS. Concomitant nuclear scans documented reduced lung perfusion. All findings were located to the lobe drained by the affected vein. Complete resolution of pulmonary findings on follow-up CT scans was demonstrated in 20% of patients. Eleven stents were inserted in 7 patients with PVS grades 2 to 4, none of which demonstrated radiologic or clinical resolution.

CONCLUSIONS

A typical CT complex of both parenchymal and vascular findings in the affected lobe is diagnostic of postablation PVS. Lack of clinical and radiologic resolution in most patients, even after stent insertion, further highlights the importance of early recognition of this underdiagnosed condition.

Bilateral pulmonary vein stenting for treatment of massive hemoptysis caused by pulmonary vein stenosis following catheter ablation for atrial fibrillation

Background

Massive hemoptysis is a life-threatening condition. Massive hemoptysis caused by pulmonary vein stenosis (PVS) after radiofrequency catheter ablation for atrial fibrillation (AF) is rare. However, bilateral lung hemorrhage following bilateral PVS is extremely rare.

Case presentation

We herein describe a 62-year-old man with refractory massive hemoptysis after radiofrequency catheter ablation for AF, which was successfully controlled by surgical lobectomy and endovascular bilateral PV stenting. The hemorrhage was derived from the bilateral lungs following PV obstruction and bilateral PVS, which was definitively diagnosed by bronchoscopic examination. The patient had no recurrence of hemoptysis during a follow-up period of 30 months, and the PV stents had not narrowed as shown by computed tomography 30 months after stent placement.

Conclusions

Massive hemoptysis can be caused by bilateral PVS after radiofrequency catheter ablation for AF, and hemorrhage from the bilateral lungs in such patients is extremely rare. Nevertheless, cardiologists, interventional radiologists, and pulmonologists should consider the potential for massive hemoptysis caused by PVS.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1141-0) contains supplementary material, which is available to authorized users.

Video-Assisted Thoracoscopic Pneumonectomy for Complications of Congenital Pulmonary Venous Stenosis

Congenital pulmonary venous stenosis is an uncommon congenital heart defect and is a consequence of failed incorporation of the common right or left pulmonary vein into the left atrium during embryologic development. Clinical manifestations include progressive exertional dyspnea, cough, chest pain, and hemoptysis. In this report, we describe a 37-year-old woman with known congenital unilateral pulmonary venous stenosis and a unilateral hypoplastic right pulmonary artery who presented with recurrent episodes of hemoptysis, requiring multiple catheter-based interventions, and symptomatic pleural effusions, requiring multiple large-volume thoracenteses. The patient underwent successful video-assisted thoracoscopic pneumonectomy with resolution of symptoms.

The use of lobectomy for management of clinically significant pulmonary vein stenosis and occlusion refractory to percutaneous intervention

Pulmonary vein stenosis (PVS) is a serious complication of radiofrequency ablation (RFA) for the treatment of atrial fibrillation. The prevalence of this complication was reported to be as high as 42% in 1999 when RFA was first implemented [1]. However, with improvements in operator technique including wide area circumferential ablation, antral isolation, and the use of intracardiac ultrasound, the incidence of symptomatic severe PVS following RFA ranges from 0% to 2.1% while the incidence of symptomatic pulmonary vein occlusion (PVO) following RFA was found to be 0.67% [2–8]. Despite a decrease in the incidence of clinically significant PVS following RFA, there have been increased reports of complications associated with PVS to include hemoptysis, scarring, lung infarction, and intraparenchymal hemorrhage [9]. Studies have shown that PVS is often misdiagnosed as pneumonia, pulmonary embolism, and lung cancer and as a result, patients are often subjected to unnecessary diagnostic procedures [2,10].

The current first line treatment for this condition is percutaneous balloon angioplasty with stenting; however, there are studies that have shown that there is a relatively high rate of restenosis despite optimal medical therapy [2–3,10,11]. Three case reports have described the use of lobectomy to treat patients with persistent respiratory symptoms in the setting of severe PVO with good outcomes [12–14]. We present a case of iatrogenic PVO and ipsilateral severe PVS following RFA who underwent attempted lobectomy for persistent exertional dyspnea and persistent hypoperfusion of the left upper lung lobe despite percutaneous intervention and six months of optimal medical therapy. The lobectomy was aborted due to the presence of a significant fibrothorax, and the patient continues to have significant exercise limitation despite participation in pulmonary rehabilitation.

Contributors Toward Pulmonary Vein Restenosis Following Successful Intervention

OBJECTIVES

This study sought to identify clinical and procedural risk factors associated with pulmonary vein (PV) restenosis.

BACKGROUND

Pulmonary vein stenosis (PVS) is a rare but morbid complication of PV isolation for atrial fibrillation (AF) ablation. Interventions such as PV balloon angioplasty (BA) or stenting achieve excellent acute success; however, subsequent restenosis is common.

METHODS

A total of 113 patients underwent invasive treatment for severe PVS between 2000 and 2014 and were followed prospectively. Baseline patient and lesion characteristics were abstracted from chart review and analyzed. Univariate and multivariate analyses were performed using patient and procedural characteristics to determine which factors were associated with an increased risk for subsequent PV restenosis.

RESULTS

Over a median follow-up of 4.6 years there was PVS recurrence in 75 veins; 52 veins (57%) were treated with index BA and 23 veins were treated with stenting. After multivariate analysis, the only patient factor that was significantly associated with restenosis was a history of more than 1 AF ablation (hazard ratio [HR]: 1.91; 95% confidence interval [CI]: 1.07 to 3.41; p = 0.03). Multivariate analysis on a per-vein level demonstrated a significantly lower risk of restenosis in veins treated with a stent (HR: 2.84; 95% CI: 1.75 to 4.61; p < 0.0001). In veins treated with BA alone, inflation of the balloon to higher atmospheres significantly reduced the risk of recurrence (HR: 0.87; 95% CI: 0.78 to 0.98; p = 0.02).

CONCLUSIONS

Restenosis is common after a successful PV intervention and the risk of restenosis is highest in those with a history of multiple AF ablations and in those treated with BA. Proceduralists should take into account the number of AF ablations a patient has undergone and should strongly consider stent deployment when intervening on PVS to reduce risk of restenosis.

Spontaneous massive hemothorax presenting as a late complication of stent implantation in a patient with pulmonary vein stenosis following radiofrequency ablation for atrial fibrillation

Catheter ablation for symptomatic and drug-resistant atrial fibrillation is considered as the main acquired cause of pulmonary vein stenosis in adults. Controversy currently exists about the optimal treatment approach of this entity. Stenting seems to achieve lower vessel restenosis rates than isolated balloon angioplasty. However, these techniques are not exempt from complications. We present a case of spontaneous massive haemothorax presenting as a late complication of stent implantation in a patient with pulmonary vein stenosis.

Long-term follow-up in patients treated by stent implantation for post-ablation pulmonary vein stenosis

PURPOSE

Symptomatic severe pulmonary vein stenosis (PVS) after catheter ablation of atrial fibrillation (AF) is a rare but well-recognized complication. Treatment options include pulmonary vein angioplasty with or without drug eluting balloons or angioplasty with stent implantation. The treatment of choice is unclear. In our center, pulmonary vein stenting is the treatment of choice for significantly stenotic veins. We present the long-term clinical outcome of 9 patients treated with stent implantation.

METHODS

Between 2001 and 2015, 3048 patients with AF were treated with catheter ablation at our institution, of which 9 developed symptomatic PVS. A total of 11 PVS were treated. Pre-procedural imaging (CT, MR, transesophageal echocardiography, angiography) was performed in all patients.

RESULTS

Mean time from ablation to stenting was 18 months. Three patients had recurrent pneumonia and the remaining reduced functional capacity (NYHA 2). All patients were in functional capacity NYHA 1 (p < 0.05) after a mean follow-up of 64 (18-132) months. Three patients still had paroxysmal AF, of which two have undergone repeated ablation.

CONCLUSIONS

Symptomatic PVS after AF ablation can be successfully treated by stent implantation with durable results and good clinical outcome. AF ablation is still a feasible option after stent deployment.

Comprehensive Cross-sectional Imaging of the Pulmonary Veins

The pulmonary veins carry oxygenated blood from the lungs to the heart, but their importance to the radiologist extends far beyond this seemingly straightforward function. The anatomy of the pulmonary veins is variable among patients, with several noteworthy variant and anomalous patterns, including supernumerary pulmonary veins, a common ostium, anomalous pulmonary venous return, and levoatriocardinal veins. Differences in pulmonary vein anatomy and the presence of variant or anomalous anatomy can be of critical importance, especially for preoperative planning of pulmonary and cardiac surgery. The enhancement or lack of enhancement of the pulmonary veins can be a clue to clinically important disease, and the relationship of masses to the pulmonary veins can herald cardiac invasion. The pulmonary veins are also an integral part of thoracic interventions, including lung transplantation, pneumonectomy, and radiofrequency ablation for atrial fibrillation. This fact creates a requirement for radiologists to have knowledge of the pre- and postoperative imaging appearances of the pulmonary veins. Many of these procedures are associated with important potential complications involving the pulmonary veins, for which diagnostic imaging plays a critical role. A thorough knowledge of the pulmonary veins and a proper radiologic approach to their evaluation is critical for the busy radiologist who must incorporate the pulmonary veins into a routine "search pattern" at computed tomography (CT) and magnetic resonance imaging. This article is a comprehensive CT-based imaging review of the pulmonary veins, including their embryology, anatomy (typical and anomalous), surgical implications, pulmonary vein thrombosis, pulmonary vein stenosis, pulmonary vein pseudostenosis, and the relationship of tumors to the pulmonary veins. Online supplemental material is available for this article. ^©RSNA, 2017.

Acquired Whole-lung Mismatched Perfusion Defects on Pulmonary Ventilation/Perfusion Scintigraphy

Despite the increasing use of computed tomography pulmonary angiography to evaluate for pulmonary embolism (PE), ventilation/perfusion (V/Q) scintigraphy is still a fairly common examination. A rare finding on V/Q scintigraphy is whole-lung mismatched perfusion defect. Although this finding can occur with PE, it has an important, limited differential diagnosis. In this pictorial essay, we describe different causes of acquired whole-lung mismatched perfusion defect.

How to prevent, recognize and manage complications of AF ablation?

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.

Idiopathic pulmonary vein thrombosis: An unexpected cause of respiratory distress and acute heart failure. A case report and review of the literature

Introduction

Pulmonary vein thrombosis is a potentially fatal disease. The association between pulmonary vein thrombosis and chronic heart failure has not been described in the literature.

Case report

Herein, we report a case involving a 73-year-old woman, with a medical history of ischemic congestive heart failure, who was hospitalised for acute decompensated heart failure with respiratory distress. A computed tomography pulmonary angiography was performed to rule out the possibility of pulmonary embolism, and it showed evidence of pulmonary vein thrombosis. No cause was determined for the pulmonary vein thrombosis; hence, it was considered idiopathic and anticoagulation therapy was initiated for the patient. However, the patient died a few days after admission to the intensive care unit.

Conclusion

This case of pulmonary vein thrombosis is presented to promote awareness of this disease entity. We also want to emphasize the importance of maintaining a high index of clinical suspicion for this diagnosis, particularly in patients with acute decompensated heart failure who are refractory to standard therapy.

Impact of Radiofrequency Ablation of Atrial Fibrillation on Pulmonary Vein Cross Sectional Area: Implications for the Diagnosis of Pulmonary Vein Stenosis

Introduction

Restoration of normal sinus rhythm by radiofrequency ablation (RFA) in atrial fibrillation (AF) patients can result in a reduction of left atrial (LA) volume and pulmonary vein (PV) dimensions. It is not clear if this PV size reduction represents a secondary effect of overall LA volume reduction or true PV stenosis. We assessed the relationship between LA volume reduction and PV orifice area pre- and post-RFA.

Methods

A retrospective cohort study was conducted at a tertiary care academic hospital. Pre- and post-RFA cardiac computed tomography (CT) studies of 100 consecutive AF patients were reviewed. Studies identifying obvious segmental PV narrowing were excluded. Left atrial volumes and PV orifice cross-sectional areas (PVOCA) were measured using proprietary software from the CT scanner vendor (GE Healthcare, Waukesha, WI).

Results

The cohort had a mean age of 60 ± 8 years, 73% were male, and 90% were Caucasian. Non-paroxysmal AF was present in 76% of patients with a mean duration from diagnosis to RFA of 55 ± 54 months. Mean procedural time was 244 ± 70 min. AF recurred in 27% at 3 month follow-up. Pre-RFA LA volumes were 132 ± 60 ml and mean PVOCA was 2.89 ± 2.32 cm². In patients with successful ablation, mean LA volume decreased by 10% and PVOCA decreased by 21%. PVOCA was significantly reduced in patients with successful RFA compared to those who had recurrence (2.18 ± 1.12 vs. 2.8 ± 1.9 cm², p = 0.04) but reduction in LA volume between groups was not significant (118 ± 42 vs. 133 ± 54 ml, p=0.15).

Conclusions

The study demonstrates that both PV orifice dimensions and LA volume are reduced after successful AF ablation. These data warrant a reassessment of criteria for diagnosing PV stenosis based on changes in PV caliber alone, ideally incorporating LA volume changes.

Asymptomatic Pulmonary Vein Stenosis: Hemodynamic Adaptation and Successful Ablation

Pulmonary vein stenosis is a well-established possible complication following an atrial fibrillation ablation of pulmonary veins. Symptoms of pulmonary vein stenosis range from asymptomatic to severe exertional dyspnea. The number of asymptomatic patients with pulmonary vein stenosis is greater than originally estimated; moreover, only about 22% of severe pulmonary vein stenosis requires intervention. We present a patient with severe postatrial fibrillation (AF) ablation pulmonary vein (PV) stenosis, which was seen on multiple imaging modalities including cardiac computed tomography (CT) angiogram, lung perfusion scan, and pulmonary angiogram. This patient did not have any pulmonary symptoms. Hemodynamic changes within a stenosed pulmonary vein might not reflect the clinical severity of the obstruction if redistribution of pulmonary artery flow occurs. Our patient had an abnormal lung perfusion and ventilation (V/Q) scan, suggesting pulmonary artery blood flow redistribution. The patient ultimately underwent safe repeat atrial fibrillation ablation with successful elimination of arrhythmia.

Pulmonary Hypertension due to Radiofrequency Catheter Ablation (RFCA) for Atrial Fibrillation: The Lungs, the Atrium or the Ventricle?

Atrial fibrillation is the most common heart rhythm disorder in United States, characterised by rapid and irregular beating of both the atria resulting in the similar ventricular response. While rate and rhythm control using pharmacological regimens remain the primary management strategies in these patients, radiofrequency catheter ablation (RFCA) is rapidly rising as an alternative modality of treatment. Increase in the incidence of RFCA has shed light on complications associated with this procedure. Pulmonary hypertension (PH) is one of the long-term complications that has been observed postcatheter ablation. There have been multiple mechanisms which have been proposed to explain these elevated pulmonary pressures. These include the involvement of the lungs due to pulmonary vein stenosis, pulmonary vein occlusion and, rarely, pulmonary embolism. Radiofrequency catheter ablation can also lead to scarring of the atrium which can cause left atrial diastolic dysfunction leading to elevated pulmonary pressures. Recently, it was also proposed that elevated pulmonary pressure was related to the unmasking of left ventricular diastolic dysfunction occurring after this procedure. In this article, we review all the mechanisms that are associated with the development of pulmonary hypertension in patients undergoing RCFA for atrial fibrillation and the approach to diagnosis and management of such patients.