Pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations

• Published in: JACC. Cardiovascular interventions 2009-04, Vol.2 (4), p.267-276
• Main Authors: Holmes, Jr, David R, Monahan, Kristi H, Packer, Douglas
• Format: Article
• Language: English
• Subjects: Angioplasty, Balloon - instrumentation; Atrial Fibrillation - surgery; Catheter Ablation - adverse effects; Constriction, Pathologic; Echocardiography, Doppler, Color; Humans; Magnetic Resonance Angiography; Phlebography - methods; Pulmonary Veins - pathology; Pulmonary Veno-Occlusive Disease - diagnosis; Pulmonary Veno-Occlusive Disease - etiology; Pulmonary Veno-Occlusive Disease - therapy; Recurrence; Severity of Illness Index; Stents; Tomography, X-Ray Computed; Treatment Outcome
• ISSN: 1876-7605
• DOI: 10.1016/j.jcin.2008.12.014

Ablation procedures for atrial fibrillation are being performed with increasing frequency. One of the most serious complications is the development of pulmonary vein stenosis, which occurs in 1% to 3% of current series. The presentation of pulmonary vein stenosis varies widely. The majority of patients are symptomatic although specific referral bias patterns can affect this. Symptoms may include dyspnea or hemoptysis or may be consistent with bronchitis. These symptoms are affected by the number of stenotic veins as well as the severity of the stenosis. The more severe the stenosis and the greater number of stenosed veins result in more symptoms. Because of the variability in symptoms, clinicians must have heightened sensitivity to the presence of the condition. Diagnostic tests of value include magnetic resonance angiography and computed tomography. Although echocardiography has been used, it does not usually provide adequate assessment. Progression of stenosis is unpredictable and may be rapid. The specific anatomy of the stenosis varies widely and affects management. Because of the presence of antral fusion of the origin of the left superior and left inferior pulmonary vein, a stenosis involving 1 or the other can impinge and affect outcome. In this setting, bifurcation techniques familiar to interventional cardiology are very helpful. Controversy currently exists about the optimal treatment approach. The use of balloons and larger stents (approximately 10 mm) results in more optimal results than just balloon angioplasty alone; however, even with stent implantation, recurrent restenosis may occur in 30% to 50% of patients. Follow-up of these patients typically involves computed tomography imaging to document restenosis. If significant restenosis is identified, it should be treated promptly because of the potential for progression to total occlusion.