Drug-eluting stents for the treatment of pulmonary vein stenosis after atrial fibrillation ablation

Antithrombotic therapy after angioplasty of pulmonary vein stenosis due to atrial fibrillation ablation: A two-center experience and review of the literature

Background

Pulmonary vein stenosis (PVS) is a severe complication of atrial fibrillation (AF) ablation resulting in narrowing of affected pulmonary veins (PVs). Interventional treatment consists of angioplasty with or without PV stenting. The optimal postprocedural antithrombotic therapy is not known.

Study aims

To investigate the impact of antithrombotic medical therapy on recurrence of PVS after PV angioplasty.

Methods

A retrospective study of patients undergoing PV angioplasty with or without stent implantation in two German centers was performed. Postinterventional antithrombotic therapy consisted of either dual antiplatelet therapy (DAPT) or a combination of oral anticoagulation with single or dual antiplatelet therapy for 3-12 months after intervention. Angiographic follow-up was recommended 3, 6, and 12 months after intervention and in case of symptom recurrence.

Results

Thirty patients underwent treatment of 42 PVS. After intervention, twenty-eight patients received triple therapy and 14 patients received dual therapy/DAPT; restenosis occurred in 5/22 (22.7%) patients with triple therapy and 8/14 (57.1%) patients with dual therapy/DAPT PV (p = .001). Estimated freedom from PV restenosis after 500 days was 18.8 ± 15.8% (dual therapy/DAPT) and 76.2 ± 10.5% (triple therapy) (p = .003). Univariate regression analysis revealed postprocedural medication as a significant risk factor for restenosis (p = .019). No bleeding events occurred regardless of applied antithrombotic therapy.

Conclusion

Triple antithrombotic therapy after PV angioplasty is associated with less frequent restenosis as compared to dual antiplatelet therapy or a combination of anticoagulation and single antiplatelet therapy. No severe bleeding events occurred in patients on triple therapy. These findings need to be confirmed in larger patient cohorts.

Pulmonary Vein Stenosis-Balloon Angioplasty Versus Stenting: A Systematic Review and Meta-Analysis

Pulmonary vein stenosis (PVS) may arise from a variety of conditions and result in major morbidity and mortality. In some patients, pharmacologic therapy may help, but more often in advanced stages, mechanical treatment must be considered. Transcatheter approaches, both balloon angioplasty (BA) and stent implantation, have been applied. Although both are effective, they continue to be limited by restenosis. In this systematic review and meta-analysis, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus were searched for English-language studies in humans published between January 1, 2010, and August 2, 2021. Two independent reviewers screened for studies in which BA or stenting was performed for PVS with reporting of restenosis outcomes, and data were independently extracted. A systematic review was performed, and overall restenosis rates were reported across all 34 included studies. Meta-analysis was then performed using RevMan version 5.4, assessing rates of restenosis and restenosis requiring reintervention. For restenosis rates, 4 studies treated in those studies with available data reported. For restenosis rates, 4 studies treated a total of 340 patients with 579 pulmonary vein interventions (225 with BA and 354 with stenting, mean follow-up 13-69 months). Restenosis requiring repeat intervention was reported in 3 studies, including 301 patients with 495 pulmonary vein interventions (157 with BA and 338 with stenting). Compared with BA, stenting was associated with both a lower risk for restenosis (risk ratio: 0.36; 95% CI: 0.18-0.73; P = 0.005) and a lower risk for restenosis requiring reintervention (RR: 0.36; 95% CI: 0.15-0.86; P = 0.02). For PVS intervention, restenosis and reintervention rates may be improved by stent implantation compared with BA.

Experience using drug-coated balloon venoplasty for acquired pulmonary vein stenosis after radiofrequency ablation

Pulmonary vein stenosis is a rare but severe complication of catheter ablation for arterial fibrillation (AF). Symptoms include dyspnea, hemoptysis, recurrent pneumonia, and pulmonary hypertension. We herein discuss a 27-year-old male patient who presented with hemoptysis and dyspnea three months after catheter ablation for AF. Computed tomography demonstrated an occluded left inferior pulmonary vein (LIPV) and left lower lung edema secondary to severe stenosis of the LIPV. The patient underwent treatment, including drug-coated balloon (DCB) venoplasty. Treatment of pulmonary vein stenosis involving percutaneous interventions with balloon angioplasty and stenting carry a high risk of restenosis. DCB therapy may be used to prevent stenosis. <Learning objective: The use of a drug-coated balloon is feasible and may provide good long-term outcomes in acquired pulmonary vein stenosis after radiofrequency ablation.>.

Hemoptysis secondary to pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation: A case report and literature review

Objectives

Pulmonary vein stenosis (PVS) is a known complication after radiofrequency ablation of atrial fibrillation (RAAF) and is often misdiagnosed owing to lack of awareness regarding PVS among noncardiologists. Misdiagnosis results in unnecessary treatment; therefore, greater understanding of PVS can improve the management of these patients.

Methods

We report the case of a 38-year-old man with a history of RAAF who presented with massive hemoptysis. His symptoms persisted despite undergoing transcatheter bronchial artery embolization on two occasions.

Results

Pulmonary computed tomography angiography revealed a completely occluded left superior pulmonary vein. Considering the patient’s history of RAAF, we diagnosed him with RAAF-induced PVS and performed left superior lobectomy after which hemoptysis did not recur.

Conclusions

Unexplained massive hemoptysis should alert clinicians regarding the possibility of RAAF-induced PVS. Balloon angioplasty and stent placement are used to treat PVS; however, their efficacy is controversial considering the high recurrence rates associated with these interventions.

Successful Treatment of a Stenotic Pulmonary Vein to Left Atrium Conduit With a Drug-Eluting Stent

Partial anomaly of the pulmonary venous return is a rare congenital condition treated with surgical redirection of the blood flow through the creation of a conduit to the left atrium. We report the case of a stenotic pulmonary vein to left atrium conduit successfully treated with the implantation of a drug-eluting stent. Pulmonary vein or conduit stenosis is generally treated with balloon dilation or bare-metal stent but is often met with underwhelming outcomes. Given the successful outcome of the case presented, drug-eluting stents may represent an attractive treatment option in suitable anatomies.

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.

Acquired Pulmonary Vein Stenosis After Radiofrequency Ablation for Atrial Fibrillation: Single-Center Experience in Catheter Interventional Treatment

OBJECTIVES

The aim of the present study was to analyze and report a single-center experience with catheter interventional treatment of radiofrequency-induced pulmonary vein stenosis (PVS) following atrial fibrillation (AF) ablation.

BACKGROUND

Catheter interventional treatment of radiofrequency-induced PVS following AF ablation remains a challenging field because of a lack of randomized data and treatment guidelines.

METHODS

All patients at a single center who underwent catheter interventional treatment for radiofrequency-induced PVS were retrospectively assessed.

RESULTS

From January 2004 to September 2017, the total rate of PVS following interventional AF ablation was 0.78% (87 of 11,103). Thirty-nine patients with PVS were treated with 84 catheter interventions: 68 (81%) with percutaneous transluminal balloon angioplasty (PTA) and 16 (19%) with stent implantation. The distribution of stent type was 3 drug-eluting stents (19%) and 13 bare-metal stents (81%). The overall restenosis rate was 53% after PTA versus 19% after stent implantation (p = 0.007) after a median follow-up period of 6 months (interquartile range: 3 to 55 months). The total complication rate for PTA was 10% versus 13% for stenting (p = NS).

CONCLUSIONS

This study demonstrates significantly better outcomes in terms of restenosis after stent implantation versus PTA only, with comparable complication rates for these 2 options of interventional treatment of radiofrequency-induced PVS. In summary, despite the lack of randomized studies, the present data and currently available published studies seem to favor stent implantation as a first-line therapy in patients with radiofrequency-induced severe PVS.

Assessment and Management of Pulmonary Vein Occlusion After Atrial Fibrillation Ablation

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.

Outcomes and Management of Patients With Severe Pulmonary Vein Stenosis From Prior Atrial Fibrillation Ablation

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.

[Complications of the Catheter Treatment of Atrial Fibrillation: Stenosis of All Pulmonary Veins after Radiofrequency Ablation]

Radiofrequency ablation is the "gold standard" in atrial fibrillation treatment. The frequency of complications is about 3.5-3.9 %. The symptomatic pulmonary vein stenosis is one of the most severe complications. In this report we present a clinical case of stenosis of all four pulmonary veins after redo catheter ablation of atrial fibrillation in 61year-old patient, and discussion of possible causes, specific features of diagnosis, and possible approaches to treatment of this complication.

Rate of acquired pulmonary vein stenosis after ablation of atrial fibrillation referred to electroanatomical mapping systems: Does it matter?

BACKGROUND

Thermal injury during radiofrequency ablation (RFA) of atrial fibrillation (AF) can lead to pulmonary vein stenosis (PVS). It is currently unclear if routine screening for PVS by imaging (echocardiography, computed tomography) is clinically meaningful and if there is a correlation between PVS and the electroanatomical mapping system (EAMS) used for the ablation procedure. It was therefore investigated in the current single center experience.

METHODS

All patients from January 2004 to December 2016 with the diagnosis of PVS after interventional ablation of AF by radiofrequency were retrospectively analyzed. From 2004 to 2007, transesophageal echocardiography was routinely performed as screening for RFA-acquired PVS (group A). Since 2008, diagnostics were only initiated in cases of clinical symptoms suggestive for PVS (group B).

RESULTS

The overall PVS rate after interventional RFA for AF of the documented institution is 0.72% (70/9754). The incidence was not influenced by screening: group A had a 0.74% PVS rate and group B a 0.72% rate (NS). Referred to as the EAMS, there were significant differences: 20/4229 (0.5%) using CARTO®, 48/4510 (1.1%) using EnSite®, 1/853 (0.1%) using MediGuide®, and 1/162 (0.6%) using Rhythmia®. Since 2009, no significant difference between technologies was found.

CONCLUSIONS

The present analysis of 9754 procedures revealed 70 cases of PVS. The incidence of PVS is not related to screening but to the application of different EAMS. Possible explanations are technological backgrounds (magnetic vs. electrical), learning curves, operator experience, and work-flow differences. Furthermore, incorporation of new technologies seems to be associated with higher incidences of PVS before workflows are optimized.

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.

Reintervention Is Associated With Improved Survival in Pediatric Patients With Pulmonary Vein Stenosis

OBJECTIVES

The aim of this study was to evaluate survival following catheter intervention in pediatric patients with pulmonary vein stenosis (PVS).

BACKGROUND

Despite aggressive surgical and catheter intervention on PVS in children, recurrence and progression of stenosis can lead to right heart failure and death. Clinicians continue to seek effective treatment options for PVS.

METHODS

A single-center, retrospective study was performed including all patients <18 years of age who underwent catheter intervention (balloon angioplasty and bare-metal stent and drug-eluting stent insertion) on PVS. Endpoints included death, vein loss, and rate of reintervention.

RESULTS

Thirty patients underwent intervention (balloon angioplasty, n = 9; bare-metal stent, n = 5; drug-eluting stent, n = 16) at a median age of 6.4 months (4.3 to 9.9 months). Median follow-up duration was 30.6 months (77 days to 10.5 years). Fourteen patients (47%) died at a median of 2.0 months (0.4 to 3.2 months) following intervention. There was no association between DES placement and survival (p = 0.067). Reintervention (catheter or surgical) was associated with improved survival (p = 0.001), with a 1-year survival rate of 84% compared with 25% for no reintervention. Vein loss occurred in 34 of 58 (59%) veins at a median of 3.3 months (1.0 to 5.0 months). One-year vein survival was higher with DES implantation (p = 0.031) and with reintervention (p < 0.001).

CONCLUSIONS

DES implantation at first catheter intervention appears to be associated with improved vein survival but may not result in improved patient survival. However, reintervention appears to be associated with improved patient survival and vein patency, suggesting that despite mode of treatment, frequent surveillance is important in the care of these patients.

Recurrent haemoptysis as a symptom of severe pulmonary vein stenosis-a rare complication of catheter ablation in atrial fibrillation

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.

Severe Pulmonary Vein Stenosis Resulting From Ablation for Atrial Fibrillation

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.

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.

Pulmonary vein stenosis: Etiology, diagnosis and management

Pulmonary vein stenosis (PVS) is rare condition characterized by a challenging diagnosis and unfavorable prognosis at advance stages. At present, injury from radiofrequency ablation for atrial fibrillation has become the main cause of the disease. PVS is characterized by a progressive lumen size reduction of one or more pulmonary veins that, when hemodynamically significant, may raise lobar capillary pressure leading to signs and symptoms such as shortness of breath, cough, and hemoptysis. Image techniques (transesophageal echocardiography, computed tomography, magnetic resonance and perfusion imaging) are essential to reach a final diagnosis and decide an appropriate therapy. In this regard, series from referral centers have shown that surgical and transcatheter interventions may improve prognosis. The purpose of this article is to review the etiology, assessment and management of PVS.

Pulmonary Vein Stenosis Complicating Radiofrequency Catheter Ablation: Five Case Reports and Literature Review

The aim of this study is to characterize the clinical manifestations and features of pulmonary vein stenosis (PVS) by retrospectively analyzing clinical data of patients in addition to reviewing the literature simultaneously to improve the understanding of PVS complicating radiofrequency catheter ablation and to provide evidence for early diagnosis and timely treatment.Clinical, imaging, and follow-up data of 5 patients with PVS-complicating radiofrequency catheter ablation were retrospectively analyzed between January 2012 and December 2014 in Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China. Relevant studies previously reported were also reviewed.Three out of 5 patients received pulmonary angiography. The initial symptoms were not specific, presenting chest pain in 3 cases, hemoptysis in 2 cases. The average duration between radiofrequency ablation to the onset of symptoms was 5.8 months. The chest image results were consolidation and pleural effusion mainly. Veins distributed in the left lungs were mostly influenced in 4 patients, and the inferior veins in 3 patients. Cardiac ultrasound examinations showed pulmonary arterial hypertension in 2 patients. Two patients received selective bronchial artery embolization after bronchial artery radiography because of hemoptysis. One patient underwent video-assisted thoracoscopic biopsy because of the suspicion of tumor.PVS is a condition mostly undetected because of its silent manifestations and inconsistent follow-up. The accurate clinical diagnosis is very difficult. A careful review of medical history and follow-up observation may be useful for all the patients who received the radiofrequency catheter ablation to recognize PVS in the early stage.

Simultaneous kissing stent in a patient with severe bifurcation pulmonary vein stenosis

Pulmonary vein stenosis (PVS) is a late and rare complication of pulmonary vein isolation for the treatment of atrial fibrillation. The ideal approach to the management of PVS has not yet been established, however, corrective procedures may include both surgical and percutaneous techniques. We describe the case of a complex bifurcation lesion involving the left superior pulmonary vein. The condition required percutaneous intervention using a modified kissing stent technique with bare metal stents that resulted in an excellent post-operative course, sustained symptomatic relief, and uncomplicated 1-year follow-up. © 2014 Wiley Periodicals, Inc.

Novel balloon catheter device with pacing, ablating, electroporation, and drug-eluting capabilities for atrial fibrillation treatment--preliminary efficacy and safety studies in a canine model

Pulmonary vein isolation is an established therapeutic procedure for symptomatic atrial fibrillation (AF). This approach involves ablation of atrial tissue just outside the pulmonary veins. However, patient outcomes are limited because of a high rate of arrhythmia recurrence. Ablation of electrically active tissue inside the pulmonary vein may improve procedural success, but is currently avoided because of the complication of postablation stenosis. An innovative device that can ablate inside pulmonary veins and prevent stenosis is a viable strategy to increase long-term efficacy. We have developed a prototypical balloon catheter device capable of nonthermal pulmonary vein ablation along with elution of an antifibrotic agent intended to eliminate arrhythmogenic substrate without the risk of stenosis and have demonstrated its functionality in 4 acute canine experiments. Further optimization of this device may provide an innovative means to simultaneously ablate and prevent pulmonary vein stenosis for improved AF treatment in humans.

[Complications associated with catheter ablation of atrial fibrillation]

The past years catheter ablation has gained significant importance in the treatment of atrial fibrillation (AF), hence procedure numbers have risen worldwide. Initially, data concerning complications were only available through surveys and single center reports but international classification of diseases (ICD) code-based data have recently been published representing real world conditions. The rate of overall acute complications is 6.3 % and has risen slightly in the past 10 years whereby cardiac complications occurred most frequently, followed by vascular, respiratory and neurological complications. Risk factors for a higher complication rate are advanced age (> 80 years), female gender and less experienced investigators and hospitals.

Management Of Pulmonary Vein Stenosis Following Catheter Ablation Of Atrial Fibrillation

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.

The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation

PURPOSE

Pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) is associated with pulmonary vein stenosis (PVS). Although the reported incidence of PVS has fallen in recent years, the precise rate of PVS is unknown. Coherent guidelines for screening and treatment of PVS are not established. We reviewed literature to investigate the incidence, diagnosis, and management of PVS as a complication of PVI.

METHODS

We reviewed 41 manuscripts that described a total of 4,615 subjects (median, 84 subjects/study).

RESULTS

The incidence of PVS after PVI reported in literature from 1999 to 2004 ranges from 0 to 44% (mean, 6.3%; median, 5.4%), whereas studies after 2004 report an incidence of 0-19% (mean, 2%; median, 3.1%; p < 0.001). PVS symptoms typically occur with reduction of lung perfusion by 20-25%. Variable criteria exist for diagnosis of PVS by magnetic resonance imaging, computed tomography, and perfusion imaging. The restenosis rate for treatment with balloon angioplasty ranges from 30 to 87% (mean, 60%; median, 47%), compared with immediate stenting that ranges from 14 to 57% (mean, 34%; median, 33%).

CONCLUSIONS

Recent peer-reviewed articles suggest that PVI carries a 3-8% risk of developing PVS, but they likely underestimate the incidence of PVS, as specific screening and diagnostic guidelines are not established. Imaging modalities should be used to screen patients after ablation of AF since early recognition of PVS improves treatment outcomes. Treatment with angioplasty and stent placement can improve symptoms and lung perfusion but the benefit of treatment with immediate stent placement remains controversial. It is critical to maintain a high clinical index of suspicion for PVS in at-risk individuals to ensure timely detection and treatment.

Pulmonary Vein Stenting for Atrial Fibrillation Ablation-Induced Pulmonary Vein Stenosis

Pulmonary vein stenosis (PVS) is a known complication of pulmonary vein isolation in the treatment of atrial fibrillation. Patients with PVS can present with a great variety of symptoms. Clinicians should have a low threshold to evaluate for this potentially morbid and treatable condition. PVS can be treated by stenting affected pulmonary veins via transseptal access to the left atrium and use of bare metal biliary stents.