Utility of simultaneous triple balloon inflation technique through a single 6-French sheath in treating pulmonary vein stenosis

Pulmonary vein stenosis continues to pose significant challenges in children, frequently requiring repeated cardiac catheterisation procedures. This report describes a successful application of a "triple kissing balloon" technique to treat complex pulmonary vein stenosis in two patients, all accomplished with the use of a single 6-French sheath.

Pulmonary vein stenosis in heart transplant patients

BACKGROUND

Pulmonary vein stenosis (PVS) is a rare pediatric condition associated with significant mortality and morbidity. PVS in patients following heart transplant (HT) has not yet been described.

METHODS

Patients who had clinically significant PVS following a heart transplant during the time period of April 1, 2013 to April 30, 2023, at Seattle Children's Hospital were identified. Clinically significant PVS was defined as an atretic vein or a vein with a gradient of ≥4 mmHg across at least one vein by echocardiogram or during cardiac catheterization. Patients who had a diagnosis of PVS prior to their transplant were excluded. A total of six patients were identified. We collected clinical data on these patients from their pre-transplant course to their most recent status.

RESULTS

The median age at HT was 7.5 months (range 2-13 months). The median time from HT to diagnosis of PVS was 3.5 months (range 0.3-13 months). At the last follow-up, the patients had had two to five pulmonary vein interventions, and there were no mortalities. The donor-to-recipient weight and total cardiac volume (TCV) ratios were less than 2.0 in five of six of the patients.

CONCLUSIONS

PVS is a rare complication that is associated with patients who undergo HT during infancy. PVS develops soon after HT and screening should occur accordingly. Interestingly, high donor-to-recipient weight and TCV ratios are not necessarily associated with the development of PVS. Further work will need to be performed in order to determine the significance of PVS in post-HT patients.

Pathogenesis, Evaluation, and Management of Pulmonary Vein Stenosis: JACC Review Topic of the Week

Pulmonary vein stenosis (PVS) can arise from several etiologies, including congenital, acquired, and iatrogenic sources. PVS presents insidiously, leading to significant delays in diagnosis. A high index of suspicion and dedicated noninvasive evaluation are key to diagnosis. Once diagnosed, both noninvasive and invasive evaluation may afford further insights into the relative contribution of PVS to symptoms. Treatment of underlying reversible pathologies coupled with transcatheter balloon angioplasty and stenting for persistent severe stenoses are established approaches. Ongoing refinements in diagnostic modalities, interventional approaches, postintervention monitoring, and medical therapies hold promise to further improve patient outcomes.

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.