Pulmonary vein stenosis or occlusion after catheter ablation of atrial fibrillation: long-term comparison of drug-eluting versus large bare metal stents

Fink, Thomas; Schlüter, Michael; Heeger, Christian‐Hendrik; Lemeš, Christine; Lin, Tina; Maurer, Tilman; Metzner, Andreas; Mathew, Shibu; Reißmann, Bruno; Wohlmuth, Peter; Rillig, Andreas; Ouyang, Feifan; Kück, Karl‐Heinz; Tilz, Roland Richard

doi:10.1093/europace/eux291

Cited by 28 publications

(29 citation statements)

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“…20,21 However, limited data still suggest that outcome of DES alone is inferior to the larger diameter bare metal stents in this patient cohort. 22 It follows from our data that to improve outcomes of this patient cohort intervention should be undertaken before diffuse hypoplasia of the upstream pulmonary vein occurs. Previous data suggest time from ablation to intervention to be inversely associated with upstream pulmonary vein diameter.…”

Section: Discussionmentioning

confidence: 87%

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

Suntharos

Worley

Liu

et al. 2019

Cathet Cardio Intervent

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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.

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Section: Discussionmentioning

confidence: 87%

“…DES placement in both congenital PVS in small children and in adults after PVI shows promising results in small diameter vessels . However, limited data still suggest that outcome of DES alone is inferior to the larger diameter bare metal stents in this patient cohort …”

Section: Discussionmentioning

confidence: 91%

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

Suntharos

Worley

Liu

et al. 2019

Cathet Cardio Intervent

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“…In one case series of 56 patients with RFA-induced PV stenosis, stenting was found to be 95.8% successful, with significantly improved pressure gradients, vessel caliber, and symptoms [ 13 ]. Bare metal stents (which were used in our patient) have been shown to have a lower rate of restenosis than drug eluting stents [ 14 ]. In addition to instent stenosis, other complications of PV interventions include PV rupture, stroke, and phrenic nerve injury, which are all exceedingly rare [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

Pulmonary Vein Stenosis and Pulmonary Hypertension Following a Catheter-Based Radiofrequency Ablation for Atrial Fibrillation: A Case Report

et al. 2020

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Patient: Male, 78-year-old Final Diagnosis: Pulmonary vein stenosis Symptoms: Dyspnea Medication:— Clinical Procedure: Radiofrequency ablation • stenting of the pulmonary vein Specialty: Pulmonology Objective: Unusual clinical course Background: Pulmonary vein (PV) stenosis is a rare condition characterized by progressive luminal size reduction of one or more pulmonary veins (PVs), which can increase postcapillary pressure resulting in shortness of breath, cough, hemoptysis, and pulmonary hypertension (PH). The diagnosis of PV stenosis requires a high degree of suspicion. PV stenosis is a rare but recognized complication of catheter-based radiofrequency ablation (RFA) for atrial fibrillation (AF). Case Report: We present a case of a 78-year-old man who underwent a surgical MAZE procedure followed by catheter-based RFA to treat AF. He subsequently developed shortness of breath, exercise limitation, and PH. The patient was ultimately diagnosed with PV stenosis, which was a sequela of the RFA and the cause of his PH. The patient was treated by stenting of his PV, with improvement in his exercise capacity and PH. Follow-up imaging showed improved pulmonary blood flow and reduced pulmonary pressures. Conclusions: We conclude that PV stenosis should be high in the differential as the cause of dyspnea in patients with PH and a previous history of RFA for AF management. Early recognition and treatment can prevent complete occlusion of the affected PV and lead to an improvement in the patient’s symptoms and quality of life.

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“…Previously our group demonstrated that stenting significantly reduced the risk of restenosis compared to treatment with balloon angioplasty alone . A recent cohort study by Fink et al of 25 PVS cases reported restenosis in veins treated with large‐diameter BMS (range 7.0–10.0 mm) was one third of that in the DES group (range 4.0–5.0 mm) (21 vs. 67%, p = .08) . This suggests stent diameter may be an important predictor of restenosis.…”

Section: Discussionmentioning

confidence: 81%

Recurrent pulmonary vein stenosis after successful intervention: Prognosis and management of restenosis

Fender

Widmer

Mahowald

et al. 2019

Cathet Cardio Intervent

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Objectives: The aim of this study was to describe management of recurrent pulmonary vein stenosis (PVS) and determine if stenting is superior to balloon angioplasty (BA) in preventing subsequent restenosis.Background: PVS is a serious complication of atrial fibrillation ablation. BA and stenting are effective therapies; however, restenosis frequently occurs. Here we report management of recurrent stenosis. Methods:This was a prospective observational study performed from 2000 to 2014.Results: One hundred and thirteen patients with severe PVS underwent intervention in 88 veins treated with BA and 81 treated with stenting. Forty-two patients experienced restenosis. Restenosis was more common in veins treated with BA (RRR 53%[95% CI 32-70%, p = .008]). A second intervention was performed in 41 patients. In the 34 vessels treated with initial BA, 24 were treated for restenosis with a stent and 10 were treated with a second BA. The recurrence rate was 46% in those treated with BA followed by stenting and 50% in those treated with two BA procedures. In the 22 veins treated with initial stenting, 9 were treated with another stent and 13 were treated with BA. The recurrence rate was 44% in those treated with a second stent and 46% for those treated with a stent followed by BA. The risk of a third stenosis was the same among all groups (Analysis of variance [ANOVA] p = .99). Limited sample size precluded analysis of outcome by stent size. Conclusions: Restenosis occurred in 44% of patients overall. Management is challenging; stenting does not appear to be superior to BA. K E Y W O R D S pulmonary vein stenosis, vascular patency, stents, balloon angioplasty, catheter ablation 1 | INTRODUCTION Pulmonary vein stenosis (PVS) is estimated to complicate between 0.3 and 3.4% of atrial fibrillation (AF) ablation procedures. 1-4 Severe PVS is frequently symptomatic; over 80% of patients experienced symptoms of shortness of breath, cough, chest pain, hemoptysis, and pulmonary infarction. 5 High grade stenosis can be effectively managed Abbreviations: AF, atrial fibrillation; ANOVA, analysis of variation; BA, balloon angioplasty; BMI, body mass index; BMS, bare metal stent; CHA 2 DS 2 VASc, congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke or TIA or thromboembolism, vascular disease, age 65-75, sex (female); CI, confidence interval; CT, computed tomography; DCB, drugcoated balloon; DES, drug-eluting stent; HR, hazard ratio; ICE, intracardiac echo; IQR, interquartile range; PV, pulmonary vein; PVS, pulmonary vein stenosis; RR, relative risk; SD, standard deviation; TIA, transient ischemic attack. This work was conducted at the Mayo Clinic, Rochester, MN. ;95:954-958. wileyonlinelibrary.com/journal/ccd All variables were analyzed using software from SAS (version 9.4, Cary, NC). Statistical analysis was carried out on both a per patient and a per vein level. Normally distributed continuous variables are reported as a mean and SD, whereas nonuniformly distributed continuous variables are reported using the median ...

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Pulmonary vein stenosis or occlusion after catheter ablation of atrial fibrillation: long-term comparison of drug-eluting versus large bare metal stents

Abstract: The use of LD-BMS for the treatment of PVS/O was associated with an acceptable long-term outcome. Coronary DES implantation resulted in a high rate of restenosis and should therefore not be performed. Larger trials are needed to confirm our findings.

Cited by 28 publications

References 15 publications

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

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

Pulmonary Vein Stenosis and Pulmonary Hypertension Following a Catheter-Based Radiofrequency Ablation for Atrial Fibrillation: A Case Report

Recurrent pulmonary vein stenosis after successful intervention: Prognosis and management of restenosis

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