Pulmonary Vein Total Occlusion Following Catheter Ablation for Atrial Fibrillation

Abstract

Patients with single PVO are mostly asymptomatic and should undergo routine imaging. On the other hand, patients with concomitant ipsilateral PV stenosis/PVO and a CSI > or =75% require early and, when necessary, repeated pulmonary interventions for restoration of pulmonary flow and prevention of associated lung disease.

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…Since first reported in 1998, numerous studies have sought to determine the incidence, cause, diagnostic strategy and treatment approach for PV stenosis. 434,927,1142,1143,1144,1145 Although the precise pathophysiological mechanisms are still uncertain, a progressive neointimal proliferation and myocardial fibrosis resulting in endovascular contraction has been reported after extensive radiofrequency energy ablation (RFA) to canine PVs. 1146 PV stenosis has been described for both point-by-point RF ablation as well as CBA.…”

“…927,1152 Prominent symptoms are dyspnea, hemoptysis, cough, (recurrent) pulmonary infections or pneumonia, and chest pain. 1142,1143,1152 These have often led to a misdiagnosis of pneumonia, pulmonary embolism, or even lung cancer; thus, patients should be told of the importance of returning to their ablation center if such signs or symptoms develop. There are data showing a progression of stenosis during 3 months after RFA despite a normal imaging examination at 1 month after the index procedure.…”

“…927,1142,1143,1152,1155 Stent sizes of 9 mm or more, and especially drug-eluting stents, revealed significantly better results, although drug-eluting stents of this size are not available. 1142,1143,1144,1156 Whether or not primary stenting of PV stenosis offers better results than angioplasty alone has now been systematically studied by several groups. 1144,1155 The risk of restenosis is significantly less with PV stenting, providing a stent of 8–10 mm in diameter can be used.…”

“…Complications of interventional treatment of PV stenosis include LA perforation with or without tamponade, but also PV dissection with massive bleeding, stent embolization, and stent thrombosis. 1142,1143 There are limited data regarding the need for and intensity of anticoagulation and antiplatelet therapy. For cases in which anticoagulation is otherwise indicated for AF, a regimen including the addition of clopidogrel is most commonly used.…”

“…1142,1143,1144,1145,1155,1156 Thus, follow-up strategies and intensity should be based on symptoms. Patients with restenosis usually report an increase of complaints existing prior to the intervention.…”