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ARTICLE

Pulmonary Vein Stenosis after Catheter Ablation of Atrial Fibrillation: Emergence of a New Clinical Syndrome

Eduardo B. Saad, MD; Nassir F. Marrouche, MD; Cynthia P. Saad, MD; Edward Ha, MD; Dianna Bash, RN; Richard D. White, MD; John Rhodes, MD; Lourdes Prieto, MD; David O. Martin, MD; Walid I. Saliba, MD; Robert A. Schweikert, MD; and Andrea Natale, MD

15 April 2003 | Volume 138 Issue 8 | Pages 634-638

Background: Pulmonary vein isolation is a new, effective curative procedure for selected patients with atrial fibrillation. Pulmonary vein stenosis is a potential complication and may lead to symptoms that are often underrecognized.

Objective: To describe the clinical course and symptoms associated with pulmonary vein stenosis developing after ablation in the pulmonary veins.

Design: Retrospective study.

Setting: Tertiary care referral center.

Patients: 335 patients referred for catheter ablation of drug-refractory atrial fibrillation.

Intervention: Pulmonary vein electrical isolation using radiofrequency catheter ablation.

Measurements: Three months after ablation, patients underwent routine screening for pulmonary vein stenosis with spiral computed tomography. Screening was considered earlier if symptoms suggestive of stenosis developed and was repeated at 6 and 12 months if any pulmonary vein narrowing was observed. Pulmonary vein angiography and dilatation were offered to patients with severe (>70%) stenosis.

Results: Severe pulmonary vein stenosis was detected in 18 patients (5% [95% CI, 3.2% to 8.4%]) a mean (±SD) of 5.2 ± 2.6 months after ablation. Eight of these 18 patients (44%) were asymptomatic, but 8 (44%) reported shortness of breath, 7 (39%) reported cough, and 5 (28%) reported hemoptysis. Radiologic abnormalities were present in 9 patients (50%) and led to diagnoses of pneumonia (4 patients), lung cancer (1 patient), and pulmonary embolism (2 patients). Pulmonary vein stenosis was not considered in any patient during the initial work-up. Dilatation of the affected vein was performed in 12 patients. Postintervention lung perfusion scans revealed significant improvement in lung flow.

Conclusions: Severe pulmonary vein stenosis after catheter ablation of atrial fibrillation is associated with respiratory symptoms that frequently mimic more common diseases, often leading to erroneous diagnostic and therapeutic procedures. Awareness of this syndrome is important for proper and prompt management.

Editors' Notes Context Because electrical signals initiating atrial fibrillation originate in the pulmonary veins, radiofrequency catheter ablation has been highly successful in curing the arrhythmia. Pulmonary vein stenosis is a recognized complication of this procedure, but past research has not established its frequency or clinical characteristics. Contribution Of 335 patients who received catheter ablation, 18 developed severe pulmonary vein stenosis. Only 44% were symptomatic. Failure to recognize the problem often led to inappropriate work-up and treatment. After pulmonary vein dilatation and stenting, 57% of patients improved. Implications Pulmonary vein stenosis following catheter ablation of atrial fibrillation is relatively common and clinically recognizable. Mechanical relief of venous obstruction can alleviate symptoms. –The Editors

 

Author and Article Information

From The Cleveland Clinic Foundation, Cleveland, Ohio.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Andrea Natale, MD, Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Desk F15, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail, natalea{at}ccf.org.

Current Author Addresses: Drs. E.B. Saad, Marrouche, Ha, White, Rhodes, Prieto, Martin, Saliba, and Schweikert and Ms. Bash: The Cleveland Clinic Foundation, Desk F26, 9500 Euclid Avenue, Cleveland, OH 44195.

Dr. C.P. Saad: Department of Pulmonary and Critical Care Medicine, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A90, Cleveland, OH 44195.

Dr. Natale: Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Desk F15, 9500 Euclid Avenue, Cleveland, OH 44195.

Author Contributions: Conception and design: E.B. Saad, N.F. Marrouche, C.P. Saad, D.O. Martin, W.I. Saliba, R.A. Schweikert, A. Natale.

Analysis and interpretation of the data: E.B. Saad, C.P. Saad, E. Ha, R.D. White, D.O. Martin, W.I. Saliba, R.A. Schweikert, A. Natale.

Drafting of the article: E.B. Saad, C.P. Saad.

Critical revision of the article for important intellectual content: E.B. Saad, N.F. Marrouche, C.P. Saad, R.D. White, J. Rhodes, L. Prieto, D.O. Martin, W.I. Saliba, R.A. Schweikert, A. Natale.

Final approval of the article: W.I. Saliba, R.A. Schweikert, A. Natale.

Provision of study materials or patients: N.F. Marrouche, E. Ha, D. Bash, R.D. White, J. Rhodes, L. Prieto, D.O. Martin, W.I. Saliba, R.A. Schweikert, A. Natale.

Statistical expertise: C.P. Saad, D.O. Martin.

Administrative, technical, or logistic support: N.F. Marrouche, E. Ha, D. Bash, J. Rhodes, L. Prieto, W.I. Saliba, R.A. Schweikert, A. Natale.

Collection and assembly of data: E.B. Saad, N.F. Marrouche, C.P. Saad, E. Ha, D. Bash, J. Rhodes, L. Prieto, D.O. Martin, W.I. Saliba, R.A. Schweikert, A. Natale.

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Summaries for Patients
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