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

  1. Eduardo B. Saad, MD;
  2. Nassir F. Marrouche, MD;
  3. Cynthia P. Saad, MD;
  4. Edward Ha, MD;
  5. Dianna Bash, RN;
  6. Richard D. White, MD;
  7. John Rhodes, MD;
  8. Lourdes Prieto, MD;
  9. David O. Martin, MD;
  10. Walid I. Saliba, MD;
  11. Robert A. Schweikert, MD; and
  12. Andrea Natale, MD
  1. From The Cleveland Clinic Foundation, Cleveland, Ohio.

    Abstract

    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.

    Article and Author Information

    • 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.

    Summary for Patients

    • Summaries for Patients:Radiofrequency Treatment of Abnormal Heart Rhythm Can Damage the Vessels That Return Blood from the Lungs to the Heart Ann Intern Med April 15, 2003 138:I-41
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    1. Ann Intern Med April 15, 2003 vol. 138 no. 8 634-638
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