Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation.
BACKGROUND
Although segmental or circumferential ablation is effective in eliminating pulmonary vein (PV)-mediated atrial fibrillation (AF), this procedure may be complicated by the occurrence of PV stenosis.


RESULTS
To establish the clinical presentation, diagnostic manifestations, and interventional management of PV stenosis, 23 patients with stenosis of 34 veins complicating ablation of AF were evaluated. Each patient became symptomatic 103+/-100 days after undergoing ablation. In 8 veins, the ablation producing the PV stenosis was a repeated procedure for continued AF. Nineteen patients presented with dyspnea on exertion, 7 with dyspnea at rest, 9 with cough, and 6 with chest pain. On multirow spiral computed tomography examination, the narrowest lumen of the affected PVs measured 3+/-2 mm compared with 13+/-3 mm at baseline (P< or =0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4+/-3% of total perfusion compared with 22+/-10% in unaffected segments. At percutaneous intervention, these veins showed 80+/-13% stenosis, with a mean gradient of 12+/-5 mm Hg. This was significantly reduced to a residual stenosis of 9+/-8% (P< or =0.001) and a residual gradient of 3+/-4 mm Hg (P< or =0.001). Twenty veins were treated with balloon dilatation alone, whereas 14 veins were stented with standard 10-mm-diameter bare-metal stents. Although the symptomatic response was nearly immediate and impressive, 14 patients developed in-stent or in-segment restenosis, requiring repeated interventions in 13.


CONCLUSIONS
Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AF. Nevertheless, alternative treatment methods will be required to decrease recurrent in-stent or in-segment restenosis.
Packer
Douglas L
DL
Division of Cardiac Electrophysiology/Cardiology, Department of Internal Medicine, Mayo Clinic and Foundation, Saint Mary's Hospital Complex, Rochester, Minn 55902, USA. packer@mayo.edu
Keelan
Paul
P
Munger
Thomas M
TM
Breen
Jerome F
JF
Asirvatham
Sam
S
Peterson
Laura A
LA
Monahan
Kristi H
KH
Hauser
Mary F
MF
Chandrasekaran
K
K
Sinak
Lawrence J
LJ
Holmes
David R
DR
D000328:Adult; D001281:Atrial Fibrillation / Q000150:complications / Q000601:surgery*; D017115:Catheter Ablation; D003251:Constriction, Pathologic / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000000981:diagnostic imaging / Q000601:surgery*; D011668:Pulmonary Veno-Occlusive Disease / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D014057:Tomography, X-Ray Computed