title: Severe Pulmonary Vein Stenosis Resulting From Ablation for Atrial Fibrillation: Presentation, Management, and Clinical Outcomes.
abstract: BACKGROUND
  The frequency of pulmonary vein stenosis (PVS) after ablation for atrial fibrillation has decreased, but it remains a highly morbid condition. Although treatment strategies including pulmonary vein dilation and stenting have been described, the long-term impacts of these interventions are unknown. We evaluated the presentation of severe PVS, and examined the risk for restenosis after intervention using either balloon angioplasty (BA) alone or BA with stenting.
  
  
  METHODS
  This was a prospective, observational study of 124 patients with severe PVS evaluated between 2000 and 2014.
  
  
  RESULTS
  All 124 patients were identified as having severe PVS by computed tomography in 219 veins. One hundred two patients (82%) were symptomatic at diagnosis. The most common symptoms were dyspnea (67%), cough (45%), fatigue (45%), and decreased exercise tolerance (45%). Twenty-seven percent of patients experienced hemoptysis. Ninety-two veins were treated with BA, 86 were treated with stenting, and 41 veins were not treated. A 94% acute procedural success rate was observed and did not differ by initial management. Major procedural complications occurred in 4 of the 113 patients (3.5%) who underwent invasive assessment, and minor complications occurred in 15 patients (13.3%). Overall, 42% of veins developed restenosis including 27% of veins (n=23) treated with stenting and 57% of veins (n=52) treated with BA. The 3-year overall rate of restenosis was 37%, with 49% of BA-treated veins and 25% of stented veins developing restenosis (hazard ratio, 2.77; 95% confidence interval, 1.72-4.45; P<0.001). After adjustment for age, CHA2DS2-VASc score, hypertension, and the time period of the study, there was still a significant difference in the risk of restenosis for BA versus stenting (hazard ratio, 2.46; 95% confidence interval, 1.47-4.12; P<0.001).
  
  
  CONCLUSIONS
  The diagnosis of PVS is challenging because of nonspecific symptoms and the need for dedicated pulmonary vein imaging. There is no difference in acute success by type of initial intervention; however, stenting significantly reduces the risk of subsequent pulmonary vein restenosis in comparison with BA.
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.).
authors: Erin A
authors: EA
authors: Fender
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.).
authors: R Jay
authors: RJ
authors: Widmer
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.).
authors: David O
authors: DO
authors: Hodge
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.).
authors: George M
authors: GM
authors: Cooper
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.).
authors: Kristi H
authors: KH
authors: Monahan
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.).
authors: Laurie A
authors: LA
authors: Peterson
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.).
authors: David R
authors: DR
authors: Holmes
authors: From Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (E.A.F., R.J.W., K.H.M., L.A.P., D.R.H., D.L.P.); and Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL (D.O.H., G.M.C.). packer.douglas@mayo.edu.
authors: Douglas L
authors: DL
authors: Packer
mesh_terms: D000328:Adult; D000800:Angioplasty, Balloon / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000628:therapy*; D019468:Disease Management; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000000981:diagnostic imaging / Q000502:physiology; D012307:Risk Factors; D012720:Severity of Illness Index; D000071078:Stenosis, Pulmonary Vein / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: ablation techniques; angioplasty; atrial fibrillation; pulmonary; valve stenosis