Case Study: Pulmonary vein stenting for stenosis following pulmonary vein isolation for atrial fibrillation
Amar Krishnaswamy, MD, E. Murat Tuzcu, MD, Bryan Baranowski, MD, and Samir R. Kapadia, MD
A 25-year-old man had been diagnosed with symptomatic atrial fibrillation and prescribed antiarrhythmic medications. Due to inadequate rate and rhythm control, he was referred for pulmonary vein isolation (PVI) at another institution. Within a few weeks of the procedure, he experienced the onset of cough, mild left-sided chest discomfort and worsening dyspnea. He presented to Cleveland Clinic for further evaluation and management.
Chest X-ray was unremarkable. However, a CT scan of the chest demonstrated complete occlusion of the left superior pulmonary vein (LSPV, Figure 1A). A nuclear perfusion scan of the lungs demonstrated a marked reduction in perfusion to the left upper lung field, concurrent with reduced drainage of the left upper lung due to the LSPV occlusion. Given the patient’s significant symptoms, the decision was made to treat the LSPV occlusion percutaneously.
The patient was brought to the cardiac catheterization laboratory. After sterile preparation and administration of local anesthesia and conscious sedation, venous access was obtained in the left femoral vein. An intracardiac echocardiography probe was introduced and advanced into the right atrium to facilitate transseptal puncture from the right atrium to the left atrium. Via access in the right femoral vein, a transseptal puncture needle was passed and advanced to the left atrium. An angiogram of the left atrium demonstrated subtotal occlusion of the LSPV (Figure 1B). A wire was passed through the occlusion into the LSPV branches. A drug-eluting stent was then placed in the ostium of the LSPV, yielding complete patency of the vessel (Figure 1C). Follow-up CT scan demonstrated patency of the LSPV stent (Figure 1D). At 1-year follow-up, the patient remained free of his presenting symptoms.
Severe pulmonary vein stenosis (PVS) is seen in 1-2 percent of patients after PVI. Although contemporary PVI techniques have substantially reduced the incidence of this complication, vigilance in diagnosing PVS is important. We recommend routine CT scanning of the pulmonary veins 3-4 months after PVI as surveillance.
Symptomatic pulmonary vein stenosis may present with coughing, hemoptysis, and/or dyspnea. In this setting, treatment is beneficial for symptom relief. In patients with severe but asymptomatic PV stenosis, the role of treatment is unclear. In patients who are asymptomatic, but demonstrate significant perfusion defect on nuclear scanning, treatment may still be reasonable. Up to 10 percent of patients with a moderate degree of stenosis on CT scanning at 3-month follow-up may develop worsening stenosis by 6-12 month follow-up and should be subsequently evaluated.