Incidence Of Pulmonary Vein Stenosis Research Articles

Pulmonary Vein Stenosis After Catheter Ablation of Atrial Fibrillation Using a Cryoballoon, Hot Balloon, or Laser Balloon.

Pulmonary vein stenosis (PVS) after PV isolation (PVI) for atrial fibrillation (AF) is a severe complication that requires angioplasty. This study aimed to compare the reduction of the cross-sectional PV area (PVA) and the incidence of PVS after cryoballoon (CB)-PVI, hot balloon (HB)-PVI, or laser balloon (LB)-PVI.Methods and Results: A total of 320 patients who underwent an initial catheter ablation procedure for AF using a CB, HB, or LB in 2 hospitals were included. They underwent contrast-enhanced multidetector CT before and 3 months after the procedure. In all 4 PVs, the reduction in PVA was more significant in the LB group than in the CB or HB groups, respectively. Moderate (50-75%) and severe (>75%) PVS were observed in 5.3% and 0.5% of the PVs, respectively. Although moderate PVS was more frequently observed in the LB group than in the CB or HB groups (8.2%, 3.8%, and 5.0%; P=0.03), the incidence of severe PVS was similar in the LB, CB, and HB groups (0.3%, 0.5%, and 1.0%; P=0.46). Symptomatic PVS requiring intervention occurred in 1 (0.3%) patient. Although the reduction in cross-sectional PVA and the incidence of moderate PVS after LB-PVI was more significant than after CB-PVI or HB-PVI, it rarely led to severe PVS. Symptomatic PVS requiring intervention was rare after the balloon ablation of AF.

Pulmonary vein stenosis after HotBalloon pulmonary vein isolation of paroxysmal atrial fibrillation.

HotBalloon-based pulmonary vein isolation (HBPVI) has yielded encouraging clinical results in the treatment of paroxysmal atrial fibrillation (PAF). However, pulmonary vein (PV) stenosis remains a concern. The influence of longer application duration on PV stenosis has not yet been systematically evaluated. All patients who underwent first HBPVI of PAF with pre- and post-ablation computed tomography (CT) were included. We used single-shot technique with application duration of 180s in the RSPV, 180-240s in the LSPV, and 120s in the lower PV procedures. PV stenosis was analyzed using CT and categorized as moderate (50-70%), and severe (> 70%) reduction in PV diameter. We analyzed imaging of the PV anatomy before ablation and during follow-up in 84 patients. Among them, 7 (8.3%) showed moderate stenosis, and 3 (3.6%) had severe stenosis including one total occlusion patient. All severe stenosis and total occlusion occurred in RSPV and LSPV procedures with longer application duration. No severe stenosis nor total PV occlusion occurred in inferior PV procedures with shorter application duration. The incidence of PV stenosis ≥ 50% or total PV occlusion was significantly lower in inferior PV than RSPV and LSPV procedures (0.6%, 6.0%, 8.0%, p = 0.01, respectively). All cases of PV stenosis including total PV occlusion patients were asymptomatic. No intervention for PV stenosis was performed. The risk of PV stenosis in HBPVI was rare in lower PV procedure with shorter application duration. An application duration setting of 120s in lower PV procedure might be effective to prevent PV stenosis.

Current Endovascular Approach in Adult Patients with Pulmonary Vein Stenosis: A State-of-the-Art Approach

Regarding to more invasive treatment of atrial arrhythmia (atrial fibrillation ablation) and pulmonary vein isolation (PVI), the rate of acquired pulmonary vein stenosis (PVS) is increasing and at present, PV ablation for AF has become the principal cause of PVS in adult patients. On the other way, by improvement in procedural techniques, equipment, and the experience of the operators, the incidence of PVS has been decreased. There is some controversy about the manner of follow-up of these patients and in most centers, just symptomatic patients are considered for imaging and treatment. Almost always, those with PV stenosis more than 70% or multiple PV involvement become symptomatic and if give them up without treatment, pulmonary symptoms and finally irreversible pulmonary hypertension will occurred. So, intensive pursue after the procedure is highly recommended. Whereas in pediatric patients with congenital or acquired PVS, the best treatment approach is surgery, in adult patients, the preferred type of treatment is the transcatheter intervention with high acute success rate. In this present review, we have scrutinized about the diagnostic modalities, the indications for intervention, the diverse treatment strategies, and principally clarify an accurate stepwise approach during transcatheter procedure.

Low Risk of Pulmonary Vein Stenosis After Contemporary Atrial Fibrillation Ablation - Lessons From Repeat Procedures After Radiofrequency Current, Cryoballoon, and Laser Balloon.

The incidence of pulmonary vein stenosis (PVS) after AF ablation following contemporary procedures remains unclear. We compared the incidence of PVS/narrowing (PVS/N) after PV isolation (PVI) for (1) 3-D mapping-guided wide-area encircling irrigated radiofrequency current (RFC) ablation; (2) first-third-generation big cryoballoon (CB1-3) ablation; and (3) laser balloon (LB) ablation.Methods and Results:All patients undergoing a second procedure between January 2012 and November 2016 were subgrouped according to index ablation (PVI): RFC; CB; or LB. PVS/N was classified using PV diameter ratio (second/index procedure) on selective PV angiogram performed before ablation: mild, 25-49%; moderate, 50-74%; or severe, ≥75%. A total of 344 patients (1,362 PV) were analyzed (RFC, n=211; 840 PV; CB1, n=21; 82 PV; CB2,3, n=64; 250 PV; LB, n=48; 190 PV). In the LB group, 45 patients (94%) were treated with dose ≥8.5 W. Second procedures were performed on average 14.9±14.1 months after the index procedure. Mild PVS/N was observed in 18.4%, 9.5% and 3.6% of PV in the LB, RFC and CB groups, respectively (P<0.01). Moderate PVS was recognized in 2 PV (0.1%; RFC, LB). Severe PVS was never observed, and no PV intervention/surgery was required. The risk for significant PVS is low after RFC/CB. The incidence of mild PVS/N was highest after standard-dose LB ablation and lowest after high-dose CB ablation.

Incidence of pulmonary vein stenosis after radiofrequency catheter ablation of atrial fibrillation

Pulmonary vein (PV) stenosis is a well known complication of the early era of radiofrequency catheter ablation (RFCA) of atrial fibrillation. Its diagnosis has decreased over time and with technical improvement, but less is known about its true prevalence, because of non-specific symptoms and the need for dedicated PV imaging, which is usually not performed systematically after PV isolation. To evaluate the incidence of PV stenosis with current methods of RFCA. This was a retrospective, observational study of 387 patients who underwent RFCA of atrial fibrillation between 2012 and 2016. All patients had a computed tomography scanner of left atrium and pulmonary veins before and 3 months after the procedure. All underwent last generation 3-dimensional electroanatomic mapping to guide RFCA. Severe (≥ 70%) PV stenosis was detected in 12 patients (3.1%), and moderate (50–69%) occurred in 38 (9.8%). Twenty-eight patients developed one PV stenosis (7.2%) and 10 patients developed two or more PV stenosis (2.6%). The localization of the PV stenosis was in the left superior PV in 38% (19 PVs), in the left inferior PV in 28% (14 PVs, in the right superior PV in 16% (8 PVs) and in the right inferior PV in 16% (8 PVS). There were significantly more PV stenosis in the left PVs ( P = 0.006) but there was no statistical significant difference between the upper and lower veins ( P = 0.31). In this study the incidence of asymptomatic PV stenosis remains a frequent complication after radiofrequency ablation and raises the question of the indication of a routine scanner. A 3-month waiting period seems appropriate for the diagnosis of PV stenosis and subsequent discussion of optimal management, depending on symptoms but also on the severity of stenosis.

Balloon angioplasty versus stenting for pulmonary vein stenosis after pulmonary vein isolation for atrial fibrillation: A meta-analysis

BackgroundThe incidence of pulmonary vein stenosis (PVS) as complication after pulmonary vein isolation (PVI) for atrial fibrillation (AF) has decreased in the last decade. However, as PVI for AF is becoming more prevalent, the incidence remains considerable in absolute terms. The purpose of this meta-analysis is to investigate the optimal approach for management of PVS after PVI for AF. Methods and resultsWe searched electronic scientific databases for studies comparing plain balloon angioplasty (BA) versus stenting for PVS after PVI for AF. Aggregate data were pooled to perform a meta-analysis. The primary and secondary outcomes were restenosis requiring repeated intervention and procedure-related complications, respectively.A total of 4 studies, treating 315 PVS in 188 patients (BA, n=171 versus stent, n=144 PVS) were considered. After a median follow-up of 32months, the overall incidence of restenosis was 46%. A percutaneous therapy with BA was associated with a higher risk for restenosis requiring repeat intervention compared to stent (risk ratio — RR, 95% confidence interval [95% CI]=2.18 [1.64–2.89], p<0.001). Procedure-related complications were comparable between BA and stent (RR [95% CI]=0.96 [0.19–4.96], p=0.96). The time to diagnosis of PVS after PVI for AF did not modify the treatment effect for the primary outcome with BA versus stent (p for interaction=0.16). ConclusionsIn patients presenting PVS after PVI for AF, a percutaneous therapy with BA is associated with higher risk for restenosis requiring repeat intervention as compared to stent. These percutaneous therapies display comparable safety.

Incidence of Pulmonary Vein Stenosis After Radiofrequency Catheter Ablation of AtrialFibrillation.

This study aimed to determine incidence of pulmonary vein stenosis (PVS) and evaluate PVS-related symptoms. The real-life incidence of PVS after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is unknown. All patients who underwent RFCA of AF from 2005 to 2016 with routine pre- and post-ablation screening by magnetic resonance imaging or computed tomography were included. Primary ablation strategy was PV antrum isolation alone in all patients. PVS, defined as a significant reduction in the superoinferior or anteroposterior PV diameter, was classified as mild (30% to 50%), moderate (50% to 70%), or severe (>70%). Sufficient quality imaging of the PV anatomy before ablation and during follow-up (mean 6 ± 4 months) was performed in 976 patients (76.4% men, 59.1% paroxysmal AF). Of these patients, 306 (31.4%) showed mild stenosis, 42(4.3%) revealed moderate stenosis, and 7 (0.7%) had a severe stenosis in at least 1 PV. Incidence of PVS fluctuated over the past decade. All severe PVS cases were likely caused by ablations being performed inside the PVs. Only 1 (0.1%) patient reported PVS-related symptoms of severe dyspnea during follow-up. Computed tomography revealed a subtotal occlusion of the left inferior PV and a severe stenosis of the left superior PV, requiring stenting. Although mild PVS was frequently observed after RFCA in this large cohort, incidence of severe PVS was<1% and incidence of symptomatic PVS necessitating intervention was negligible. Based on these findings, it seems appropriate to only screen for PVS in patients with suggestive symptoms.

Pulmonary Vein Stenosis After Second-Generation Cryoballoon Ablation.

Pulmonary vein stenosis (PVST) can occur after first-generation cryoballoon ablation. This study aimed to evaluate the incidence, severity, and characteristics of PVST after second-generation cryoballoon ablation. In total, 103 patients underwent PV isolation of paroxysmal atrial fibrillation using second-generation cryoballoons with a single big-balloon 3-minute freeze technique. Cardiac enhanced multidetector computed tomography (MDCT) was performed both before and a median of 6.0 (4.0-8.0) months after the procedure in all. PVST was classified as follows: minimal (<25%), mild (25-50%), moderate (50-70%), or severe (>70%). In total, 406 PVs were analyzed. MDCT demonstrated PV stenosis in 10(2.5%) PVs among 8(7.8%) patients. In detail, minimal and mild PVSTs were observed in 6 and 4 PVs, respectively. PVST occurred in the left superior (LSPV), left inferior, and right superior PVs in 6, 1, and 3 PVs, respectively. No stenosis was observed in 15 PVs with active balloon deflations during freezing. All PVSTs had concentric patterns except for 2 PVs with minimal stenosis. Balloon deformities were observed during freezing of 2 PVs with mild stenosis. When the PVST was defined as a >25% decreased diameter, the incidence was 0.98% (4/406; including 3 LSPVs). PVST did not progress further during the follow-up period. Although the incidence of PVST was low, it could occur even if a single big-balloon short freeze technique was applied. The risk of PV stenosis significantly differed among the 4 PVs, and reaching balloon temperatures of -60 °C and active balloon deflations during freezing were not associated with any PV stenosis.

Abstract 14782: Incidence and Characteristics of Pulmonary Vein Stenosis Following Catheter Ablation of Atrial Fibrillation: Insights From the Contemporary Multicenter ADVICE Trial

Introduction: Pulmonary vein (PV) stenosis is a well-described complication of atrial fibrillation (AF) ablation. Available data regarding the incidence of pulmonary vein (PV) stenosis associated with radiofrequency catheter ablation of AF are limited to surveys, single-center studies, and small trials. We prospectively assessed the incidence of PV stenosis after catheter ablation of AF in the context of a large randomized multicenter international study (ADVICE). Methods: Patients undergoing a first PV isolation procedure for the treatment of symptomatic paroxysmal AF were enrolled from 13 centers. PV isolation was performed by encircling all PVs using an irrigated-tip radiofrequency ablation catheter guided by a circular mapping catheter with the endpoint of electrical PV isolation. Systematic imaging of the left atrium and PVs using computed tomography-scan (CT-Scan) or magnetic resonance (MRI) was performed at 90 days post ablation to assess the incidence of PV stenosis. Significant PV stenosis was defined by a narrowing of PV luminal diameter greater than 70% as per Heart Rhythm Society guidelines. The incidence of moderate PV stenosis defined by a narrowing between 50% and 70% was also analyzed. Predictors of PV stenosis were explored by logistic regression analyses. Results: A total of 197 patients (mean age 59±9 yrs, 71% male) were included in this study. Electrical PV isolation was achieved in all patients. On the post ablation imaging study (performed at a mean of 103±33 days post ablation), a significant PV stenosis was observed in 1.52% [95% confidence interval (0.00%-3.23%)] of patients. In addition, a moderate PV stenosis was seen in 3.55% [95% confidence interval (0.97%-6.14%)] of patients. The affected PVs included 8 left inferior PVs, 1 right inferior and 1 right middle PV. None of the patients were symptomatic or required an intervention related to the PV stenosis. The presence of PV stenosis could not be predicted by clinical, hemodynamic, or procedural parameters. Conclusions: Our systematic evaluation of the incidence of PV stenosis in the context of a prospective multinational trial confirms previously reported low rates of significant PV stenosis following radiofrequency catheter ablation of AF.

Primary Sutureless Repair and Anterior Translocation of the Atrial Septum for Cardiac Total Anomalous Pulmonary Venous Connection

The incidence of pulmonary vein stenosis after correction of a cardiac total anomalous pulmonary venous connection in neonates may be underestimated because of the small population of patients; however, it is associated with significant mortality and morbidity. This report describes a primary sutureless repair and anterior translocation of the atrial septum to create a large left atrial cavity and avoid post-repair pulmonary vein stenosis.

Invited Commentary

Invited Commentary

How to identify and treat patient with pulmonary vein stenosis post atrial fibrillation ablation

The diagnosis of pulmonary vein stenosis, following catheter ablation of atrial fibrillation, potentially carries significant morbidity for affected patients. It is important that physicians remain aware of the entity and have an understanding of how to treat such patients. There has been controversy in how to assess patients following atrial fibrillation ablation, and how to treat asymptomatic patients with pulmonary vein stenosis. This article reviews the recently published data. The reported incidence of pulmonary vein stenosis is decreasing. Nonetheless, it may not be found if not sought, as even patients with severe pulmonary vein stenosis may be asymptomatic. Also, patients with symptoms may be misdiagnosed if pulmonary vein stenosis is not included in the differential diagnosis. Computed tomography (CT) and MRI have been shown to be the diagnostic modalities of choice. The treatment options for severe pulmonary vein stenosis and occlusion are primarily that of pulmonary vein angioplasty with or without stenting. Despite the observed rate of restenosis, patients derive benefit from pulmonary vein angioplasty. The best imaging modalities to assess for pulmonary vein stenosis are CT and MRI. Early intervention in symptomatic patients with severe pulmonary vein stenosis is warranted; in asymptomatic patients, the data suggest that such patients will also derive benefit.

Incidence of Pulmonary Vein Stenosis in Patients Submitted to Atrial Fibrillation Ablation: A Comparison of the Selective Segmental Ostial Ablation vs the Circumferential Pulmonary Veins Ablation

Pulmonary vein (PV) stenosis is an important complication of the AF ablation and could be underestimated if their assessment is not systematically done. Selective Segmental Ostial Ablation (SSOA) and Circunferential Pulmonary Veins Ablation (CPVA) have demonstrated efficacy in atrial fibrillation (AF) treatment. In this study the real incidence of PV stenosis in patients (pts) submitted to both SSOA and CPVA was compared. Those pts with focal activity and normal left atrial size were submitted to SSOA, remaining pts were submitted to CPVA to treat refractory, symptomatic AF. Contrast enhanced magnetic resonance angiography (MRA) was routinely performed in all patients 4 months after the procedure. A series of 73 consecutive patients (mean age of 51 +/- 11 years; 75% male) were included. SSOA was performed in 32 patients, and the remaining 41 patients underwent to CPVA, obtaining similar efficacy rates (72% vs 76% arrythmia free probability at 12 months; log rank test p = NS). Six patients had a significant PV stenosis, all in SSOA group none in CPVA group (18.8% vs 0%; p = 0.005). All patients were asymptomatic and the stenosis was detected in routine MRA. No predictors of stenosis has been identified analysing patient procedure characteristics. PV stenosis is a potential complication of SSOA not seen in CPVA. The study confirms than MRA is useful for identifying patients with asymptomatic PV stenosis.

Incidence of pulmonary vein stenosis after pulmonary vein isolation by use of cryoenergy in patients with therapy-refractory atrial fibrillation in the long-term course

Incidence of pulmonary vein stenosis after pulmonary vein isolation by use of cryoenergy in patients with therapy-refractory atrial fibrillation in the long-term course

1114-200 Increased incidence of pulmonary vein stenosis in patients with atrioventricular canal: A multi-institutional study

1114-200 Increased incidence of pulmonary vein stenosis in patients with atrioventricular canal: A multi-institutional study

Cardiovascular News

Cardiovascular News

Incidence of pulmonary vein stenosis 2 years after radiofrequency catheter ablation of refractory atrial fibrillation.

Pulmonary vein ablation offers the potential to cure patients with atrial fibrillation. In this study, we investigated the incidence of pulmonary vein stenosis after radiofrequency catheter ablation of refractory atrial fibrillation by systematic long-term follow-up. Forty-seven patients with refractory and highly symptomatic atrial fibrillation underwent radiofrequency catheter ablation of arrhythmogenic triggers inside the pulmonary veins and/or ostial pulmonary vein isolation with conventional mapping and ablation technology. These patients had follow-up examinations at 2 years with transoesophageal doppler-echo and/or angio magnetic resonance imaging for the evaluation of the pulmonary veins. Seventy-seven percent of the patients were free from atrial fibrillation, 51% were without antiarrhythmic drugs, and 26% were on previously ineffective antiarrhythmic drug therapy. However, 13 of the 47 patients showed significant pulmonary vein stenosis or occlusion. Only three of these 13 patients complained of dyspnoea. Distal ablations inside the pulmonary vein were associated with a 5.6-fold higher risk of stenosis than ostial ablations. At 2-year follow-up, the risk of significant pulmonary vein stenosis/occlusion after radiofrequency catheter ablation of refractory atrial fibrillation with conventional mapping and ablation technology was 28%. Distal ablations inside smaller pulmonary veins should be avoided because of the higher risk of stenosis than ablation at the ostium.

Low incidence of pulmonary vein stenosis following ostial pulmonary vein ablation

Low incidence of pulmonary vein stenosis following ostial pulmonary vein ablation