Iatrogenic Pulmonary Vein Stenosis After Multiple Atrial Fibrillation Ablations
Presenter
Douglas Patrick Rheam, DO, The Heart House, Little Egg Harbor Twp, NJ
Douglas Patrick Rheam, DO, The Heart House, Little Egg Harbor Twp, NJ, Vincent Varghese, D.O., FSCAI, Pennsylvania Hospital, Marlton, NJ, Chunguang Chen, MD, Deborah Heart and Lung Center, Browns Mills, NJ and Pedram Kazemian, MD, MPH, Deborah Heart And Lung Center, Browns Mills, NJ
Title
Iatrogenic Pulmonary Vein Stenosis after multiple Atrial Fibrillation Ablations
Introduction
Pulmonary Vein stenosis is a rare yet debilitating complication of Atrial Fibrillation Ablations. While incidence of pulmonary vein stenosis has decreased significantly over the years, presentation is often delayed and can mimic other etiologies delaying treatment. If not considered and recognized promptly, Pulmonary Vein Stenosis may progress and result in irreversible stenosis, lung damage, or pulmonary hypertension.
Clinical Case
49 year old female with a history of atrial fibrillation and multiple pulmonary vein isolation ablations presents with severe lifestyle limiting dyspnea on exertion. She underwent CT morphology of the heart which demonstrated normal right upper and lower pulmonary veins. The left upper pulmonary vein anomalously inserted into the superior vena cava. The left lower pulmonary vein appeared sub-totally occluded. Prior CT Morphology of the heart completed before a previous ablation did not have any pulmonary vein stenosis. Right common femoral vein access was obtained with insertion of a 6F sheath. An SL 0 Transseptal sheath with a Brockenbrough needle was advanced into the right atrium and entered into the left atrium under TEE guidance. A ProTrack wire was then placed into the left atrium and the SL 0 sheath was removed. An 8.5F Agiles Sheath was then inserted into the left atrium and placed at the ostium of the left pulmonary vein. A Runthrough wire was advanced into the distal left lower pulmonary vein. A 0.035 inch Quick Cross catheter was inserted over the Runthrough wire, and wire removed. Contrast Injection through the Quick cross catheter confirmed position within the left lower pulmonary vein and severe 99% proximal vein stenosis. TEE demonstrated turbulent flow within the pulmonary vein, with mean gradient of 12.5 mm Hg. The Runthrough wire was then placed into the pulmonary vein, and the Quick Cross catheter was removed. The stenosis was predilated with 3x12 mm balloon. Intravascular ultrasound performed which demonstrated severe stenosis of the proximal pulmonary vein with a reference vessel of 7 mm. Further balloon angioplasty was performed with a 7 mm balloon. An Everflex 7x20 mm self-expanding nitinol stent was deployed in the proximal left pulmonary vein. The stent was post dilated with a 7 mm balloon. TEE confirmed significant improvement of pulmonary vein flow with improved mean gradient of 2 mm Hg.
Discussion
Pulmonary vein stenosis is an infrequent complication of PVI ablation; yet, should be recognized to deliver prompt therapy. TEE-assisted Pulmonary Vein Angioplasty offers treatment for symptomatic patients that are refractory to medical therapy. Like coronary and other endovascular assessment, IVUS serves as an excellent imaging modality for proper balloon and stent sizing of these vessels.