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The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation

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Abstract

Purpose

Pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) is associated with pulmonary vein stenosis (PVS). Although the reported incidence of PVS has fallen in recent years, the precise rate of PVS is unknown. Coherent guidelines for screening and treatment of PVS are not established. We reviewed literature to investigate the incidence, diagnosis, and management of PVS as a complication of PVI.

Methods

We reviewed 41 manuscripts that described a total of 4,615 subjects (median, 84 subjects/study).

Results

The incidence of PVS after PVI reported in literature from 1999 to 2004 ranges from 0 to 44 % (mean, 6.3 %; median, 5.4 %), whereas studies after 2004 report an incidence of 0–19 % (mean, 2 %; median, 3.1 %; p < 0.001). PVS symptoms typically occur with reduction of lung perfusion by 20–25 %. Variable criteria exist for diagnosis of PVS by magnetic resonance imaging, computed tomography, and perfusion imaging. The restenosis rate for treatment with balloon angioplasty ranges from 30 to 87 % (mean, 60 %; median, 47 %), compared with immediate stenting that ranges from 14 to 57 % (mean, 34 %; median, 33 %).

Conclusions

Recent peer-reviewed articles suggest that PVI carries a 3–8 % risk of developing PVS, but they likely underestimate the incidence of PVS, as specific screening and diagnostic guidelines are not established. Imaging modalities should be used to screen patients after ablation of AF since early recognition of PVS improves treatment outcomes. Treatment with angioplasty and stent placement can improve symptoms and lung perfusion but the benefit of treatment with immediate stent placement remains controversial. It is critical to maintain a high clinical index of suspicion for PVS in at-risk individuals to ensure timely detection and treatment.

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Abbreviations

AF:

Atrial fibrillation

CT:

Computed tomography

ICE:

Intracardiac echocardiography

MRI:

Magnetic resonance imaging

PH:

Pulmonary hypertension

PV(s):

Pulmonary vein(s)

PVI:

Pulmonary vein isolation

PVO:

Pulmonary vein occlusion

PVS:

Pulmonary vein stenosis

RFA:

Radiofrequency ablation

TEE:

Transesophageal echocardiogram

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Acknowledgments

Dr. Narayan is supported, in part, by grants from the NIH (HL83359 and HL103800). He is coauthor of an intellectual property owned by the University of California Regents and licensed to Topera Inc. Topera does not sponsor any research, including that presented here. Dr. Narayan holds equity in Topera, and reports having received honoraria from Medtronic, St. Jude Medical, and Biotronik.

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Authors and Affiliations

  1. Cardiac Noninvasive Laboratory, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA

    Armand Rostamian, Louise Thomson & Robert J. Siegel

  2. University of California, San Diego, 200 W. Arbor St, San Diego, CA, 92121, USA

    Sanjiv M. Narayan

  3. UCLA Center for the Health Sciences, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA

    Michael Fishbein

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  1. Armand Rostamian
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  2. Sanjiv M. Narayan
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  3. Louise Thomson
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  5. Robert J. Siegel
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Correspondence to Robert J. Siegel.

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Rostamian, A., Narayan, S.M., Thomson, L. et al. The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation. J Interv Card Electrophysiol 40, 63–74 (2014). https://doi.org/10.1007/s10840-014-9885-z

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