Acquired pulmonary vein stenosis resulting in haemoptysis: a case series

Abstract

Background: Acquired pulmonary vein stenosis (PVS) is an infrequent complication of atrial fibrillation ablation that is often misdiagnosed due to predominant respiratory symptoms. It can result in pulmonary venous hypertension, with varying presentations, ranging from shortness of breath to haemoptysis.

Case summary: We report two patients with a history of paroxysmal atrial fibrillation treated with radiofrequency ablation and pulmonary vein (PV) isolation, who subsequently developed PVS. Case 1 initially presented with indolent symptoms of shortness of breath and cough. He was initially diagnosed with and treated for pneumonia. In contrast, Case 2 presented with massive haemoptysis, requiring intubation and intensive care unit admission. Both patients were eventually diagnosed with PVS by computed tomography. They were treated with PV angioplasty and stenting.

Discussion: While previously limited to the congenital heart disease population, PVS is occurring more frequently now in adult patients as a complication of ablation procedures. It is most effectively treated with angioplasty and stent implantation but has a high rate of recurrence.

Keywords: Ablation complication; Case report; Congenital heart disease; Haemoptysis; Pulmonary vein stenosis; Pulmonary vein stenting.

Figure 1:

Case 1. Chest X-ray demonstrating pleural effusion at time of initial presentation, asterisk (A). Chest X-ray, following pulmonary vein stenting procedure (B). Computed tomography angiography on which pulmonary vein stenosis diagnosed, arrow. Computed tomography also notable for left pleural effusion and subsegmental atelectasis in left lower lobe. (C). Pulsed wave Doppler of pulmonary vein, mean gradient 7 mmHg pre-procedure. Systolic and diastolic components marked on slide (D). Pulsed wave Doppler, mean gradient 3.8 mmHg post-procedure. Systolic and diastolic components marked on slide (E).

Figure 2:

Case 1. Computed tomography reconstruction, demonstrating restenosis of left-sided pulmonary veins following initial angioplasty.

Figure 3:

Case 2. Chest X-ray at time of presentation to our centre, demonstrating complete collapse of left lung, asterisk (A). Chest X-ray several days after pulmonary vein stenting procedure (B). Computed tomography angiography on which pulmonary vein stenosis diagnosed, arrow (C). Pulmonary vein angiography via trans-septal access, before stent was placed. Left upper pulmonary vein is occluded, arrow (D). Pulmonary vein angiography via trans-septal access, post-stent placement. The branch veins are incompletely opacified due to brisk antegrade flow of contrast. Left upper pulmonary vein is stented, arrow (E).