Case report: a breathtaking complication after ablation-using multi-modal imaging for timely diagnosis of acquired pulmonary vein stenosis and its implication for effective management

Abstract

Background: Acquired pulmonary vein stenosis (PVS) is a rare, but serious, complication that can develop after treatment with ablations for atrial fibrillation. Prompt diagnosis is difficult because it can often present similarly to other pulmonary disease processes.

Case summary: We describe a 62-year-old female with history of persistent symptomatic atrial fibrillation that resolved status post two radio-frequency ablations who presents with ongoing dyspnoea, productive cough, pleuritic chest pain, and haemoptysis over multiple admissions. She was misdiagnosed with recurrent pneumonias and pulmonary embolism that failed to improve her symptoms. She was referred to our centre for further evaluation finding severe stenosis in the left superior pulmonary vein with complete obliteration of the left inferior pulmonary vein on computed tomography scan. Multi-modal imaging including an echocardiogram and pulmonary angiogram was used to confirm the diagnosis. Percutaneous intervention with transvenous pulmonary vein venoplasty with pulmonary vein stenting of the left upper pulmonary vein was offered which resolved the patient's aforementioned symptoms.

Conclusion: Prompt diagnosis of acquired pulmonary vein stenosis is critical to plan for effective management. Our case highlights the need to consider PVS with a high index of clinical suspicion when a patient's medical history is significant for a prior history of ablation. We also review the use of multi-modal imaging to diagnose and plan for effective management with percutaneous intervention.

Keywords: Acquired pulmonary vein stenosis; Case report; Catheter ablation; Pulmonary vein stenting.

Figure 1

A repeat computed tomography angiography (CTA) chest showed severe stenosis in the left superior pulmonary vein.

Figure 2

A transoesophageal echocardiography was completed showing stenotic pulmonary veins with a mean pressure gradient of 6 mmHg and peak gradient of 13 mmHg. Continuous wave Doppler of the stenotic left superior pulmonary vein.

Figure 3

A diagnostic pulmonary angiogram confirmed the diagnosis of pulmonary vein stenosis. Measurement of the pre-stenosis segment of the left superior pulmonary vein.

Figure 4

The patient subsequently underwent staged transvenous pulmonary vein venoplasty with pulmonary vein stenting of the left upper pulmonary vein with an Abbott Omnilink Elite Stent (9×19 mm) using fluoroscopy and TEE guidance. Occluded left superior pulmonary vein status pre-balloon venoplasty.