Pulmonary vein stenosis requiring angioplasty or surgical treatment following pulmonary vein isolation: case series

Abstract

Background: Pulmonary vein stenosis (PVS) after pulmonary vein isolation (PVI) is a rare but severe complication. Its severity depends on the cause, number of stenosed veins, and symptoms. For symptomatic patients, angioplasty is the first choice, while surgery is not recommended due to its high invasiveness.

Case summary: Patient 1: A 60-year-old male developed symptomatic left superior and inferior PVS after two procedures of PVI using radiofrequency energy. Eight-millimetre stent in left-superior and 7-mm stent in left-inferior PV were placed. Patient 2: A 64-year-old male underwent PVI using radiofrequency energy with a high-power short-duration setting. Although the patient was asymptomatic, CT revealed left-inferior PVS along with infiltrative shadow of the same area. Considering the risk of pulmonary infarction and with the patient's informed consent, a 7-mm diameter stent was placed. Patient 3: A 56-year-old male underwent PVI with a 28-mm cryoballoon, followed by radiofrequency ablation for bilateral inferior PV reconductions. Subsequently, he developed severe left-inferior PVS, uncontrollable haemoptysis, and pulmonary infarction, necessitating lower lung-lobe resection.

Discussion: Classical PVS often results from multiple radiofrequency ablations, as seen in Patients 1 and 3. High-power short-duration ablation, as a novel technique associated with specific risks, should also be acknowledged. While PVS treatment is typically for symptomatic cases, it may be justified in high-risk asymptomatic patients, as in Patient 2. Although not first-line, surgery should be considered in cases with refractory symptoms, as in Patient 3.

Keywords: Angioplasty; Atrial fibrillation; Case series; Pulmonary vein isolation; Pulmonary vein stenosis; Surgical resection.

Figure 1

Clinical data for Patient 1. (A) An electroanatomical map of the left atrium (LA) was merged with computed tomography (CT) and is presented in a posterior–anterior (PA) view. The left panel shows pulmonary vein isolation (PVI) in the index procedure, and the right panel shows anterior ridge ablation of the left PV and posterior wall isolation in the second procedure. The spheres on the 3D map indicate the ablation sites. (B) Constructed 3-dimensional (3D) CT of the LA. The left panel CT was taken before the index procedure, while the right panel CT was taken after the second procedure, revealing severe stenosis in the left-superior PV (LSPV) and the left-inferior PV (LIPV). Arrowheads mark the locations of the stenosis in LSPV and LIPV. (C) Perfusion images with Tc-99m macroaggregated albumin demonstrate diminished perfusion in the left lung, as indicated by the arrows. The left panel corresponds to the anterior–posterior (AP) view, and the right panel corresponds to the PA view. (D) The left panel presents venography of the LSPV, with arrows indicating the site of stenosis. The right panel shows venography following stent placement. (E) The left panel exhibits venography of the LIPV, with arrows indicating the site of stenosis. The right panel shows venography following stent placement.

Figure 2

Clinical data for Patient 2. (A) An electroanatomical map of the LA merged with CT is presented. The left panel displays the map in an AP view, while the right panel shows the PA view. The spheres on the 3D map indicate the ablation sites. (B) The chest CT image shows an infiltrative shadow in the left lower lung field, which corresponds to the area of LIPV stenosis. (C) The 3D construction of the LA using CT is depicted. The left panel CT was taken before the procedure while the right panel CT was taken after the PVI procedure, demonstrating pronounced stenosis in the LIPV, as indicated by the arrows. (D) Tc-99m macroaggregated albumin perfusion images are presented. The left panel shows the AP view, and the right panel shows the left lateral view. As highlighted by the arrow, a reduction in uptake was noted in regions consistent with LIPV stenosis. (E) The left panel shows the venography presenting severe stenosis in the LIPV as indicated by the arrowhead. The right panel shows the venography after stent deployment.

Figure 3

Clinical data for Patient 3. (A) An electroanatomical LA map was merged with the CT in the second procedure. The left panel shows a map of the AP view, while the right panel shows that of a PA view. The spheres on the 3D map indicate the ablation sites. (B) A 3D CT image of the LA is shown: the left panel CT was taken before the index procedure. The left panel showed CT before the index procedure, and the right panel CT was taken after the second procedure, revealing severe stenosis of LIPV. The arrow denotes the precise location of the stenosis in the LIPV. (C) This macro image displays the resected left lower lobe, revealing pronounced congestion. (D) The vascular remodelling of the pulmonary artery and vein was evaluated using Elastica van Gieson staining. The arrowheads indicate pulmonary venous occlusion with fibrotic intimal thickening, while the blue arrows demonstrate pulmonary artery occlusion with myofibroblast proliferation.