Headed in the Wrong Direction: Chronic and Acute Derangements in Pulmonary Blood Flow Distribution in a Patient with Severe Pulmonary Vein Stenosis
Luisa Morales‐NebredaChristopher S. ChungRishi AgrawalAnjana V. YeldandiBenjamin D. SingerAnkit BharatDonald R. McCrimmonJames M. Walter
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Pulmonary vein stenosis
1218 Objectives: Symptomatic pulmonary vein stenosis after the treatment of patients with atrial fibrillation with radiofrequency ablation (RF) is a known complication that occurs in up to 2% of patients. Although the degree of anatomic stenosis is best evaluated by ECG-gated CTA, scintigraphic imaging plays a critical role in determining the hemodynamic significance of stenosis. The goal of this educational exhibit is to give an illustrative, case-based review of the nuclear medicine pulmonary perfusion imaging in the evaluation of pulmonary vein stenosis.
Methods: Cases evaluated at the University of Pennsylvania Health System will be included in this educational exhibit. Our experiences with clinical patient selection and study interpretation will be discussed.
Results: The exhibit will include a presentation of the following:
● discussion of pulmonary vein isolation using RF ablation
● appropriate clinical indications for scintigraphic perfusion imaging in the work-up of pulmonary vein stenosis
● discussion of interventions to treat pulmonary vein stenosis including the problem of restenosis after treatment
● representative imaging findings for a variety of patient presentations including evaluation of initial stenosis and restenosis after percutaneous intervention
Summary/Conclusions:The development of pulmonary vein stenosis is an uncommon but serious complication after pulmonary vein isolation using RF ablation. Scintigraphic imaging plays a helpful role in determining the hemodynamic significance of stenoses. The development of a quantitative perfusion-only scintigraphic protocol should be considered for optimal evaluation in these patients. Furthermore, although no definite guidelines have been developed, consideration should be given to the development of a screening protocol for pulmonary venous stenosis after RF ablation, particularly in patients after intervention given the relatively high rate of restenosis.
References
1. Barrett CD et al . How to Identify and Treat Patient with Pulmonary Vein Stenosis post Atrial Fibrillation Ablation. Curr OpinCardiol. 2009;24:42.
2. Nanthakumar K et al . Functional Assessment of Pulmonary Vein Stenosis using Radionuclide Ventilation/Perfusion Imaging. Chest. 2004;126:645.
3. Preito LR. The State of the Art in Pulmonary Vein Stenosis - Diagnosis & Treatment. J Atr Fibrillation. 2010;2:228.
Pulmonary vein stenosis
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Atrial fibrillation ablation 411At the time of ablation 72.8% patients were on class Ic or III AADs.Procedure time (106.4±45.5 min.),and fluoroscopic time (29.3±14.9min) as well as the rate of acute procedural complications (3.4% of which 0.9% transient diaphragmatic paralysis) were not different in PAF and PerAF.After a follow up of 11.8±11.2months, the freedom from symptomatic recurrence was 79.1% for PAF and 77% for PerAF (p=0.576).Recurrence rate was not related to either LA size or LVEF.Class Ic or III AADs treatment had dropped from 72.8% before ablation to 34.7% (p<0.001). Conclusions:In a large real life observational cohort CB-PVI has been extensively applied to treat PAF and Per AF in SHD.The recurrence rate after a single procedure was not related either to the degree of structural remodeling or to the type of AF and was lower than previously reported in SHD in other large series and metanalyses on radiofrequency ablation.Further studies are needed to define whether these differences are specifically due to the ablation technique.
Pulmonary vein stenosis
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Pulmonary vein (PV) stenosis is 1 of the crucial complications of PV isolation. Although several cases of severe PV stenosis requiring angioplasty after cryoballoon ablation have been reported, no cases have been reported with hot balloon (HB) ablation.
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The efficacy and safety of catheter ablation for the management of atrial fibrillation (AF) has been improved in recent years. Radiofrequency (RF) catheter ablation for maintaining sinus rhythm is superior to the current antiarrhythmic drug therapy in selected patients. Pulmonary vein isolation (PVI) is the cornerstone of various catheter ablation strategies. It is well recognized that pulmonary vein (PV) antrum contributes to the AF initiation and/or perpetuation. Since PV stenosis is a complication of ablation within a PV, the ablation site for PVI has shifted to the junction between the left atrium and the PV rather than the ostium of the PV. However, PV reconnection after ablation is the major cause of recurrence of AF. The recovery of PV conduction could be caused by anatomical variations such as the failure to produce complete transmural lesion or gaps at the ablation line due to the transient electrophysiologic effects from the RF ablation. In this review, we discussed several factors to be considered for the achievement of the best PVI, including clinical aspects and technical aspects.
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Pulmonary vein isolation (PVI) is the standard ablative strategy for the treatment of paroxysmal atrial fibrillation (AF), with success rates of 60-80% after a single procedure. 1-3 Antral ablation usually is preferred over ostial ablation in order to include ostial foci within the level of isolation and minimize the risk of pulmonary vein (PV) stenosis.
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Acquired pulmonary vein stenosis is a rare cardiac defect and diagnosis can often be challenging, as many cases present with refractory or prolonged oxygen requirement over the expected course. Comorbid conditions can cloud this diagnosis further. Prognosis is poor for most patients. We present a case of idiopathic acquired pulmonary vein stenosis and discuss diagnostics, treatment options, and the need for further collaborative studies.
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A novel circular pulmonary vein ablation catheter (PVAC) has been introduced for pulmonary vein isolation (PVI). Accurate delineation of left atrium-pulmonary vein (LA-PV) anatomy is important for this technique. The aim of this study was to test whether the 3-dimensional rotational angiography (3D RTA) of the left atrium can facilitate PVI using PVAC technique.Twenty patients with paroxysmal atrial fibrillation (AF) were enrolled in this study. The 3D RTA was reconstructed and registered with live fluoroscopy in all the patients. AF ablation was performed with a PVAC catheter in the navigation of registered 3D RTA.The 3DRTA image was successfully reconstructed and registered with live fluoroscopy in all patients (100%). The LA-PV anatomy was delineated clearly in all patients. Navigation of the PVAC inside the registered 3D RTA, ensured accurate placement within the atrium to perform ablation, and the PVAC was correctly placed inside the PV ostium to verify the PVI. All the PVs were isolated. Total procedural time was (87.5 ± 12.1) minutes, and fluoroscopy time was (20.1 ± 6.3) minutes. Follow-up after (7.1 ± 1.5) months showed freedom from AF in 70% (14/20) patients. No PV stenosis was observed.Intraprocedure reconstructed and registered 3D RTA can clearly delineate the LA-PV anatomy in real-time. The results demonstrate the feasibility and reliability of combining use of 3DRA and PVAC in AF ablation procedures.
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