Pulmonary Vein Stenosis After Atrial Fibrillation Ablation
An Iatrogenic Problem Larger Than the Primary Problem
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See Article by Raeisi-Giglou et al
Catheter-based ablation procedures for patients with symptomatic atrial fibrillation (AF) have steadily increased over the past decade in the United States. Despite significant technological advances and better understanding of the anatomic substrate, AF ablation can still result in rare, yet life-threatening complications. One such complication is pulmonary vein stenosis (PVS) and can incur substantial patient morbidity with recalcitrant symptoms. The incidence of severe PVS has fallen dramatically from 42.4% reported in an early study from 19991 to between 0.29% and 3.4% in studies after 2000.2–7 A high index of suspicion is required as presentation is often delayed (weeks to months after ablation), atypical, and can mimic a case of bronchitis, pneumonitis, or malignancy.8,9 Symptoms depend on the number of pulmonary veins involved, lesion severity, and presence and extent of collaterals. Diagnosis is often delayed or missed, as routine imaging after ablation is not mandated by the current Heart Rhythm Society consensus statements.10 If not recognized early, PVS may progress rapidly and result in total pulmonary venous occlusion, chronic pulmonary hypertension, irreversible lung parenchymal damage, and its sequelae.11,12 Treatment of PVS is also challenging and far from ideal. Pulmonary venous interventions using balloon angioplasty or stenting have been reported from single-center studies, but outcomes have remained suboptimal.13–17 Restenosis rates requiring reintervention are significant and observed in 56% to 72% of the balloon angioplasty cases compared with 27% to 33% of the stenting cases.13,14 Recently, surgical repair of severe PVS has been reported in a small series, with a restenosis rate of 38% over long-term follow-up.18
In this issue of the Circulation: Arrhythmia and Electrophysiology, Raeisi-Giglou et al19 present the Cleveland Clinic experience of outcomes and …