Ann Thorac Surg 2009;87:292-295. doi:10.1016/j.athoracsur.2008.06.060
© 2009 The Society of Thoracic Surgeons
Case Reports
Complete Pulmonary Venous Occlusion After Radiofrequency Ablation for Atrial Fibrillation
Deepika Nehra, MDa,
Moishe Liberman, MDa,
Parsia A. Vagefi, MDa,
Nathaniel Evans, MDa,
Ignacio Inglessis, MDb,
Richard L. Kradin, MDc,
Jill Ono, MDc,
David J. Kanarek, MDd,
Henning A. Gaissert, MDa,*
a Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
b Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
c Division of Pathology, Massachusetts General Hospital, Boston, Massachusetts
d Division of Pulmonary Medicine, Massachusetts General Hospital, Boston, Massachusetts
Accepted for publication June 19, 2008.
* Address correspondence to Dr Gaissert, Division of Thoracic Surgery, Massachusetts General Hospital, Blake 1570, 55 Fruit St, Boston, MA 02114 (Email: hgaissert{at}partners.org).
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Abstract
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Pulmonary vein stenosis is a known, yet under-recognized complication of radiofrequency ablation for atrial fibrillation. We present the case of a patient developing complete left-sided pulmonary venous occlusion following radiofrequency ablation. Recommendations are made to allow earlier diagnosis of this complication.
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Introduction
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Pulmonary vein stenosis is a known complication of radiofrequency ablation for atrial fibrillation with a reported incidence as high as 42% [1, 2]. We present a patient with complete occlusion of both left-sided pulmonary veins after radiofrequency ablation for atrial fibrillation.
A 58-year-old woman presented 6 years earlier with atrial fibrillation and congestive heart failure. Echocardiography was normal. Normal sinus rhythm was restored with cardioversion, and medical treatment was instituted. Three years later, she experienced symptomatic, paroxysmal atrial fibrillation and underwent circumferential radiofrequency ablation of both left pulmonary veins. Paroxysmal atrial fibrillation refractory to medical therapy recurred after 5 weeks. A transesophageal echocardiogram 2 months after ablation showed a left atrial thrombus and anticoagulation with warfarin was begun. Magnetic resonance imaging demonstrated 70% stenosis of the left inferior pulmonary vein and uncertain visualization of the superior vein. An electrophysiologic study 2 years later found the left veins isolated, but high frequency electrical activity was present at the left atrial appendage and around the right-sided veins. Repeat circumferential ablation of the right-sided veins restored sinus rhythm. Transeptal left atrial catheterization showed an occluded left superior vein and a 70% stenosis of the inferior vein without pressure gradient. Right-sided veins were patent. Ventilation-perfusion scintigraphy demonstrated 17% perfusion to the left lung (Fig 1A). Anticoagulation was continued. Over the ensuing months, additional cardioversions were administered for recurrent episodes of symptomatic atrial fibrillation associated with progressive exertional dyspnea.
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Fig 1. Ventilation-perfusion scan demonstrating mismatched perfusion with (A) 83% perfusion to the right lung and 17% perfusion to the left lung followed by progression of occlusion with worsening perfusion mismatch resulting in (B) no perfusion to the left lung.
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Repeat scintigraphy a few months later showed no perfusion to the left lung (Fig 1B). Two minor episodes of hemoptysis on warfarin were followed by massive hemoptysis. Anticoagulation was reversed and the patient was transferred to Massachusetts General Hospital.
Computed tomography demonstrated occlusion of both left pulmonary veins. The right veins were normal (Fig 2). Echocardiography demonstrated an ejection fraction of 62%. During cardiac catheterization, right ventricular pressure was 55/3, pulmonary artery pressure 55/25 (mean, 40), and right lower pulmonary capillary wedge pressure 15 mm Hg.
Bronchoscopy found striking hyperemia and brisk bleeding to touch of the mid and distal left mainstem bronchus with a clot in the left lower lobe bronchus.
A left pneumonectomy was performed to permit resumption of anticoagulation. The lung was extremely pale while small hilar vessels were maximally engorged (Figs 3A and 3B). The pulmonary artery had no pulse and the veins were obliterated. The perivascular planes were inflamed and the vessel walls were thickened. With meticulous ligation of all hilar tissues (Fig 3C), the pulmonary vessels were divided and oversewn. The bronchus was divided and closed at the carina, reinforcing the stump with a pericardial fat pad. The specimen was pale with a yellow hue (Fig 3D). The patient was immediately extubated and had an uneventful recovery. She remains anti-coagulated for paroxysmal atrial fibrillation.
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Fig 3. Perihilar neovascularization overlying (A) the descending thoracic aorta and (B) the pericardium. (C) Multiple ligatures were required to control perihilar vessels, which were supplying the left lung. (D) The entire left lung demonstrated a pale yellow hue.
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Histologic examination demonstrated severe thickening and dilatation of tortuous hilar pulmonary veins (Figs 4A and 4B), a severe arterial obliterative fibro-intimal proliferation (Fig 4C), and focal thrombi. The lung parenchyma demonstrated patchy interstitial edema, fibrosis, and hemosiderin deposition consistent with chronic venous hypertension. Three quarters of the venous lumen was occupied by adherent clot, while the artery was totally occluded by organized clot (Fig 4D).
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Fig 4. Severe venular vascular pathology with (A) marked dilatation and (B) thickening of tortuous hilar pulmonary veins. Severe arterial pathology with (C) marked arterial obliterative fibro-intimal proliferation with (D) focal thrombi.
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Comment
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Pulmonary vein occlusion after radiofrequency ablation is an important and probably under-recognized complication with an estimated incidence ranging from < 2% to 42% depending on ablative technique and investigative method [3, 4]. Progression of the injury in time was demonstrated in animal data showing intimal proliferation, collagen replacement of necrotic myocardium, endovascular contraction, and proliferation of the elastic lamina [5]. Clinically silent stenosis or obliteration may be missed in the absence of specific investigation. Venous compromise after ablation is often misdiagnosed as pneumonia, new-onset asthma, pulmonary embolism, or lung cancer [4]. The median time to onset of symptoms after ablation in one interventional study was 7.5 weeks, with a further 16-week delay between onset of symptoms and diagnosis [6]. This delay favors progression to complete occlusion as seen in our patient [4].
Management of pulmonary vein stenosis or occlusion is often unsuccessful. Data on the safety and efficacy of angioplasty and stenting is limited to a few small-scale studies. Qureshi and colleagues [6] reported on 17 patients who underwent angioplasty of 30 pulmonary veins with an increase in vessel diameter from 2.6 mm to 6.6 mm (approximately 70% of normal). These procedures were complicated by hemorrhage, venous tear requiring open repair, and stroke in 13% of patients. At a median follow-up of 43 weeks, 47% of patients experienced re-stenosis with all requiring repeat intervention. Overall, repeat intervention was performed on 19 of 30 (63%) veins [6]. In 23 patients with vein stenosis following radiofrequency ablation, Packer and colleagues [7] reported similar results. Twenty veins were dilated and 14 were stented. Re-stenosis occurred in 14 patients (60%). Neither study demonstrated a lasting return to normal perfusion in any dilated vascular territory. The proportion of patients with normal sinus rhythm after these procedures was not reported.
Since the results of angioplasty or stenting for pulmonary vein stenosis are so far unsatisfactory, and because high-grade stenosis or occlusion of a single pulmonary vein leads to loss of 25% of pulmonary function on average, we propose the following guidelines for radiofrequncy ablation:
- 1 Candidates with shortness of breath or exertional dyspnea should undergo pulmonary function studies with carbon monoxide diffusing capacity before their first radiofrequency ablation. Unrelated significant pulmonary disease may influence the decision to perform ablation.
- 2 Patients with new or progressive shortness of breath and dyspnea after radiofrequency ablation should be evaluated with pulmonary function studies, ventilation–perfusion scintigraphy, and computed tomographic angiography.
- 3 The diagnosis of stenosis of any severity in a single pulmonary vein should constitute a contraindication to radiofrequency ablation.
The functional loss of an entire lung and the operative risk of lung resection, lobectomy, or pneumonectomy mitigate any functional improvement derived from radiofrequency ablation. The usual diagnostic delay associated with pulmonary venous injury precludes early intervention to prevent these strictures. The profound cicatricial response of pulmonary veins to injury suggests that the solution to this problem lies in prevention, rather than treatment.
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References
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- Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation Circulation 1999;100:1879-1886.[Abstract/Free Full Text]
- Yu WC, Hsu TL, Tai CT, et al. Acquired pulmonary vein stenosis after radiofrequency catheter ablation of paroxysmal atrial fibrillation J Cardiovasc Electrophysiol 2001;12:887-892.[Medline]
- Purerfellner H, Aichinger J, Martinek M, et al. Incidence, management, and outcome in significant pulmonary vein stenosis complicating ablation for atrial fibrillation Am J Cardiol 2004;93:1428-1431A10.[Medline]
- Saad EB, Marrouche NF, Saad CP, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome Ann Intern Med 2003;138:634-638.[Abstract/Free Full Text]
- Taylor GW, Kay GN, Zheng X, et al. Pathological effects of extensive radiofrequency energy applications in the pulmonary veins in dogs Circulation 2000;101:1736-1742.[Abstract/Free Full Text]
- Qureshi AM, Prieto LR, Latson LA, et al. Transcatheter angioplasty for acquired pulmonary vein stenosis after radiofrequency ablation Circulation 2003;108:1336-1342.[Abstract/Free Full Text]
- Packer DL, Keelan P, Munger TM, et al. Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation Circulation 2005;111:546-554.[Abstract/Free Full Text]
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D. Nehra, I. Inglessis, and H. A. Gaissert
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Abstract
Introduction
