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(Circulation. 2002;105:2571.)
© 2002 American Heart Association, Inc.

Images in Cardiovascular Medicine

Pulmonary Vein Stenosis After Catheter Ablation of Atrial Arrhythmias

Niranjan Seshadri, MD; Gian M. Novaro, MD; Lourdes Prieto, MD; Richard D. White, MD; Andrea Natale, MD; Richard A. Grimm, DO; William J. Stewart, MD

From the Departments of Cardiology (N.S., G.M.N., R.D.W., A.N., R.A.G., W.J.S.), Pediatric Cardiology (L.P.), and Radiology (R.D.W.), Cleveland Clinic Foundation, Cleveland, Ohio.

Correspondence to William J. Stewart, MD, Department of Cardiology/Desk F-15, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. E-mail stewarw{at}ccf.org

A 78-year-old woman presented with a 2-month history of worsening dyspnea, orthopnea, and cough with hemoptysis. Her past medical history was significant for hypertension and severe mitral regurgitation for which she had undergone mitral valve repair 3 years previously. In addition, she had recurrent atrial tachycardia requiring 2 radiofrequency ablations, which included ablation of several left-sided pathways. The last ablation was performed 3 months before her presentation.

A transesophageal echocardiogram was performed and showed turbulent Doppler flow and increased systolic and diastolic velocities in the right lower (Figure 1) and left upper pulmonary veins. A contrast-enhanced, retrospectively gated helical CT scan showed 60% to 70% stenoses of the right lower (Figure 2, left panel) and left upper pulmonary veins. A ventilation-perfusion scan revealed a large perfusion defect in the right lower lobe. The patient subsequently underwent a successful balloon dilation of the right lower and left upper pulmonary veins (Figure 3). Pulmonary artery pressures before dilation were 85/30 mm Hg, and dropped to 55/20 mm Hg immediately after dilation. A transesophageal echocardiogram performed after the procedure showed normal flows in the previously stenotic pulmonary veins. A CT scan completed several days after the procedure showed a reduction in the degree of stenosis in both right lower (Figure 2, right panel) and left upper pulmonary veins. The patient’s acute symptoms were markedly improved, although her condition subsequently deteriorated secondary to multiple other medical problems.

View larger version (28K): [in this window] [in a new window]   Figure 1. Transesophageal echocardiogram of the right lower pulmonary veins (RLPV) before angioplasty. The 2D color Doppler image (A) shows multicolor aliasing from an increased velocity of blood flow into the left atrium (LA). The pulsed Doppler (B) shows blunted systolic velocity and a prolonged elevated diastolic velocity with a long pressure-half time.

View larger version (69K): [in this window] [in a new window]   Figure 2. Retrospectively gated helical CT volume imaging after contrast administration permitted production of maximal intensity projections. On the pre-angioplasty image (left), the right lower pulmonary vein shows an asymmetric discrete annular narrowing of 60% to 70% (arrow) as the vein joins the left atrium (LA). After angioplasty (right), there was reduction of the focal stenosis of the right lower pulmonary vein to 20% to 30% (arrow).

View larger version (80K): [in this window] [in a new window]   Figure 3. A, Selective angiogram of the left upper pulmonary vein (LUPV) in the lateral projection demonstrating moderate stenosis at its insertion into the left atrium (arrow). B, LUPV after balloon angioplasty demonstrating significant improvement in the stenosis, with a 49% increase in luminal diameter from 3.5 mm before dilation to 5.2 mm after dilation (arrow).

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Seshadri, N. Articles by Stewart, W. J. Search for Related Content PubMed PubMed Citation Articles by Seshadri, N. Articles by Stewart, W. J. Related Collections Ablation/ICD/surgery Catheter-based coronary and valvular interventions: other CT and MRI Echocardiography Arrhythmias, clinical electrophysiology, drugs