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(Circulation. 2003;108:3102-3107.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Pulmonary Vein Stenosis After Radiofrequency Ablation of Atrial Fibrillation

Functional Characterization, Evolution, and Influence of the Ablation Strategy

Eduardo B. Saad, MD; Antonio Rossillo, MD; Cynthia P. Saad, MD; David O. Martin, MD; Mandeep Bhargava, MD; Demet Erciyes, MD; Dianna Bash, RN; Michelle Williams-Andrews, RN; Salwa Beheiry, RN; Nassir F. Marrouche, MD; James Adams, MD; Ennio Pisanò, MD; Raffaele Fanelli, MD; Domenico Potenza, MD; Antonio Raviele, MD; Aldo Bonso, MD; Sakis Themistoclakis, MD; Joannes Brachmann, MD; Walid I. Saliba, MD; Robert A. Schweikert, MD; Andrea Natale, MD

From the Center for Atrial Fibrillation (E.B.S., D.O.M., M.B., D.B., M.W.-A., N.F.M., W.I.S., R.A.S., D.E., A.N.) and Department of Pulmonary and Critical Care Medicine (C.P.S.), Cleveland Clinic Foundation, Cleveland, Ohio; the Department of Cardiology, Umberto I Hospital, Mestre-Venice, Italy (A. Rossillo, A. Raviele, A.B., S.T.); the Department of Cardiology, Marin Heart Institute, San Francisco, Calif (S.B., J.A.); the Department of Cardiology, Casa Sollievo della Soffrenza, S. Giovanni Rotondo, Italy (E.P., R.F., D.P.); and the Department of Cardiology, Klinikum Coburg, Coburg, Germany (J.B.).

Correspondence to Andrea Natale, MD, Co-Head, Section of Cardiac Pacing and Electrophysiology, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F15, Cleveland, OH 44195. E-mail natalea{at}ccf.org

Received July 10, 2003; revision received September 16, 2003; accepted September 22, 2003.

Background— Pulmonary vein (PV) stenosis is a complication of ablation for atrial fibrillation. The impact of different ablation strategies on the incidence of PV stenosis and its functional characterization has not been described.

Methods and Results— PV isolation was performed in 608 patients. An electroanatomic approach was used in 71 and circular mapping in 537 (distal isolation, 25; ostial isolation based on PV angiography, 102; guided by intracardiac echocardiography, 140; with energy delivery based on visualization of microbubbles, 270). Severe (70%) narrowing was detected in 21 patients (3.4%), and moderate (50% to 69%) and mild (<50%) narrowing occurred in 27 (4.4%) and 47 (7.7%), respectively. Severe stenosis occurred in 15.5%, 20%, 2.9%, 1.4%, and 0%, respectively. Development of symptoms was correlated with involvement of >1 PV with severe narrowing (P=0.01), whereas all patients with mild and moderate narrowing were asymptomatic. In the latter group, lung perfusion (V/Q) scans were normal in all but 4 patients. All patients with severe stenosis had abnormal perfusion scans.

Conclusions— V/Q scans are useful to assess the functional significance of PV stenosis. Mild and moderate degrees of PV narrowing are not associated with development of symptoms and seem to have no or minimal detrimental effect on pulmonary flow. The incidence of severe PV stenosis seems to be declining with better imaging techniques to ensure ostial isolation and to guide power titration. Mild narrowing 3 months after ablation does not preclude future development of severe stenosis and should be assessed with repeat imaging studies.

Key Words: fibrillation • veins • ablation • stenosis

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