J Interv Card Electrophysiol (2014) 40:63–74 DOI 10.1007/s10840-014-9885-z
REVIEWS
The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation Armand Rostamian & Sanjiv M. Narayan & Louise Thomson & Michael Fishbein & Robert J. Siegel
Received: 6 December 2013 / Accepted: 6 February 2014 / Published online: 14 March 2014 # Springer Science+Business Media New York 2014
Abstract Purpose Pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) is associated with pulmonary vein stenosis (PVS). Although the reported incidence of PVS has fallen in recent years, the precise rate of PVS is unknown. Coherent guidelines for screening and treatment of PVS are not established. We reviewed literature to investigate the incidence, diagnosis, and management of PVS as a complication of PVI. Methods We reviewed 41 manuscripts that described a total of 4,615 subjects (median, 84 subjects/study). Results The incidence of PVS after PVI reported in literature from 1999 to 2004 ranges from 0 to 44 % (mean, 6.3 %; median, 5.4 %), whereas studies after 2004 report an incidence of 0–19 % (mean, 2 %; median, 3.1 %; p50 %
Luminal narrowing >50 %
Luminal narrowing >70 %
Luminal narrowing >70 %
Luminal narrowing >50 %
Luminal narrowing >50 %
Luminal narrowing >50 %
Luminal narrowing >50 %
Luminal narrowing >25 %
Luminal narrowing >50 %
Increase in PV peak flow velocity>mean+2 SD MRA: PV diameter reduction >50 % TEE: PV flow velocity >110 cm/s and turbulent flow Luminal narrowing >70 %
Peak PV inflow velocity >80 cm/s PV diameter reduction >50 % High-velocity turbulence near the ostia High velocity turbulence near the ostia No specific criteria defined
Luminal narrowing >50 %
Criteria for significant PVS
Cryo
Ostium
HIFU
Cryo
Cryo
Circ, Segmand, Lasso −
−
Ostium
−
−
2
0
3
1
0
− Antrum
0 14
Antrum
− Variable
0
0
0
0
−
12
3
3
3
3
3−25
12
7
7
2
4±3
variable
12 3
0
3
12
24
7±3
15±8
10.4±4.5
6
8±5
6
Variable
F/u duration (months)
−
Ostium
>5 mm from ostium
1–2 cm from ostium
Ostium
−
Ostium
Segm
Circ
Circ, Linear
Segm
Circ, Segm
Circ
1
10
−
−
Circ Segm
Circ
3
Inside Ostium
Segm
1
1
0
−
Inside ostium
>5 mm from ostium
0
2
2
41
Symptoms (N)
−
Segm
Circ
>5 mm from ostium
15 mm from ostium
− Circ
Inside PV
−
Ablation location
−
Variable
RFA type
CT or MRI
TEE
CT
−
Angiography
CT
CT
MRA
MRA
MRI
Angiography
MRI, Angiography
CT
CT,TEE
MRA
CT, Angiography
TEE,MRA
VQ scan, angiography, and MRI TEE
TEE
TEE
Angiography
TEE
MRI and angiography
Imaging modality
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Variable
Variable
No
No
Yes
No
−
No
No
No
No
No
−
Use of ICE
Circ circumferential, Cryo cryoablation, F/U follow-up, HIFU, high-intensity-focused ultrasound, N subjects, Ref reference, Segm Segmental
There were a mean 1.7 PVs with >50 % PVS per affected subject. Prior to 2004, mean incidence of PVS was 5.4 % compared with 1.2 % (p50 % with a sensitivity of 86 % and a specificity of 95 % when PVS is defined as a minimum peak velocity of >1 m/s [43]. Jander et al. found a perfect correlation between TEE and MRI when PVS was defined by an elevated peak velocity of >1.1 m/s and turbulent flow with little phasic variation [44]. However, TEE also poses technical challenges in assessing all PVs, since the left inferior PV cannot be adequately visualized up to 24 % of the time [43, 44], and detection of mild PVS is difficult. Furthermore, most studies assessing the efficacy of TEE utilize experienced operators that may not be available at all centers. Most patients undergo RFA with ICE and less frequently with continuous TEE guidance. Although these are not the optimal methods for detecting PVS, operators should assess all visualized PVs at the time of ablation.
8 Perfusion imaging Perfusion studies may be limited in detecting mild PVS [2, 4, 26] but are reliable in screening for moderate to severe PVS (Fig. 2) [4, 14, 30]. When compared with CT and pulmonary venography, perfusion studies revealed decreased perfusion with >60 % PV luminal narrowing but no perfusion defects for stenoses of 25 % or clinical symptoms of PVS after undergoing PVI. Forty-five patients were asymptomatic and had no perfusion deficits, while all 6 symptomatic patients had at least one lobar perfusion deficit [3]. Perfusion imaging should be interpreted cautiously since compensating ipsilateral vein flow may affect its accuracy [2]. Nonetheless, perfusion studies provide a less costly method of diagnosing clinically significant PVS and can be used as a routine screening method for PVS. 8.1 Treatment There are no clear pharmacological interventions for PVS. Treatment consists of venoplasty with or without stenting. Generally, asymptomatic PVS from 50 to 85 % is monitored frequently with imaging every 3–6 months. Some centers intervene for PVS of >75 % [30] and others proceed with treatment in the presence of PVS involving ipsilateral PVs. Increasing evidence suggests that intervention should be performed early, since late restoration of venous patency may not improve perfusion to affected lung segments [8] likely due to pathophysiological venoconstriction that can lead to irreversible PH [13, 31]. In addition, progression of PVS to PVO can occur rapidly and total PVO is not easily amenable to intervention [30, 37, 42]. Recently, however, Prieto et al. performed successful angioplasty with subsequent stenting in 8 of 9 PVs with total PVO that had a visible remnant seen on angiography. Mean reference diameter increased from 5.8±
70
J Interv Card Electrophysiol (2014) 40:63–74
Fig. 5 Pulmonary vein stenosis on CT and angiography. a Coronal and b axial CT images of the PVs revealing LLPV stenosis (arrow), noted to be narrower in the anteroposterior (AP) view than in the craniocaudal view. On CT, the LLPV is typically narrow in the AP view, which can be
accentuated by leftward shift, increased left atrium volume, and pectus deformities. c In the same patient, pulmonary angiography later revealed patent PVs without any evidence of stenosis.
2.2 to 6.9±1.7 mm with a significant improvement in symptoms and lung perfusion from 5.6 to 12.2 % [42]. However, this study had a small sample size and larger population trials are needed to draw more definitive conclusions.
Di Biase et al. found that patients with a concomitant ipsilateral PVS or PVO with cumulative stenosis index (CSI) >75 % should receive immediate intervention to minimize reference vessel atrophy [2, 45]. CSI is a measure of the average cumulative stenosis of the PVs draining each independent lung. Using this criterion, there was a significantly negative correlation between improvements in CSI and time to intervention using either venoplasty or stenting (p
REVIEWS
The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation Armand Rostamian & Sanjiv M. Narayan & Louise Thomson & Michael Fishbein & Robert J. Siegel
Received: 6 December 2013 / Accepted: 6 February 2014 / Published online: 14 March 2014 # Springer Science+Business Media New York 2014
Abstract Purpose Pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) is associated with pulmonary vein stenosis (PVS). Although the reported incidence of PVS has fallen in recent years, the precise rate of PVS is unknown. Coherent guidelines for screening and treatment of PVS are not established. We reviewed literature to investigate the incidence, diagnosis, and management of PVS as a complication of PVI. Methods We reviewed 41 manuscripts that described a total of 4,615 subjects (median, 84 subjects/study). Results The incidence of PVS after PVI reported in literature from 1999 to 2004 ranges from 0 to 44 % (mean, 6.3 %; median, 5.4 %), whereas studies after 2004 report an incidence of 0–19 % (mean, 2 %; median, 3.1 %; p50 %
Luminal narrowing >50 %
Luminal narrowing >70 %
Luminal narrowing >70 %
Luminal narrowing >50 %
Luminal narrowing >50 %
Luminal narrowing >50 %
Luminal narrowing >50 %
Luminal narrowing >25 %
Luminal narrowing >50 %
Increase in PV peak flow velocity>mean+2 SD MRA: PV diameter reduction >50 % TEE: PV flow velocity >110 cm/s and turbulent flow Luminal narrowing >70 %
Peak PV inflow velocity >80 cm/s PV diameter reduction >50 % High-velocity turbulence near the ostia High velocity turbulence near the ostia No specific criteria defined
Luminal narrowing >50 %
Criteria for significant PVS
Cryo
Ostium
HIFU
Cryo
Cryo
Circ, Segmand, Lasso −
−
Ostium
−
−
2
0
3
1
0
− Antrum
0 14
Antrum
− Variable
0
0
0
0
−
12
3
3
3
3
3−25
12
7
7
2
4±3
variable
12 3
0
3
12
24
7±3
15±8
10.4±4.5
6
8±5
6
Variable
F/u duration (months)
−
Ostium
>5 mm from ostium
1–2 cm from ostium
Ostium
−
Ostium
Segm
Circ
Circ, Linear
Segm
Circ, Segm
Circ
1
10
−
−
Circ Segm
Circ
3
Inside Ostium
Segm
1
1
0
−
Inside ostium
>5 mm from ostium
0
2
2
41
Symptoms (N)
−
Segm
Circ
>5 mm from ostium
15 mm from ostium
− Circ
Inside PV
−
Ablation location
−
Variable
RFA type
CT or MRI
TEE
CT
−
Angiography
CT
CT
MRA
MRA
MRI
Angiography
MRI, Angiography
CT
CT,TEE
MRA
CT, Angiography
TEE,MRA
VQ scan, angiography, and MRI TEE
TEE
TEE
Angiography
TEE
MRI and angiography
Imaging modality
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Variable
Variable
No
No
Yes
No
−
No
No
No
No
No
−
Use of ICE
Circ circumferential, Cryo cryoablation, F/U follow-up, HIFU, high-intensity-focused ultrasound, N subjects, Ref reference, Segm Segmental
There were a mean 1.7 PVs with >50 % PVS per affected subject. Prior to 2004, mean incidence of PVS was 5.4 % compared with 1.2 % (p50 % with a sensitivity of 86 % and a specificity of 95 % when PVS is defined as a minimum peak velocity of >1 m/s [43]. Jander et al. found a perfect correlation between TEE and MRI when PVS was defined by an elevated peak velocity of >1.1 m/s and turbulent flow with little phasic variation [44]. However, TEE also poses technical challenges in assessing all PVs, since the left inferior PV cannot be adequately visualized up to 24 % of the time [43, 44], and detection of mild PVS is difficult. Furthermore, most studies assessing the efficacy of TEE utilize experienced operators that may not be available at all centers. Most patients undergo RFA with ICE and less frequently with continuous TEE guidance. Although these are not the optimal methods for detecting PVS, operators should assess all visualized PVs at the time of ablation.
8 Perfusion imaging Perfusion studies may be limited in detecting mild PVS [2, 4, 26] but are reliable in screening for moderate to severe PVS (Fig. 2) [4, 14, 30]. When compared with CT and pulmonary venography, perfusion studies revealed decreased perfusion with >60 % PV luminal narrowing but no perfusion defects for stenoses of 25 % or clinical symptoms of PVS after undergoing PVI. Forty-five patients were asymptomatic and had no perfusion deficits, while all 6 symptomatic patients had at least one lobar perfusion deficit [3]. Perfusion imaging should be interpreted cautiously since compensating ipsilateral vein flow may affect its accuracy [2]. Nonetheless, perfusion studies provide a less costly method of diagnosing clinically significant PVS and can be used as a routine screening method for PVS. 8.1 Treatment There are no clear pharmacological interventions for PVS. Treatment consists of venoplasty with or without stenting. Generally, asymptomatic PVS from 50 to 85 % is monitored frequently with imaging every 3–6 months. Some centers intervene for PVS of >75 % [30] and others proceed with treatment in the presence of PVS involving ipsilateral PVs. Increasing evidence suggests that intervention should be performed early, since late restoration of venous patency may not improve perfusion to affected lung segments [8] likely due to pathophysiological venoconstriction that can lead to irreversible PH [13, 31]. In addition, progression of PVS to PVO can occur rapidly and total PVO is not easily amenable to intervention [30, 37, 42]. Recently, however, Prieto et al. performed successful angioplasty with subsequent stenting in 8 of 9 PVs with total PVO that had a visible remnant seen on angiography. Mean reference diameter increased from 5.8±
70
J Interv Card Electrophysiol (2014) 40:63–74
Fig. 5 Pulmonary vein stenosis on CT and angiography. a Coronal and b axial CT images of the PVs revealing LLPV stenosis (arrow), noted to be narrower in the anteroposterior (AP) view than in the craniocaudal view. On CT, the LLPV is typically narrow in the AP view, which can be
accentuated by leftward shift, increased left atrium volume, and pectus deformities. c In the same patient, pulmonary angiography later revealed patent PVs without any evidence of stenosis.
2.2 to 6.9±1.7 mm with a significant improvement in symptoms and lung perfusion from 5.6 to 12.2 % [42]. However, this study had a small sample size and larger population trials are needed to draw more definitive conclusions.
Di Biase et al. found that patients with a concomitant ipsilateral PVS or PVO with cumulative stenosis index (CSI) >75 % should receive immediate intervention to minimize reference vessel atrophy [2, 45]. CSI is a measure of the average cumulative stenosis of the PVs draining each independent lung. Using this criterion, there was a significantly negative correlation between improvements in CSI and time to intervention using either venoplasty or stenting (p
