INTRODUCTION: Pulmonary vein stenosis (PVS) following radiofrequency ablation (RFA) for symptomatic atrial fibrillation (AF) poses a diagnostic challenge for clinicians. Symptoms, signs and radiographic findings of PVS are nonspecific and can be attributed incorrectly to pneumonia, thromboembolism or interstitial lung disease. For this reason, identification of clues to the diagnosis of PVS is important. We report a case of PVS with pulmonary hypertension (PH) where the presence and location of PVS was suggested by the observation of regional loss of a V wave during the measurement of pulmonary artery wedge pressure. To the best of our knowledge, this is the first description of this sign of PVS or occlusion.
CASE PRESENTATION: A 65-year old male with a history of chronic AF resistant to anti-arrhythmic therapy and electrical cardioversion was referred to the PH clinic 3 years after mini maze and 2 years after RFA. He reported dyspnea on exertion and cough. Evaluation in the emergency department several weeks before resulted in a diagnosis of left lower lobe pneumonia which did not improve with antibiotics. PVS was suspected and magnetic resonance angiography was performed. The images showed obstruction of the left inferior pulmonary vein. A transesophageal echocardiogram showed mitral regurgitation. Measurements of left atrial pressure, recorded during attempted balloon angioplasty, showed a V-wave. Right sided heart catheterization assessed suspected PH. The right pulmonary artery wedge pressure (Pawp) pressure recording showed a V wave and the right Pawp was 22mmHg. The left Pawp wave form showed no V wave and the left Pawp was 35mmHg.
DISCUSSIONS: PVS after RFA presents with nonspecific symptoms, signs, and radiographic findings, and may be associated with PH. Pulmonary artery catheterization is essential to the assessment of PH. Others have described variation of Pawp between sites in the lungs as a clue to the diagnosis of pulmonary veno-occlusive disease, but the loss of a V wave on Pawp hemodynamic tracings has not been described before as a clue to the diagnosis and location of PVS.
CONCLUSION: Regional loss of V waves recorded during pulmonary artery wedge pressure measurements is a clue to the diagnosis and location of pulmonary vein stenosis.
DISCLOSURE: Mateo Porres Aguilar, No Financial Disclosure Information; No Product/Research Disclosure Information