SESSION TITLE: Cardiovascular Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 30, 2013 at 11:30 AM - 12:30 PM
INTRODUCTION: Pulmonary vein stenosis (PVS) is a rare complication of radiofrequency ablation for atrial fibrillation with an incidence of 0.5-2%.1 We report a case of recurrent hemoptysis with late presentation after prior radiofrequency ablation (RFA) procedure successfully managed with percutaneous stent placement.
CASE PRESENTATION: 64 year old male with chronic obstructive pulmonary disease , atrial fibrillation with RFA 3 years prior, and hypertension presented with recurrent episodes of hemoptysis over the past year. Six months after RFA he developed shortness of breath and was treated for COPD with some improvement. He developed hemoptysis 3 years after RFA with one episode requiring endotracheal intubation. Patient subsequently underwent bronchoscopy and ultimately left bronchial artery embolization with resolution of his hemoptysis. One year after embolization, hemoptysis recurred and was managed on an outpatient basis given evidence of bronchiectasis in left lower lobe, with plan for lobectomy. He was again admitted for increased hemoptysis and new left sided pleural effusion, with CT scan revealing pulmonary vein stenosis bilaterally without evidence of pulmonary embolism or worsening bronchiectasis. Echocardiogram revealed pulmonary hypertension and pleural effusion was transudative. Workup with gated CT scan revealed 50% right superior pulmonary vein (RSPV) stenosis and complete occlusion of left sided pulmonary veins. Ventilation-perfusion scanning revealed decreased blood flow to the right lung and almost absent profusion to the left lung. He underwent stenting of RSPV with immedate improvement of pulmonary artery pressures. Left sided pulmonary veins were not intervened on, he was started on Aspirin 325mg daily, and patient has been asymptomatic for the past year.
DISCUSSION: Pulmonary vein stenosis is a complication of RFA that should be recognized early to prevent hemoptysis, dyspnea on exertion, orthopnea, pulmonary hypertension, cough, bronchiectasis, and recurrent pulmonary infections. Incidence has decreased considerably over the years as RFA procedures have improved and ablation less commonly occurs within the pulmonary veins. Mechanisms of vein occlusion include thrombosis, neointimal hyperplasia, collagen and other cytoskeletal contraction. PVS may be treated with angioplasty and stenting of stenosed vessels. Our patient presented late after RFA given that most PVS complications are seen in 2-5 months post-procedure. Appropriate imaging early when symptoms arise may aide in recognition of PVS with early intervention to minimize development of pulmonary hypertension and other complications. Stenosis may recur and close monitoring is advised.1
CONCLUSIONS: Although usually an early complication of RFA, PVS can present years later and should be considered in a patient with hemoptysis.
Reference #1: Holmes, D. "Pulmonary Vein Stenosis Complicating Ablation for Atrial Fib.: Clinical Spectrum and Interventional Considerations." JACC (2009): 267-276.
DISCLOSURE: The following authors have nothing to disclose: Bryan Husta, Cristina Reichner, Ashish Haryani, Anne O'Donnell
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