Cardiovascular Disease |

A 48-Year-Old Male With Chest Pain and Hemoptysis From Pulmonary Vein Stenosis: A Rare Diagnosis That Is Easily Overlooked FREE TO VIEW

Jonathan Cooke, MD; Andrew Schlachter, MD; Elaine Chen, MD
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Rush University Medical College, Chicago, IL

Chest. 2013;144(4_MeetingAbstracts):127A. doi:10.1378/chest.1703873
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SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary vein stenosis (PVS) is a rare complication seen after ablation procedures for atrial fibrillation (AF). Diagnosis is often delayed which can lead to significant morbidity. We report a complex case of PVS seen at our institution.

CASE PRESENTATION: A 48 year old male presented with pleuritic chest pain and hemoptysis. He was healthy other than paroxysmal AF for which he had undergone two ablations, most recently six months prior. CT chest with contrast showed dense patchy RUL and RML consolidation. Two courses of oral antibiotics for community acquired pneumonia resulted in temporary improvement in symptoms with recurrence days after. Bronchoscopy demonstrated an edematous RUL with thin bloody secretions; lavage fluid was monocyte predominant without significant microbiologic or cytologic findings. Vasculitis workup was notable only for CRP of 111.5 mg/L (normal <8.0). After further hemoptysis, CT guided biopsy of the RUL lesion was performed, revealing recent alveolar hemorrhage without etiology. Given his history of prior AF ablation, thin-slice cardiac CT was performed which suggested severe stenosis of the RUL pulmonary vein, the site of his most recent ablation. Pulmonary angiogram confirmed severe RUL and moderate RML pulmonary vein stenosis which were successfully stented. He has remained well without recurrence of symptoms five months since the intervention.

DISCUSSION: PVS can be a devastating complication following ablation for AF. Its frequency, once estimated as high as 42%, has significantly decreased by optimizing the location of and energy used for the ablation. Presentation may mimic pneumonia or vasculitis leading to missed or delayed diagnosis. Symptoms of PVS manifest on average about 100 days following ablation and are more frequent with multiple ipsilateral sites of ablation. CT scan is most commonly used in establishing a diagnosis but requires high clinical suspicion given common variations in pulmonary venous drainage. Early intervention should be attempted in symptomatic patients to optimize the likelihood of reperfusion of the affected vein(s). Stenting is the preferred treatment to surgical lobectomy though the rate of restenosis is estimated at 20%. As PVS related to ablation procedures is a relatively new entity with evolving interventional techniques, long term prognostication is difficult.

CONCLUSIONS: PVS can be very difficult to diagnose without high clinical suspicion. In our patient, the diagnosis was delayed but fortunately made in time to perform an optimal therapeutic intervention which has resulted in cessation of symptoms.

Reference #1: DL Packer, et al. Clinical presentation, investigation and management of pulmonary vein stenosis complicating ablation for atrial fibrillation. Circulation. 111 (2005), 546-554.

Reference #2: L Di Biase, et al. Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up. J Am Coll Cardiol. 48 (2006), 2493-2499.

DISCLOSURE: The following authors have nothing to disclose: Jonathan Cooke, Andrew Schlachter, Elaine Chen

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