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Pulmonary Vascular Disease |

Pulmonary Venous Infarction: A Complication of Pulmonary Venous Stenosis From Ablation Procedure for Atrial Fibrillation

Leena Pawar, MD; Umbreen Arshad, MD; Dinesh Ananthan, MD; Anil Ghimire, MD
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SUNY Upstate Medical University, Syracuse, NY


Chest. 2014;146(4_MeetingAbstracts):869A. doi:10.1378/chest.1995153
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Abstract

SESSION TITLE: Pulmonary Vascular Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: About 50,000 ablation procedures are attempted every year. However, pulmonary venous stenosis has been a limiting factor. The presentation of pulmonary venous stenosis varies widely and so does the symptomatology.

CASE PRESENTATION: A 51 year old Caucasian male with history of difficult to control atrial fibrillation s/p two ablation procedures, preceded by two failed cardioversion procedures and a trial of multiple anti arrhythmic medications ; presented with hemoptysis and dyspnea in December. He had two ablation procedures, one in May and the other in October of the same year. During his ablation procedures, the EP studies showed three branches of the right pulmonary vein which were silent. He had a single entrance of the two left pulmonary veins as a confluence, at which site the ablation was done. CT on admission was suggestive of a confluent airspace opacity in the left upper lobe and lingula. Bronchoscopy with a transbronchial biopsy of left upper lobe superior lingular segment revealed a venous infarction with features indicative of pulmonary venous outflow obstruction. A CTA thorax done for pulmonary venous assessment revealed diminished flow within the left lingular pulmonary vein.

DISCUSSION: The likely mechanism is intense periadventitial inflammation or collagen deposition . The left superior, left inferior and right superior PV involvement is roughly 30%. Because of the presence of the antral fusion of the origin of the left superior and left inferior pulmonary vein, the stenosis involving one or the other can impinge and affect outcome. Imaging has documented antral fusion of the left PV in more than 50% of patients. Transesopageal echo is limited by its inability to image deeply into all 4 PVs. CT and MRI currently provide the best tests for evaluation. A Balloon dilation, over the guidewire stent or over the balloon stent, through a trans septal puncture is the used intervention. PVS stenosis can progress rapidly and recurrence of stenosis is common.

CONCLUSIONS: Pulmonary venous stenosis could be detected early on regular follow up of patients who undergo ablation. If so, the degree of involvement could be less serious and more amenable to intervention. The symptoms/presentation are not specific and hence increased awareness of existence of this possibility needs to be exercised.

Reference #1: Holmes et al Pulmonary Vein Stenosis complicating ablation for afib. jacc:cardiovascular interventions,2009;2:4

DISCLOSURE: The following authors have nothing to disclose: Leena Pawar, Umbreen Arshad, Dinesh Ananthan, Anil Ghimire

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