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Pulmonary Vascular Disease: Pulmonary Vascular Disease |

Pulmonary Vein Total Occlusion and Pulmonary Infarction After Radiofrequency Ablation for Atrial Fibrillation FREE TO VIEW

Jordan Lee, MD; Ching-Fei Chang, MD
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University of Southern California, Los Angeles, CA


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(4_S):A503. doi:10.1016/j.chest.2016.02.525
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SESSION TITLE: Pulmonary Vascular Disease

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Pulmonary vein total occlusion (PVTO) is a rare condition with an overall incidence of 0.8-2.1%. Most cases are asymptomatic, but approximately 2-3 patients a year require intervention for dyspnea and hypoxemia. We present a case of PVTO after radiofrequency ablation (RFA) for atrial fibrillation, with a dilemma in management.

CASE PRESENTATION: A 65-year-old non-smoking female professor presented with worsening cough, shortness of breath, mild hypoxemia, and inability to lecture two weeks after RFA for atrial fibrillation. Chest x-ray showed a new left lower lobe infiltrate and pleural effusion (Fig-1). PaO2 was 64mmHg on room air. Echocardiogram demonstrated preserved left ventricular ejection fraction, normal valvular function, and a small pericardial effusion with thickened pericardium. A cardiac CT scan revealed complete thrombosis of the left inferior pulmonary vein with evidence of evolving pulmonary infarction in the left lower lobe (Fig-2). Cumulative stenosis score (CSI) was calculated as 50%. Surprisingly, a ventilation-perfusion scan (V/Q) was unremarkable, with only mild retention of activity in the left lower lung suggestive of obstructive physiology. Although the patient was severely symptomatic and her CT scans showed early pulmonary infarction, endovascular intervention (thrombolysis, angioplasty/stenting) was considered high-risk. Given the absence of severe impairment on V/Q scan, CSI score less than 75%, and the fact that her symptoms could be partially due to pericarditis, the decision was made to treat conservatively with anticoagulation and close monitoring. Six months later, she is now asymptomatic, and weaned off all antiarrhythmic and anticoagulant medications.

DISCUSSION: Pulmonary vein thrombosis or stenosis can occur as a complication of RFA for atrial fibrillation. Although CT imaging may be impressive, most patients are asymptomatic. When patients are symptomatic, endovascular interventions should be considered if the patient is at risk of lung infarction. This can be assessed by V/Q scan and calculating a CSI score (%stenosis of upper vein + %stenosis of lower vein) / (number of ipsilateral veins). CSI scores >75% have been validated as a marker of poor lung perfusion and need for early intervention. Both modalities can be used to follow therapeutic response and alert clinicians to the need for repeat intervention, especially since re-stenosis occurs in up to 50% of cases within the first year.

CONCLUSIONS: Asymptomatic patients with PVTO may only require anticoagulation and close follow-up. In symptomatic patients, however, endovascular interventions should be considered when the CSI score >75% or V/Q scan reveals a mismatch.

Reference #1: Saad EB, et al. Pulmonary Vein Stenosis After Radiofrequency Ablation of Atrial Fibrillation. Circulation. 2003 Dec 23;108(25):3102-7.

Reference #2: Biase DL, et al. Pulmonary vein total occlusion following catheter ablation for atrial fibrillation. J Am Coll Cardiol. 2006 Dec 19;48(12):2493-9.

DISCLOSURE: The following authors have nothing to disclose: Jordan Lee, Ching-Fei Chang

No Product/Research Disclosure Information


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