Author + information
- Received January 7, 2018
- Revision received May 3, 2018
- Accepted May 8, 2018
- Published online August 20, 2018.
- Erin A. Fender, MD, MSa,
- R. Jay Widmer, MD, PhDa,
- David O. Hodge, MSb,
- Douglas L. Packer, MDa and
- David R. Holmes Jr., MDa,∗ ()
- aDepartment of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
- bDepartment of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
- ↵∗Address for correspondence:
Dr. David R. Holmes, Jr., Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905.
Objectives This study sought to evaluate the sensitivity of noninvasive imaging in the assessment of severely stenosed and occluded pulmonary veins, and examine clinical outcomes following percutaneous intervention.
Background PV stenosis (PVS) is a rare complication of atrial fibrillation ablation, but is associated with significant morbidity. Patients present with nonspecific pulmonary symptoms that can result in delayed diagnosis and progression to PV occlusion. The assessment and management of PV occlusion has rarely been described.
Methods This was a prospective observational study performed from 2000 to 2014.
Results Computed tomography identified 124 patients with severe PVS, including 46 patients with at least 1 occluded vein. Patients with PV occlusion more frequently presented with cough (64.1% vs. 32.8%; p = 0.002) and hemoptysis (39.1% vs. 14.1%; p = 0.0015) and were more likely to have pulmonary parenchymal consolidation (77.3% vs. 41.7%; p = 0.0002). Intervention was attempted in 65 occluded veins and a residual microchannel was identified in 22 (34.0%). Balloon angioplasty was performed in 11, and 11 were treated with stenting. Over 3 years the rates of restenosis were similar for patients with PVS and PV occlusion (47.0% vs. 35.0%; p = 0.24). Among patients with PV occlusion, stenting significantly reduced the rate of restenosis (hazard ratio: 3.97; 95% confidence interval: 1.14 to 13.85; p = 0.03).
Conclusions Veins deemed occluded on noninvasive imaging require invasive characterization, as residual microchannels may be present in one-third of patients. In patients with a microchannel, intervention can be performed with either balloon angioplasty or stenting. Recurrence remains a common problem; however, stenting significantly reduces the rate of subsequent restenosis.
Dr. Packer has served as a consultant for Abiomed, Biosense Webster, Boston Scientific, CardioDX, CardioFocus, CardioInsight Technologies, InfoBionic, Johnson & Johnson Healthcare Systems, Johnson & Johnson, MediaSphere Medical, Medtronic CryoCath, Sanofi, Siemens, St. Jude Medical, and Topera Medical (he received no personal compensation for these consulting activities); has received research funding from an AHA Foundation Award, Biosense Webster, Boston Scientific/EPT, CardioInsight, CardioFocus, Endosense, EpiEP, EP Rewards, Hansen Medical, Medtronic CryoCath LP, National Institutes of Health, St. Jude Medical, and Siemens. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Fender and Widmer contributed equally to this paper.
- Received January 7, 2018.
- Revision received May 3, 2018.
- Accepted May 8, 2018.
- 2018 American College of Cardiology Foundation
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