Author + information
- Karl-Heinz Kuck, MD∗ (, )
- Thomas Fink, MD and
- Andreas Metzner, MD
- ↵∗Address for correspondence:
Dr. Karl-Heinz Kuck, Department of Cardiology, Asklepios Klinik St. Georg, Lohmühlenstrasse 5, 20099 Hamburg, Germany.
Iatrogenic pulmonary vein stenosis (PVS) and total pulmonary vein occlusion (PVO) after catheter ablation for atrial fibrillation (AF) are well-known and feared complications of catheter interventional AF treatment. Fortunately, improved ablation techniques have reduced the incidence of these complications. Potential treatment options include percutaneous transluminal balloon angioplasty (PTA) with or without stent implantation and surgical repair. Data on the available treatment strategies are limited to small retrospective studies.
Two studies in this issue of JACC: Cardiovascular Interventions expand our knowledge of the characteristics and possible treatment options of PVS and PVO (1,2). In the light of limited available studies, the investigators are to be commended for their important contributions to this topic.
Schoene et al. (1) report an incidence of PVS of 0.74%, corresponding to 81 patients with diagnosed PVS among 10,971 patients undergoing AF ablation at the University Heart Center in Leipzig, Germany, between 2004 and 2017. Thirty-nine of the 81 patients with PVS underwent PTA with or without stenting in a total of 84 catheter interventions. The follow-up data show a high incidence (53%) of restenosis after PTA, yet only 19% after stent implantation. All patients followed were free of symptoms after a median of 6 months.
The study by Fender et al. (2) focuses on the potential of interventional treatment in 46 patients with at least 1 occluded pulmonary vein. Catheter intervention was attempted in a total of 65 PVOs and turned out successful, using PTA alone and stent implantation in 11 patients each, in the 22 PVOs (34%) in which residual microchannels were identified. At 3 years, the restenosis rate of 47% was similar to that in patients treated for PVS without total occlusion (35%; p = 0.24).
In both studies, stent implantation was superior in terms of freedom from restenosis than PTA alone. Schoene et al. (1) observed incidences of severe complications of 10% after PTA and 13% after PTA and stenting; Fender et al. (2) reported severe complications in 18% after treatment for PVO.
What can we learn from these data? First, the high rate of PVS recurrence and the incidence of periprocedural complications indicate the complexity of PVS treatment. Therefore, patients with PVS should be treated only at experienced centers.
Second, stent implantation should be the therapy of choice, if possible. The 2 studies confirm earlier studies that demonstrated superior outcomes of stenting after PTA than after PTA alone (3–5). Additionally, the implantation of coronary stents should be avoided if the pulmonary vein anatomy allows the implantation of larger stent diameters. Interestingly, in the study by Schoene et al. (1), restenosis occurred only in patients treated with stents of diameters <8 mm. This reflects our own experience that the implantation of larger stents avoids a possible stent–pulmonary vein mismatch, which occurs with small stent diameters (6). However, because of small numbers, neither study appropriately addressed the question of which type of stent, bare metal or drug eluting, should be preferred.
Third, Fender et al. (2) show that recanalization of totally occluded pulmonary veins is possible with acceptable results. In our own experience (6), recanalization of a PVO was possible in selected cases; however, a PVO intervention can be challenging, and recanalization procedures harbor the risk for severe complications such as cardiac tamponade, pulmonary vein rupture, and stroke. Nevertheless, the study by Fender et al. also underscores the fact that early treatment of nonoccluded PVS should be undertaken before total occlusion develops.
Finally, the incidence of PVS reported from Leipzig did not differ between 2004 to 2008 and 2008 to 2017 (0.74% and 0.73%, respectively). This reminds us that this complication still occurs today, and it emphasizes the most important message to remember when it comes to PVS and/or PVO: with all the difficulties of PVS and PVO treatment in mind, avoiding this devastating complication should be first and foremost.
One other important issue is not addressed at all in either study, namely, the time span during which recanalization of an occluded pulmonary vein should be performed. The risk for debris embolization from the pulmonary veins will increase if recanalization is delayed for more than 6 months, and an attempt at reopening the vessel should then preferably be done using a cerebral protection system. The indication for recanalization should be based not only on the patient’s symptoms but also on perfusion/ventilation scintigraphy of the lungs. A severe mismatch of lung perfusion and ventilation may indicate serious lung damage. It is unknown whether the lungs recover and to what extent if perfusion is significantly reduced. Further research in this important field is urgently needed. Until then, the best treatment of PVO or severe PVS is its prevention by appropriate ablation outside the pulmonary vein ostia.
↵∗ Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
Dr. Kuck has received consulting fees from Medtronic, Boston Scientific, Abbott, and Biosense Webster. Dr. Metzner has received consulting fees from Medtronic and Cardiofocus. Dr. Fink has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
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