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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Pulmonary Vein Total Occlusion Following Catheter Ablation for Atrial Fibrillation

Clinical Implications After Long-Term Follow-Up

Luigi Di Biase, MD^_*,,1, Tamer S. Fahmy, MD^_*, Oussama M. Wazni, MD^_*, Rong Bai, MD^_*,,1, Dimpi Patel, MD^_*, Dhanunjaya Lakkireddy, MD^_*, Jennifer E. Cummings, MD^_*, Robert A. Schweikert, MD^_*, J. David Burkhardt, MD^_*, Claude S. Elayi, MD^_*, Mohamed Kanj, MD^_*, Lucie Popova, MD^_*,2, Subramanya Prasad, MD^_*, David O. Martin, MD^_*, Lourdes Prieto, MD^_*, Walid Saliba, MD^_*, Patrick Tchou, MD^_*, Mauricio Arruda, MD^_* and Andrea Natale, MD^_*,_*

^_* Department of Cardiovascular Medicine, Section of Cardiac Electrophysiology and Pacing, Cleveland Clinic, Cleveland, Ohio
Department of Cardiovascular Science, University of Insubria, Varese, Italy.

Manuscript received June 28, 2006; revised manuscript received August 1, 2006, accepted August 8, 2006.

^_* Reprint requests and correspondence: Dr. Andrea Natale, Department of Cardiovascular Medicine, Head, Section of Cardiac Electrophysiology and Pacing, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195. (Email: natalea{at}ccf.org).

OBJECTIVES: We present the clinical course and management outcomes of patients with total pulmonary vein occlusion (PVO).

BACKGROUND: Pulmonary vein occlusion is a rare complication that can develop after radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The long term follow-up data of patients diagnosed with PVO are minimal.

METHODS: Data from 18 patients with complete occlusion of at least one pulmonary vein (PV) were prospectively collected. All patients underwent RFA for AF using different strategies between September 1999 and May 2004. Pulmonary vein occlusion was diagnosed using computed tomography (CT) and later confirmed by angiography when intervention was warranted. Lung perfusion scans were performed on all patients before and after intervention. The percent stenoses of the veins draining each independent lung were added together to yield an average cumulative stenosis of the vascular cross-sectional area draining the affected lung (cumulative stenosis index [CSI]).

RESULTS: The patients’ symptoms had a positive correlation with the CSI (r = 0.843, p < 0.05) and a negative one with the lung perfusion (r = –0.667, p < 0.05). A CSI 75% correlated well with low lung perfusion (<25%; r = –0.854, p < 0.01). Patients with a CSI 75% appeared to improve mostly when early (r = –0.497) and repeated dilation/stenting (r = 0.0765) were performed.

CONCLUSIONS: Patients with single PVO are mostly asymptomatic and should undergo routine imaging. On the other hand, patients with concomitant ipsilateral PV stenosis/PVO and a CSI 75% require early and, when necessary, repeated pulmonary interventions for restoration of pulmonary flow and prevention of associated lung disease.

Abbreviations and Acronyms   AF = atrial fibrillation   CSI = cumulative stenosis index   CT = computed tomography   NYHA = New York Heart Association   PPI = percutaneous pulmonary intervention   PV = pulmonary vein   PVO = pulmonary vein occlusion   PVS = pulmonary vein stenosis   RFA = radiofrequency catheter ablation

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