Author + information
- Received July 5, 2016
- Revision received August 29, 2016
- Accepted September 1, 2016
- Published online April 17, 2017.
- Matthew C. Hyman, MD, PhDa,
- Jian-Fang Ren, MDa,
- Venkatesh Y. Anjan, MDb,
- Robert L. Wilensky, MDb and
- David S. Frankel, MDa,∗ ()
- aElectrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- bInterventional Cardiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- ↵∗Addres for correspondence:
Dr. David S. Frankel, Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, Pennsylvania 19104.
- atrial fibrillation ablation
- electroanatomic mapping
- intracardiac echocardiography
- pulmonary vein occlusion
- pulmonary vein stenosis
- pulmonary vein stenting
A 70-year-old woman with history of symptomatic, paroxysmal atrial fibrillation refractory to flecainide underwent antral pulmonary vein (PV) isolation. The left superior pulmonary vein (LSPV) required additional ablation along the posterior roof to achieve entrance and exit block (Figure 1A). The patient was subsequently free from arrhythmias. Seven months later, she presented with hemoptysis and pleuritic chest pain. A computed tomography scan demonstrated total occlusion of the LSPV (Figure 1B), leading to venous congestion and left upper lobe pulmonary infarction.
LSPV stenting was performed using fluoroscopy, intracardiac echocardiography (ICE), and electroanatomic mapping (CARTO, Biosense Webster, Diamond Bar, California) to define left atrial and PV anatomy. Electroanatomic mapping (Figure 1C) demonstrated “bird-beaking” (red arrow) of the LSPV as well as chronic isolation of all PVs. The guide catheter was positioned at the ostium of the occluded PV using electroanatomic mapping, fluoroscopy, and ICE (Figures 1D to 1F). ICE showed an absence of color flow Doppler in the LSPV confirming total occlusion. Fluoroscopy and ICE provided real-time feedback while a 0.014-inch hydrophilic was used to cross the occlusion. A compliant 3.0-mm angioplasty balloon (Sprinter, Medtronic, Minneapolis, Minnesota) was used to dilate the PV. Next, a 6 × 29 mm hepatobiliary stent (Genesis, Cordis, Miami Lakes, Florida) was positioned at the ostium of the LSPV over a Wholey wire (Medtronic). The stent was deployed with a 45-s, 9-atm inflation (Figures 1G and 1H). Normal Doppler peak velocities within the LSPV demonstrated restoration of normal pulmonary venous flow following stent deployment (Figures 1I and 1J).
PV stenosis is an uncommon complication of PV isolation that occurs in 1% to 2% of patients (1,2). The presentation of PV stenosis can be quite variable, ranging from asymptomatic to profound dyspnea and hemoptysis. In symptomatic cases, pulmonary venoplasty and stenting can provide significant relief (3). In most circumstances, the ostium of the stenosed PV can be readily identified using fluoroscopy and pulmonary wedge angiography (2). In this case, occlusion of the PV made identification of the LSPV ostium more challenging. Multimodality imaging, including ICE and electroanatomic mapping, provided a significant informational advantage over fluoroscopy alone and thereby facilitated a successful outcome.
The authors would like to thank Shannon McGrath, RN, CCRN, CEPS, for her assistance with preparing the CARTO images.
Funding for this study was provided in part by the Richard T. and Angela Clark Innovation Fund in Cardiovascular Medicine as well as the F. Harlan Batrus Cardiac Electrophysiology Research and Education Fund. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received July 5, 2016.
- Revision received August 29, 2016.
- Accepted September 1, 2016.
- 2017 American College of Cardiology Foundation
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