Assessment and Management of Pulmonary Vein Occlusion After Atrial Fibrillation Ablation

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.