Complications of Atrial Fibrillation Ablation

When Prevention Is Better Than Cure

Antonio Sorgente; Gian-Battista Chierchia; Carlo de Asmundis; Andrea Sarkozy; Lucio Capulzini; Pedro Brugada

Disclosures

Europace. 2011;13(11):1526-1532. 

In This Article

Pulmonary Vein Stenosis

Occurring in 1–3% of cases, PV stenosis after AF catheter ablation was first described in 2000.[53] As stated in the guidelines,[1] 'according to the percentage reduction of the luminal diameter, the severity of PV stenosis is generally defined as mild (<50%), moderate (50–70%), or severe (>70%)'. The real incidence of PV stenosis has further decreased under 1%, thanks to the progressive shift of the site of ablation from the internal portion of the veins towards the PV antrum and thanks to the great improvement in spatial accuracy of the most used mapping systems.[54] Pulmonary vein stenoses are often clinically silent; symptoms are extremely variegated and may include cough, dyspnea, chest pain, haemoptysis, and recurrent respiratory infections.[49] Severity of the clinical presentation relies on the entity of the stenosis and the number of PVs involved.[55] Since the clinical picture associated with PV stenosis is extremely variable, PV stenosis should be suspected in every patient presenting with one the above clinical symptoms after an AF catheter ablation. Cardiac computed tomography and cardiac magnetic resonance are the diagnostic tools commonly used to make the diagnosis; transthoracic, or transoesophageal echocardiography could help only partially but might be useful to assess pulmonary vein flows.[50] Radionuclide ventilation/perfusion imaging may serve also as a screening tool in symptomatic patients and help to clarify the haemodynamic significance of PV stenosis.[56]

Optimal treatment for PV stenosis is still unknown. Balloon angioplasty alone or in association with stent implantation seems to be efficacious in the acute setting but is also associated with restenosis in 30–50% of the patients.[50] Taken this in mind, prevention of PV stenosis is mandatory and warrants widening the encircling of PVs to include the PV antra. Intense scientific debate is ongoing also on the possibility that different sources of energy, such as cryothermal energy applied through cryoballoon technology, could reduce the risk of PV stenosis. Even though theoretically cryothermal energy should avoid the development of fibrosis and/or stenosis, concern has been raised recently after the publication of the results of the STOP-AF trial, where cryoballoon therapy was associated with a 3.1% incidence of PV stenosis.[57]

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