Pulmonary vein stenosis following radiofrequency pulmonary vein isolation: Presentation, diagnosis, and management using self-expandable, bare metal stents

Abstract

Pulmonary vein (PV) stenosis is a rare complication following PV isolation (PVI) for atrial fibrillation. Despite the benefit of early intervention, screening is not conducted, emphasizing the importance of maintaining a high index of suspicion. Standardized management approaches are unavailable for this serious complication. This report presents the case of a 56-year-old male with PV stenosis following PVI. During an annual follow up, the patient was asymptomatic, however a left pleural effusion was noted. Subsequent investigations, including a cardiac computed tomography (CT), confirmed the presence of left superior and inferior PV stenosis. Balloon angioplasty (BA) of both PVs was performed, followed by stenting of the left inferior PV with a balloon-expandable bare metal stent (BMS). The stent slipped shortly after deployment requiring snaring and removal. Re-stenosis was confirmed on repeat CT and successful stenting with self-expandable BMSs was performed. Dual anti-platelet treatment was prescribed post-procedure, with lifelong single anti-platelet therapy after 3 months. Patent PVs with stents in-situ were noted on CT three months post-stenting. A recognized consensus among the literature favors stenting over BA, however, no prospective studies have demonstrated the superiority of drug-eluting stents versus BMSs, or balloon-expandable against self-expandable stents. Effective management requires a tailored, multidisciplinary approach.

Learning objectives

Pulmonary vein (PV) stenosis is a rare complication of PV isolation ablation for atrial fibrillation with no guideline-directed treatment protocols. Maintaining a high index of suspicion for PV stenosis is essential to ensure timely intervention to improve lung perfusion and alleviate symptoms. Our case demonstrates the superiority of stenting over balloon angioplasty in maintaining PV patency following stenosis, as well as the successful application of self-expandable stents following slippage of a balloon-expandable stent.