Korean Circ J.  2017 Jul;47(4):528-531. 10.4070/kcj.2016.0382.

Controlled Atrial Fibrillation after Pulmonary Vein Stenting

Affiliations
  • 1Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea. hnpak@yuhs.ac

Abstract

When there is no pulmonary vein reconnection after catheter ablation for atrial fibrillation, patients can experience recurrence of atrial fibrillation without clear evidence of non-pulmonary vein foci. We describe a patient with significant pulmonary vein stenosis and recurrent atrial fibrillation after four ablation procedures. After successful pulmonary vein stenting, the symptoms were resolved, and sinus rhythm was maintained for 2 years without treatment with antiarrhythmic medication. We believe pulmonary vein stenting potentially controlled atrial fibrillation by providing pulmonary vein pressure relief or by compressing the epicardial triggers occurring at the pulmonary vein ostium.

Keyword

Atrial fibrillation; Catheter ablation; Balloon angioplasty

MeSH Terms

Angioplasty, Balloon
Atrial Fibrillation*
Catheter Ablation
Constriction, Pathologic
Humans
Pulmonary Veins*
Recurrence
Stents*
Veins

Figure

  • Fig. 1 Electroanatomical map and CT images. (A) 3D-CT merged NavX electroanatomical map of the 3rd AF catheter ablation (2 years prior). (B) Five months after the last ablation procedure, severe stenosis of the left superior PV was observed (white arrows). (C) Twelve-month follow-up CT after PV stenting. 3D: 3-dimensional, CT: computed tomography, PV: pulmonary vein.

  • Fig. 2 Image diagnosis of PV stenosis and PV stenting. (A, B) A transesophageal echocardiogram shows increased PV systolic flow velocity in the pulse wave Doppler and turbulent flow at the PV ostium in the color Doppler. (C, D) Left superior PV venograms before (C) and after (D) angioplasty. PV: pulmonary vein.

  • Fig. 3 Tachogram from a 24-month follow-up Holter after PV stenting. There were no episodes of AF after the PV stenting. A single peak at 16:35 in the tachogram (arrow) was a transient non-sustained atrial tachycardia with 12 consecutive beats. BPM: beats per minute, PV: pulmonary vein, AF: atrial fibrillation.


Reference

1. Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339:659–666.
2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64:e1–e76.
3. Pak HN, Hwang C, Lim HE, Kim JS, Kim YH. Hybrid epicardial and endocardial ablation of persistent or permanent atrial fibrillation: a new approach for difficult cases. J Cardiovasc Electrophysiol. 2007; 18:917–923.
4. Verheule S, Eckstein J, Linz D, et al. Role of endo-epicardial dissociation of electrical activity and transmural conduction in the development of persistent atrial fibrillation. Prog Biophys Mol Biol. 2014; 115:173–185.
5. Chang SL, Chen YC, Chen YJ, et al. Mechanoelectrical feedback regulates the arrhythmogenic activity of pulmonary veins. Heart. 2007; 93:82–88.
6. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm. 2012; 9:632–696.e21.
7. Hsieh MH, Tai CT, Lee SH, et al. The different mechanisms between late and very late recurrences of atrial fibrillation in patients undergoing a repeated catheter ablation. J Cardiovasc Electrophysiol. 2006; 17:231–235.
8. Montserrat S, Sitges M, Calvo N, et al. Effect of repeated radiofrequency catheter ablation on left atrial function for the treatment of atrial fibrillation. Am J Cardiol. 2011; 108:1741–1746.
9. Hwang ES, Pak HN, Park SW, et al. Risks and benefits of an open irrigation tip catheter in intensive radiofrequency catheter ablation in patients with non-paroxysmal atrial fibrillation. Circ J. 2010; 74:644–649.
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