Pulmonary Vein Stenting for the Treatment of Acquired Severe Pulmonary Vein Stenosis after Pulmonary Vein Isolation: Clinical Implications after Long-Term Follow-Up of 4 Years

Introduction: Severe pulmonary vein stenosis (PVS) after catheter ablation of atrial fibrillation (AF) is a well-recognized complication with a further reported incidence of 1.3%. The preferred therapy for symptomatic PVS is pulmonary vein (PV) angioplasty, but this treatment modality is followed by restenosis in 44–70%. Whether there is additional long-term benefit from PVS stenting is uncertain. The aim of this study was the evaluation of the long-term success after PV stenting of severe stenosis.
Methods and Results: Ten patients (pts) with 13 PVS were prospectively evaluated. PV stenting was performed with Palmaz Genesis stents. Magnetic resonance imaging (MRI), lung perfusion scans, and CT-scans were performed before, directly after, and every 12 months thereafter. Primary endpoint of the study was the occurrence of restenosis after PV stenting. After a median follow-up of 47.7 (IQRs 25/75 47.2–48.5) months, the primary endpoint was achieved in 3 out of 13 PVs (23% of the treated PVs). We observed two in-stent restenosis 2 and 4 years after PV stenting. These pts experienced onset of dyspnea some weeks before. After an additional balloon angioplasty, the in-stent restenosis was resolved. In one asymptomatic patient, we observed an occlusion of the PV stent 13 months poststenting. Normalization of lung perfusion was noted 4 years after PV stenting versus directly poststenting in all pts without in-stent restenosis (n = 7).
Conclusion: PVS stenting with stent sizes ≥10 mm seems to be an adequate therapy modality for treatment of severe acquired PVS. Late in-stent restenosis after PVS stenting can occur. The normalization of the initially disturbed lung perfusion scan is possible and remains stable, even 4 years after PVS stenting.     

Pulmonary Vein Antrum Isolation and Terminal Part of the P Wave

Background: Delayed interatrial conduction, manifested on the electrocardiogram as a P wave ≥110 ms (interatrial block, IAB), is highly prevalent and associated with atrial fibrillation (AF). It is correlated with P‐terminal force (Ptf; product of the duration and amplitude of the negative terminal phase of the P wave in lead V1). Our purpose was to describe the modifications of the P‐wave duration and Ptf after pulmonary vein antrum isolation (PVAI) in patients with paroxysmal AF. Methods: PVAI was performed in 45 patients with paroxysmal AF, either with the cryoballoon technique (n = 15) or radiofrequency ablation (n = 30). Electrocardiograms were recorded before PVAI, 3 and 6 months after ablation. Results: From the sample (median age 60 [53; 66] years; female 40%), median P‐wave duration was 122 [114; 134] ms before PVAI and 116 [106; 124] ms at 3‐month follow‐up (P < 0.001). IAB was observed in 42 patients (93.3%) before ablation and in 31 patients (68.9%) at 3‐month follow‐up. Median Ptf was 0.047 [0.020; 0.068] before ablation and 0.013 [0.004; 0.025] at 3‐month follow‐up (P < 0.001). Twenty‐six patients (57.8%) had a Ptf > 0.04 mV x ms before ablation and only one (2.2%) at 3‐month follow‐up. P‐wave duration and Ptf were not significantly modified between 3‐ and 6‐month follow‐up. Conclusion: The terminal part of the P wave is modified after PVAI, perhaps due to the loss of pulmonary vein antrum signals. P‐wave duration and Ptf must be carefully interpreted after such a procedure. The prognostic value of these modifications should be evaluated. (PACE 2010; 784–789)