Close relationship between the bronchi and pulmonary veins: implications for the prevention of atriobronchial fistula after atrial fibrillation ablation

Introduction: Atrio-bronchial fistula (ABF) can be a rare but potentially lethal complication following the catheter ablation of atrial fibrillation (AF). Understanding the extent of the contact between the bronchial tree and pulmonary veins (PVs) is critical to avoid this complication. We investigated the anatomic relationship between the four PVs and bronchial tree using multi-detector computed tomography (MDCT) images.
Methods and Results: Seventy patients with drug refractory AF were included. They underwent 16-slice MDCT before the ablation. The spatial relationship between the bronchus and PVs was demonstrated by the multi-planar images. The bronchus was in direct contact with four PVs in the vast majority of patients. The mean distances between the bronchus and the ostia of right superior, left superior, right inferior, and left inferior PV were 7.1 ± 5.5, 3.5 ± 4.8, 12.3 ± 5.6, and 17.9 ± 6.8 mm, respectively. Patients were categorized into two groups: Group I: proximal contact (<5 mm from the PV ostium) and Group II: distal contact (>5 mm from the PV ostium). For the right superior pulmonary vein (RSPV), the Group I patients were associated with thinner connective tissue between them (P = 0.001), a larger RSPV (17.2 ± 2.2 vs 15.5 ± 2.1 mm, P < 0.001), and right inferior pulmonary vein (RIPV) diameter (15.9 ± 1.9 vs 14.6 ± 1.6 mm, P < 0.01). For the left superior pulmonary vein (LSPV), the Group I patients were associated with an older age (P = 0.02).
Conclusion: Isolation of the superior PVs may carry the potential risk of bronchial damage. The clinical or anatomic characteristics associated with the proximal contact between the bronchi and superior PVs can provide useful information to prevent this complication.