Pulmonary vein stenosis:Etiology,diagnosis and management

Pulmonary vein stenosis(PVS) is rare condition characterized by a challenging diagnosis and unfavorable prognosis at advance stages. At present, injury from radiofrequency ablation for atrial fibrillation has become the main cause of the disease. PVS is characterized by a progressive lumen size reduction of one or more pulmonary veins that, when hemodynamically significant, may raise lobar capillary pressure leading to signs and symptoms such as shortness of breath, cough, and hemoptysis. Image techniques(transesophageal echocardiography, computed tomography, magnetic resonance and perfusion imaging) are essential to reach a final diagnosis and decide an appropriate therapy. In this regard, series from referral centers have shown that surgical and transcatheter interventions may improve prognosis. The purpose of this article is to review the etiology, assessment and management of PVS.

Safety and efficacy of balloon angioplasty compared to stent-basedstrategies with pulmonary vein stenosis:A systematic review and meta-analysis

BACKGROUND Pulmonary vein stenosis(PVS)is an uncommon but known cause of morbidity and mortality in adults and children and can be managed with percutaneous revascularization strategies of pulmonary vein balloon angioplasty(PBA)or pulmonary vein stent implantation(PSI).AIM To study the safety and efficacy outcomes of PBA vs PSI in all patient categories with PVS.METHODS We performed a literature search of all studies comparing outcomes of patients evaluated by PBA vs PSI for PVS.We selected all published studies comparing PBA vs PSI for PVS with reported outcomes of restenosis and procedure-related complications in all patient categories.In adults,PVS following atrial fibrillation ablation and in children PVS related to congenital etiology or post-procedural PVS following total or partial anomalous pulmonary venous return repair were included.The patient-centered outcomes were risk of restenosis requiring re-intervention and procedural-related complications.The metaanalysis was performed by computing odds ratios(ORs)using the random effects model based on underlying statistical heterogeneity.RESULTS Eight observational studies treating 768 severe PVS in 487 patients met our inclusion criteria.The age range of patients was 6 months to 70 years and 67%were males.The primary outcome of the re-stenosis requiring re-intervention occurred in 196 of 325 veins in the PBA group and 111 of 443 veins in the PSI group.Compared to PSI,PBA was associated with a significantly increased risk of re-stenosis(OR 2.91,95%CI:1.15-7.37,P=0.025,I2=79.2%).Secondary outcomes of the procedurerelated complications occurred in 7 of 122 patients in the PBA group and 6 of 69 in the PSI group.There were no statistically significant differences in the safety outcomes between the two groups(OR:0.94,95%CI:0.23-3.76,P=0.929,I^(2)=0.0%).CONCLUSION Across all patient categories with PVS,PSI is associated with reduced risk of re-intervention and is as safe as PBA and should be considered first-line therapy for PVS.

Hemoptysis secondary to pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation: A case report and literature review

Objectives: Pulmonary vein stenosis(PVS) is a known complication after radiofrequency ablation of atrial fibrillation(RAAF) and is often misdiagnosed owing to lack of awareness regarding PVS among noncardiologists.Misdiagnosis results in unnecessary treatment;therefore, greater understanding of PVS can improve the management of these patients.Methods: We report the case of a 38-year-old man with a history of RAAF who presented with massive hemoptysis.His symptoms persisted despite undergoing transcatheter bronchial artery embolization on two occasions.Results: Pulmonary computed tomography angiography revealed a completely occluded left superior pulmonary vein. Considering the patient’s history of RAAF, we diagnosed him with RAAF-induced PVS and performed left superior lobectomy after which hemoptysis did not recur.Conclusions: Unexplained massive hemoptysis should alert clinicians regarding the possibility of RAAF-induced PVS. Balloon angioplasty and stent placement are used to treat PVS;however, their efficacy is controversial considering the high recurrence rates associated with these interventions.

A case report of acute pulmonary vein stenosis

Hemoptysis is a common emergency symptom for pulmonary embolism. It's important to differential diagnosis for this symptom. This article reports a case of pulmonary vein stenosis. The patient was transferred to a number of hospitals for medical treatment, but was misdiagnosed for 7 months. This article aims to improve clinician's ability to differentially diagnose hemoptysis, and to deepen the knowledge of pulmonary vein stenosis.

Sutureless Repair of Left Primary Pulmonary Vein Stenosis—A Case Report

Primary left pulmonary vein stenosis is a very rare condition. It is associated with variable form of Pulmonary artery hypertension. Catheter based intervention is used to treat the disease like balloon dilation and stenting but this has high recurrence rate. Here is a case in which we did a sutureless repair of left pulmonary vein thus decreasing the possibility of recurrence. Sutureless surgical management is technically superior and less challenging than direct left atrial wall anastomosis and it provides better results than catheter based intervention in terms of recurrence of stenosis.

Standardized Management of Acute Pulmonary Hemorrhage after Percutaneous Pulmonary Vein Intervention

Introduction:Pulmonary hemorrhage(PHm)is a life-threatening complication that can occur after catheter-based interventions in patients with pulmonary vein stenosis(PVS).Inhaled racemic epinephrine(iRE)and tra-nexamic acid(iTXA)have been used in other conditions,but a standardized approach in PVS has not been described.We aimed to describe the current management of PHm after PVS catheter-based interventions.Methods:We present a retrospective review of episodes of PHm from July 2022 to February 2024.PHm was defined as frank blood suctioned from the endotracheal tube including blood-tinged secretions and>3%decrease in saturations and/or ventilatory changes with or without acute chest X-ray changes.Each individual episode of PHm was considered a separate event.Incidence was calculated based on the total number of PVS interventions during the study period.Results:Eleven episodes of PHm were identified out of 108 PVS interventions,resulting in an incidence of 10.2%.Five(45.5%)had primary PVS,and seven(63.6%)had bilateral PVS.The median age at PHm was 23 months(3-91 months).Four episodes were treated with iRE,five with both iRE and iTXA,and two with only iTXA due to a history of suprasystemic right ventricular pressures.Median time on mechanical ventila-tion after PHm was 24 h(15-72 h)and a median ICU stay of 2 days(1-8 days).Hemostasis was achieved in all events.There were no adverse events after iTXA,however,transient hypertension was observed after iRE which was dose-related.Conclusions:The implementation of a standardized protocol for the treatment of PHm in PVS has the potential to improve procedural planning,has a wider availability of medications,and greater awareness by the providers involved,possibly leading to earlier detection of PHm and appropriate treatment.

Percutaneous transhepatic stenting for acute superior mesenteric vein stenosis after pancreaticoduodenectomy with portal vein reconstruction:A case report

BACKGROUND Percutaneous transhepatic stent placement has become a common strategy for the postoperative treatment of portal vein(PV)/superior mesenteric veins(SMV)stenosis/occlusion.It has been widely used after liver transplantation surgery;however,reports on stent placement for acute PV/SMV stenosis after pancreatic surgery within postoperative 3 d are rare.CASE SUMMARY Herein,we reported a case of intestinal edema and SMV stenosis 2 d after pancreatic surgery.The patient was successfully treated using stent grafts.Although the stenosis resolved after stent placement,complications,including bleeding,pancreatic fistula,bile leakage,and infection,made the treatment highly challenging.The use of anticoagulants was adjusted multiple times to prevent venous thromboembolism and the risk of bleeding.After careful treatment,the patient stabilized,and stent placement effectively managed postoperative PV/SMV stenosis.CONCLUSION Stent placement is effective and feasible for treating acute PV/SMV stenosis after pancreatic surgery even within postoperative 3 d.

Reversal of pulmonary vein remodeling after catheter ablation of atrial fibrillation

Background Pulmonary veins （PV） and the atria undergo electrical and structural remodeling in atrial fibrillation （AF）. This study aimed to determine PV and left atrial （LA） reverse remodeling after catheter ablation for AF assessed by chest computed tomography （CT）. Methods PV electrophysiologic studies and catheter ablation were performed in 63 patients （68% male; mean ± SD age： 56 ± 10 years） with symptomatic AF （49% paroxysmal, 51% persistent）. Chest CT was performed before and 3 months after catheter ablation. Results At baseline, patients with persistent AF had a greater LA volume （91 ±29 cm3 vs. 66 ± 27 cm3; P = 0.003） and mean PV ostial area （241 ＋ 43 mm2 vs. 212 ± 47 mm2; P = 0.03） than patients with paroxysmal AF. There was no significant correlation between the effective refractory period and the area of the left superior PV ostium. At 3 months of follow-up after ablation, 48 patients （76%） were AF free on or off antiarrhythmic drugs. There was a significant reduction in LA volume （77 ±31 cm3 to 70 ± 28 cm3; P 〈 0.001） and mean PV ostial area （224 ± 48 mm2 to 182 ± 43 mm2; P 〈 0.001）. Patients with persistent AF had more reduction in LA volume （11.8 ± 12.8 cm3 vs. 4.0 ± 11.2 cm3; P = 0.04） and PV ostial area （62 mm2 vs. 34 mm2; P = 0.04） than those who have paroxysmal AF. The reduction of the averaged PV ostial area was significantly correlated with the reduction of LA volume （r = 0.38, P = 0.03）. Conclusions Catheter ablation of AF improves structural remodeling ofPV ostia and left atrium. This finding is more apparent in patients with persistent AF treated by catheter ablation.

Paroxysmal atrial fibrillation ablation:Achieving permanent pulmonary vein isolation by point-by-point radiofrequency lesions

Pulmonary vein isolation by point-by-point radiofrequency catheter ablation constitutes the cornerstone of catheter ablation strategies for the treatment of atrial fibrillation. However, despite advances in pulmonary vein isolation ablation strategies, long-term success rates after ablation remain suboptimal, which highlights the need to develop techniques to achieve more durable lesions. Strategies proposed to improve the durability of pulmonary vein isolation can be divided into two groups: Those addressed to improving the quality of the lesion and those that optimize the detection of acute PV reconnection during the ablation procedure. This manuscript reviews the role and potential benefits of these techniques according to current clinical evidence.

Impact of Pulmonary Vein Anatomy on Long-term Outcome of Cryoballoon Ablation for Atrial Fibrillation

Variant pulmonary vein anatomy （PVA） has been reported to influence the recurrence of atrial fibrillation （AF） after radiofrequency ablation. However, the effects of PVA on AF in patients undergoing cryoballoon ablation （CBA） remain unknown. The present study aimed to examine the impact of PVA on the long-term outcome of CBA for AF. A total of 78 patients （mean age 60.7±10.9 years, 64.1% males） with symptomatic and drug-refractory paroxysmal AF were enrolled in the study. Left atrium （LA） and PVA acquired at computed tomography angiography （CTA） were reconstructed with CARTO 3 SYSTEM. Patients were routinely evaluated by 24-hour Holter monitoring following CBA. Cox regression was used to detect the predictors of AF recurrence after CBA. The results showed abnormal PVA in 30 patients （38.5%） and 18 patients （23.1%） had left common PV （LCPV）. Electrical pulmonary vein isolation was achieved in all patients. After a mean follow-up of 689.5±103.8 days, it was found that patients with abnormal PVA had similar AF recurrence rate to those with normal PVA （26.7% vs. 25.0%, P=0.54）, and there was no significant difference in AF recurrence rate between LCPV patients and non-LCPV patients （33.7% vs. 23.3%, P=0.29）. Cox regression analysis showed that AF duration （72.9±9.0 vs. 42.3±43.2 months, HR 1.001; 95%CI 1.003- 1.014; P〈0.001） and cryo-applications of right-side PVs （3.0±1.6 vs. 4.7±1.7, HR 0.661; 95% CI 0.473-0.925; P=0.016） were independent predictors of freedom from AF, but PVA was not identified as a predictor of long-term success. In conclusion, the variant PVA cannot significantly influence the long-term outcome of AF patients undergoing CBA; longer AF duration and less cryo-applications of right-side PVs are associated with higher AF recurrent rate.

Segmental radiofrequency ablation of pulmonary vein ostia for patients with refractory paroxysmal atrial fibrillation using multi-slice spiral computed tomography guidance

Objective： To evaluate the safety and clinical efficacy of segmental radiofrequency ablation of pulmonary vein （PV） ostia for patients with refractory paroxysmal atrial fibrillation （AF） under multi-slice spiral computed tomography （MSCT） guidance before the procedure. Methods： A series of 58 consecutive patients with refractory paroxysmal AF were enrolled to undergo segmental radiofrequency ablation ofPV ostia. The 36 male and 22 female patients with mean age of （57.4±9.5） （32-79） years and no obvious organic heart disease. Before ablation, patients received MSCT to generate 3-dimentional image of the left atrium （LA） and proximal PVs. Patients then underwent segmental radiofrequency ablation ofPV ostia using PV circular mapping catheter manipulated several times to ensure complete isolation between PVs and LA. Results： No complications occurred during the procedure. One patient developed delayed cardiac tamponade, which was drained percutaneously. The mean follow-up time was （17.1±9.3） months. Forty-one patients （95%） experienced improved quality of life one month after the procedure. Thirty-six patients （83%） showed stable sinus rhythm, while 10 patients （23%） required additional anti-arrhythmic drugs. AF returned≥1 time in 6 （14%） patients who underwent anti-arrhythmic drug therapy, but the number of episodes was less than that before the procedure. However, one patient experienced recurrent episodes of atrial flutter. Conclusion： It is safe and effective to perform segmental radiofrequency ablation of PV ostia for patients with refractory paroxysmal AF using MSCT guidance mappening.

Portal venous stent placement for treatment of portal hypertension caused by benign main portal vein stenosis

AIM: To evaluate the value of endovascular stent in the treatment of portal hypertension caused by benign main portal vein stenosis.METHODS: Portal vein stents were implanted in six patients with benign main portal vein stenosis (inflammatory stenosis in three cases, postprocedure of liver transplantation in another three cases). Changes in portal vein pressure, portal vein patency, relative clinical symptoms, complications, and survival were evaluated.RESULTS: Six metallic stents were successfully placed across the portal vein stenotic or obstructive lesions in six patients. Mean portal venous pressure decreased significantly after stent implantation from (37.3±4.7) cm H2O to (18.0±1.9) cm H2O. The portal blood flow restoredand the symptoms caused by portal hypertension were eliminated. There were no severe procedure-related complications. The patients were followed up for 1-48 mo. The portal vein remained patent during follow-up. All patients survived except for one patient who died of other complications of liver transplantation. CONCLUSION: Percutaneous portal vein stent placement for the treatment of portal hypertension caused by benign main portal vein stenosis is safe and effective.

Pulmonary vein isolation implemented by second-generation cryoballoon for treating hypertrophic cardiomyopathy patients with symptomatic atrial fibrillation:a case-control study

Background Atrial fibrillation(AF)is a generally acknowledged turning-point of the natural history of hypertrophic cardiomyopathy(HCM);however,data from the cryoballoon ablation(CBA)for AF in HCM patients are relatively scarce.The study aimed to evaluate the efficacy and safety of CBA in HCM patients with AF.Methods We retrospectively analyzed HCM patients among 1253 patients with symptomatic AF who underwent CBA for pulmonary vein isolation in a single center.The study analyzed the AF recurrence and assessed the CBA indexes,including nadir temperature,time-to-isolation,CBA failure,pulmonary vein potentials(PVPs),and redo procedure.Results A total of 108 patients were included(mean age:59.0±6.9 years),27 patients(25%)had HCM,with the median follow-up duration of 25.5 months.The one-year AF-free rates were 79.0%vs.63.0%(non-HCM vs.HCM),while the two-year AF-free rates were 77.8%vs.55.1%[hazard ratio(HR)=2.758,log-rank P=0.024].Patients with persistent AF had poor AF-free rates compared to those with paroxysmal AF(P<0.001).The CBA failure was the most common in the right inferior pulmonary veins,which had the lowest PVPs.Multivariate Cox regression analysis indicated that HCM and persistent AF were risk factors for AF recurrence(HR=2.74,95%CI:1.29–5.79,P=0.008;and HR=3.97,95%CI:1.85–8.54,P<0.001,respectively).Conclusions The CBA can be effectively and safely used to treat HCM patients with symptomatic AF.The freedom from AF for HCM patients after CBA is relatively low compared to that for non-HCM patients.

Ischemic colitis secondary to inferior mesenteric arteriovenous fistula and portal vein stenosis in a liver transplant recipient

Arteriovenous fistula （AVF） involving the inferior mesenteric vessels is rare, and the affected patients usually present with abdominal pain, mass, or features of established portal hypertension. Colonic ischemia is a less common and more serious manifestation of AVE We report a case of ischemic colitis secondary to inferior mesentedc AVF in a patient who underwent a previous liver transplantation, subsequently developed portal vein stenosis, and then presented with acute lower gastrointestinal bleeding. He underwent percutaneous transhepatic placement of a portal vein stent and left colectomy.

Experimental Study of Tissue-type Plasminogen Activator Gene to Prevent Vein Grafts Stenosis

The effects of in vivo local expression of recombined human tissue-type plasminogen activator （t-PA） gene on the thrombosis and neointima formation of vein grafts were explored. Jugular vein-to-artery bypass grafting was performed on 72 New Zealand white rabbits. The rabbits were divided into 3 groups according to the different processing methods： transfected t-PA gene group （n = 24）, vector group （n= 24） and blank control group （n = 24）. Samples of vein grafts were harvested at different time points after surgery. The expression of t-PA gene in vein graft was detected by RT-PCR and the synthesis of t-PA protein by Western-Blot assay. The t-PA activity was measured by chromogenic substrate assay. The Cr51 labeled platelets accumulation in vein grafts was counted. The histopathological changes were compared in intima hyperplasia index among the three groups after operation. The results showed that at the 2^nd , 5^th , 14^th and 28^th day after operation, RT-PCR and Western-blot confirmed the expression of t-PA mRNA and protein at the site of gene transfer. The t-PA activity detected on the 2^nd, 5^th, 14^th and 28^th day in experimental group was 370. 63±59. 44, 344. 13±48. 47, 252.87±51.80 and 161.75±68. 94 U/g respectively, and disappeared on the 60^th day and undetected in the control groups. The number of platelets accumulated in the vein grafts in gene group, vector group and blank control group was （85. 04 ± 21.58） 10s, （225.87±85.13） 10^6 and （211.57±78.02） 10^6 respectively. The number of platelets accumulated in gene group was significantly fewer than that in the control groups. Morphometric analysis revealed that intimal hyperplasia was markedly reduced in the t-PA gene group as compared with that in the control groups. It was suggested that the local expression of t-PA gene in vein graft significantly inhibited the accumulation of platelets, thrombosis and concomitant intimal hyperplasia, by which stenosis of bypass graft could be prevented effectively.

Increased ostial pulmonary vein diameter in congestive heart failure:a multi-slice computed tomography angiography evaluation

Background and Objectives The relationship between left atrial(LA)size and congestive heart failure(CHF)is well recognized;however,there is little information on the association of pulmonary vein(PV)diameter and CHF.The purpose of this study was to investigate the changes of PV and LA sizes in CHF patients by multislice computed tomography(MSCT)angiography using a new 64-slice scanner.Methods and Results We assessed diameters of PVs ostium and LA by 64-slice MSCT with three-dimensional reconstruction in 25 CHF patients and in 26 age-and sex-matched non-CHF controls.Compared with controls,CHF patients showed significant greater diameters of left superior pulmonary vein(LSPV)and right inferior pulmonary vein(RIPV)in both anteriorposterior(AP)and superior-inferior(SI)directions(P<0.01),significant dilation of right superior pulmonary vein(RSPV)in AP direction(P<0.05),as well as significant increase of LA transverse,AP,and SI diameters(P<0.01).Conclusion Significant dilation of PVs with simultaneous LA enlargement was demonstrated in CHF patients.This anatomic and geometric changes may participate in the perpetuation of AF.

Pulmonary Vein Stenosis:A Review

Pulmonary vein stenosis(PVS)is an extremely rare and lethal disease caused by multiple etiologies.PVS has a bimodal distribution in the population,affecting children and adults.Congenital PVS is the usual PVS type in children,which sometimes develops after cardiothoracic surgery.Acquired PVS,in turn,is the most common PVS type in adults.A review of the relevant literature has shown that PVS after radiofrequency ablation of atrial fibrillation is the most common,as well as that caused by compression of proliferative fibrous tissues or tumor in the mediastinum(eg,PVS caused by fibrosing mediastinitis,lung tumors,metastases,etc).This article provides a comprehensive review of PVS in terms of embryology and anatomy,etiology and triggers,classification,clinical symptoms and signs,treatment,and prognosis,intending to promote the understanding and treatment of this disease.

Pulmonary vein thrombosis in a patient with polycythemia vera

Pulmonary vein thrombosis(PVT) is a rarely encountered disease entity with varied clinical presentations. It is usually associated with lung carcinoma, lung surgeries and as a complication of the radiofrequency catheter ablation procedure for atrial fibrillation. Its clinical manifestations can vary from mild hemoptysis to lung infarction with hemodynamic compromise. A 76-year-old male presented with a 2-d history of pleuritic left sided chest pain. His past medical history included polycythemia vera, atrial fibrillation, coronary artery disease, pulmonary embolism and pulmonary hypertension. Chest radiograph was normal, troponins were normal and the 12-lead electrocardiogram did not show any ischemic changes. A computerized tomography pulmonary angiogram revealed a filling defect in the left lower lobe pulmonary vein. He was treated with subcutaneous enoxaparin and his symptoms improved. This case highlights a rare etiology of chest pain and the first reported case of the association of polycythemia vera and pulmonary vein thrombosis. A high index of suspicion is required for appropriate diagnostic work up. PVT can mimic pulmonary embolism. The diagnostic work up and treatment strategies depend on acuity of presentation.

Successful Stenting for Pulmonary Vein Thrombosis Complicating Pulmonary Vein Stenosis Following Atrial Fibrillation Ablation:A Case Report

Pulmonary vein thrombosis is a rare disease and is usually represented as a complication of pulmonary tumors,lung lobectomy,and atrial fibrillation ablation.Although it is a potentially life-threatening condition,it is easily misdiagnosed because of non-specific symptoms and its characteristics on imaging modalities.Here,we report a case of thrombotic occlusion at the ostium of the left superior pulmonary vein resulting from pulmonary vein stenosis following radiofrequency ablation for atrial fibrillation.This report extends the available approach with anticoagulant therapy and interventional angioplasty to pulmonary vein thrombosis secondary to pulmonary vein stenosis.

Cryoballoon pulmonary vein isolation and left atrial appendage occlusion prior to atrial septal defect closure: A case report

BACKGROUND In patients who suffer from both atrial fibrillation(AF)and atrial septal defect(ASD),cryoballoon pulmonary vein isolation(PVI),sequential left atrial appendage(LAA)occlusion and ASD closure could be a strategy for effective prevention of stroke and right heart failure.CASE SUMMARY A 65-year-old man was admitted to our institution due to recurrent episodes of palpitations and shortness of breath for 2 years,which had been worsening over the last 48 h.He had a history of AF,ASD,coronary heart disease with stent implantation and diabetes.Physical and laboratory examinations showed no abnormalities.The score of CHA2DS2VASc was 3,and HAS-BLED was 1.Echocardiography revealed a 25-mm secundum ASD.Pulmonary vein(PV)and LAA anatomy were assessed by cardiac computed tomography.PV mapping with 10-pole Lasso catheter was performed following ablation of all four PVs with complete PVI.Following the cryoballoon PVI,the patient underwent LAA occlusion under transesophageal echocardiographic monitoring.Lastly,a 34-mm JIYI ASD occlude device was implanted.A follow-up transesophageal echocardiography at 3 mo showed proper position of both devices and neither thrombi nor leakage was found.CONCLUSION Sequential cryoballoon PVI and LAA occlusion prior to ASD closure can be performed safely in AF patients with ASD.