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.

Pulmonary Hypertension Crisis in Patient with Tetralogy of Fallot and Mixed Total Anomalous Pulmonary Vein Connection after the Primary Correction:A Rare Case Report

Tetralogy of Fallot(TOF)with total anomalous pulmonary vein connections(TAPVC)is a rare type of complex congenital heart disease among all TOF cases.Co-presentation of major aortopulmonary collateral arteries(MAPCAs)compensates for the lack of central pulmonary bloodflow and decreases the severity of right-to-left shunting in TOF.We present a case of a 2-year-old child with complex diagnoses of TOF,TAPVC,a large secun-dum atrial septal defect(ASD),and intraoperatively identified MAPCAs.She underwent surgery to repair the TAPVC,valve-sparing reconstruction of the right ventricular outflow tract,interventricular defect closure,and the creation of patent foramen ovale(PFO).After the operation,hemodynamic instability happened along with sudden blood pressure drop,desaturation,and increased central venous pressure,which subsided after adminis-tering inhalational nitric oxide(NO).A postoperative pulmonary hypertension crisis was suggested when the patient experienced recurrent symptoms after the termination of NO.Echocardiographicfindings of a D-shaped left ventricle(LV),right-to-left PFO shunt and high tricuspid valve gradientfirmly established the diagnosis.It was subsequently managed with continuous NO inhalation and sildenafil,which rendered a satisfactory outcome.Repaired TOF and TAPVC could be at particular risk of developing pulmonary hypertension crisis,especially in the presence of MAPCAs due to possible remodeling of the pulmonary vasculature.Furthermore,a relatively non-compliant LV function and small left atrial size may exacerbate the risk of developing postcapillary pulmonary hypertension after TAPVC repair.A successful postoperative outcome calls for a meticulous preoperative analysis of the anatomical lesions,as well as careful monitoring.

Right Sub-Axillary Incision for Right Pulmonary Vein Atresia in a Child:A Case Report and Literature Review

Unilateral pulmonary vein atresia(UPVA)in children is a rare disease that is characterized by a recurrent pulmonary infection and hemoptysis in childhood.This paper is a report of a case of pulmonary venous atresia treated by a right sub-axillary incision.Hopefully,more literature can be produced to improve the awareness and treatment level of pulmonary vein atresia.

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.

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.

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.

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.

Feasibility of Transabdominal Real-time CDFI and HDFI Techniques for Fetal Pulmonary Vein Display in the First Trimester

Objective This study aimed to assess the feasibility and usefulness of transabdominal color Doppler flow imaging(CDFI)technology and the high-definition flow imaging(HDFI)technique in detecting fetal pulmonary veins(PVs)in the first trimester(11–13^(+6)weeks).Methods From December 2018 to October 2019,328 pregnant women with 328 normal singleton fetuses(crown-rump length:45–84 mm)who had undergone CDFI and HDFI scans for fetal heart and vessel examination were enrolled in this study.The cases were divided into three groups according to the gestational age:group A,11^(+0)−11^(+6)weeks;group B,12^(+0)−12^(+6)weeks;and group C,13^(+0)−13^(+6)weeks.Baseline sonograms and CDFI and HDFI images were analyzed by two senior radiologists independently and blindly.The abilities of CDFI and HDFI to display PVs were compared.Results Successful PV display rates via CDFI and HDFI were 2.3%and 68.2%(P<0.01),22.4%and 82.4%(P<0.01),41.5%and 91.2%(P<0.01)for group A,group B,and group C,respectively.The total successful display rates for the two methods were 28.9%(CDFI)and 84.8%(HDFI)(P<0.01).Conclusions The HDFI technique is more valuable than CDFI for detecting PVs in early pregnancy(11–13^(+6)weeks).HDFI can detect at least one PV in all cases and may be used to detect pulmonary venous anomalies early.

Radiofrequency Ablation Mapping with Circumferential Catheter for Paroxys- mal Atrial Fibrillation Originating From the Pulmonary Veins

Objectives To assessed the feasibility and effectiveness of electrophysiological mapping of pulmonary veins with a circumferential 10 - electrode catheter and radiofrequency catheter ablation therapy for patients with paroxysmal atrial fibrillation. Background Standard mapping and ablation of focal sources of atrial fibrillation are associated with very long procedure times and low efficacy. Mapping and ablation pulmonary veins guide with a circular catheter could overcome these limitations. Methods 16 patients [male 11, female 5, mean age (51 ±14. 5) years] with paroxysmal atrial fibrillation refractory to antiarrhythmic drugs were included in this group. A circumferential 10 - electrode catheter was used to pulmonary vein mapping during sinus rhythm or CSd pacing to determine the origin of atrial premature contractions. When the ablative target pulmonary vein was found, the pulmonary vein potentials' distribution and activation were assessment pulmonary veins' ostial ablation was performed at the segments showing earliest activation of pulmonary vein potentials. The end point was designed: 1) elimination of pulmonary vein potential; 2) pulmonary vein potential dissociation from atrial waves; 3) atrial ectopic beats disappear. Results A total of 36 pulmonary veins were ablated, including 16 left superior, 12 right superior, 7 left inferior and 1 right inferior. 1 pulmonary vein in 2 patients was ablated, 2 pulmonary veins in 8 patients were ablated, 3 pulmonary veins were ablated in 5 patients and 4 pulmonary veins were ablated in 1 pa- tient. Procedure duration and fluoroscopy time respectively were 186. 7±63. 8 min and 51. 5±15. 0 min. During the follow-up 1-12 months, 11 patients (68. 7 % ) were free of AF without any antiarrhythmic drugs, 2 of them were reablation, effective in 3/16 (18. 7 % ) and unsuccessful in 2/16 (12. 6 % ) . 2 cases recurred with atrial premature, 1 was treated with amiodarone and the other was repeat electrophysiologi-cal mapping and ablation, 5 cases with paroxysmal a-trial fibrillation recurred, 3 of them were treated with amiodarone (2 cases) or sotalol (1 case) , one was implantled with DDDR pacemaker (having programmer of anti - atrial fibrillation), one was repeat ablation. PV's diameter in 2 of them reduced more than 50 % , but they were asymptomatic during the follow - up period. 1 case had pneumothorax complication and disappeared after 7 days. Conclusions This study suggests that careful mapping and elimination of these ectopic foci under the guide of circular catheter may have higher success rate and splendid future.

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.

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.

Effect of anxiety and depression on the recurrence of persistent atrial fibrillation after circumferential pulmonary vein ablation

Background The effects of anxiety and depression on the recurrence of persistent atrial fibrillation （AF） after circumferential pulmonary vein ablation （CPVA） are not clear. Whether CPVA can alleviate the anxiety and depression symptoms of persistent AF patients is unknown. Methods One hundred and sixty-four patients with persistent AF, of which 43 treated with CPVA （CPVA group） and 103 treated with anti-arrhythmics drugs （medicine group）, were enrolled. The Zung Self-Rating Anxiety Scale （SAS）, and Zung Self-Rating Depression Scale （SDS） were assessed before and 12 months after treatment in all patients. Results The scores of SAS （40.33±7.90 vs. 49.76±9.52, P 〈0.01） and SDS （42.33±8.73 vs. 48.17±8.77, P 〈0.01） decreased 12 months after CPVA. Over 12 months follow-up, AF relapsed in 17 patients in CPVA group. Compared with the data in the recurrent group （17 patients）, the scores of SAS and SDS were significantly lower in the non-recurrent group （26 patients） at baseline. The results of multivariate Logistic regression analysis showed normal scores of SAS and SDS were the independent risk factors of AF recurrence after CPVA. Conclusions Anxiety and depression increase the recurrence risk of persistent AF after CPVA. CPVA can ameliorate the anxiety and depression symptoms in patients with persistent AF.

Impact of right upper pulmonary vein isolation on atrial vagal innervation and vulnerability to atrial fibrillation

Background Based on the hypothesis that pulmonary vein isolation could result in the damage of the epicardial fat pads, this study aimed to investigated the impact of right upper pulmonary vein （RUPV） isolation on vagal innervation to atria. Methods Bilateral cervical sympathovagal trunks were decentralized in 6 dogs. Metoprolol was given to block sympathetic effects. Multipolar catheters were placed into the right atrium （R.A） and coronary sinus （CS）. RUPV isolation was performed via transseptal procedure. Atrial effective refractory period （ERP）, vulnerability window （VW） of atrial fibrillation （AF）, and sinus rhythm cycle length （SCL） were measured at RA and distal coronary sinus （CSd） at baseline and vagal stimulation before and after RUPV isolation. Serial sections of underlying tissues before and after ablation were stained with haematoxylin and eosin. Results SCL decreased significantly during vagal stimulation before RUPV isolation （197±21 vs 13±32 beats per minute, P〈0.001）, but remained unchanged after RUPV isolation （162±29 vs 140±39 beats per minute, P〉0.05）. ERP increased significantly before RUPV isolation compared with that during vagal stimulation [（85.00±24.29） ms vs （21.67±9.83） ms at RA, P〈0.001; （90.00± 15.49） ms vs （33.33±25.03） ms at CSd P〈0.005], but ERP at baseline hardly changed after RUPV isolation compared with that during vagal stimulation [（103.33 ± 22.50） vs （95.00± 16.43） ms at RA, P = 0.09; （98.33±24.83） vs （75.00±29.50） ms at CSd, P=0.009]. The ERP shortening during vagal stimulation after RUPV isolation decreased significantly [（63.33 ±22.51） ms vs （8.33 ± 9.83） ms at RA, P〈0.005; （56.67±20.66） ms vs （23.33± 13.66） ms at CSd, P〈0.05]. AF was rarely induced at baseline before and after RUPV isolation （VW close to 0）, while VW of AF to vagal stimulation significantly decreased after RUPV isolation [（40.00± 10.95） vs 0 ms at RA, P〈0.001; （45.00±32.09） vs （15.00±23.45） ms at CS, P 〈0.05]. The architecture of individual ganglia was significantly altered after ablation. Conclusions The less ERP shortening to vagal stimulation and altered architecture of individual ganglia after right upper pulmonary vein isolation indicate that isolation may result in damage of the epicardial fat pads, thereby attenuating the vagal innervation to atria. The decreased vulnerability window of atrial fibrillation indicates that vagal denervation may contribute to its suppression.

A randomized prospective comparison of CartoMerge and CartoXP to guide circumferential pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation

Background CartoXP and CartoMerge have been used to treat atrial fibrillation （AF） for several years. Our randomized prospective study compared clinical outcomes of these two versions of three dimensional electroanatomic mapping system in guiding catheter ablation for paroxysmal atrial fibrillation （PAF）. Methods Eighty-one patients with symptomatic, drug refractory PAF were randomly assigned to CartoMerge group （n=-42, mean age （54.5 ＋ 13.1） years, history of AF = 3.2 years） or CartoXP group （n=39, mean age （59.8 ± 15.6） years, history of AF = 2.9 years）. All patients underwent 64-slice computed tomography （MSCT） 1 to 3 days prior to ablation procedure. Using CartoMergeTM Image Integration Module, 3D anatomical images of the left atrium （LA） and pulmonary veins （PVS） derived from MSCT of CartoMerge group were established and merged with the electroanatomical map. The integrated images were used to guide the procedure of circumferential pulmonary vein isolation （CPVl）. In the other group, CPVl was guided just by CartoXP. The endpoint of CPVl in both groups was abolition or dissociation of pulmonary vein potentials （PVPs）. Results Mapping points to establish the electroanatomical model of the LA/PVs were 48.7＋13.4 in CartoMerge group and 62.5±15.7 in CartoXP group （P〈0.001）. Mean distance between mapping points and the MSCT surfaces in CartoMerge group was （1.59±0.33） mm. Accomplishment of abolition or dissociation of PVPs was achieved 95.2% in CartoMerge group and 92.3% in CartoXP group. Durations of procedure and exposure to X-ray were （156±25） minutes, （179±21） minutes （P〈0.001） and （19.6±7.5） minutes, （28.5±12.8） minutes （P 〈0.001）, respectively. After a follow-up with duration of （11.9＋3.1） months vs （12.4±3.6） months post the first ablation procedure, patients free of AF were 33 （78.6%） in CartoMerge group and 29 （74.4%） in CartoXP group （P〉0.50）. No patient suffered pulmonary vein stenosis, atenoesophageal fistula, stroke or death. Conclusion Compared to CartoXP, CartoMerge shortened the catheter ablation procedure and exposure to X-ray, without affecting the clinical outcomes of circumferential pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation in experienced centres.

Electroanatomical systems to guided circumferential pulmonary veins ablation for atrial fibrillation: initial experience from comparison between the Ensite/NavX and CARTO system

Background The circumferential pulmonary vein ablation (CPVA) has been proved effective for atrial fibrillation (AF) treatment and is becoming more widely accepted and practiced. This study aims to evaluate the characteristics of the CARTO and the Ensite/NavX system and draw a comparison between them on the aspects of procedural parameters and clinical effectiveness. Methods Seventy-five cases with paroxysmal or chronic symptomatic AF were randomly assigned to CPVA procedure guided by the Ensite/NavX system (group I, n = 40) and by the CARTO system (group II, n = 35). After successful transseptal procedure, the geometry of left atrium was created under the guidance of the two systems. Radiofrequency energy was applied to circumferentially ablate tissues out of pulmonary veins' (PVs') ostia. In cases with chronic AF, linear ablation was applied to modify the substrate of left atrium LA). The endpoint of the procedure was complete PVs isolation. Results Seventy-five cases underwent the procedure successfully. The total procedure and fluoroscopic durations in group II were significantly shorter than in group I [(150 +/- 23) min and (18 +/- 17) min versus (170 +/- 34) min and (25 +/- 16) min, P = 0.03 and 0.04, respectively]. There was no significant difference in the fluoroscopic and procedure durations for geometry creation between group I and group II [ (8 4) min and (16 +/- 11) min versus (5 +/- 4) min and (14 +/- 8) min, respectively]. The fluoroscopic durations for CPVA were (15 5) min in group I versus (10 6) min in group II (P = 0.05), and the CPVA procedural durations were significantly shorter in group II than in group I [(18 +/- 11) min versus (25 +/- 10) min, P 0.04]. AF was terminated by radio frequency delivery in 14 cases (35%) in group I versus 5 cases (14%) in group II (P = 0.035). After CPVA complete PV isolation was attained in 26 cases (65%)in group I versus 11 cases (31%) in group II (P = 0.004). During a mean follow-up of 7 months, 32 (80%) cases in group I and 24 (69%) cases in group II were arrhythmia-free (P = 0.06). One case developed pericardium effusion and another one case was found to have intestinal artery thrombosis in group II. One case had moderate hemothorax in group I. All the complications were cured by proper treatment. No PV stenosis was observed. Conclusions The CPVA procedure for atrial fibrillation is effective and safe. Although there is difference between the CARTO and the Ensite/NavX system, the CPVA procedure guided by either of them yields similar clinical results.

Initial experience with circumferential pulmonary vein ablation guided by fusion of magnetic resonance imaging with three-dimensional electroanatomic mapping

Catheter ablation for the treatment of atrial fibrillation （AF） has been a focal target ofelectrophysiological study in recent years. Up to date, circumferential pulmonary vein ablation （CPVA） guided by three-dimensional （3-D） electreanatomic mapping （Carto, USA） has been one of the most favourable procedures for the treatment of AF. However, it is still difficult to acquire the detailed information on number, location, and branching pattern of all pulmonary veins （PVs） when the 3-D electroanatomic mapping system is used alone.

Pulmonary vein occlusion and remodeling after electrical isolation treatment for atrial fibrillation: a case report

Pulmonary vein (PV) stenosis or occlusion is a recently describedcomplication of radiofrequency ablation for atrial fibrillation (AF), though favorable results of PVostial ablation have fueled great enthusiasm. The presenting symptoms include dyspnea, cough,hemoptysis, pleural infusion and pulmonary consolidation. We report a case with left PVs occlusionafter ablations, treated with the surgical operation for the PV reconstruction. All the symptomsincluding the left pleural effusion were relieved after the operation. To our knowledge, the case wepresent here is the first surgical operation for PVs occlusion in China's Mainland, which will extendthe understanding of the pulmonary complications and provide an effective strategy for removing thePV occlusion.

Postcardiac injury syndrome complicating circumferential pulmonary vein radiofrequency ablation for atrial fibrillation

Postcardiac injury syndrome （PCIS） is characterized by inflammation of the pericardium, pleura and pulmonary parenchyma following a cardiac injury. It has been described in many patients after a variety of cardiac insults including infarction, surgery, trauma, implantation of a pacemaker, percutaneous coronary angioplasty and radiofrequency ablation of cardiac arrhythmias.We report a rare case of PCIS that occurred after circumferential pulmonary vein radiofrequency ablation for atrial fibrillation （AF）.

Pulmonary vein tachycardia after pulmonary vein isolation in patients with atrial fibrillation

Background Pulmonary vein （PV） isolation has been developed to treat patients with atrial fibrillation （AF）, and the electrophysiological endpoint of PV isolation is the disappearance or dissociation of pulmonary vein potentials （PVPs）. Pulmonary vein tachycardia （PVT） is the dissociated PV rhythm with a rapid rate. However, the characteristics and significance of PVT after pulmonary vein isolation in patients with AF remains unclear. Methods From June 2003 to June 2005, a total of 285 consecutive patients with drug refractory AF were included in this study, and they underwent segmental pulmonary vein ablation （SPVA） or circumferential pulmonary vein ablation （CPVA）. PV isolation was the initial endpoint for both approaches with documenting disappearance or dissociation of PVPs. PVT was characterized as dissociated activities within PVs with a circle length （CL） of 〈300 ms, and was classified into organized PVT or disorganized PVT according to the variance of CL. Systematic follow-up was conducted after initial procedures. Continuous variables were analyzed by Student＇s t test and categorical variables were analyzed by chi-square test. Results Three hundred and fifteen PVs were ablated in 85 patients underwent SPVA approach, 400 circular lesions surrounding ipsilateral PVs （including 790 PVs） were produced in the rest of 200 patients received CPVA approach. Electrical isolation was achieved in all of these PVs. Of these, PVPs were abolished in 89.8% （992/1105） of the ablated PVs, dissociated PV rhythms were documented in the rest 10.2 % （113/1105） of the treated PVs. Among the 113 dissociated PV rhythms, 28 met the criteria of PVT with mean CL of （155±43） ms （2 PYTs in 2 patients received SPYA, 26 PYTs in 18 patients underwent CPVA）. PVT was more frequently documented in patients underwent CPVA approach [9.0% （18/200） vs 2.3% （2/85）, P=0.04]. During the 6-month follow-up, it was indicated that no significant difference existed in AF free rate between patients with PVT and those without PVT （P=0.75）. Conclusions PVT dissociated from LA activations can be documented after PV isolation, especially in patients underwent CPVA approach. However, PVT does not affect the follow-up results.