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European Heart Journal (2005) 26, 1410–1414
doi:10.1093/eurheartj/ehi279
Pulmonary haemodynamics at rest and during exercise in
patients with significant pulmonary vein stenosis after
radiofrequency catheter ablation for drug resistant atrial
fibrillation
¨rg von Rosenthal,
¨rkle, Jo
Thomas Arentz*, Reinhold Weber, Nikolaus Jander, Gerd Bu
Thomas Blum, Jochem Stockinger, Laurent Haegeli, Franz Josef Neumann, and Dietrich Kalusche
¨dring 15, 79188 Bad Krozingen, Germany
Abteilung Rhythmologie, Herz-Zentrum, Su
Received 6 January 2005; revised 7 March 2005; accepted 18 March 2005; online publish-ahead-of-print 26 April 2005
See page 1355 for the editorial comment on this article (doi:10.1093/eurheartj/ehi313)
KEYWORDS
Aims Iatrogenic pulmonary vein (PV) stenosis after radiofrequency catheter ablation for atrial fibrillation (AF) is a new pathology in cardiology. The effects of PV stenosis on the pulmonary circulation
are not yet known. We provide long-term follow-up data in patients with significant PV stenosis including magnetic resonance imaging (MRI) and Swan Ganz (SG) right heart catheterization.
Methods and results One hundred and seventeen patients had MRI 12–24 months after the AF ablation
procedure. Eleven patients (58+7 years, nine males) with significant stenosis (n ¼ 9) or occlusion of the
proximal PV (n ¼ 5) at this follow-up were re-examined using MRI and SG right heart catheterization at
rest and during exercise (follow-up time since PV ablation 50 + 15 months). None of these underwent
previous PV angioplasty. When compared with prior MRI studies, no significant changes were noted.
At rest, no patient had pulmonary hypertension. At 100 W, seven patients had elevated pulmonary
artery pressures, three of them probably caused, in part, by left ventricular dysfunction.
Conclusion Significant stenosis/occlusions of one or two PV do not create pulmonary hypertension at
rest during long-term follow-up. However, seven of the 11 patients develop pulmonary hypertension
during exercise. All three patients with stenosis/occlusions of two PV were affected.
Introduction
Methods
The pulmonary veins (PV) had been identified as the dominant initiator or perpetuator of atrial fibrillation (AF).1–3
Current catheter ablation techniques for AF aim to isolate
the PV electrically from the left atrium by radiofrequency
energy (RF)4–7 or to create circumferential lesions around
the PV.8–10 PV stenosis is a known potential complication
of these procedures.11–15 The risk of PV stenosis had been
reduced by avoiding ablations inside the vessel.14,16
However, in view of the growing number of PV ablation procedures, this complication might become more frequent in
the near future. Most of the patients with significant PV stenosis have no or only few symptoms.14 In those patients,
little is known about the sequela of PV stenosis/occlusion
on pulmonary circulation.
The aim of our study was to reveal possible long-term
complications and pulmonary haemodynamics in patients
with known significant PV stenosis/occlusion after PV-RF
ablation. Clinical evaluation, magnetic resonance imaging
(MRI), and Swan Ganz (SG) right heart catheterization at
rest and during exercise were performed.
Study design and patients characteristics
* Corresponding author. Tel: þ49 7633 4020; fax: þ49 7633 402538.
E-mail address: [email protected]
In this prospective study, 117 patients had MRI 12–24 months after
the AF ablation procedure. Eleven patients (9.4%) with significant
stenosis (70%) or occlusion of the proximal PV at this follow-up
were re-examined 27 + 12 months later (median 25, interquartile
range 19–36) using MRI and SG right heart catheterization at rest
and during exercise. The total follow-up time since the ablation procedure in these 11 patients was 50 + 15 months (median 49, interquartile range 43–60). Written informed consent was obtained from
all patients.
The ablation procedure was a focal trigger ablation in six patients
(1997–98), an ostial isolation procedure without circular mapping
catheter in four patients (1999–2000), and ostial isolation using a
multipolar basket catheter in one patient (2002). The results of
MRI of eight of the 11 patients, 2 years after the ablation procedure,
including analysis of parameters predictive of PV stenosis had been
published previously.14
Magnetic resonance imaging
Imaging was performed using a 1.5 T imager (Magnetom Sonata,
Siemens, Erlangen, Germany) and with a body array coil as a receiver. An aliquot of 18–22 mL of Gadiodiamid (Nycomed,
Braunschweig, Germany) was injected intravenously at a flow rate
& The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: [email protected]
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Atrial fibrillation;
Pulmonary veins;
Stenosis;
Ablation;
Pulmonary hypertension
Pulmonary haemodynamics in patients with PV stenosis
of 3 mL/s. The acquisition of the images was ECG-gated within a
breath hold. Imaging parameters used for the series were as
follows: repetition time (second)/echo time (second)/flash 3D,
1.72/0.6/208; matrix, 256 126; field of view, 400 320 mm2;
and section thickness, 2 mm. Partitions of 36 images were acquired
performing nine measurements repeatedly. Post-processing
included maximum intensity projection. Subtraction of the arterial
phase was performed. Morphology and diameter of the PV stenosis
(Figure 1 ) were assessed by means of a multiplanar reconstruction
algorithm as described by Kato et al. 17 MRI images at this followup were compared with those performed 2 years after the ablatsion
procedure.
1411
19–36) ago, no significant changes were noted.
The minimal mean diameter of the stenosis was
6.0 + 1.6 mm, 2 years after the ablation procedure and
6.2 + 1.6 mm at this follow-up (P ¼ 0.83). The linear correlation analysis excluded an effect of time between first and
second follow-up examination on change in minimal stenosis
diameter (P ¼ 0.63). No late progression of stenosis to
occlusion was observed.
SG catheter right heart catheterization
Eleven patients (58+7 years, nine males) with known significant PV stenosis were examined, and five of them had
organic heart disease (Table 1 ) as reported subsequently:
Discussion
All medications of the patients were stopped more than five halftimes before haemodynamic testing. SG right heart catheterization
was performed from the antecubital vein using a balloon floating
catheter. Right heart, pulmonary artery (PA), and pulmonary capillary wedge pressures (PCP) were measured and compared with
normal values at rest and during exercise established in our institution.18 Cardiac output was calculated using the Fick’s equation.
Exercise was a supine bicycle ergometric starting at 50 W, with
25–50 W increments for every 5 min. Exercise was stopped at
maximal exertion, for severe dyspnoea or angina, or if the patients
were unable to maintain a cycling frequency .40 r.p.m.
Statistical analysis
Parametric data are presented as mean + SD; the duration of
follow-up time as median and interquartile range. The paired twosided t-test was used to compare continuous variables. A linear
regression analysis was performed between the follow-up time
and the change of the minimal diameter of stenosis. Statistical significance was defined as P , 0.05. Data were analysed by use of
BMDP Statistical software, 1993.
Results
.
.
.
arterial hypertension (n ¼ 3), one with left ventricular
hypertrophy;
VVIR pacemaker after AV nodal ablation, chronic AF, and
left ventricular dysfunction with an ejection fraction
(EF) of 45% (n ¼ 1);
coronary heart disease, chronic AF (n ¼ 1);
Only three patients had dyspnoea during moderate or vigorous exercise. No patient had pneumonia during follow-up.
None of these underwent previous PV angioplasty.
Magnetic resonance imaging
Eight patients had a single PV stenosis (Figure 1 ) or occlusion, two patients had two stenosis of the upper PV, and
one patient had occlusion of both upper PV (Table 1 ), as
reported subsequently:
.
.
.
.
ostial PV occlusion (n ¼ 4);
distal PV occlusion (2 cm from the ostium) (n ¼ 1);
.70% ostial stenosis (n ¼ 2) (Figure 1 );
.70% distal stenosis of the main vessel (n ¼ 7).
When compared with prior MRI studies performed on these
patients 27 + 12 months (median 25, interquartile range
PV stenosis after RF catheter ablation of AF is a new problem
in cardiology. Recurrent and drug resistant pneumonia or
dyspnoea due to pulmonary hypertension may be the subacute complication necessitating intervention in the form of
angioplasty or stenting.19–21 However, the question
remains how to deal with the majority of patients with significant PV stenosis who have no or only discrete symptoms.
Saad et al. 16 recommended PV dilation for patients with
luminal narrowing of 70%, irrespective of the presence of
symptoms.16 The rationale for intervening in these patients
was the unknown risk of developing pulmonary hypertension
as well as the risk of lesion progression to total occlusion.
However, the results of PV angioplasty or stenting reported
by Quereshi et al. 21 are disappointing. First, angioplasty
was associated with a high restenosis rate of 45%, a
problem not completely resolved by stenting. Secondly,
major adverse events occurred in 29%, including pulmonary
haemorrhage, PV tear requiring immediate surgery, and cerebral embolic event.21
To our knowledge, we report for the first time long-term
follow-up data in patients with significant PV stenosis but
no or only few clinical symptoms. Our study describes morphologic changes of PV stenosis revealed by MRI and
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Study patients
At rest, no patient had pulmonary arterial hypertension. The
maximum work load achieved was 100 + 37 W. Stable PCP
position during exercise was recorded in 10 of the 11
patients. At 50 W four patients and at the maximum power
level of 100 + 37 W seven patients had elevated mean PA
pressures when compared with normal values (Figure 2 ).
However, three of these seven patients had elevated PCP
(Figure 3 ), which may be due to left ventricular dysfunction
[one patient with arterial hypertension and left ventricular
hypertrophy, one with reduced left ventricular function
(EF of 45%) and VVIR pacemaker after AV nodal ablation,
and one with coronary heart disease and chronic AF]. The
remaining four patients, three with stenosis/occlusions of
two PV, had elevated PA pressures, while PCP were normal.
Two patients showed an inadequate increase of cardiac
index (CI) during exercise: one patient with VVIR pacemaker
after HIS bundle ablation who was unable to increase the
heart rate and one patient with stenosis of both upper PV
(Figure 4 ). Ten patients had a normal increase of heart
rate during exercise.
Normally, pulmonary vascular resistance decreases during
exercise. In our patient group, the mean value of pulmonary
resistance (PVR) remained unchanged during exercise
(Figure 5 ). Only the patient with occlusion of both upper
PV had an important increase of PVR during exercise.
SG right heart catheterization
1412
T. Arentz et al.
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Figure 1 Angio-MRI of a stenosed left upper PV. (A, B ) Definition of the long axis in coronal and axial orientations after multiplanar reconstruction. The diameter
will be determined by the mean of two perpendicular measurements of the cross-sectional view of the minimal diameter (C ). (D ) A 3D reconstruction in
anterior–posterior view.
haemodynamic evaluation of pulmonary circulation at rest
and during exercise.
Progression of PV stenosis has been observed during
the first 6 months after ablation.15,16,22 We have reported
one case of progression of stenosis to occlusion between
the 12 and the 15 month follow-up.14 In this current study,
no significant changes in degree or morphology of stenosis
was noted between the 2 years follow-up, and the current
late follow-up was reported 50 + 15 months (median 49,
interquartile range 43–60) after the ablation procedure.
None of the 11 patients had pulmonary hypertension at
rest. However, during exercise seven patients had pulmonary hypertension. Three of these seven patients had simultaneous augmentation of PA and PCP pressures, likely
caused by left ventricular dysfunction. All three patients
with stenosis/occlusion in two PVs had augmentation of PA
pressures during exercise, while PCP remained normal and
all these patients had clinical symptoms in form of
dyspnoea.
The mean pulmonary vascular resistance in our patient
group did not decrease during exercise as normally
expected. This may indicate that the pulmonary vascular
capacity to dilate during exercise was used, in part, at
rest to compensate PV stenosis. The potential long-term
effects of exercise induced pulmonary hypertension in this
patient population are not yet known.
On the basis of our data, invasive therapy in form of PV
angioplasty or PV stenting might be considered in patients
with two or more stenosed PV to prevent pulmonary hypertension during exercise. Whether patients with one stenosed
PV and no or only few clinical symptoms need invasive
therapy to prevent pulmonary hypertension may be
answered by prospective randomized studies.
Limitations
.
The sample size of the study including 11 patients with 14
PV stenosis is small. In addition, there were eight distal
luminal narrowing of the main vessel, a finding, that
becomes rarer nowadays as RF lesions are applied more
ostially.
Pulmonary haemodynamics in patients with PV stenosis
1413
Table 1 Demographic and clinical characteristics of the 11 patients with PV stenosis
Age
(years)
Sex
1
2
3
4
5
6
7
8
9
10
11
52
63
39
55
56
56
63
62
63
63
62
M
F
M
M
M
M
M
M
F
M
M
Average/Total
58 + 7
9 male
Heart
disease
AH, Hypertrophy
AF, Coronary heart disease
AH
AH
EF 45%, AF, VVIR
Type of
ablation
PV
affected
Degree of
stenosis (%)
Changes in
PV diameter (mm)
Distal
Ostial
Ostial
Ostial
Distal
Distal
Distal
Distal
Ostial
Distal
Ostial
LU
LU
LL
RU
RU
LU
LU, RU
LU, RU
LU, RU
RU
LU
80
100
70
100
100
90
70,80
80,70
100,100
80
80
20.1
—
20.2
—
—
20.1
0/20.5
þ0.1/þ0.1
—
þ0.1
þ0.8
6 distal, 5 ostial
14 PVs
þ0.2
M, male; F, female; AH, arterial hypertension; LU, left upper PV; RU, right upper; LL, left lower.
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Figure 2 Mean PA pressures (PAm) of 11 patients with PV stenosis at rest, at
50 W, and at the mean maximum exercise level of 100 + 37 W. Normal values
are indicated by the grey line. The dotted lines represent the three patients
with elevated PCP during exercise (Figure 3 ).
Figure 3 PCP of 10 patients at rest, at 50 W, and at the mean maximum
exercise level of 100 + 37 W. Normal values are indicated by the grey line.
Figure 4 CI at rest, at 50 W, and at the mean maximum exercise level of
100 + 37 W. The values of the 11 patients and the mean values are shown.
Figure 5 Pulmonary resistance at rest, at 50 W, and at the mean maximum
exercise level of 100 + 37 W. The values of 10 patients in whom a PCP position was reached and the mean values are shown.
1414
.
.
No SG right heart catheterization was performed in a
control group of AF patients without significant stenosis
after PV ablation or after successful dilation of a PV
stenosis.
Lung scanning to assess the functional consequence of PV
stenosis was not performed in this study.
Conclusions
One or two significant PV stenosis/occlusions do not create
pulmonary hypertension at rest during long-term followup. However, seven of the 11 patients develop pulmonary
hypertension during exercise. All three patients with stenosis/occlusions of two PV were affected. No progression of PV
stenosis was observed .2 years after the ablation
procedure.
T. Arentz et al.
9.
10.
11.
12.
13.
Acknowledgements
The authors thank Dr Peter Ott from Sarver Heart Centre, University
of Arizona, for his excellent work to revise the manuscript and
Professor E. Weitzenblum from the Department of Pneumology,
University of Strasbourg, France, to help us to discuss the haemodynamic results.
14.
15.
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