The use of lobectomy for management of clinically significant pulmonary vein stenosis and occlusion refractory to percutaneous intervention

Pulmonary vein stenosis (PVS) is a serious complication of radiofrequency ablation (RFA) for the treatment of atrial fibrillation. The prevalence of this complication was reported to be as high as 42% in 1999 when RFA was first implemented 1. However, with improvements in operator technique including wide area circumferential ablation, antral isolation, and the use of intracardiac ultrasound, the incidence of symptomatic severe PVS following RFA ranges from 0% to 2.1% while the incidence of symptomatic pulmonary vein occlusion (PVO) following RFA was found to be 0.67% 2-8. Despite a decrease in the incidence of clinically significant PVS following RFA, there have been increased reports of complications associated with PVS to include hemoptysis, scarring, lung infarction, and intraparenchymal hemorrhage 9. Studies have shown that PVS is often misdiagnosed as pneumonia, pulmonary embolism, and lung cancer and as a result, patients are often subjected to unnecessary diagnostic procedures 2,10. The current first line treatment for this condition is percutaneous balloon angioplasty with stenting; however, there are studies that have shown that there is a relatively high rate of restenosis despite optimal medical therapy 2-3,10,11. Three case reports have described the use of lobectomy to treat patients with persistent respiratory symptoms in the setting of severe PVO with good outcomes 12-14. We present a case of iatrogenic PVO and ipsilateral severe PVS following RFA who underwent attempted lobectomy for persistent exertional dyspnea and persistent hypoperfusion of the left upper lung lobe despite percutaneous intervention and six months of optimal medical therapy. The lobectomy was aborted due to the presence of a significant fibrothorax, and the patient continues to have significant exercise limitation despite participation in pulmonary rehabilitation.