Balloon angioplasty with stent placement resolved hemoptysis in a 78-year-old man with post-ablation pulmonary vein stenosis, though a left lung perfusion defect (24.5%) persisted at 6 months.
Case Report (n=1)
This case highlights the diagnostic complexity of pulmonary vein stenosis following atrial fibrillation ablation, particularly in patients with co-existing pulmonary disease, and underscores the importance of early surveillance.
Abstract Pulmonary vein stenosis (PVS) is a rare but serious complication of atrial fibrillation (AF) ablation, resulting from thermal injury and subsequent pulmonary vein (PV) scarring. The incidence is higher with radiofrequency ablation, particularly when energy is delivered near or within PVs. PVS is frequently underdiagnosed due to delayed presentation, nonspecific symptoms, and rarity; missed or late diagnosis can cause irreversible pulmonary damage. A 78-year-old man with chronic obstructive pulmonary disease-asthma overlap syndrome (ACOS) and persistent AF underwent catheter ablation in June 2023 involving PV antral and left atrial wall isolation. He maintained sinus rhythm post-procedure and resumed anticoagulation. Months later, he developed exertional dyspnea and reduced exercise tolerance, initially attributed to AF or ACOS. In September 2024, while in Switzerland, he experienced massive hemoptysis requiring nebulized tranexamic acid and empiric bilateral bronchial artery embolization. After returning to the United States, hemoptysis persisted. Computed tomography angiography (CTA) showed infiltrative soft tissue in the left hilum and peribronchial regions, with a small right upper lobe pulmonary embolus (PE). Positron Emission Tomography-Computed Tomography (PET-CT) was unrevealing, and endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) of left hilum was non-diagnostic. A lung perfusion scan demonstrated marked asymmetry, with diminished left lung perfusion despite CTA excluding left-sided PE. Closer CTA review raised concern for left superior PV stenosis and post-ablation fibrosis, subsequently confirmed by coronary angiography (Figure 1). The patient underwent balloon angioplasty with stent placement performed by an interventional pediatric cardiologist, complicated by proximal restenosis requiring repeat intervention. Following the procedures, he reported symptomatic improvement and resolution of hemoptysis. At six-month follow-up, perfusion scan showed a persistent left lung perfusion defect (24.5% vs. 75.5% right). PVS can markedly impair quality of life, with symptoms severity correlating with luminal narrowing and number of veins involved. Severe cases may lead to pulmonary venous hypertension, perfusion loss, or infarction, occasionally necessitating pneumonectomy. Early post-ablation imaging at approximately three months is recommended to detect subclinical stenosis and prevent irreversible injury. CT or magnetic resonance imaging is preferred diagnosis modalities, while balloon angiography with stent placement remains the therapeutic gold standard. Large-diameter bare-metal stents (BMS) are generally favored over small coronary drug-eluting stents (DES) due to lower restenosis rates. Further studies are warranted to optimize stent sizing and evaluate hybrid BMS-DES strategies. This case illustrates the diagnostic complexity of PVS, particularly in patients with co-existing pulmonary disease, and underscores the importance of early surveillance and multidisciplinary care. This abstract is funded by: None
Sabbagh et al. (Fri,) conducted a case report in Pulmonary vein stenosis after atrial fibrillation ablation (n=1). Balloon angioplasty with stent placement was evaluated. Balloon angioplasty with stent placement resolved hemoptysis in a 78-year-old man with post-ablation pulmonary vein stenosis, though a left lung perfusion defect (24.5%) persisted at 6 months.