Key result
Multiple percutaneous radiofrequency ablations for atrial fibrillation can lead to severe stiff left atrial syndrome and pulmonary vein occlusion, resulting in progressive right heart failure and the need for heart transplantation.
Why the study?
Stiff left atrial syndrome and pulmonary vein occlusion are rare, potentially major complications after radiofrequency ablation for AF that can progress to refractory congestive heart failure and pose ongoing management challenges.
Case Report (n=1)
No
Pulmonary vein occlusion and stiff left atrial syndrome after percutaneous radiofrequency ablation can lead to progressive, refractory right heart failure ultimately requiring heart transplantation.
May warrant caution with repeated AF ablation in refractory right heart failure; case report leaves open true incidence and prevention needs.
Background Stiff left atrial syndrome (SLAS) and pulmonary vein (PV) occlusion are rare yet potentially major life-long complications after radiofrequency ablation for atrial fibrillation (AF). While mostly controlled by medical management, SLAS can progress to refractory congestive heart failure. Treatment of PV stenosis and occlusion remains a challenging problem with ongoing risk for recurrence regardless of techniques employed. Herein we present the case of a now 50-year-old male with acquired PV occlusion and SLAS who, over the course of ten years, despite multiple interventions, ultimately required a heart transplantation. Case presentation: After undergoing three radiofrequency catheter procedures for paroxysmal AF, a hybrid ablation was planned due to reappearance of symptomatic AF. Preoperative echocardiography and chest computed tomography revealed an occlusion of both left PVs. Furthermore, left atrial dysfunction, high pulmonary artery and pulmonary wedge pressures were diagnosed as well as an important reduction of the left atrial volume. The diagnosis of stiff left atrial syndrome was made. Primary surgical repair of the left-sided PVs was performed using a pericardial patch as a tubular neo-vein, combined with cryoablation in the left and right atrium to treat the patient’s arrhythmia. Initial results were favorable, however, after two years the patient experienced progressive restenosis with hemoptysis. Therefore, stenting of the common left PV was performed. Over the years, progressive right heart failure with severe tricuspid regurgitation developed, despite maximal medical therapy, which led to the need for heart transplantation. Conclusion The impact of PV occlusion and SLAS after percutaneous radiofrequency ablation can be lifelong and devastating for the clinical course of the patient. Since the presence of a small left atrium could be an important predictor for SLAS in case of redo ablation, preprocedural imaging should guide the operator to an algorithm of a decision making containing lesion set, energy source and safety of re-ablation.
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Kronenberger et al. (2022) conducted a case report in Stiff left atrial syndrome and pulmonary vein occlusion (n=1). Percutaneous radiofrequency ablation was evaluated. Multiple percutaneous radiofrequency ablations for atrial fibrillation can lead to severe stiff left atrial syndrome and pulmonary vein occlusion, resulting in progressive right heart failure and the need for heart transplantation.
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