Dr. Douglas Packer

AF Symposium 2015

The Risk of Pulmonary Vein Stenosis in A-Fib Ablation

by Steve S. Ryan, PhD

In his presentation assessing the risks of A-Fib Ablation, Dr. Douglas Packer of the Mayo Clinic called attention to a dangerous complication most of the attendees thought was now relatively uncommon—pulmonary vein stenosis.

Back in the early days of catheter ablation, pulmonary vein (PV) stenosis was an all too frequent complication, because ablations were often done inside the PVs. Today’s ablations are performed at the PV openings or in the antrum area where there is much less chance of swelling or stenosis blocking a PV. From 1998 to 2005 there was a huge difference in the severity of PV stenosis due to EPs learning to ablate outside the PVs.

Rare But Serious Complications From Undetected PV Stenosis

However, the Mayo Clinic. which is a referral center for PV stenosis, has seen in the last two years “by far and away the very worst pulmonary vein stenosis complications that we’ve ever seen.” Dr. Packer thinks this is because the stenosis goes undetected. Doctors don’t look for it any more. Doctors have stopped doing CT scans or MRIs at three months to detect stenosis “which is an incredible mistake.” One of the reasons is that insurance companies won’t pay for them. There is litigation that may change the insurance companies’ policy. And the Heart Rhythm Society has an obligation when writing guidelines to insist that patients be checked for PV stenosis.

Dr. Packer pointed out that if PV stenosis is detected at 3-6 months, it’s fairly easy to deal with. After a stent is inserted into a PV with stenosis, patients do well. But if the stenosis isn’t detected until one or two years, then the veins are occluded. If a doctor is able to insert a stent, they can’t keep it open. Patients come back again and again for a stent redo procedure.

At 3-6 Months PV Stenosis May Look Like Flu or Bronchitis

If an MRI or CT scan can’t be done, at a minimum patients should be told that if they have any pulmonary symptoms at 3-6 months, they must come in and get checked. It may be the flu or bronchitis, but it could be PV stenosis.

PV Stenosis often goes undetected, because patients aren’t seeing their EP doctors anymore. Their primary care doctors or pulmonologists aren’t aware of stenosis and don’t look for it. Many PV stenosis cases are referred to the Mayo Clinic by pulmonologists (who often think they are seeing lung cancers). If an EP, for whatever reason, can’t monitor a patient they have ablated, they must get the word out to the patient’s primary care doctor. If that patient comes in with pulmonary symptoms, look at the pulmonary veins.

Risk of Perforation From A-Fib Ablation Probably Reduced by Contact-Force Sensing Catheters

The risk of cardiac perforation is usually stated at 0.5%-1% and is related to the experience, skill and manual dexterity of the EP. But Dr. Packer thinks perforation rates may actually be higher 1%-2%. “The message is to use caution.” He thinks that the new contact-force sensing catheters will probably lessen the risk of perforation.

Editor’s Comments:

If you experience any pulmonary problems such as flu-like symptoms after an ablation, make sure your report them to your EP. Even though PV stenosis is relatively rare because most ablations are now performed outside of the PVs, it can happen. If PV stenosis is caught early, it’s relatively easily fixed.

When you select an EP to do your ablation, make sure they use contact force-sensing catheters. If they don’t, go somewhere else. It’s worth the extra effort and travel.

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Last updated: Thursday, April 30, 2015