Figura 1. The ablation electrodes are visible; these were used to locate the pulmonary veins and th...

Figura 2. CT angiography. A) Left superior pulmonary vein stenosis. B) Left inferior pulmonary vein...

Figura 3. Drug-eluting peripheral balloon angioplasty is shown for in-stent restenosis in the pulmon...

Introduction

Catheter ablation has become the therapeutic alternative in cases of atrial fibrillation (AF), using energy to isolate the pulmonary veins (PVs) by radiofrequency. As the tissue is ablated through thermal injury, fibrosis and scarring develop and extend deeply into the treated pulmonary vein from the ostium, leading to vascular lumen stenosis2, 4-5. Pulmonary vein stenosis is usually diagnosed between 3 to 5 months after the catheter procedure, and its incidence has substantially decreased from 22.9% (range 3.4 to 42.4%) to 0.85% (range 0.7 to 1%) as a result of antral isolation, circumferential ablation, three-dimensional mapping, and the use of intracardiac ultrasound3, 5. Clinically, PV stenosis may present with exertional dyspnea, cough, pleuritic pain, and hemoptysis, and it can be progressive, causing irreversible damage to the pulmonary parenchyma, pulmonary hypertension, and heart failure. Therapeutic management includes percutaneous intervention with balloon angioplasty (BA) or pulmonary vein stenting (PVS). Cases of restenosis can occur within three years from the last intervention1-2. The use of drug-eluting balloons has shown significant results and is considered an option for in-stent restenosis, a complex problem, and for the treatment of small vessel disease6-7.

Case description

A 56-year-old man, with a history of arterial hypertension, gastric bypass, and atrial fibrillation treated on three occasions with extensive ablation of the right PVs, was admitted again with New York Heart Association (NYHA) class II clinical dyspnea, which—he reported—had been present since the last ablation one year before. A CT angiography revealed left PV stenosis. A choice was made to conduct another AF ablation and stent angioplasty of the left PVs (Figure 1). Extensive antral isolation of the right PVs was performed with point-by-point application of 40 watts on the anterior wall and 30 watts on the posterior wall, reaching up to 40 °C, guided by VISITAG SURPOINT®. Isolation of all four PVs was confirmed.

Subsequently, angioplasty was performed by placing 7 × 56-mm Biotronik Dynamic® stents (8 ATM) in each of the superior and inferior left PV branches, using transesophageal Doppler echocardiography to confirm proper opening and absence of gradient.

After 26 months, the patient was readmitted for NYHA class II–III dyspnea; a new CT angiography showed calcified PV ostia with associated periostial thickening.

The left superior pulmonary vein (LSPV) had an approximately 54-mm long ostial stent, extending from 10 mm inside the atrial cavity to an inferior secondary branch. The vein was patent but showed focal eccentric restenosis. The minimal luminal area was 7 mm2, for a maximal luminal area of 26 mm2, with a 5.5-mm reference diameter at 17 mm from the atrial end. The left inferior pulmonary vein (LIPV) had an ostial stent extending approximately 8 mm into the atrial cavity; imaging showed severe concentric focal restenosis at the ostium (Figure 2). The right PVs showed no stenosis, and there were no signs of thrombosis. A choice was made to conduct another angioplasty using drug-eluting balloons: Passeo Lux™ Biotronik OTW, 0.018”, 7 × 40 mm × 2 (Paclitaxel 3.0 μg/mm2, polymer: Paclitaxel and butyryl-tri-hexyl citrate BTHC) (Figure 3). The procedure was completed without complications, followed by medical treatment with dual antiplatelet therapy. The patient evolved favorably and remained in sinus rhythm and without dyspnea during follow-up.

Discussion

Pulmonary vein (PV) ablation has become an important therapeutic approach in the treatment of cardiac arrhythmia, with stenosis being a serious, infrequent, but clinically relevant complication. Stenosis is defined as a reduction of 3 mm or more in its diameter. It depends particularly on the ablation techniques applied and is higher with segmental or focal ablation at the PV ostium, around 21%, compared to circumferential ablation and antral isolation, for which it is estimated at only 0.6%1. Therapeutic management includes percutaneous intervention with balloon angioplasty (BA) or pulmonary vein stenting (PVS). After evaluating a systematic review reporting eight observational studies with 487 patients with inclusion criteria, the primary outcome of restenosis requiring reintervention occurred in 196 of 325 veins in the BA group and in 111 of 443 veins in the PVS group. Compared to PVS, BA was associated with a significantly higher risk of restenosis (odds ratio [OR] = 2.91; 95% confidence interval [CI]: 1.15-7.37. PAG=0.025; I2= 79.2%)1, 2. The mechanisms involved in PV restenosis after an initially successful recanalization are not fully understood but may relate to a combination of neointimal hyperplasia, fibrosis, and thrombus formation. Drug-eluting balloons (DEB) have demonstrated safety and efficacy for the treatment of restenosis. Late lumen loss during follow-up is consistently low (< 0.2 mm), and no thrombotic events have been reported when using DEBs. The European Society of Cardiology has given DEBs a class IIa, level B recommendation for the treatment of in-stent restenosis6, 7.

Conclusion

The use of DEB in restenosis was considered in this patient as a safe and beneficial alternative. In correlation with the evidence, it proves to be an innovative method promising significant clinical results. It constitutes an evolving technology of great interest due to its potential applications in various coronary, cardiac, and extracardiac interventions6, 7.

1. Campo-Rivera N, Negrete-Salcedo A, Tenorio-Tascón C, Rodríguez-Martínez A, Escobar-Rojas W. Angioplastia con balón de venas pulmonares por estenosis tras ablación percutánea de fibrilación auricular. Revista Colombiana De Cardiología 2022;28(5), vol. 28, no 5, p. 473-477.

2. Agasthi P, Sridhara S, Rattanawong P, Venepally N, Chao C, et al. Safety and efficacy of balloon angioplasty compared to stent-based-strategies with pulmonary vein stenosis: a systematic review and meta-analysis. World Journal of Cardiology, 2023, vol. 15, no 2, p. 64.

3. Ogawa T, Yamashita S, Oseto H, Yokoyama M, Itakura R, et al. Pulmonary vein angioplasty for pulmonary vein stenosis after ablation therapy for atrial fibrillation – a report of 7 cases –. Circulation Journal 2022;86(8):1229-1236.

4. Fink T, Vogler J, Proietti R, Sciacca V, Heeger C, et al. Antithrombotic therapy after angioplasty of pulmonary vein stenosis due to atrial fibrillation ablation: a two‐center experience and review of the literature. Journal of Arrhythmia 2022;38(6):1009-1016.

5. Fender E, Widmer R, Hodge D, Cooper G, Monahan K, et al. Severe pulmonary vein stenosis resulting from ablation for atrial fibrillation. Circulation 2016;134(23):1812-1821.

6. Kleber F, Mathey D, Rittger H, Scheller B. How to use the drug-eluting balloon: recommendations by the german consensus group. EuroIntervention 2011;7(K): K125-K128.

7. Choo G-H. Drug-eluting balloons: future potential indications and applications. EuroIntervention 2011;7: K112-K118.

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Drug-eluting balloon angioplasty for pulmonary vein re-stenosis secondary to multiple atrial ablations

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