Functional Assessment of Pulmonary Vein Stenosis Using Radionuclide Ventilation/Perfusion Imaging

doi:10.1378/chest.126.2.645

Chest

Volume 126, Issue 2, August 2004, Pages 645-651

https://doi.org/10.1378/chest.126.2.645 Get rights and content

Pulmonary vein (PV) stenosis following catheter ablation of atrial fibrillation (AF) is a new clinical syndrome. The optimal method of assessing this syndrome is not known. We evaluated radionuclide perfusion imaging, anatomic imaging, and direct measurements of PV-left atrial (LA) pressure gradients in patients suspected of having PV stenosis after catheter ablation for the treatment of AF. The study included 11 consecutive patients who were referred to a tertiary referral center for the evaluation of symptoms suggesting or imaging evidence of PV stenosis following catheter ablation for AF. All patients underwent anatomic imaging of their PVs with direct pulmonary venography or CT scanning as well as radionuclide perfusion imaging. PV stenosis (> 50% diameter) was diagnosed by venography in 6 of the 11 patients and in 16 of 44 PVs. All six patients with PV stenosis had perfusion defects in the affected pulmonary lobe. In contrast, all of the patients without anatomic evidence of PV stenosis had normal perfusion. There were 14 PVs with stenoses of > 80% of the luminal diameter, all of which had a corresponding perfusion abnormality ascertained by perfusion scanning. In all 14 PVs with a resting PV-LA gradient of > 5 mm Hg, there was a corresponding perfusion defect. PV stenosis results in decreased perfusion in the affected lobe when the resting PV-LA pressure gradient is at least 5 mm Hg or when there is 80% luminal stenosis. A perfusion scan may serve as an effective screening tool for PV stenosis and may be most useful in assessing the hemodynamic significance of an anatomic PV stenosis.

Section snippets

Study Population

The study population included 11 consecutive patients who were referred to the University of Alabama at Birmingham for evaluation of possible PV stenosis. These patients had symptoms or imaging evidence that was suggestive of PV stenosis after being treated for AF with catheter ablation (Table 1). AF had been paroxysmal in eight patients and permanent in three patients. All patients had received either radiofrequency catheter ablation to isolate the PVs (eight patients) or linear LA ablation to

Results

The clinical characteristics of the patients are shown in Table 1. Linear LA ablation was performed in three patients, and segmental PV isolation was performed in eight patients. Of the three patients evaluated with suspected PV stenosis who underwent linear ablation, two had stenosis and presented with shortness of breath. Of the eight patients who had PV isolation with segmental approach and were investigated for possible stenosis, four had PV stenosis. In this cohort of patients, the

Discussion

Among 11 consecutive patients with suspected PV stenosis, nuclear perfusion scanning identified a lobar perfusion deficit corresponding to every PV with > 80% stenosis and a PV-LA gradient of > 5 mm Hg. No patient without PV stenosis demonstrated a defect in perfusion imaging. This report of radionuclide imaging in patients with PV stenosis following AF ablation confirms the complementary contributions of physiologic and anatomic imaging methods. This finding may prove to be useful in the

Conclusion

Nuclide perfusion imaging is noninvasive and widely available, and it provides physiologic information regarding pulmonary blood flow in patients suspected of having PV stenosis. When the degree of PV stenosis was > 80%, a lobar perfusion defect was identified in all patients. In contrast, when the degree of stenosis was < 50%, there were no perfusion defects noted. The technique is simple to perform and interpret, and may be especially suitable for centers without experience in CT scanning or

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Pathogenesis, Evaluation, and Management of Pulmonary Vein Stenosis: JACC Review Topic of the Week
2023, Journal of the American College of Cardiology
Pulmonary vein stenosis (PVS) can arise from several etiologies, including congenital, acquired, and iatrogenic sources. PVS presents insidiously, leading to significant delays in diagnosis. A high index of suspicion and dedicated noninvasive evaluation are key to diagnosis. Once diagnosed, both noninvasive and invasive evaluation may afford further insights into the relative contribution of PVS to symptoms. Treatment of underlying reversible pathologies coupled with transcatheter balloon angioplasty and stenting for persistent severe stenoses are established approaches. Ongoing refinements in diagnostic modalities, interventional approaches, postintervention monitoring, and medical therapies hold promise to further improve patient outcomes.
Cardiovascular magnetic resonance pulmonary perfusion for functional assessment of pulmonary vein stenosis
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Cardiovascular magnetic resonance (CMR) imaging allows to combine pulmonary perfusion measurements and pulmonary venous angiography during a single-session examination with both imaging modules representing the basis for accurate diagnosis and therapeutic stratification of pulmonary vein (PV) stenosis. The present study investigated the clinical utility of dynamic pulmonary perfusion imaging integrated into a comprehensive CMR protocol for the evaluation of patients with suspected PV stenosis.
162 patients with clinically suspected PV stenosis after catheter ablation of atrial fibrillation underwent a combined single-session CMR examination (cardiac cine imaging, dynamic pulmonary perfusion, and three-dimensional PV angiography). CMR angiography was used for visual grading of PV stenoses; dynamic pulmonary perfusion imaging was evaluated per lung lobe visually and quantitatively.
All PV stenosis ≥90% showed a visible perfusion deficit of the corresponding lung lobe (60/60, 100%) while all PVs with luminal narrowing <50% exhibited normal pulmonary perfusion (680/680, 100%). However, every third 70–89% stenosis showed a normal pulmonary perfusion (10/31, 32%) while every fourth 50–69% PV stenosis was associated with hypoperfusion of the corresponding lung lobe (9/39, 23%). For quantitative pulmonary perfusion measurements, ROC analysis demonstrated high discriminatory power regarding PV stenosis detection with the highest AUC values for time-to-peak enhancement (cut-off value, 8.5 s).
The combination of CMR angiography and CMR pulmonary perfusion allowed for assessment of the anatomical degree of PV stenosis and its hemodynamic impact on the pulmonary parenchymal level. Thus, the proposed comprehensive CMR protocol provided an efficient diagnostic work-up of patients with suspected PV stenosis.
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Citation Excerpt :
However, its spatial resolution is slightly inferior to that of CT, it requires a longer scanning time, and it may be contraindicated in patients with metal implants. The ventilation/perfusion scan is usually performed for the detection of pulmonary embolism but is also reported to serve as an effective screening tool for the detection of hemodynamically relevant PVS.16,17 This exam, however, is not valuable for the etiological diagnosis of PVS and may be altered in other pathologies that decreased lobar perfusion (i.e., pulmonary thromboembolism).
Pulmonary vein stenosis (PVS) is a rare condition, often difficult to diagnose and associated with poor prognosis at advanced stages. Lung parenchymal abnormalities are indirect evidence of PVS and can manifest as multifocal opacities, nodular lesions, unilateral effusions, and interstitial septal thickening. These can lead to erroneous diagnoses of airway disease, pneumonia, malignancies or interstitial lung disease. This review summarizes the current literature about the approach to, evaluation and management of these patients. Our case report demonstrates that PVS is an under-recognized complication of cardiovascular surgery and should be considered in all patients presenting with respiratory symptoms after a cardiac procedure.
Clinical Relevance of Computed Tomography Pulmonary Venography
2016, Heart Lung and Circulation
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As a result of regional differences in pulmonary vascular resistance, the pulmonary blood flow redirects towards regions with lower vascular resistance [8,9]. Therefore, perfusion deficits in lung perfusion scans can be caused both by pulmonary arterial and by pulmonary venous obstruction [10]. Differentiation between pulmonary arterial and pulmonary venous origin of perfusion deficits is not possible [11,12].
In clinical routine, the pulmonary contrast-enhanced chest computer tomography (CT) is usually focussed on the pulmonary arteries. The purpose of this pictorial essay is to raise the clinicians’ awareness for the clinical relevance of CT pulmonary venography.
A pictorial case series illustrates the clinical consequences of different pulmonary venous pathologies on systemic, pulmonary and bronchial circulation.
Computed tomography pulmonary venography must be considered before atrial septal defect (ASD) closure and pulmonary lobectomy. Computed tomography pulmonary venography should be considered for patients with right ventricular overload and pulmonary hypertension, as well as for patients with unclear recurrent pulmonary infections, progressive dyspnoea, pleural effusions, haemoptysis, and for patients with respiratory distress after lung-transplantation.
Interventional cryoablation therapy of paroxysmal atrial fibrillation in young patients with low CHADS<inf>2</inf> score: Worth the risk of periprocedural and long-term adverse events?
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: Dr. Nanthakumar is supported by the Clinician Scientist Program of the Canadian Institute of Health Research.

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Selected ReportsFunctional Assessment of Pulmonary Vein Stenosis Using Radionuclide Ventilation/Perfusion Imaging

Section snippets

Study Population

Results

Discussion

Conclusion

Pulmonary vein stenosis after catheter ablation of atrial fibrillation

Circulation

Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome

Ann Intern Med

Evaluation of pulmonary vein stenosis after catheter ablation of atrial fibrillation

Card Electrophysiol Rev

Acquired pulmonary vein stenosis after radiofrequency catheter ablation of paroxysmal atrial fibrillation

J Cardiovasc Electrophysiol

Pathological effects of extensive radiofrequency energy applications in the pulmonary veins in dogs

Circulation

First human experience with pulmonary vein isolation using a through-the-balloon circumferential ultrasound ablation system for recurrent atrial fibrillation

Circulation

A new radiofrequency thermal balloon catheter for pulmonary vein isolation

J Am Coll Cardiol

Laser ablation of the pulmonary veins by using a fiberoptic balloon catheter: implications for treatment of paroxysmal atrial fibrillation

Lasers Surg Med

Incidence of pulmonary vein stenosis 2 years after radiofrequency catheter ablation of refractory atrial fibrillation

Eur Heart J

Selected Reports
Functional Assessment of Pulmonary Vein Stenosis Using Radionuclide Ventilation/Perfusion Imaging