The Effect of the Cryosurgical Cox-Maze Procedure on Pulmonary Veins Diameter and Left Atrial Size

Objective The Cox-Maze procedure using cryoablation results in transmural lesions, which follow the lesion pattern of the cut-and-sew Cox-Maze procedure. The purpose of our study was to evaluate the effect of the Cox-Maze procedure on left atrial and pulmonary vein size using computed tomography angiogram (CTA). An additional aim was to evaluate pulmonary vein anatomic variability. Methods Six patients (four women and two men; ages 39–63 years, mean age 54.3) underwent chest CTA 1 day before and 38 to 104 days (mean 62.6 days) after the cryosurgical Cox-Maze procedure. Measurements of pulmonary vein ostia and left atrial cranio-caudal, left-to-right and anterior-posterior diameters were derived by consensus. The change in diameters after therapy was compared using the Wilcoxon nonparametric test for paired measurements. Four patients (1 woman and 3 men; age 57–73 years; mean age 59) were evaluated with postoperative CTA alone 296–530 days (mean 447) after surgery, for the development of postoperative pulmonary vein stenosis. A single patient underwent preoperative CTA, but surgery was not performed. Pulmonary venous anatomy was recorded in all 11 patients. Results Sinus rhythm was restored in all operated patients. No focal ostial stenosis of the pulmonary veins was observed. The quantitative assessment in the six patients with preoperative and postoperative studies disclosed only slight changes in pulmonary vein diameter with either reduction or dilatation of no more than 20% from baseline (P > 0.05). There was a consistent trend toward decrease in left atrial dimensions, which did not reach statistical significance. Six patients (55%) had standard pulmonary venous anatomy and five patients (45%) had at least one variation in their pulmonary vein anatomy. Conclusions In this study, we found that a very intensive cryoablation protocol around the pulmonary veins did not result in pulmonary vein stenosis. In addition, a relatively high incidence of anatomic variations of the pulmonary veins was documented.

Download Full-text

Abstract 14990: Pulmonary Vein Stenosis After Epicardial Atrial Fibrillation Ablation and Epicardial Left Atrial Appendage Occlusion: A Diagnostic Dilemma and Challenges in Management

Circulation ◽

10.1161/circ.142.suppl_3.14990 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Moghniuddin Mohammed ◽

Nachiket Apte ◽

Mohammed Ansari ◽

Amit Noheria ◽

Seth Sheldon ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Maze Procedure ◽

Pulmonary Vein Stenosis ◽

Epicardial Ablation ◽

Left Atrial Appendage Occlusion ◽

Vein Stenosis

Background: Pulmonary vein stenosis is a dreaded complication of endocardial atrial fibrillation (AF) ablation but rare after epicardial ablation and has not been reported after epicardial left atrial appendage occlusion (LAAO). Case: A 55-year-old male was referred to our tertiary hospital for management of left superior pulmonary vein (LSPV) stenosis causing dyspnea on exertion. About 2 years prior to presentation, he underwent quadruple coronary artery bypass grafting for non-ST elevation myocardial infarction along with modified Cox-Maze procedure with pulmonary vein and posterior wall isolation as well as epicardial LAAO with AtriClip for history of paroxysmal AF. At our institute, V/Q scan showed ventilation-perfusion mismatch and absent perfusion of the left upper lobe (Figure 1A). Cardiac CT showed persistent LSPV occlusion (Figure 1B). TEE showed atrial appendage occluded with a clip and no flow was observed from LSPV (Figure 1C). After multidisciplinary discussion between cardiology and cardiothoracic surgery teams, surgical approach to remove the AtriClip was deemed futile as it was placed 2 years ago and less likely to result in resolution of stenosis. Thus, an endovascular approach was attempted with left atrial and pulmonary vein angiography showing LSPV to be 100% occluded (Figure 1D). Pulmonary vein recanalization was attempted but was not successful. Conclusion: Our case highlights the importance of recognition of PVS as a possible complication after epicardial LAAO as early intervention can improve patient outcomes. PVS has been previously described with Maze procedure but that patient was successfully treated with catheter-balloon angioplasty. Given 100% occlusion and difficulty with recanalization makes epicardial ablation a less likely cause of occlusion in our case. More careful application of Atriclip protocols might be necessary to prevent this potential complication.

Download Full-text

Correlation of Intravascular Ultrasound with Histology in Pediatric Pulmonary Vein Stenosis

Children ◽

10.3390/children8030193 ◽

2021 ◽

Vol 8 (3) ◽

pp. 193

Author(s):

Ryan Callahan ◽

Zachary Gauthier ◽

Shuhei Toba ◽

Stephen P. Sanders ◽

Diego Porras ◽

...

Keyword(s):

Pulmonary Vein ◽

Intravascular Ultrasound ◽

Pulmonary Veins ◽

Pulmonary Vein Stenosis ◽

Elastic Fibers ◽

Gradual Transition ◽

Wall Thickening ◽

Thin Wall ◽

Myxoid Matrix ◽

Vein Stenosis

Preliminary intravascular ultrasound (IVUS) images of suspected pediatric intraluminal pulmonary vein stenosis (PVS) demonstrate wall thickening. It is unclear how the IVUS-delineated constituents of wall thickening correlate with the histology. We analyzed six postmortem formalin-fixed heart/lung specimens and four live patients with PVS as well as control pulmonary veins using IVUS and light microscopic examination. In PVS veins, IVUS demonstrated wall thickening with up to two layers of variable echogenicity, often with indistinct borders. Histologically, the veins showed fibroblastic proliferation with areas rich in myxoid matrix as well as areas with abundant collagen and elastic fibers. Discrete vein layers were obscured by scarring and elastic degeneration. A lower reflective periluminal layer by IVUS corresponded with hyperplasia of myofibroblast-like cells in abundant myxoid matrix. The hyper-reflective layer by IVUS extended to the outer edge of the vessel and corresponded to a less myxoid area with more collagen, smooth muscle and elastic fibers. The outer less reflective edge of the IVUS image correlated with a gradual transition into adventitia. Normal veins had a thin wall, correlating with histologically normal cellular and extracellular components, without intimal proliferation. IVUS may provide further understanding of the anatomy and mechanisms of pediatric pulmonary vein obstruction.

Download Full-text

Relationship between Clinical Features and Histopathologic Findings in Patients with Pulmonary Vein Stenosis

Ukrainian journal of cardiovascular surgery ◽

10.30702/ujcvs/19.3505/044061-063 ◽

2019 ◽

pp. 61-63 ◽

Cited By ~ 1

Author(s):

Y. Mykychak ◽

D. Kozhokar ◽

I. Yusifli ◽

O. Yachnik ◽

V. Zakharova ◽

...

Keyword(s):

Pulmonary Vein ◽

Clinical Features ◽

Pulmonary Veins ◽

Clinical Manifestations ◽

Lung Parenchyma ◽

Pulmonary Vein Stenosis ◽

Pathophysiological Mechanism ◽

Patient Groups ◽

Vein Stenosis ◽

Histopathologic Findings

Pulmonary vein stenosis (PVS) is a rare but serious condition characterized by obstruction of extrapulmonary segments of pulmonary veins which leads to progressive pulmonary hypertension. Objective. In this study we aimed to determine relationship between clinical features and histopathologic findings in patients with PVS. Material and methods. We retrospectively reviewed 34 consecutive patients who underwent PV stenosis repair. Surgical wedge biopsy specimens were collected intraoperatively in 11 patients and reviewed using light microscopy. Results. Affected pulmonary veins in patients with primary PVS were characterized by diffuse stenosis extending into the lung parenchyma. In post-surgical group stenosis was found in a limited segment of pulmonary vein at its ostium. Microscopically, abnormal intimal proliferation was identified in both patient groups. Scaring was predominant finding in patients with post-surgical PVS. Conclusion. In patients with PVS, pathophysiological mechanism influences the severity and extent of clinical manifestations. A comprehensive understanding of this mechanism may improve results of the treatment.

Download Full-text

Asymptomatic Pulmonary Vein Stenosis: Hemodynamic Adaptation and Successful Ablation

Case Reports in Cardiology ◽

10.1155/2016/4979182 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4

Author(s):

John J. Lee ◽

Denis Weinberg ◽

Rishi Anand

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Artery ◽

Pulmonary Vein ◽

Pulmonary Veins ◽

Lung Perfusion ◽

Atrial Fibrillation Ablation ◽

Clinical Severity ◽

Pulmonary Vein Stenosis ◽

Multiple Imaging ◽

Vein Stenosis

Pulmonary vein stenosis is a well-established possible complication following an atrial fibrillation ablation of pulmonary veins. Symptoms of pulmonary vein stenosis range from asymptomatic to severe exertional dyspnea. The number of asymptomatic patients with pulmonary vein stenosis is greater than originally estimated; moreover, only about 22% of severe pulmonary vein stenosis requires intervention. We present a patient with severe postatrial fibrillation (AF) ablation pulmonary vein (PV) stenosis, which was seen on multiple imaging modalities including cardiac computed tomography (CT) angiogram, lung perfusion scan, and pulmonary angiogram. This patient did not have any pulmonary symptoms. Hemodynamic changes within a stenosed pulmonary vein might not reflect the clinical severity of the obstruction if redistribution of pulmonary artery flow occurs. Our patient had an abnormal lung perfusion and ventilation (V/Q) scan, suggesting pulmonary artery blood flow redistribution. The patient ultimately underwent safe repeat atrial fibrillation ablation with successful elimination of arrhythmia.

Download Full-text

Modified sutureless repair using left atrial appendage flap for acquired left-sided pulmonary vein stenosis

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa032 ◽

2020 ◽

Vol 58 (2) ◽

pp. 395-397

Author(s):

Hideki Ito ◽

Masato Mutsuga ◽

Yoshiyuki Tokuda ◽

Akihiko Usui

Keyword(s):

Catheter Ablation ◽

Pulmonary Vein ◽

Left Atrial ◽

Radiofrequency Catheter Ablation ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Successful Outcome ◽

Pulmonary Vein Stenosis ◽

Sutureless Technique ◽

Vein Stenosis

Abstract Pulmonary vein stenosis is a well-known complication after radiofrequency catheter ablation of atrial fibrillation. Although surgical repair is indicated for younger patients and patients with multiple stenoses, the appropriate procedure for acquired pulmonary vein stenosis has not been established. In this study, we report the successful outcome of our modified sutureless technique using a left atrial appendage flap for left-sided pulmonary vein stenosis after radiofrequency catheter ablation.

Download Full-text

CT Visualization and Histopathological Assessment of Cryoablation in Pulmonary Veins

ASME 2009 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2009-206640 ◽

2009 ◽

Cited By ~ 1

Author(s):

Mithun M. Shenoi ◽

Xiaoqing Zhang ◽

Ramji T. Venkatasubramanian ◽

Erin D. Grassl ◽

Lenny George ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Veins ◽

The United States ◽

The Body ◽

Pulmonary Vein Stenosis ◽

Invasive Technique ◽

Freezing Process ◽

Ectopic Beats ◽

Vein Stenosis

Over 2 million adults in the United States are affected by atrial fibrillation (AF), a common cardiac arrhythmia that is associated with decreased survival, increased cardiovascular morbidities, and a decrease in quality of life. Atrial fibrillation can be initiated by ectopic beats originating in the myocardial sleeves surrounding the pulmonary veins [1]. Pulmonary vein (PV) isolation via radiofrequency ablation is the current gold standard for treating patients with drug-refractory AF [2]. However, cryoablation is emerging as a new minimally-invasive technique to achieve PV isolation. Cryoablation is fast gaining acceptance due to its minimal tissue disruption, decreased thrombogenicity, and reduced complications (RF can lead to low rate of pulmonary vein stenosis) [2]. One important question in regard to this technology is whether the PV lesion is transmural and circumferential and to what extent adjacent tissues are involved in the freezing process. As ice formation lends itself to image contrast in the body, we hypothesized that intraprocedural CT visualization of the iceball formation would allow us to predict the extent of the cryolesion and/or provide us with a measure of the adjacent tissue damage.

Download Full-text