Total pulmonary vein occlusion complicating pulmonary vein isolation: Diagnosis and treatment

BACKGROUND Pulmonary vein stenosis (PVS) complicating pulmonary vein isolation (PVI) can progress to total pulmonary vein occlusion (PVO). Little is known about the accuracy of noninvasive diagnosis and treatment of PVO. OBJECTIVE The purpose of this study was to study the diagnostic accuracy of noninvasive testing and the feasibility and outcome of percutaneous intervention for PVO. METHODS Computed tomography (CT)-diagnosed and angiographically confirmed PVOs were identified from percutaneous interventions for PVS complicating PVI between December 2000 and December 2008. Diagnostic accuracy of CT combined with lung perfusion scan was studied. Outcome of percutaneous intervention was reviewed. RESULTS CT diagnosed "PVO" in 53 PVs, with only 20 of 53 determined angiographically to be totally occluded. True PVO had lower perfusion (4.0%) compared with CT-diagnosed "PVO" (7.3%, P = .024). Recanalization was attempted in 9 and successful in 8. Of the 8 patients, 7 were dilated with 4.5- to 7-mm balloons and 1 was stented primarily (7 mm). At repeat catheterization 2.9 +/- 0.8 months later, 6 of 7 pulmonary veins (PVs) were stented to 5 to 10 mm. At follow-up of 11.3 +/- 8.7 months, all but 1 PV remained patent (mean diameter 6.9 +/- 1.7 mm). Flow to the lung quadrant increased from 5.6% before recanalization to 12.2% at last follow-up (P = .016). Symptoms improved in all but one patient. CONCLUSION PVO is overestimated by CT. Quantification of lung perfusion improves diagnostic accuracy, but angiography remains the gold standard. Recanalization of PVO can be attempted when a remnant of the PV is visible. Good mid-term patency rates and improved perfusion were observed with a two-stage approach of initial dilation and subsequent stenting. Longer follow-up and larger numbers of patients are needed to better understand when to intervene for PVO.