Packer Douglas L, Keelan Paul, Munger Thomas M, Breen Jerome F, Asirvatham Sam, Peterson Laura A, Monahan Kristi H, Hauser Mary F, Chandrasekaran K, Sinak Lawrence J, Holmes David R
Division of Cardiac Electrophysiology/Cardiology, Department of Internal Medicine, Mayo Clinic and Foundation, Saint Mary's Hospital Complex, Rochester, Minn 55902, USA.
Circulation. 2005 Feb 8;111(5):546-54. doi: 10.1161/01.CIR.0000154541.58478.36.
Although segmental or circumferential ablation is effective in eliminating pulmonary vein (PV)-mediated atrial fibrillation (AF), this procedure may be complicated by the occurrence of PV stenosis.
To establish the clinical presentation, diagnostic manifestations, and interventional management of PV stenosis, 23 patients with stenosis of 34 veins complicating ablation of AF were evaluated. Each patient became symptomatic 103+/-100 days after undergoing ablation. In 8 veins, the ablation producing the PV stenosis was a repeated procedure for continued AF. Nineteen patients presented with dyspnea on exertion, 7 with dyspnea at rest, 9 with cough, and 6 with chest pain. On multirow spiral computed tomography examination, the narrowest lumen of the affected PVs measured 3+/-2 mm compared with 13+/-3 mm at baseline (P< or =0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4+/-3% of total perfusion compared with 22+/-10% in unaffected segments. At percutaneous intervention, these veins showed 80+/-13% stenosis, with a mean gradient of 12+/-5 mm Hg. This was significantly reduced to a residual stenosis of 9+/-8% (P< or =0.001) and a residual gradient of 3+/-4 mm Hg (P< or =0.001). Twenty veins were treated with balloon dilatation alone, whereas 14 veins were stented with standard 10-mm-diameter bare-metal stents. Although the symptomatic response was nearly immediate and impressive, 14 patients developed in-stent or in-segment restenosis, requiring repeated interventions in 13.
Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AF. Nevertheless, alternative treatment methods will be required to decrease recurrent in-stent or in-segment restenosis.
尽管节段性或环形消融在消除肺静脉（PV）介导的心房颤动（AF）方面有效，但该手术可能会并发PV狭窄。
为明确PV狭窄的临床表现、诊断表现及介入治疗方法，对23例因AF消融术后出现34条静脉狭窄的患者进行了评估。每位患者在接受消融术后103±100天出现症状。在8条静脉中，导致PV狭窄的消融是针对持续性AF的重复手术。19例患者表现为劳力性呼吸困难，7例为静息时呼吸困难，9例为咳嗽，6例为胸痛。在多排螺旋计算机断层扫描检查中，受累PV的最窄管腔直径为3±2mm，而基线时为13±3mm（P≤0.001）。同位素扫描显示，受累肺段的相对灌注减少至总灌注的4±3%，而未受累段为22±10%。在经皮介入治疗时，这些静脉显示狭窄率为80±13%，平均压差为12±5mmHg。这显著降低至残余狭窄率为9±8%（P≤0.001），残余压差为3±4mmHg（P≤0.001）。20条静脉仅接受了球囊扩张治疗，而14条静脉植入了标准的10mm直径裸金属支架。尽管症状缓解几乎立竿见影且效果显著，但14例患者出现了支架内或节段内再狭窄，其中13例需要再次干预。
对于AF射频消融术后出现高度症状性PV狭窄的患者，经皮介入治疗可迅速显著缓解症状。然而，需要采用其他治疗方法来减少支架内或节段内再狭窄的复发。
