Diagnostic dilemmaA History Lesson: Pulmonary Vein Stenosis
Section snippets
Presentation
Signs and symptoms suggested infection, but the true diagnosis was rooted in the patient's recent past. A 46-year-old man who spends his winters in Arizona had been bothered by right-sided back and shoulder pain for 5 months. He sought care with his chiropractor but grew concerned after the pain worsened, and he developed new night sweats, subjective fevers, dry cough, and fatigue. The patient was a nonsmoker with a medical history of gastroesophageal reflux, hypertension, and atrial
Assessment
The patient's focal consolidation and symptoms were concerning for malignancy. Fungal infection, such as coccidiomycosis, was another possible consideration, because the Coccidioides species are endemic to Arizona. A bronchoscopy was performed, but cytology, fungal antibody testing, and bacterial cultures were all negative. A CT-guided needle biopsy also failed to demonstrate evidence of infection or malignancy. Because of his severe pain and ongoing hemoptysis, the patient was started on
Diagnosis
Pulmonary vein stenosis is a serious complication of ablation for atrial fibrillation.1, 2 The incidence of pulmonary vein stenosis has fallen to approximately 0.3% to 3.4% with modern ablation techniques; however, with nearly 10,000 ablations performed annually, hundreds of patients are potentially at risk.3, 4, 5, 6 The symptoms develop insidiously over the weeks and months after ablation (Table).1, 2, 7, 8 Misdiagnosis is common because the most frequent symptoms, including dyspnea,
Management
Three days after diagnosis our patient underwent successful stenting of the right superior pulmonary vein (Figure 3). His symptoms began to improve immediately, and he experienced complete resolution within 2 weeks. Because patients are at risk for recurrent stenosis after a successful intervention, he had follow-up contrast-enhanced pulmonary CT with delayed image acquisition at 3, 6, and 12 months. These confirmed that the vein remained stable and patent.
Early recognition of pulmonary vein
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Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation
Circulation
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Severe pulmonary vein stenosis resulting from ablation for atrial fibrillation: presentation, management, and clinical outcomes
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Circ Arrhythm Electrophysiol
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Funding: None.
Conflict of Interest: DLP provides consulting for Abiomed, Biosense Webster, Inc, Boston Scientific, CardioDX, CardioFocus, CardioInsight Technologies, InfoBionic, Inc, Johnson & Johnson Healthcare Systems, MediaSphere Medical, LLC, Medtronic CryoCath, Sanofi-Aventis, Siemens, St. Jude Medical, and Topera Medical; DLP received no personal compensation for these consulting activities.
Authorship: All authors participated in the writing of the manuscript and had full access to all data.