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272 6—LEFT ATRIAL INTERVENTIONS
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If crossing the stenosis with a multipurpose catheter is not possible, a hydrophilic 4F Glidehead
catheter can be used to cross the stenosis and act as a placeholder to switch the crossing wire for one
with more support. The choice of working wire will depend on the equipment required to dilate the
stenosis. The goal of the intervention will be to deliver and successfully expand a 10-mm bare-metal
biliary or peripheral stent to the affected PV, which will likely require an exchange-length stiff
Amplatz wire.
The most common stent delivered in our series was the 10 mm 3 19 mm Genesis bare-
metal stent used in an off-label fashion. This should be the goal size, as smaller stents lead to
higher residual gradients and less improvement with more restenosis. Leading up to this, one
might need to use a series of balloon dilations with smaller coronary balloons and subsequently
peripheral balloons to adequately prepare the lesion. Ideally a 1:1 balloon preparation before
stent implantation would be pursued; however, this must be balanced with the risk for vein
perforation. Another important piece of information to balloon-expand these lesions is that
they often initiate the intimal proliferation and fibrosis seen with in-stent restenosis. Procedurally, this means there is a high likelihood of the balloon slipping out of the stenosis when
expanding and “watermelon seeding” either farther into the PV or back out into the LA (and
potentially losing wire position). To avoid this, careful attention to balloon positioning, longer
balloons, and slow inflations will aid in successfully dilating these difficult lesions. Other techniques, such as cutting balloons, can be attempted but with great caution, as there is a risk for
perforation with these devices, and their maximal diameter (usually not greater than 4 mm)
often precludes their use in these procedures.
Once the severity of stenosis is confirmed, a balloon is positioned and dilated across the point
of maximal stenosis, and the lesion is adequately prepared, one must decide on the final intervention to maintain vessel patency for the longest period. Unfortunately, most PVS interventions require a bare-metal stent (BMS), as the lesions tend to be too large to accommodate a
4-mm coronary drug eluting stent (DES). Despite newer DESs that can dilate to over 5 mm,
this will likely not be able to adequately address this size discrepancy. As mentioned, peripheral
or BMS used in an off-label fashion is the most commonly used device in our series. Our series
demonstrates a 54% relative risk reduction in PV restenosis over 4 years when stents are used
for the final result compared with balloon dilation alone
see Fig. 23.3). Although these are retrospective, single-center data with the usual confounders,
if the vessel will accommodate a stent, this should be used to improve vessel patency over the
long term. As some PV anatomy can vary, these stents have also been used with success as a
two-stent strategy, deploying simultaneous kissing stents should the lesion affect two PVs at the
antrum leading into both vessels.
12
(number needed to treat [NNT] 5 3;
Procedural Steps
Figs. 23.4 to 23.10 demonstrate the steps necessary for this procedure.
After transvenous access for insertion of ICE and for transseptal puncture, the following steps
are performed sequentially.
Procedural Outcomes
Our series does show anecdotal success with DES should the vessel be small and only allowing a
4-mm stent. Similarly, we have an instance of using a drug eluting balloon (DEB) to successfully
treat one specific lesion. Certainly, PVS could be niche targets for DEB should your institution
have access and knowledge to use such devices. However, with current DEB devices approved for
peripheral applications, the device length of several centimeters may mean that the proximal end
will be positioned in the RA back through the septum.
23—PULMONARY VEIN STENOSIS: MANAGEMENT AND OUTCOMES 273
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Fig. 23.4 Transseptal puncture and establishing left
atrial access. For transseptal access, typically either an
8F transseptal sheath or an Agilis sheath is used to cross
to the left atrium (LA), and the wire position is established
in the LA with an Amplatz stiff or Inoue wire (pictured)
placed through the sheath that was used to initially cross
the septum.
Fig. 23.5 A steerable sheath (e.g., Agilis or Dexterity
sheath) is introduced into the left atrium (LA) for more
precise movement and positioning. A 6F multipurpose
catheter is used to intubate the affected pulmonary vein.
Fig. 23.6 Wiring the stenotic pulmonary vein. The
stenotic pulmonary vein was crossed using a 0.0350
guidewire or a 0.0140 coronary wire, depending on the
degree and character of the stenosis.
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Fig. 23.7 Simultaneous pressure measurements. If
possible, advance the multipurpose catheter into the PV
for simultaneous PV/LA pressure measurements. LA
pressure can either be obtained with a second catheter
(4F multipurpose) in the LA or through the sidearm of the
steerable catheter.
Fig. 23.8 Exchange for a stiff wire to enable delivery
of balloons/stents. If the multipurpose catheter can be
passed across the stenosis, then the crossing wire can
be exchanged for a stiff Amplatz wire, which can then be
used to deliver over-the-wire peripheral balloons and
stents.
Fig. 23.9 Balloon dilation. A series of balloon dilations
may be needed with smaller coronary balloons and
subsequently peripheral balloons to adequately prepare
the lesion.
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Fig. 23.10 Stent delivery. If the vein is of sufficient
caliber, we aim to deliver a 1 3 19 mm Genesis
bare-metal stent into the pulmonary vein over the
Amplatz super-stiff wire.
Once the intervention is completed, vessel patency with angiography in multiple planes, Doppler velocities obtained by TEE or ICE, and obliteration or marked reduction of the vein–LA
pressure gradient will confirm successful intervention. One should carefully evaluate stent expansion and apposition so as to reduce the risk of stent embolization and/or fracture. As part of this
process, the LA end of the stent should be flared. Videos 23.1 and 23.2 show pre- and post-PVS
results angiographically.
Care should be taken to carefully monitor the patient for oxygen desaturation, hemoptysis, pulmonary edema, air/thrombus embolization, and pericardial effusion throughout the procedure and
potentially in a closely monitored setting afterward, as these are the most common complications
noted (Table 23.2).
POSTPROCEDURE CARE
Patients continue on clopidogrel 75 mg/day for up to 1 year after stent placement and, if clinically
indicated, restart Coumadin with bridging from a heparin drip or subcutaneous LMWH until the
INR is between 2 and 3. Before discharge, patients can be assessed with repeat CT and V/Q scans.
TABLE 23.2 n Procedural Complications for 113 Patient Cases
Complications N 5 19
Mild self-limiting hemoptysis 5
Severe hemoptysis, PV perforation 3
Tamponade 2
Dislodged stent 4
Postprocedural pleural effusion 2
Transient ST elevation/hypotension 1
Pericardial effusion without tamponade 2
PV, Pulmonary vein.
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Acute success is typically defined as less than 30% residual PV stenosis with improvement in flow
(both angiographically and on CT) with a concomitant reduction in echocardiographic vein Doppler
velocities and improvement in V/Q mismatch in the affected lung segment. Patients should return
at 3 and 6 months for repeat assessment, including serial CT and V/Q scanning. Subsequent
evaluations with repeat imaging can be guided by clinical symptoms.
Conclusions
PVS is an underrecognized syndrome that can result in significant and debilitating symptoms.
Invasive management with balloon angioplasty or stenting is highly effective in the acute setting; however, the risk of recurrence is high. Historically, there have been little data to guide
the interventionalist as to the best method of managing PVS, and an even less nuanced set of
instructions to guide the specific intervention. By highlighting our extensive experience over
the past few decades with PVS, the chapter fills an important gap in the structural literature
by presenting current techniques based on a prospective examination of the largest cohort of
patients treated invasively for severe PVS. Our findings are consistent with what has previously been reported and confirm that stenting is significantly superior to balloon angioplasty
for reducing the risk of recurrent PVS after an initial intervention. Despite the encouraging
results of our experience, there is significant room for improvement to address what remains
a high incidence of restenosis. There is significant potential for improvement in both ablative
techniques to minimize PVS. New technologies, including drug-coated balloons, may offer
further improvement in the risk of recurrent PVS.
Summary and Take-Home Messages
n
PVS is an underrecognized syndrome that presents after AF ablation with symptoms
including dyspnea, fatigue, chest pain, cough, and hemoptysis.
n
Invasive management should be performed in an experienced center.
n
Pulmonary balloon angioplasty and stenting are effective, but restenosis risk is high.
n
Stenting is associated with lower rates of restenosis, particularly if the stent diameter is
.10 mm.
References
1. Saad EB, Rossillo A, Saad CP, et al. Pulmonary vein stenosis after radiofrequency ablation of atrial fibrillation: functional characterization, evolution, and influence of the ablation strategy. Circulation. 2003;
108(25):3102-3107. doi:10.1161/01.CIR.0000104569.96907.7F.
2. Dong J, Vasamreddy CR, Jayam V, et al. Incidence and predictors of pulmonary vein stenosis following
catheter ablation of atrial fibrillation using the anatomic pulmonary vein ablation approach: results from
paired magnetic resonance imaging. J Cardiovasc Electrophysiol. 2005;16(8):845-852. doi:10.1111/
j.1540-8167.2005.40680.x.
3. Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety
of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(1):32-38.
doi:10.1161/CIRCEP.109.859116.
4. Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the
pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation. 1999;100(18):1879-1886. doi:10.1161/01.cir.100.18.1879.
5. Saad EB, Marrouche NF, Saad CP, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome. Ann Intern Med. 2003;138(8):634-638. doi:10.7326/0003-
4819-138-8-200304150-00010.
23—PULMONARY VEIN STENOSIS: MANAGEMENT AND OUTCOMES 277
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6. Marrouche NF, Martin DO, Wazni O, et al. Phased-array intracardiac echocardiography monitoring
during pulmonary vein isolation in patients with atrial fibrillation: impact on outcome and complications.
Circulation. 2003;107(21):2710-2716. doi:10.1161/01.CIR. 0000070541.83326.15.
7. Qureshi AM, Prieto LR, Latson LA, et al. Transcatheter angioplasty for acquired pulmonary vein stenosis after
radiofrequency ablation. Circulation. 2003;108(11):1336-1342. doi:10.1161/01.CIR.0000086322.21781.6A.
8. Cappato R, Calkins H, Chen SA, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005;111(9):1100-1105. doi:10.1161/01.
CIR.0000157153.30978.67.
9. Tamborero D, Mont L, Nava S, et al. Incidence of pulmonary vein stenosis in patients submitted to atrial
fibrillation ablation: a comparison of the Selective Segmental Ostial Ablation vs the Circumferential Pulmonary Veins Ablation. J Interv Card Electrophysiol. 2005;14(1):21-25. doi:10.1007/s10840-005-4513-6.
10. De Potter TJ, Schmidt B, Chun KR, et al. Drug-eluting stents for the treatment of pulmonary vein
stenosis after atrial fibrillation ablation. Europace. 2011;13(1):57-61. doi:10.1093/europace/euq419.
11. Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert
consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary. Heart
Rhythm. 2017;14(10):e445-e494. doi:10.1016/j.hrthm.2017.07.009.
Further Reading
Calkins H, Brugada J, Packer DL, et al. HRS/EHRA/ECAS expert Consensus Statement on catheter and
surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A
report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation.
Heart Rhythm. 2007;4(6):816-861.
Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of
catheter ablation for human atrial fibrillation. Circulation. 2010;3(1):32-38.
Cappato R, Calkins H, Chen SA, et al. Worldwide survey on the methods, efficacy, and safety of catheter
ablation for human atrial fibrillation. Circulation. 2005;111(9):1100-1105.
Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the
pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency
ablation. Circulation. 1999;100(18):1879-1886.
De Potter TJ, Schmidt B, Chun KR, et al. Drug-eluting stents for the treatment of pulmonary vein stenosis
after atrial fibrillation ablation. Europace. 2011;13(1):57-61.
Dong J, Vasamreddy CR, Jayam V, et al. Incidence and predictors of pulmonary vein stenosis following cath-
eter ablation of atrial fibrillation using the anatomic pulmonary vein ablation approach: results from paired
magnetic resonance imaging. J Cardiovasc Electrophysiol. 2005;16(8): 845-852.
Marrouche NF, Martin DO, Wazni O, et al. Phased-array intracardiac echocardiography monitoring during
pulmonary vein isolation in patients with atrial fibrillation: impact on outcome and complications. Circulation.
2003;107(21):2710-2716.
Qureshi AM, Prieto LR, Latson LA, et al. Transcatheter angioplasty for acquired pulmonary vein stenosis
after radiofrequency ablation. Circulation. 2003;108(11):1336-1342.
Saad EB, Marrouche NF, Saad CP, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation:
emergence of a new clinical syndrome. Ann Intern Med. 2003;138(8):634-638.
Saad EB, Rossillo A, Saad CP, et al. Pulmonary vein stenosis after radiofrequency ablation of atrial
fibrillation: functional characterization, evolution, and influence of the ablation strategy. Circulation.
2003;108(25):3102-3107.
Tamborero D, Mont L, Nava S, et al. Incidence of pulmonary vein stenosis in patients submitted to atrial
fibrillation ablation: a comparison of the Selective Segmental Ostial Ablation vs the Circumferential
Pulmonary Veins Ablation. J Interv Card Electrophysiol. 2003;14(1):21-25.
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e1
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Abstract: The development of pulmonary vein stenosis (PVS) after attempted ablation for atrial
fibrillation represents a major complication. Although advances in ablation techniques have decreased the incidence of postablation PVS, treatment remains a significant challenge. Severe PVS is
highly symptomatic and warrants invasive management. Although treatment strategies, including
dilation with or without adjunctive stenting, have been described, the long-term effect on outcomes
appears to demonstrate a more favorable result with stenting, particularly when stents .10 mm in
diameter can be deployed. This chapter outlines preliminary diagnostic tools, step-by-step procedural instructions, and postprocedure care/surveillance for the practicing interventionalist who
routinely sees PVS in practice.
Keywords: Pulmonary vein, pulmonary vein stenosis, atrial fibrillation complications
Tricuspid Valve
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SECTION 7
279
CHAPTER 24
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Tricuspid Valve-in-Valve/Valvein-Ring Therapy
Allison K. Cabalka Abdallah El Sabbagh Mackram F. Eleid
Background
Transcatheter valve replacement is becoming an increasingly favored option to treat a failing tricuspid
bioprosthetic valve (BPV). As clinical experience grows and valve technology expands, the option of
implanting a new tricuspid valve in the cardiac catheterization laboratory is a viable alternative to a
conventional surgical valve replacement therapy, which remains relatively high risk. Patients may
have undergone tricuspid valve replacement for underlying congenital heart disease (such as Ebstein
anomaly or tricuspid valve dysplasia) or to treat functional tricuspid regurgitation when valve repair
is not possible. BPVs are utilized most commonly for surgical tricuspid valve replacement. Often
these patients have underlying right ventricular dysfunction and other issues that may complicate
reoperation or increase surgical risk. Therefore catheter-based tricuspid valve-in-valve (TVIV)
therapy is an attractive option, especially in patients who have undergone repeated median sternotomy and elderly patients who are likely to have significant comorbidities.
In addition, patients who have undergone tricuspid valve repair utilizing annuloplasty ring
may be offered transcatheter valve replacement therapy, but are less optimal candidates due to the
elliptical nature of annuloplasty ring anatomy, with potential for significant residual “paravalvular”
leak after valve-in-ring deployment.
Indications
n
Symptomatic severe tricuspid bioprosthesis stenosis or regurgitation.
n
BPV thrombosis should first be treated with a trial of anticoagulation therapy and/or
thrombolytic therapy before undergoing valve-in-valve (VIV).
Contraindications
Active endocarditis is considered a contraindication to TVIV. Device leads for defibrillators and
pacemakers are not a contraindication for the procedure. Leads that are external to the sewing
ring are ideal; however, transvalvular device leads can also be “trapped” between the transcatheter
valve and surgical valve without affecting lead function in limited case series, although it is preferable to have an alternative lead available for “backup pacing” in patients who are pacemaker
dependent.
Workup for Valve-in-Valve Procedure
Transthoracic or transesophageal echocardiography is usually sufficient for precatheterization
valve evaluation and determination of need for therapy. Computed tomography (CT) with 3D
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