Complex cases of acquired pulmonary vein stenosis after radiofrequency ablation: is surgical repair an option?

AIMS: Results of catheter based interventional treatment for pulmonary vein stenosis (PVS) following radiofrequency ablation (RFA) for atrial fibrillation remain suboptimal. Surgical repair may represent an alternative therapy, though long-term results have not been thoroughly investigated. METHODS AND RESULTS: We retrospectively assessed all patients in our centre undergoing surgical repair for radiofrequency-induced PVS. Data regarding surgical technique, clinical outcome, and rate of pulmonary vein (PV) restenosis were collected and analysed. Between 2004 and 2016, the rate for PVS resulting from RFA for atrial fibrillation in our institution was 0.79% (76/9633). During this period, five male patients with multiple PVS (3 ± 1) underwent surgical repair of a total of 13 symptomatic PVS. Surgery was performed in a standard setting under cardiopulmonary bypass. Stenotic veins were incised longitudinally followed by a patch augmentation plasty using either bovine pericard (n = 7) or polytetrafluoroethylene (PTFE) patches (n = 5). Localization of incision was on the anterior side of the PV only (n = 8) or on both the anterior and posterior sides (n = 4). In one PVS lesion, mechanical dilatation was sufficient. Long-term follow-up after 60 ± 69 months revealed an average restenosis rate of 38%. Restenosis was defined as narrowing >70%. All patients reported clinical improvement of symptoms at follow-up. CONCLUSION: Even in the era of wide circumferential lesions, PVS still occurs. While surgical PV patch plasty represents a valuable treatment option, restenosis remains an issue during follow-up. Nevertheless, surgical repair achieves highly acceptable long-term results for RFA-acquired PVS. Hence, it should be routinely discussed as a therapeutic option in cases with multiple PVS.

Covered Stents in the Treatment of Pulmonary Arteriovenous Malformations.

Seven patients with pulmonary arteriovenous malformations (PAVMs) not well suited to coil and/or plug treatment were treated with expanded polytetrafluoroethylene-covered stents. Mean diameter of treated arteries was 6 mm. Complete technical success was achieved in 7 of 8 PAVMs, 6 using only covered stents and 1 using both a covered and a bare stent owing to endoleak. In 1 patient, the parent vessel was sacrificed after identification of additional feeding vessels following stent graft placement. In 6 patients with median imaging follow-up of 8 months (range, 1-121 months), all stent grafts were patent, and all treated PAVMs were completely excluded without persistence.

A preliminary study of pulmonary vein implant applicability and safety as a potential ablation platform in a follow-up study in pigs.

BACKGROUND: Recurrence of atrial fibrillation after an ablation procedure remains a major problem which emphasizes the need for improved pulmonary vein isolation techniques. AIMS: The aim of this study was to describe an implantation procedure of a pulmonary vein-stent which may possibly serve as an ablation technique in the future and to examine stent safety in a follow-up study in pigs. METHODS AND RESULTS: Eight pigs were catheterized and nine self-expanding nitinol stents were implanted through a transfemoral or transatrial approach into the antra of the pulmonary veins. After 3 months' follow-up, the animals were euthanized for further examination. During the follow-up phase, no complications were observed. Absence of thrombus formation or pulmonary vein wall dissection was noticed during anatomical and histological evaluation of the heart-lung packages. All implants were almost completely covered by neo-intima, of which thickness varied between 0.2 and 3.9 mm. CONCLUSIONS: Stents can safely be positioned and deployed into the antra of the pulmonary veins without any acute or long-term (3 months) adverse effects. In the future, these implants could function as a permanently implanted ablation device and provide new therapeutic strategies for pulmonary vein isolation in patients with atrial fibrillation.

Isolation of pulmonary veins using a thermoreactive implantable device with external energy transfer: Evaluation in a porcine model.

BACKGROUND: Pulmonary vein isolation (PVI) is a well-established method for the treatment of symptomatic paroxysmal atrial fibrillation, but is only partly successful with a high rate of electrical reconnection. We introduce a novel technique in which PVI is accomplished by noninvasive heating of a dedicated thermoresponse implant inserted into the pulmonary veins (PV), demonstrated in a porcine model. METHODS: A self-expanding nitinol-based implant was positioned in the common inferior PV of 11 pigs, using a fluoroscopy-guided transatrial appendage approach. Ablation was performed through contactless energy transfer from a primary extracorporal coil to a secondary heat ring (HR) embedded in the proximal part of the implant. Electrophysiological conduction was assessed prior to and postablation, and at 3 months. Histological samples were obtained acutely (n  =  4) and after 3 months (n  =  7). RESULTS: In total, 13 PV implants were successfully positioned in the inferior PVs of 11 animals. Ablation was performed without injury of adjacent structures. PVI and bidirectional block was electrophysiologically confirmed in all cases immediately at the time of implantation and 3 months later in seven chronic animals in whom testing was repeated. Marked evidence of ablation around the proximal HR was evident at 3 months postprocedure, with scar tissue formation and only mild neointimal proliferation. CONCLUSIONS: Successful PVI can be obtained by external electromagnetic heat transfer to a novel pulmonary vein implant.

Correction of Adult Scimitar Syndrome Using a Lateral Endoscopic Approach with Robotics.

We present two adult patients in whom anatomic correction of scimitar syndrome (SS) was accomplished by redirecting the anomalous pulmonary venous drainage into the left atrium using a reinforced polytetrafluoroethylene (PTFE) graft extension. A right lateral endoscopic approach with robotic instrumentation (LEAR) was utilized with excellent early and long-term results.

Inferior sinus venosus defects: anatomic features and echocardiographic correlates.

Inferior sinus venosus defects (SVDs) are rare imperfections located in the inferior portion of the atrial septum, leading to an overriding inferior vena cava (IVC) and an interatrial connection. These defects have increased risk of anomalous pulmonary venous return (PAPVR) and often are confused with secundum atrial septal defects (ASDs) with inferior extension. The authors sought to review their experience with inferior SVDs and to establish at their institution an echocardiographic definition that differentiates inferior SVDs from secundum ASDs with inferior extension. The study identified 161 patients 1.5 to 32 years of age who had undergone repair of a secundum ASD with inferior extension or inferior SVD over the preceding 10 years. All surgical notes, preoperative transthoracic echocardiograms (TTEs), and preoperative transesophageal echocardiograms (TEEs) were reviewed. Based on the surgical notes, 147 patients were classified as having a secundum ASD (147/161, 91 %) and 14 patients (9 %) as having an inferior SVD. The study identified PAPVR in 7 % (1/14) of the patients with inferior SVDs and 3.5 % (5/14) of the patients with secundum ASDs. Surgical diagnosis and preoperative TTE correlated for 143 (89 %) of the 161 patients. Using a strict anatomic and echocardiographic definition with a blinded observer, the majority of the defects (14/18, 78 %) were reclassified correctly after review of their TTE images, and 100 % of the defects were correctly reclassified after TEE image review. Accurate diagnosis of inferior SVDs remains challenging. The data from this study demonstrate that use of a strict anatomic and echocardiographic definition (a defect that originates in the mouth of the IVC and continues into the inferoposterior border of the left atrium, leaving no residual atrial septal tissue at the inferior margin) allows for accurate differentiation between secundum ASDs with inferior extension and inferior SVDs. This differentiation is extremely important in planning for surgical versus device closure of these rare defects.

Expanded Polytetrafluoroethylene Patching for Recurrent Pulmonary Venous Obstructions.

Recurrent postoperative pulmonary venous obstruction after total anomalous pulmonary venous connection repair is a challenging complication. Here, we present such a case that required 4 reoperations, focusing on a sutureless method with an expanded polytetrafluoroethylene patch for the fourth reoperation. The use of artificial patch materials to reconstruct the atrial septum and neoatrial roof could be a promising alternative approach of this method to expand its applicability.

Transconduit approach for pulmonary vein stenting in an extracardiac Fontan and plastic bronchitis case.

Plastic bronchitis (PB) is a rare but severe complication in patients following the Fontan operation, the final palliative procedure for single ventricle heart disease. PB is characterised by the formation of rubbery casts of the tracheobronchial tree that may cause cough, wheezing, dyspnoea and hypoxia. Progressive airway obstruction may lead to asphyxia and death, and the overall mortality rate is 15.2%. Most patients receive a combination therapy from three different treatment strategies, that is, therapy for relief of airway obstruction, anti-inflammatory treatment and treatment to improve haemodynamics of the Fontan physiology. Therapy improving haemodynamics consists of optimising the Fontan circulation or cardiac function, antiarrhythmic therapy, inhibition of lymph leakage/production, decompression of the Fontan circulation and heart transplantation.We present the case of a child with PB after extracardiac Fontan operation, who was refractory to balloon angioplasty and surgical release for pulmonary vein (PV) stenosis. We decided to perform stent implantation for the right PVs through transconduit puncture instead of fenestration because the position of fenestration was too high to access the PVs. After PV stenting via the transconduit approach, she experienced improvement in cough, wheezing and breathlessness, and a significant reduction in airway cast formation.

Pulmonary arteriovenous malformation with metal allergy.

We present a rare case of single pulmonary arteriovenous malformation (PAVM) with multiple metal allergies, including for platinum. A 47-year-old woman presented to our hospital without any symptoms. Enhanced computed tomography showed a single PAVM in S6 of the right lung. Interviews prompted us to suspect a history of palmoplantar pustulosis associated with metal dental filling. Dermatology patch tests for metal allergy were positive for platinum, cobalt, tin and potassium dichromate. The first choice of treatment for PAVM is endovascular treatment using a metal coil. Since the coil is composed of platinum alloy, we performed partial lung resection for PAVM without metal implants. Although metal allergy is rare for endovascular treatment, it causes an additional stress of removal of causative metal or long-term steroidal treatment. Therefore, for single PAVM with multiple metal allergies to the implants, surgical treatment without metal implants should be considered.

Prospective feasibility study of sealing pulmonary vessels with energy in lung surgery.

OBJECTIVE: Vascular sealing with an energy vessel sealing system during lung resection may allow surgeons to treat small vessels with minimal dissection, possibly decreasing likelihood of injury. Few large prospective trials have examined the proximal sides of vessels not ligated in addition to sealing during surgery. We therefore assessed feasibility of an energy device to seal pulmonary artery and vein branches without further ligation. METHODS: This prospective, preoperative registration study at 2 institutions evaluated safety of energy sealing with the LigaSure (Medtronic, Minneapolis, Minn), with no additional reinforcing material such as suture ligation, for pulmonary vessels as large as 7 mm during anatomic lung resection (cohort 1 study). A postoperative hemorrhage occurred in the 128th case, so a cohort 2 study proceeded after we changed inclusion criterion for pulmonary arteries from a maximum of 7 mm to a maximum of 5 mm. RESULTS: In cohort 1 (n = 128) and cohort 2 (n = 200), 216 and 250 pulmonary arteries and 189 and 213 pulmonary veins, respectively, were treated with energy sealing. Overall postoperative hemorrhage rate was 0.3% (1/328 patients); however, no serious postoperative complications were associated with energy sealing among the 200 patients in cohort 2. Subsequent inspection of the torn artery stump confirmed that the bleeding in the 128th case was in an area adjacent to the sealing zone. CONCLUSIONS: Energy sealing without reinforcement allows secure treatment during lung resection of pulmonary arteries as large as 5 mm in diameter and pulmonary veins as large as 7 mm.

Feasibility, safety, and efficacy of a novel preshaped nitinol esophageal deviator to successfully deflect the esophagus and ablate left atrium without esophageal temperature rise during atrial fibrillation ablation: The DEFLECT GUT study.

BACKGROUND: Esophageal thermal injury is a feared complication of radiofrequency ablation for atrial fibrillation (AF). Rise in luminal esophageal temperature (LET) limits the ability to deliver radiofrequency energy on the posterior wall of the left atrium. OBJECTIVE: The purpose of this study was to evaluate the feasibility, safety, and efficacy of a mechanical esophageal deviation (ED) tool during AF ablation. METHODS: We evaluated 687 patients who underwent radiofrequency ablation for AF. In 209 patients, the EsoSure (Northeast Scientific) was used to deflect the esophagus away from the ablation site. Propensity score matching was performed to obtain 180 patients each in the ED and non-ED arms. ED was used for LET rise seen in 61.7% of patients (111/180) and was used if the esophagus was in the line of ablation on fluoroscopy in 38.3% of patients (69/180). RESULTS: Mean deviation of trailing edge of esophagus with EsoSure was 2.45 ± 0.9 cm (range 1-4.5). LET rise >1°C was significantly lower in the ED than non-ED group (3% vs 79.4%; P <.001). Mean LET rise was also lower in the ED arm (ED 0.34 ± 0.59 vs non-ED 1.66 ± 0.54; P <.001). Intraprocedural success of pulmonary vein antral isolation, was slightly improved in the ED arm than in the non-ED arm without statistical significance. AF recurrence was lower in the ED arm at 3-month, 6-month, and 1-year follow-up than in the non-ED arm. No ED-related complications were noted. CONCLUSION: Mechanical displacement of the esophagus with EsoSure seems to be feasible, safe, and efficacious in enabling adequate radiofrequency energy delivery to the posterior wall of the left atrium without significant LET rise and obvious clinical signs of esophageal injury.

The use of absorbable monofilament polydioxanone suture in pediatric cardiovascular operations.

Growth of suture lines and anastomoses is required for long-term success after the repair of congenital cardiovascular anomalies. Polydioxanone, an absorbable monofilament suture material, has been used in a variety of operations since April, 1983. Twenty-two of the 46 procedures were coarctation repairs. Complete repairs for anomalous pulmonary veins and transposition of the great arteries, as well as Fontan procedures and systemic-pulmonary shunts, have been performed. Angiographic, gross, and microscopic examination showed good healing. There was no anastomotic disruption or aneurysm formation. The results with this absorbable vascular suture have been uniformly encouraging in a follow-up of up to 30 months.

Combined intracardiac and extracardiac repair of scimitar syndrome with anomalous pulmonary veins to both cavae.

Anomalous pulmonary venous drainage from the right lung to the inferior vena cava (scimitar syndrome) is a rare finding. This paper briefly discusses this syndrome and presents a case of anomalous pulmonary venous return to both the superior and the inferior cavae, which was corrected with a combined extracardiac and intracardiac approach. Polytetrafluoroethylene was utilized for reconstruction of pathways to the left atrium. To our knowledge, this is the first time this technique has been used to correct this anomaly.

Total anomalous pulmonary venous connection: surgical repair with a double-patch technique.

A double-patch technique has been used to repair total anomalous pulmonary venous connection in 35 patients (mean age, 4.9 months; mean weight, 4.2 kg). In all patients with supracardiac or subdiaphragmatic type of total anomalous pulmonary venous connection, repair has been accomplished by enlarging the "new" left atrium. There were three early deaths (3 of 35 = 8.6%) and no late deaths in a mean follow-up of 30 months (3 to 71 months). We propose this double-patch technique as an alternative surgical option for total anomalous pulmonary venous connection.

Absorbable polydioxanone suture and results in total anomalous pulmonary venous connection.

BACKGROUND: Despite theoretical advantages of absorbable suture in the growing vascular anastomosis, there has not been a documented advantage over nonabsorbable suture in preventing late anastomotic stenosis in total anomalous pulmonary venous connection (TAPVC). METHODS: We reviewed our experience from 1982 to 1994 with 65 hospital survivors of total TAPVC repair to examine the influence of suture type on survival and incidence of late pulmonary venous obstruction. From 1982 until 1988, we used continuous nonabsorbable polypropylene suture for the pulmonary venous-left atrial anastomosis in supracardiac, infracardiac, and mixed types of TAPVC: In 1989, we adopted a running absorbable polydioxanone suture technique. Cardiac catheterization and echocardiography were used to evaluate late pulmonary venous obstruction. RESULTS: Late pulmonary venous obstruction occurred in 17% (4/23) of survivors after repair with polypropylene suture compared with 3.2% (1/32) after repair with polydioxanone suture (p < 0.05). There were no instances of late pulmonary venous obstruction in the intracardiac TAPVC group (0/10). All late pulmonary venous obstructions occurred within 16 months after operation. The actuarial 3-year and 5-year freedom from late pulmonary venous obstruction was 100% for intracardiac TAPVC, 96% for the polydioxanone group, and 81% for the polypropylene group. Five patients died late (5/65, 7.7%), 3 in the polypropylene suture group (3/23, 13%) and 2 in the polydioxanone group (2/32, 6%). CONCLUSIONS: Continuous absorbable polydioxanone suture for the repair of TAPVC results in a low incidence of late pulmonary venous obstruction and death and appears to offer advantages over a continuous nonabsorbable suture. A continuous nonabsorbable suture may limit growth of a vascular anastomosis, particularly one involving a "low-pressure" anastomosis such as in the repair of TAPVC:

Use of in situ pericardium for surgical relief of pulmonary venous obstruction following Mustard's operation.

A technique is described for relief of pulmonary venous obstruction following the Mustard procedure. The functional left atrium is enlarged by using the pericardium in situ. This is expected to allow for growth of the pericardial patch and to avoid recurrent obstructions. This technique has also been used in reoperations for systemic venous obstruction after enlargement of the systemic baffle with a patch.

Extracardiac Fontan operation with adjustable communication.

A modified technique for the Fontan operation is described in which an adjustable communication between the extracardiac conduit (systemic venous chamber) and the right atrium (pulmonary venous chamber) is constructed. Potential advantages of this technique consist of minimization of surgical manipulation of atrial tissue, reduction or elimination of myocardial ischemia, creation of a uniform and stable inferior vena cava-to-pulmonary artery conduit, and increased flexibility and safety in certain high-risk patients such as those with increased pulmonary vascular resistance, pulmonary hypertension, and impaired ventricular function.

Total anomalous pulmonary venous return. Review of 125 patients treated surgically.

One hundred twenty-five patients undergoing surgical correction of total anomalous pulmonary venous return were studied. The overall mortality was 37% and was related to age at the time operation was required. Mortality was 57% during the first year of life, 29% in patients between 13 and 24 months, and 15% in those between 2 and 10 years; no deaths occurred in those over 10 years. Mortality was highest in patients with infracardiac lesions (62%), and lowest in those with cardiac defects (30%). The major cause of death was pulmonary edema, and survival was closely related to the degree of increased pulmonary vascular resistance. Surgical treatment should be delayed until at least 6 months of age, but the development of congestive heart failure may necessitate earlier operation.

Echocardiographic demonstration of intracardiac glue after endoscopic obturation of gastroesophageal varices.

Systemic embolism is an unusual complication of endoscopic obturation of gastroesophageal varices with glue. This report describes a case of cerebral embolism after this procedure. Intracardiac glue within the left atrium was demonstrated by echocardiography. Cardiac fluoroscopy demonstrated an abnormal vessel connecting periesophageal veins with the right upper pulmonary vein. Cardiac surgery was performed. Intracardiac glue was removed and the entering orifice of the abnormal vessel in the right upper pulmonary vein was sutured. To our knowledge, this is the first reported case of intracardiac glue after variceal obturation. Echocardiography is useful in the diagnosis of this rare complication.