Highlights
- •Atrial fibrillation is the most common heart rhythm disorder in United States, characterised by rapid and irregular beating of both the atria resulting in the similar ventricular response.
- •Radiofrequency catheter ablation (RFCA) is rapidly rising as an alternative modality of treatment and an increase in the incidence of RFCA has shed light on complications associated with this procedure
- •Pulmonary hypertension (PH) is one of the long-term complications that have been observed postcatheter ablation.
- •The possible mechanism for PH in these patients includes the involvement of the lungs due to pulmonary vein stenosis, pulmonary vein occlusion and, rarely, pulmonary embolism.
- •RFCA can also lead to scarring of the atrium that can cause left atrial diastolic dysfunction leading to elevated pulmonary pressures
- •Another possible mechanism leading to elevated pulmonary pressures is related to the unmasking of left ventricular diastolic dysfunction occurring after this procedure.
- •Further prospective studies need to be done to assess the possible mechanisms and treatment modalities to treat PH in patients undergoing RFCA.
Atrial fibrillation is the most common heart rhythm disorder in United States, characterised by rapid and irregular beating of both the atria resulting in the similar ventricular response. While rate and rhythm control using pharmacological regimens remain the primary management strategies in these patients, radiofrequency catheter ablation (RFCA) is rapidly rising as an alternative modality of treatment. Increase in the incidence of RFCA has shed light on complications associated with this procedure. Pulmonary hypertension (PH) is one of the long-term complications that has been observed postcatheter ablation. There have been multiple mechanisms which have been proposed to explain these elevated pulmonary pressures. These include the involvement of the lungs due to pulmonary vein stenosis, pulmonary vein occlusion and, rarely, pulmonary embolism. Radiofrequency catheter ablation can also lead to scarring of the atrium which can cause left atrial diastolic dysfunction leading to elevated pulmonary pressures. Recently, it was also proposed that elevated pulmonary pressure was related to the unmasking of left ventricular diastolic dysfunction occurring after this procedure. In this article, we review all the mechanisms that are associated with the development of pulmonary hypertension in patients undergoing RCFA for atrial fibrillation and the approach to diagnosis and management of such patients.
Keywords
Introduction
Atrial fibrillation is the most common heart rhythm disorder affecting around 2.5 million people in United States. It is characterised by rapid and irregular beating of both the atria resulting in the similar ventricular response. It is associated with the risk of stroke and heart failure resulting in increased morbidity and mortality [
[1]
]. The treatment of atrial fibrillation involves rate control with anti-arrhythmic drugs like beta blockers, digoxin and amiodarone. Cardioversion is recommended in case of haemodynamic instability or after failure of pharmacological therapies. Anti-arrhythmic drugs have reasonable efficacy in controlling atrial fibrillation but are also associated with the potential of adverse effects with long-term use. Therefore, radiofrequency catheter ablation (RFCA) is rapidly rising as an alternative to anti-arrhythmic drug therapy. It has shown superior efficacy over anti-arrhythmic drugs in maintaining sinus rhythm in various randomised control trials conducted over the past few years. [2
, 3
, 4
]. As per American College of Cardiology (ACC)/ Heart Rhythm Society (HRS)/American Heart Association (AHA) guidelines of 2014, catheter ablation is recommended as a first line therapy for patients with symptomatic paroxysmal atrial fibrillation when rhythm control is required. It can also be used in patients with persistent atrial fibrillation who are intolerant to anti-arrhythmic drugs.Technique and Complications
Ablation works on the principle of Cox maze procedure, which was first introduced by Dr. James Cox at Barnes Jewish hospital in 1987. It involves creating surgical incisions in both right and left atria to form a scar [
[5]
]. The scar prevents the propagation of electrical activity and blocks macro-reentrant circuits thereby terminating atrial fibrillation. Catheter ablation involves creation of linear lines by using the same principle but different sources of energy like radiofrequency, cryoablation, laser, microwave and high-frequency ultrasound [[5]
]. Pulmonary vein antral isolation (PVAI) is one of the strategies, where circular lines are created within the atrium around the pulmonary veins. Apart from PVAI, other strategies include linear lesions, ganglionated plexi ablation, and rotor ablation. [[6]
]. Despite its ability to treat atrial fibrillation, many adverse effects have been found to be associated with catheter ablation. Complications of RFCA include aorto-oesophageal fistula, systemic emboli, pericardial effusion and pulmonary dysfunction. Pulmonary hypertension (PH) is one of the long-term complications that have been observed postcatheter ablation. As per ACC/AHA, PH is defined as the pulmonary arterial pressure (PAP) of >25 mmHg in resting state and >30 mmHg on exercise. There have been multiple mechanisms which have been proposed to explain these elevated pulmonary pressures. In this article, we review the mechanisms leading to pulmonary hypertension in patients undergoing RFCA for atrial fibrillation- Chen J.
- Dagres N.
- Hocini M.
- Fauchier L.
- Bongiorni M.G.
- Defaye P.
- et al.
Catheter ablation for atrial fibrillation: results from the first European Snapshot Survey on Procedural Routines for Atrial Fibrillation Ablation (ESS-PRAFA) Part II.
Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2015; 17: 1727-1732
The Lung
Pulmonary vein stenosis (PVS) post-RFCA is the first proposed mechanism resulting in PH in the literature. Pulmonary vein stenosis is defined as the reduction in the total diameter of pulmonary veins more than 50% from the diameter present before the ablation [
[7]
]. It results from the radiofrequency energy delivered at the ostia or within the lumen of pulmonary veins [8
, - Neumann T.
- Kuniss M.
- Conradi G.
- Sperzel J.
- Berkowitsch A.
- Zaltsberg S.
- et al.
Pulmonary vein stenting for the treatment of acquired severe pulmonary vein stenosis after pulmonary vein isolation: clinical implications after long-term follow-up of 4 years.
Journal of Cardiovascular Electrophysiology. 2009; 20: 251-257
9
, 10
]. Ernest et al. reported thickening of venous walls from myoblast proliferation and luminal sclerosis of veins characteristic of venous occlusive syndrome secondary to radiofrequency [- De Potter T.J.
- Schmidt B.
- Chun K.R.
- Schneider C.
- Malisius R.
- Nuyens D.
- et al.
Drug-eluting stents for the treatment of pulmonary vein stenosis after atrial fibrillation ablation.
Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2011; 13: 57-61
[11]
]. Previous literature reviews report 1.3 to 15.6% incidence of PVS. In a retrospective study done by Lu et al., two out of five cases had PVS after RFCA [[12]
]. Similarly, prospective studies have also described PVS in patients undergoing RFCA [13
, 14
]. Symptomatic PVS can present within a few hours to years after the ablation procedure. Chronic and untreated PVS can lead to total pulmonary vein occlusion (PVO) and eventually PH [15
, 16
]. Single PVO is usually asymptomatic but in the presence of ipsilateral PVS/PVO, the patient can present with severe symptoms [- Yang H.M.
- Lai C.K.
- Patel J.
- Moore J.
- Chen P.S.
- Shivkumar K.
- et al.
Irreversible intrapulmonary vascular changes after pulmonary vein stenosis complicating catheter ablation for atrial fibrillation.
Cardiovascular Pathology: the official journal of the Society for Cardiovascular Pathology. 2007; 16: 51-55
[15]
]. Part of the evolution in the treatment of AF has been wide area circumferential ablation (WACA), in which the encircling point-by-point PV lesions are performed 1-2 cm away from the ostia of the PV's. While this approach reduces the incidence of PVS, it increases the risk of leaving gaps in ablation lesions of the PV leading to recurrent arrhythmias [[17]
]. A decreased incidence of PVS is seen in patients in whom local extensive encircling pulmonary vein antral isolation (EEPVI) is used as the technique for RFCA [[18]
]. While there have been reports of PVS with other techniques of ablation like cryoablation and pulmonary vein catheter ablation, the occurrence is rare [19
, 20
, 21
]. No cases of PV stenosis have been reported so far with the use of laser balloon for PVI [22
, 23
].- Dukkipati S.R.
- Cuoco F.
- Kutinsky I.
- Aryana A.
- Bahnson T.D.
- Lakkireddy D.
- et al.
Pulmonary Vein Isolation Using the Visually Guided Laser Balloon: A Prospective, Multicenter, and Randomized Comparison to Standard Radiofrequency Ablation.
Journal of the American College of Cardiology. 2015; 66: 1350-1360
Pulmonary embolism is another life-threating condition seen post-RFCA which can lead to elevated pulmonary pressures and acute right heart failure. Patients with acute pulmonary embolism usually present within 24 hours of the procedure with acute dyspnoea [
[24]
]. Given that AF ablation is usually offered in patients who are therapeutically anticoagulated, this complication in less likely. It is more commonly seen in patients undergoing RFCA for other supraventricular or ventricular arrhythmias [[24]
].The Atrium
Stiff atrial syndrome after RFCA has been described as new onset of dyspnoea and congestive heart failure with PH and left atrial diastolic dysfunction (Table 1). These patients typically do not have mitral valve inadequacy, pulmonary stenosis or other factors contributing to the patient's symptoms. It has been described as occurring within days to months after surgery [
[25]
]. A meta-analysis of 17 trials done in the past showed that RFCA resulted in a decrease in the size and volume of atria (Table 2) [[26]
]. It has been suggested that the reduction in the left atrial volume after RFCA may be due to remodelling of the left atrium after AF is controlled. However, both Reant et al. [[27]
] and Muller et al. [[28]
] found that patients undergoing RFCA had reduced left atrial volume and dimensions in spite of recurrence of AF. In a comparison of patients undergoing different interventions for AF, it was noted that the reduction in the volume of the LA was greater in patients undergoing RFCA as compared to patients undergoing cardioversion [- Muller H.
- Noble S.
- Keller P.F.
- Sigaud P.
- Gentil P.
- Lerch R.
- et al.
Biatrial anatomical reverse remodelling after radiofrequency catheter ablation for atrial fibrillation: evidence from real-time three-dimensional echocardiography.
Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2008; 10: 1073-1078
[29]
]. This suggests that while the reduction of left atrial volume might be due to the control of AF itself, RFCA can worsen it further thus contributing to PH.Table 1Cases describing pulmonary hypertension due to stiff left atrial syndrome from RFCA.
| Case Report/Series | Age and Sex | Presenting complaint | Number of ablations | ECHO/Catherisation | Diagnostic Criteria | LA diameter in parasternal axis | Outcomes |
|---|---|---|---|---|---|---|---|
| Witt et al. [42] | 53-year-old male | Dyspnoea | 3 | Right Heart Catheterisation | Elevated LA pressure – 27 mmHg Large v-waves of 55 mHg RA mean pressure 18 mmHg Mild elevation in LVEDP | - | Previous normal ECHO before ablation Diagnosis of stiff atrial syndrome made due to scar formation |
| Clare et al. [43] | 56-year-old male | Dyspnoea | 2 and atrial appendage resection | Transseptal | Preablation: LA pressure of 15 mmHg and peak v wave of 30 mmHg Postablation: LA pressure of 18 mmHg and peak v-wave of 50 mmHg Mpap: 38mmHg | 45 mm | Right to left shunt on TEE with peak end systolic gradient of 28 mmHg followed by diagnosis of stiff left atrial syndrome |
| Wong et al. [39] | 72-year-old female | Dyspnoea on exertion | 2 ablations 4 years apart | ECHO followed by RHC | PASP on ECHO: 65 mmHg RHC: PASP of 85 mmHg, mPaP of 58 mmHg, Mpawp of 26 mmHg, Peak v wave Mean RAP of 27 mmHg Normal LVEF and LVEDP | 45mm | Left atrial dysfunction confirmed with catheterisation. Treatment with diuresis, spironolactone followed by 12 months of sildenafil showed improvement in exercise capacity on 6 min walk test. |
LA: left atrium; RA: right atrium, LVEDP: left ventricular end diastolic pressure; mpap: mean pulmonary artery pressure; RAP: right atrial pressure; PASP: pulmonary artery systolic pressure; Mpawp: mean pulmonary artery wedge pressure.
Table 2Meta-analysis analysing the effect of RFCA on volume of atrium and ventricle
| Study | Population | Change in volume of atrium & ventricle | Conclusion |
|---|---|---|---|
| Jeevanantham et al. [26] Meta-analysis of 17 studies | N=869 | Decrease in LAD (WMD −1.67 mm, 95% CI −2.80 to −0.54;), LAVmax (WMD −6.57 ml, 95% CI −10.09 to −3.05;), and LAVmin (WMD −2.61 ml, 95% CI −5.13 to −0.09;) during follow-up after ablation therapy. | Successful RFCA in patients with atrial fibrillation significantly decreased left atrial size and volumes and did not seem to adverse affect left atrial function |
LAD: left atrial diameter; LAV: left atrial volume.
Wylie et al. have suggested that RFCA can lead to impaired left atrial systolic function and the degree of impairment may be affected by the extent of the scar tissue after the intervention [
[30]
]. Subsequently, abnormal left atrial systolic function can lead to left atrial diastolic dysfunction due to incomplete emptying [[25]
]. Thus extensive ablation by electrophysiologists to reduce the extent of recurrence of atrial fibrillation can lead to PH due to scar formation and fibrosis.Gibson et al. [
[25]
] performed the first prospective study to assess this complication in patients undergoing ablation. Presence of PH was assessed by the presence of large V-waves (>7 mm) on pulmonary capillary wedge pressure (PCWP) tracings or left atrium (LA) tracings after excluding mitral valve regurgitation. The study showed 1.4% incidence of PH secondary to atrial diastolic dysfunction in these patients. This atrial diastolic dysfunction was also associated with increased atrial scar formation. The atrial and left ventricular systolic function was found to be preserved in this study.Yang et al. have also suggested a role of reduced response of the left atrial baroreceptors and elevated plasma arginine vasopressin levels in the development of increased left atrial and pulmonary pressures in patients after RFCA [
31
, 32
]. Apart from the above mechanisms, other factors, which were found to independently predict the risk of stiff atrial syndrome post RFCA, included LA size of <45 mm, diabetes, OSA and high LA pressures.The Ventricle
Will et al. conducted a retrospective study of 449 patients in 2013 to assess the cause of increased pulmonary artery pressures post-RFCA [
[33]
]. Right ventricular systolic pressure (RVSP) was used to measure PH. Mitral valve E/A and E/E’ ratio were used as the indicators to assess left ventricular diastolic dysfunction. The study demonstrated that the increase in mitral valve E/A and E/E’ ratio post-RFCA was associated with increased RVSP on echocardiogram. This study demonstrated that there was no association of the decrease in LA size and LV ejection fraction to the increased RVSP in these patients. Thus the PH in these patients was attributed to the left ventricular diastolic dysfunction. Possible theories for LV diastolic dysfunction included constrictive pericarditis from pericardial inflammation, or coronary artery injury by radiofrequency used in the procedure or from natural progression of the disease.- Witt C.M.
- Fenstad E.R.
- Cha Y.M.
- Kane G.C.
- Kushwaha S.S.
- Hodge D.O.
- et al.
Increase in pulmonary arterial pressure after atrial fibrillation ablation: incidence and associated findings.
Journal of Interventional Cardiac Electrophysiology: an international journal of arrhythmias and pacing. 2014; 40: 47-52
Another theory suggested by the Witt et al. proposed that the unmasking of the existing LV diastolic dysfunction might have caused the PH. They hypothesised that the increased LA size preablation was acting as a reservoir for reduced compliance of left ventricle. The reduction in LA size postablation thereby led to increased volume thus unmasking an underlying LV diastolic dysfunction [
33
, - Witt C.M.
- Fenstad E.R.
- Cha Y.M.
- Kane G.C.
- Kushwaha S.S.
- Hodge D.O.
- et al.
Increase in pulmonary arterial pressure after atrial fibrillation ablation: incidence and associated findings.
Journal of Interventional Cardiac Electrophysiology: an international journal of arrhythmias and pacing. 2014; 40: 47-52
34
]. These studies involving the atrium and the ventricle causing PH in patients undergoing RFCA are described in Table 3.Table 3Studies assessing the incidence and cause of pulmonary hypertension in patients undergoing RFCA
| Study | Population | Criteria for PH | Technique | Incidence | Mean PAP (RVSP/mPAP) in PH population | Calculated Parameters | Conclusion |
|---|---|---|---|---|---|---|---|
| ATRIUM | |||||||
| Gibson et al. 2011 [25] Prospective | N=1380 Mean age: 62+/-11(75%male) | PAP>25 mmHg at rest and >35 mmHg at exercise | Transthoracic ECHO and Right Heart Catheterisation | New onset or worsening PH with diastolic abnormalities in 19 (1.4%) patients post RFCA | Average PASP 45+/-17 mmHg Average LA systolic pressure 29+/-6 mmHg | LAP (S) 29+/-6 mmHg LAP(D) 11+/-4 mmHg LA scar 84% LA size 4.6 cm+/-0.7 cm LVEF 61+/-9 | Stiff LA syndrome after catheter ablation for AF is a potential complication of the procedure but has a low prevalence. |
| VENTRICLE | |||||||
| Witt et al. 2014 [33]
Increase in pulmonary arterial pressure after atrial fibrillation ablation: incidence and associated findings. Journal of Interventional Cardiac Electrophysiology: an international journal of arrhythmias and pacing. 2014; 40: 47-52 Retrospective | N=499 Mean age: 60.7+/-10.8(71.9%male) | Total RVSP>35 mmHg or Increase in RVSP>10mmHg | Transthoracic ECHO | New or worsening PH in 41 (8.2%) patients | Avg RVSP – (pre: 27.7+/-5.1 & post: 43.8+/-8.3 mmHg | E/A ratio (rre 1.3+/-0.3 & post 2.1+/-1.2) E/E’ratio (pre 9.9+/-2.9 & post 14.7+/-8.4) Postablation, in the increased PA pressure group had higher E/A (2.12 vs. 1.49, p<0.01) and E/e’ (14.7 vs. 11.2, p<0.01 ratios. LA expansion index values were lower in the increased PA pressure group preablation (51 vs. 92%, p<0.01), but not significantly different postablation (82 vs. 88%, p = 0.44). | Increased PAP was associated with new onset or unmasking of the previously present LV diastolic dysfunction. |
LA: left atrium; RA: right atrium, LVEDP: left ventricular end diastolic pressure; mpap: mean pulmonary artery pressure; RAP: right atrial pressure; PASP: pulmonary artery systolic pressure; Mpawp: mean pulmonary artery wedge pressure; RVSP: right ventricular systolic pressure.
Clinical Presentation and Diagnosis
Presenting signs and symptoms of PH are similar regardless of the aetiology. Patients usually present with respiratory symptoms such as chronic dyspnoea. The onset of symptoms can be acute to chronic based on the aetiology. An accurate history and physical examination is essential in narrowing down the list of differential diagnosis leading to PH. Patients with pulmonary embolism may present with dyspnoea of acute onset [
[24]
]. Pulmonary hypertension from PVS can present within hours to months after the procedure. Unilateral PVS is usually asymptomatic and is found only on screening the patients postablation whereas the presence of ipsilateral PVS/PVO can lead to severe symptoms [[15]
]. Pulmonary hypertension from stiff atrial syndrome can present with unexplained dyspnoea for months up to six years after the RFCA [25
, 34
]. Signs of right ventricular dysfunction/ right heart failure can also be the presenting symptom in cases of chronic pulmonary hypertension. Initial diagnostic evaluation involves the exclusion of primary cardiac causes of dyspnoea including ischaemia. Echocardiogram is the non-invasive technique used to assess ventricular function and screen patients for pulmonary hypertension. It helps us to assess atrial and ventricular pressures, size and index. Elevated left atrial pressures and elevated RVSP are associated with pulmonary hypertension. Increased E/A and E/E’ gradient on ECHO is associated with left ventricular diastolic dysfunction. Lung ventilation-perfusion scan is used to diagnose acute PE and PVS [[15]
]. Computed tomography (CT) of pulmonary veins has more sensitivity and specificity in diagnosing PE and also PVO/PVS. Combination of CT and ventilation can also be used to diagnose PVS [[13]
]. Angiography of pulmonary veins is the gold standard but an invasive procedure that is used not only to confirm but also correct PVS [[14]
]. In the absence of findings of PVS on CT and perfusion scans, cardiac catheterisation is recommended to look for cardiac causes of PH. Left heart catheterisation (LHC) is undertaken to assess ventricular function, coronary anatomy and mitral valve regurgitation. Right heart catheterisation (RHC) is used to look for PCWP and mean pulmonary artery pressure (mPAP) to aid with diagnosis and classification of pulmonary hypertension. Patients are also assessed for elevated V-waves on PWP tracings. In the absence of mitral regurgitation (on LHC or Echo), large V waves on PWP tracings are secondary to decreased atrial compliance [[34]
]. Other tests include a chest X-ray, pulmonary function tests and high resolution CT of the chest to rule out pulmonary causes of PH.Treatment
The treatment modalities differ in terms of the aetiology of PH post-RFCA. In the case of PVS/PVO, pulmonary vein balloon angioplasty and stent deployment can be performed. Early interventions of the affected veins have shown significant improvement in restoring the perfusion of the lung [
[15]
]. It is also important to assess the ipsilateral veins in case of total PVO because the lung perfusion is dependent on the ipsilateral veins. So, the intervention is needed if ipsilateral vein is stenosed or occluded. In a study done by Prieto et al., dilation and bare metal stent deployment of vein with size greater than 6-7 mm has shown significant improvement but the veins with a diameter of <6 mm showed complete occlusion despite initial dilation and stent [[13]
]. The rate of restenosis was found to be 47 to 61% in the case of balloon dilation alone whereas in the case of stent deployment, it has shown a significant decrease ranging from 0 to 47% [8
, - Neumann T.
- Kuniss M.
- Conradi G.
- Sperzel J.
- Berkowitsch A.
- Zaltsberg S.
- et al.
Pulmonary vein stenting for the treatment of acquired severe pulmonary vein stenosis after pulmonary vein isolation: clinical implications after long-term follow-up of 4 years.
Journal of Cardiovascular Electrophysiology. 2009; 20: 251-257
35
]. Drug eluting stents are an option but more studies are needed to determine the efficacy and safety of the stents for treating PVS/PVO [9
, 36
]. There is no role for stents in the treatment of PH when PVS is absent.Amongst the oral drugs used for PH, sildenafil has been studied for PH secondary to left heart failure (Group II). It is a novel drug that inhibits Phosphodiesterase 5 enzyme that metabolises cyclic guanosine monophosphate (cGMP). Increased cGMP mediates arterial vasodilation by relaxation of smooth muscle cells. It has shown significant improvement in the exercise capacity of patients with PH [
[37]
]. In a trial conducted by Guzzie et al., it has shown significant improvement in PAP and RV pressures in patients with HFpEF (heart failure with preserved ejection fractions), but exercise capacity was not assessed in that study [[38]
]. Recently, it has also been used in the treatment of PH from stiff atrial syndrome postablation, where it significantly improved exercise capacity and pulmonary arterial pressure of the patient [[39]
]. Multiple trials are in progress to assess the efficacy and safety of the drug in PH secondary to HFpEF.Apart from sildenafil, other oral drugs which have been studied for Group II PH include the guanyl cyclase activator, riociguat. It increases the formation of cGMP resulting in vasodilation and also inhibits smooth muscle proliferation and vascular remodelling. In the DILATE-1 trial, riociguat did not show any improvement in pulmonary arterial pressures and exercise capacity in patients with HFpEF [
[40]
]. Another class of oral drugs used for PH is selective endothelin-A receptor antagonist (EDRA) – sitaxsentan [- Bonderman D.
- Pretsch I.
- Steringer-Mascherbauer R.
- Jansa P.
- Rosenkranz S.
- Tufaro C.
- et al.
Acute hemodynamic effects of riociguat in patients with pulmonary hypertension associated with diastolic heart failure (DILATE-1): a randomized, double-blind, placebo-controlled, single-dose study.
Chest. 2014; 146: 1274-1285
[41]
]. EDRAs act on enodothelin receptor-A present on vascular smooth muscle cells thereby promoting vasodilation. This drug has also shown improvement in PH secondary to HFpEF in the clinical trials but has yet not been studied in patients with PH secondary to RFCA for atrial fibrillation.Gibson et al. noted an improved NYHA functional capacity from grade III to grade I in most of their patients treated with diuretics. This was maintained during follow-up [
[25]
]. Thus, diuretics might be considered for treatment for symptomatic patients with PH due to RFCA.Conclusion
The trend of use of RFCA to treat AF has recently been on the rise. These patients can develop PH postoperatively. It is thus necessary to look for the presence of PH in the patients presenting with dyspnoea or signs of right heart failure after RFCA. It is essential to identify the aetiology of PH in these patients so that prompt treatment measures and interventions can be instituted. Interventional procedures like stent deployment have shown improvement in the case of PH due to PVS. While multiple oral medications are approved for PH, these medications have not been studied in patients presenting with PH post-RFCA. Sildenafil has been used on a case-by-case basis, but the efficacy and safety of these drugs in this subgroup is relatively unknown. Thus, with the potentially increasing incidence of this complication, further prospective studies need to be done to assess the possible mechanisms and treatment modalities to treat PH in patients undergoing RFCA.
Financial Disclosures
None
Conflict of Interest
The authors report no conflict of interest.
Authorship Statement
All authors have contributed equally to the manuscript.
Ethical Statement
This article is not under consideration in any other journal and this manuscript has not been published elsewhere.
Appendix A. Supplementary data
References
- Ablation procedures for rhythm control in patients with atrial fibrillation: clinical and cost-effectiveness analyses.CADTH technology overviews. 2012; 2: e2101
- A systematic review of randomized trials comparing radiofrequency ablation with antiarrhythmic medications in patients with atrial fibrillation.Journal of Cardiovascular Electrophysiology. 2009; 20: 138-144
- Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study).European Heart Journal. 2014; 35: 501-507
- Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial.JAMA. 2014; 311: 692-700
- Ablation technology for the surgical treatment of atrial fibrillation.ASAIO Journal. 2013; 59: 461-468
- Catheter ablation for atrial fibrillation: results from the first European Snapshot Survey on Procedural Routines for Atrial Fibrillation Ablation (ESS-PRAFA) Part II.Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2015; 17: 1727-1732
- Prevalence, characteristics, and predictors of pulmonary vein narrowing after isolation using the pulmonary vein ablation catheter.Circulation Arrhythmia and Electrophysiology. 2012; 5: 52-60
- Pulmonary vein stenting for the treatment of acquired severe pulmonary vein stenosis after pulmonary vein isolation: clinical implications after long-term follow-up of 4 years.Journal of Cardiovascular Electrophysiology. 2009; 20: 251-257
- Drug-eluting stents ameliorate pulmonary vein stenotic changes in pigs in vivo.Pediatric Cardiology. 2010; 31: 773-779
- Drug-eluting stents for the treatment of pulmonary vein stenosis after atrial fibrillation ablation.Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2011; 13: 57-61
- Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease.Journal of Cardiovascular Electrophysiology. 2003; 14: 366-370
- Pulmonary Vein Stenosis Complicating Radiofrequency Catheter Ablation: Five Case Reports and Literature Review.Medicine. 2015; 94: e1346
- Total pulmonary vein occlusion complicating pulmonary vein isolation: diagnosis and treatment.Heart Rhythm: the official journal of the Heart Rhythm Society. 2010; 7: 1233-1239
- Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome.Annals of Internal Medicine. 2003; 138: 634-638
- Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up.Journal of the American College of Cardiology. 2006; 48: 2493-2499
- Irreversible intrapulmonary vascular changes after pulmonary vein stenosis complicating catheter ablation for atrial fibrillation.Cardiovascular Pathology: the official journal of the Society for Cardiovascular Pathology. 2007; 16: 51-55
- [Treatment of pulmonary vein stenosis after percutaneous ablation of atrial fibrillation].Arq Bras Cardiol. 2010; 94: e7-e10
- No severe pulmonary vein stenosis after extensive encircling pulmonary vein isolation: 12-month follow-up with 3D computed tomography.Heart Vessels. 2011; 26: 440-448
- Asymptomatic pulmonary vein stenosis after cryoballoon catheter ablation of paroxysmal atrial fibrillation.J Electrocardiol. 2011; 44: 473-476
- Pulmonary vein stenosis after pulmonary vein ablation catheter-guided pulmonary vein isolation.Heart Rhythm: the official journal of the Heart Rhythm Society. 2010; 7: 1306-1308
- Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial.Journal of the American College of Cardiology. 2013; 61: 1713-1723
- Pulmonary vein isolation using a visually guided laser balloon catheter: the first 200-patient multicenter clinical experience.Circulation Arrhythmia and Electrophysiology. 2013; 6: 467-472
- Pulmonary Vein Isolation Using the Visually Guided Laser Balloon: A Prospective, Multicenter, and Randomized Comparison to Standard Radiofrequency Ablation.Journal of the American College of Cardiology. 2015; 66: 1350-1360
- Clinical Features of Acute Massive Pulmonary Embolism Complicated by Radiofrequency Ablation: An Observational Study.Medicine. 2015; 94: e1711
- Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors.Heart Rhythm: the official journal of the Heart Rhythm Society. 2011; 8: 1364-1371
- Meta-analysis of the effect of radiofrequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation.The American Journal of Cardiology. 2010; 105: 1317-1326
- Reverse remodeling of the left cardiac chambers after catheter ablation after 1 year in a series of patients with isolated atrial fibrillation.Circulation. 2005; 112: 2896-2903
- Biatrial anatomical reverse remodelling after radiofrequency catheter ablation for atrial fibrillation: evidence from real-time three-dimensional echocardiography.Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2008; 10: 1073-1078
- Changes in left atrial structure and function after catheter ablation and electrical cardioversion for atrial fibrillation.Circulation journal: official journal of the Japanese Circulation Society. 2008; 72: 2051-2057
- Left atrial function and scar after catheter ablation of atrial fibrillation.Heart Rhythm: the official journal of the Heart Rhythm Society. 2008; 5: 656-662
- Stiff Left Atrial Syndrome: A Complication Undergoing Radiofrequency Catheter Ablation for Atrial Fibrillation.Journal of Cardiovascular Electrophysiology. 2016;
- The effect of the maze procedure on the secretion of arginine-vasopressin and aldosterone.The Journal of Thoracic and Cardiovascular Surgery. 2003; 126: 1095-1100
- Increase in pulmonary arterial pressure after atrial fibrillation ablation: incidence and associated findings.Journal of Interventional Cardiac Electrophysiology: an international journal of arrhythmias and pacing. 2014; 40: 47-52
- Left atrial hypertension after repeated catheter ablations for atrial fibrillation.Journal of the American College of Cardiology. 2011; 57: 1918-1919
- Transcatheter angioplasty for acquired pulmonary vein stenosis after radiofrequency ablation.Circulation. 2003; 108: 1336-1342
- Paclitaxel drug-eluting stent placement for pulmonary vein stenosis as a bridge to heart-lung transplantation.Pediatric Cardiology. 2009; 30: 1169-1171
- Sildenafil citrate therapy for pulmonary arterial hypertension.The New England Journal of Medicine. 2005; 353: 2148-2157
- Pulmonary hypertension in heart failure with preserved ejection fraction: a target of phosphodiesterase-5 inhibition in a 1-year study.Circulation. 2011; 124: 164-174
- Novel use of sildenafil in the management of pulmonary hypertension due to post-catheter ablation ‘stiff left atrial syndrome’.International Journal of Cardiology. 2015; 181: 55-56
- Acute hemodynamic effects of riociguat in patients with pulmonary hypertension associated with diastolic heart failure (DILATE-1): a randomized, double-blind, placebo-controlled, single-dose study.Chest. 2014; 146: 1274-1285
- Pulmonary hypertension secondary to heart failure with preserved ejection fraction.The Canadian Journal of Cardiology. 2015; 31: 430-439
- Recurrent dyspnea following multiple ablations for atrial fibrillation explained by the “stiff left atrial syndrome”.Catheterization and Cardiovascular Interventions: official journal of the Society for Cardiac Angiography & Interventions. 2013; 82: E747-E749
- Stiff left atrial syndrome following left atrial appendage resection and multiple ablations for atrial fibrillation.Heart. 2013; 99: 508
Article info
Publication history
Published online: July 16, 2016
Accepted:
May 31,
2016
Received in revised form:
May 21,
2016
Received:
January 14,
2016
Identification
Copyright
© 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
