Images in cardiovascular medicine. Pulmonary vein stenosis after catheter ablation of atrial arrhythmias.

A78-year-old woman presented with a 2-month history of worsening dyspnea, orthopnea, and cough with hemoptysis. Her past medical history was significant for hypertension and severe mitral regurgitation for which she had undergone mitral valve repair 3 years previously. In addition, she had recurrent atrial tachycardia requiring 2 radiofrequency ablations, which included ablation of several left-sided pathways. The last ablation was performed 3 months before her presentation. A transesophageal echocardiogram was performed and showed turbulent Doppler flow and increased systolic and diastolic velocities in the right lower (Figure 1) and left upper pulmonary veins. A contrast-enhanced, retrospectively gated helical CT scan showed 60% to 70% stenoses of the right lower (Figure 2, left panel) and left upper pulmonary veins. A ventilation-perfusion scan revealed a large perfusion defect in the right lower lobe. The patient subsequently underwent a successful balloon dilation of the right lower and left upper pulmonary veins (Figure 3). Pulmonary artery pressures before dilation were 85/30 mm Hg, and dropped to 55/ 20 mm Hg immediately after dilation. A transesophageal echocardiogram performed after the procedure showed normal flows in the previously stenotic pulmonary veins. A CT scan completed several days after the procedure showed a reduction in the degree of stenosis in both right lower (Figure 2, right panel) and left upper pulmonary veins. The patient’s acute symptoms were markedly improved, although her condition subsequently deteriorated secondary to multiple other medical problems.