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Lobectomy For Symptomatic Rfa-induced Pulmonary Vein Stenosis: Indications, Findings, And Outcomes
Tanya Pothini, MD, Muhanned Abu-Hijleh, MD, Michael Luna, MD, Michael A. Wait, MD, John K. Waters, MD, Kailee M. Hughes, NP, Michael E. Jessen, MD, Kemp H. Kernstine, Sr. MD PhD;
University of Texas, Southwestern Medical Center, Dallas, TX, USA
BACKGROUND: Pulmonary vein stenosis (PVS) is an uncommon consequence of catheter-based radiofrequency ablation (RFA), a recognized therapy for atrial fibrillation. Balloon dilation and stenting effectively treat symptomatic PVS. Surgical lung resection (lobectomy/pneumonectomy) addresses stent failures, but there is no comprehensive review of the indications, findings, and outcomes. We review the literature to illuminate anatomic lung resection's role in managing symptomatic PVS.
METHODS: We detail a PVS case unresponsive to multiple dilation/stenting attempts, ultimately necessitating lobectomy. We searched PubMed, Web of Science, and Library of Congress using "post-ablation pulmonary vein stenosis," "recurrent post-ablation pulmonary vein stenosis," and "lobectomy" or "pneumonectomy." Case report data were tabulated.
RESULTS: Our patient, a 39-year-old male martial arts instructor, exhibited severe exertional dyspnea from 3-vein anatomic PVS and unyielding left upper lobe PV, hindering work. Robotic lobectomy led to 1.8 L blood loss due to friable venous collateral controls difficult to control with usual maneuvers; subsequent evacuation cleared 1 L retained hemothorax. Discharged on POD 16. At 36 months, no symptoms recurred, enabling return to work. Literature analysis unveiled 22 articles yielding 23 patients (See
Table 1). Group median age: 49 years (17-68). Left-sided lesions in 20, single stenosis in 14, and 3 bilateral. Hemoptysis in 17 (81%), severe in 4 (24%), dyspnea in 5 (24%), cough in 6 (29%), chest pain in 5 (24%). Among 21 surgeries detailed, 18 (86%) were lobectomies, 10 (48%) left upper lobectomy. 3 (14%) were thoracoscopic; 1 (5%) halted due to tough adhesions. Operative findings (16 cases) included adhesions (31% inflammatory), tortuous collaterals (31%), contracted lobe (31%). 2 (8%) fatalities. Immediate outcomes for 14, with 4 (29%) symptom-free post-op. Hospital stay (4 patients): median 8 days (3-63). Long-term outcomes (11 patients) averaged 18 months (6-36); all symptoms resolved without recurrence, except in an abandoned lung resection case.
CONCLUSIONS: Anatomic resection proved symptomatically curative and durable for refractory PVS cases. Adhesions and delicate collaterals commonly arose, but minimally invasive procedures sufficed. Left lung, particularly upper lobe, often implicated. Pneumonectomy possibly vital for recalcitrant hemoptysis cases.
Table 1: Analysis of Case Reports from the Literature Search| 3-Year Time Intervals 2003-2023 | Total Number of Patients During Time Interval | Number w Ages of Patients | Number of Cases w Vein Stenosis Location | Number of Cases w Symptoms and/or Signs | Number of Cases Mentioning Lung Resection Type | Number of Cases w Findings and Short Term Outcomes | Number of Cases w Long Term Outcomes |
| 2003-2006 | 1 | 0 | 0 | 0 | 0 | 0 | 0 |
| 2007-2010 | 3 | 3 | 3 | 3 | 3 | 2 | 1 |
| 2011-2014 | 3 | 3 | 3 | 3 | 3 | 3 | 1 |
| 2015-2018 | 10 | 8 | 8 | 8 | 8 | 8 | 5 |
| 2019-2023 | 7 | 7 | 7 | 7 | 7 | 5 | 6 |
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