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A6466 - A Stent in the Vein for a Man’s Pain - a Case of Pulmonary Venous Stenosis Cured by a 4mm Stent
Author Block: N. Jayakumar1, M. Patel2, J. Thomas3; 1Eisenhower Medical Center, Rancho Mirage, CA, United States, 2Internal Medicine, Eisenhower Medical Center, Rancho Mirage, CA, United States, 3Interventional Pulmonology, Eisenhower Medical Center, Rancho Mirage, CA, United States.
A 70-year-old gentleman with paroxysmal atrial fibrillation (AF), presented with dyspnea on exertion one month after his radiofrequency ablation procedure. A CT angiogram of the chest done on July 2016 revealed a left hilar fullness, along with mosaic attenuation of the left upper lobe of the lung and a new 8 x 7 mm pulmonary nodule. While a negative PET/CT scan and repeat CT scan 3 months after showed interval regression of the pulmonary nodule, his symptoms worsened and there was increase in ground glass attenuation of the left upper lobe. Given these findings and the patient’s gradual onset of dyspnea on exertion, he was referred to pulmonary medicine. Upon retrospective review of his multiple CT scans, the pulmonologist noted completed occlusion of the left superior pulmonary vein. A VQ scan showed a 63.3/36.7 ratio of perfusion Right / Left (normal is ~ 55/45). He was diagnosed with pulmonary vein stenosis (PVS) and referred for a balloon angioplasty and stenting at Scripps Coastal Medical Center. The patient received a left upper pulmonary vein resolute drug eluting stent 4mm in diameter. Patency of the stent was confirmed by both angiogram and transesophageal echocardiogram. Follow up CT scans showed improvement of the left upper lobe ground glass attenuation over the course of the next five months. More importantly, the patient’s dyspnea on exertion resolved and he is now able to participate in activities such as hiking, which he was unable to perform prior to the procedure. PVS is a rare entity usually seen in tertiary care centers (2 - 3 cases annually), with diagnostic difficulty and often grim prognosis if caught late. Historically, PVS was linked with congenital heart diseases, but now radiofrequency ablation has become the principal cause of PVS (2% incidence). Although diagnostic accuracy has improved over time, specific indications for stent placement and recommended time to intervention remain controversial. Our patient with PVS presented with dyspnea on exertion, left upper lobe ground glass opacities with hilar fullness, after a radiofrequency ablation procedure. Despite the time to stent being 9 months after his diagnosis, the stenosis completely resolved (on subsequent angiograms) and he was able to resume his usual activities. Not only does this case stress the importance of clinicians to be aware of PVS as a complication of ablation procedure, but also to promptly refer the patient to a treatment capable center when there is slightest suspicion for PVS.