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Circulation. 2000;101:e154-e155

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(Circulation. 2000;101:e154.)
© 2000 American Heart Association, Inc.

Circulation Electronic Pages

Left Upper Pulmonary Vein Stenosis 2 Months After Radiofrequency Catheter Ablation of Atrial Fibrillation

Richard H. Sohn, MD; Nelson B. Schiller, MD

From the Division of Cardiology, University of California San Francisco.

Correspondence to Nelson B. Schiller, MD, University of California San Francisco, Moffitt/Long Hospital, Room 314A, Box 0214, San Francisco, CA 94143-0214. E-mail schiller{at}medicine.ucsf.edu

A37-year-old man was referred for recurrent atrial fibrillation. Surface and transesophageal echocardiography (TEE) showed his heart to be structurally within normal limits. He underwent electrophysiological testing with multisite atrial mapping, which revealed a focal trigger for atrial fibrillation within the left upper pulmonary vein (LUPV). Radiofrequency catheter ablation was performed. Several weeks later, he developed dyspnea and cough while jogging despite maintenance of sinus rhythm.

Repeat TEE revealed high-velocity flow within the left atrium (LA) emanating from the LUPV, with peak velocities more than twice that of the right upper pulmonary vein (RUPV) (see FigureDown). This suggests a pressure gradient (PG) within the LUPV that is 5-fold higher than normal, consistent with high-grade stenosis. After 3 minutes of moderate hand-crank exercise, this gradient increased to 24 mm Hg in the LUPV and only to 6 mm Hg in the RUPV (see FigureDown). Localized pulmonary venous hypertension of this degree may be sufficient to cause exertional symptoms.



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  		Figure 1. TEE color flow Doppler (CFD) and continuous-wave Doppler (CWD) of flow signal from RUPV (top panels) and LUPV (bottom panels) in LA. Flow from RUPV (top left) is laminar, whereas flow from LUPV (bottom left) is aliased. Center panels show that aliased flow signal is associated with higher flow velocity (V) and pressure, suggesting stenosis of LUPV. Hand-crank exercise for 3 minutes (right panels) further accentuated difference between normal and obstructed flow. Values for peak velocities and pressures under each panel correspond to location of manually positioned cursor. Note, velocity scales differ among flow tracings.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.




This article has been cited by other articles:


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 J Am Coll CardiolHome page
T. Tabata, J. D. Thomas, and A. L. Klein
Pulmonary venous flow by doppler echocardiography: revisited 12 years later
J. Am. Coll. Cardiol., April 16, 2003; 41(8): 1243 - 1250.
[Abstract] [Full Text] [PDF]

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Google Scholar
Right arrow Articles by Sohn, R. H.
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PubMed
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Right arrow Articles by Sohn, R. H.
Right arrow Articles by Schiller, N. B.
Related Collections
Right arrow Exercise testing
Right arrow Pulmonary circulation and disease
Right arrow Ablation/ICD/surgery
Right arrow Acute coronary syndromes
Right arrow Echocardiography

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