Incidence of pulmonary vein stenosis following atrial fibrillation ablation with standard-power long-duration, high-power and very high-power short-duration, and pulsed-field ablation
Y Oda, A Nogami, R Usui, K UnoAbstract
Background
Pulmonary vein (PV) stenosis has been considered a rare complication following catheter ablation for atrial fibrillation (AF). However, because many cases remain asymptomatic, the true incidence may be underestimated.
Purpose
To compare the incidence of PV stenosis after AF ablation using standard-power long-duration (SPLD) radiofrequency ablation (RFA), high-power short-duration (HPSD) RFA, very high-power short-duration(vHPSD) RFA and pulsed-field ablation (PFA).
Methods
We conducted a single-centre, retrospective observational study. Patients who underwent AF ablation and had both preprocedural and postprocedural follow-up computed tomography (CT) scans were included. The RF power settings were defined as follows: SPLD was 30-39 Watt for 20 seconds, HPSD was 40-44 Watt for 10-20 seconds, and vHPSD was 45-50 Watt for 10 seconds. PV stenosis was assessed using cardiac CT performed at least 30 days after the procedure.
Results
A total of 276 patients (339 procedures) were included. The primary indications for follow-up CT were repeat ablation (89% in SPLD, 81% in HPSD, 85% in vHPSD, 31% in PFA), symptom evaluation (11% in SPLD, 7% in HPSD and vHPSD, none in PFA), and PV assessment in asymptomatic patients (none in SPLD, 12% in HPSD, 8% in vHPSD, 69% in PFA). The median interval from ablation to follow-up CT was 226 days (interquartile range [IQR]: 124–400). PV stenosis was confirmed in 49 procedures (14%). In the SPLD group, one case with severe PV stenosis was identified (11.1%). In contrast, moderate (50–<90%) and severe (≥90%) PV stenosis were detected in 3% and 8% of the HPSD group, and in 9% and 10% of the vHPSD group, respectively, whereas no PV stenosis was observed in the PFA group. Notably, in the vHPSD group, most severe PV stenosis cases were associated with temperature-controlled RF ablation catheters. Stenosis most frequently involved the left inferior and right inferior PVs. In patients with PV stenosis, the ablation sites were not always anatomically adjacent to the sites of stenosis (Figure). Most cases were asymptomatic; however, two patients with symptomatic stenosis underwent interventional treatment.
Conclusions
The incidence of PV stenosis after RF AF ablation may be higher than previously reported. This observational analysis suggests that RF ablation using the vHPSD approach with a temperature-controlled ablation catheter may be associated with an increased risk of severe PV stenosis. Careful post-procedural imaging follow-up is recommended.