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Abnormal mosaic flow in the left atrium observed from a parasternal long-axis view in a patient with a history of pulmonary vein isolation: a case report

Abnormal mosaic flow in the left atrium observed from a parasternal long-axis view in a patient... IMAGES IN CARDIOLOGY European Heart Journal - Case Reports (2023) 7, 1–2 https://doi.org/10.1093/ehjcr/ytad067 Cardiovascular imaging Abnormal mosaic flow in the left atrium observed from a parasternal long-axis view in a patient with a history of pulmonary vein isolation: a case report Hironori Ishiguchi *, Yasuhiro Yoshiga, Takayuki Okamura, and Masafumi Yano Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan Received 28 December 2022; first decision 25 January 2023; accepted 3 February 2023; online publish-ahead-of-print 7 February 2023 A 48-year-old male with a history of atrial fibrillation underwent radio - was asymptomatic, had a normal chest radiograph (Figure 1B), and sub- frequency pulmonary vein (PV) isolation. The patient had normal PVs sequently underwent echocardiography for regular follow-up. An ab- (Figure 1A). First-pass and ipsilateral isolation were uneventfully accom- normal mosaic flow in the left atrium, which was undetected plished in both the right and left PVs. Three months later, the patient preoperatively, was obtained from a parasternal long-axis view Figure 1 (A) Cardiac computed tomography image in postero-anterior view obtained before pulmonary vein isolation. Pulmonary veins were intact. Arrowheads indicate left superior and left inferior pulmonary veins, respectively. (B) Chest radiograph at 3 months after pulmonary vein isolation. (C ) A mosaic flow in the left atrium from a parasternal long-axis view during echocardiography (arrow). (D) The continuous Doppler waveforms of pulmonary vein flow. The velocity of systolic (S) and diastolic (D) waves was 1.7 and 1.4 m/s, respectively. (E ) Cardiac computed tomography in postero-anterior view detects pulmonary vein stenosis (arrowheads: ostium of the left superior- and left inferior pulmonary vein). (F ) Lung scintigraphy 99m with Tc-macro-aggregated albumin in postero-anterior view indicating severe perfusion impairment of the left lung (asterisk). CCT, cardiac computed tomography; PV, pulmonary vein. * Corresponding author. Tel: +8 183 622 2248, Fax: +8 183 622 2246, Email: nilebros@gmail.com Handling Editor: Luke Joseph Laffin Peer-reviewers: Mark Abela; Suzan Hatipoglu © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 2 H. Ishiguchi et al. (Figure 1C, arrow, see Supplementary material online, Movies S1 and S2). Supplementary material It was identified as accelerated PV flow on Doppler echocardiography (Figure 1D). Supplementary material is available at European Heart Journal – Case Reports. Cardiac computed tomography (CCT) was scheduled because PV stenosis was suspected. Cardiac computed tomography confirmed PV stenosis of both the left superior and inferior sides (Figure 1E). Consent: The authors confirm that written consent for submission Lung scintigraphy showed severe perfusion impairment of the left and publication of this case report including images and associated lung (Figure 1F) with normal ventilation. The patient underwent im- text has been obtained from the patient in line with COPE plantation of a stent for the left superior PV (Express LD, Boston guidance. Scientific, Marlborough, MA, USA) and left inferior PV (Express SD), re - spectively. Postprocedural echocardiography revealed that the mosaic Conflict of interest: None declared. flow was replaced by the flow from the stent implanted in the left in - ferior PV (see Supplementary material online, Movie S3). Funding : None declared. Although PV stenosis is a rare complication (with as low as 0.7% in- 1–3 cidence), it remains a critical complication of PV isolation. Early de- tection and intervention before revascularization becomes challenging References 2,3 are warranted to treat the complication. In this case, PV stenosis 1. Teunissen C, Velthuis BK, Hassink RJ, van der Heijden JF, Vonken EPA, Clappers N, et al. was diagnosed early before the patient developed symptoms due to Incidence of pulmonary vein stenosis after radiofrequency catheter ablation of atrial fib - rillation. JACC Clin Electrophysiol 2017;3:589–598. the identification of accelerated PV flow during echocardiography at 2. Fender EA, Widmer RJ, Hodge DO, Packer DL, Holmes DR. Assessment and manage- a regular check-up. ment of pulmonary vein occlusion after atrial fibrillation ablation. JACC Cardiovasc Interv Our case is educative because it highlights that clinicians should be 2018;11:1633–1639. cautious of accelerated flow in the left atrium when performing echo - 3. Fink T, Schlüter M, Heeger CH, Lemes C, Lin T, Maurer T, et al. Pulmonary vein stenosis cardiography for patients with a history of PV isolation, even if they are or occlusion after catheter ablation of atrial fibrillation: long-term comparison of asymptomatic. drug-eluting versus large bare metal stents. Europace 2018;20:e148–e155. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Abnormal mosaic flow in the left atrium observed from a parasternal long-axis view in a patient with a history of pulmonary vein isolation: a case report

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Oxford University Press
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© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.
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10.1093/ehjcr/ytad067
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Abstract

IMAGES IN CARDIOLOGY European Heart Journal - Case Reports (2023) 7, 1–2 https://doi.org/10.1093/ehjcr/ytad067 Cardiovascular imaging Abnormal mosaic flow in the left atrium observed from a parasternal long-axis view in a patient with a history of pulmonary vein isolation: a case report Hironori Ishiguchi *, Yasuhiro Yoshiga, Takayuki Okamura, and Masafumi Yano Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan Received 28 December 2022; first decision 25 January 2023; accepted 3 February 2023; online publish-ahead-of-print 7 February 2023 A 48-year-old male with a history of atrial fibrillation underwent radio - was asymptomatic, had a normal chest radiograph (Figure 1B), and sub- frequency pulmonary vein (PV) isolation. The patient had normal PVs sequently underwent echocardiography for regular follow-up. An ab- (Figure 1A). First-pass and ipsilateral isolation were uneventfully accom- normal mosaic flow in the left atrium, which was undetected plished in both the right and left PVs. Three months later, the patient preoperatively, was obtained from a parasternal long-axis view Figure 1 (A) Cardiac computed tomography image in postero-anterior view obtained before pulmonary vein isolation. Pulmonary veins were intact. Arrowheads indicate left superior and left inferior pulmonary veins, respectively. (B) Chest radiograph at 3 months after pulmonary vein isolation. (C ) A mosaic flow in the left atrium from a parasternal long-axis view during echocardiography (arrow). (D) The continuous Doppler waveforms of pulmonary vein flow. The velocity of systolic (S) and diastolic (D) waves was 1.7 and 1.4 m/s, respectively. (E ) Cardiac computed tomography in postero-anterior view detects pulmonary vein stenosis (arrowheads: ostium of the left superior- and left inferior pulmonary vein). (F ) Lung scintigraphy 99m with Tc-macro-aggregated albumin in postero-anterior view indicating severe perfusion impairment of the left lung (asterisk). CCT, cardiac computed tomography; PV, pulmonary vein. * Corresponding author. Tel: +8 183 622 2248, Fax: +8 183 622 2246, Email: nilebros@gmail.com Handling Editor: Luke Joseph Laffin Peer-reviewers: Mark Abela; Suzan Hatipoglu © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 2 H. Ishiguchi et al. (Figure 1C, arrow, see Supplementary material online, Movies S1 and S2). Supplementary material It was identified as accelerated PV flow on Doppler echocardiography (Figure 1D). Supplementary material is available at European Heart Journal – Case Reports. Cardiac computed tomography (CCT) was scheduled because PV stenosis was suspected. Cardiac computed tomography confirmed PV stenosis of both the left superior and inferior sides (Figure 1E). Consent: The authors confirm that written consent for submission Lung scintigraphy showed severe perfusion impairment of the left and publication of this case report including images and associated lung (Figure 1F) with normal ventilation. The patient underwent im- text has been obtained from the patient in line with COPE plantation of a stent for the left superior PV (Express LD, Boston guidance. Scientific, Marlborough, MA, USA) and left inferior PV (Express SD), re - spectively. Postprocedural echocardiography revealed that the mosaic Conflict of interest: None declared. flow was replaced by the flow from the stent implanted in the left in - ferior PV (see Supplementary material online, Movie S3). Funding : None declared. Although PV stenosis is a rare complication (with as low as 0.7% in- 1–3 cidence), it remains a critical complication of PV isolation. Early de- tection and intervention before revascularization becomes challenging References 2,3 are warranted to treat the complication. In this case, PV stenosis 1. Teunissen C, Velthuis BK, Hassink RJ, van der Heijden JF, Vonken EPA, Clappers N, et al. was diagnosed early before the patient developed symptoms due to Incidence of pulmonary vein stenosis after radiofrequency catheter ablation of atrial fib - rillation. JACC Clin Electrophysiol 2017;3:589–598. the identification of accelerated PV flow during echocardiography at 2. Fender EA, Widmer RJ, Hodge DO, Packer DL, Holmes DR. Assessment and manage- a regular check-up. ment of pulmonary vein occlusion after atrial fibrillation ablation. JACC Cardiovasc Interv Our case is educative because it highlights that clinicians should be 2018;11:1633–1639. cautious of accelerated flow in the left atrium when performing echo - 3. Fink T, Schlüter M, Heeger CH, Lemes C, Lin T, Maurer T, et al. Pulmonary vein stenosis cardiography for patients with a history of PV isolation, even if they are or occlusion after catheter ablation of atrial fibrillation: long-term comparison of asymptomatic. drug-eluting versus large bare metal stents. Europace 2018;20:e148–e155.

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European Heart Journal - Case Reports – Oxford University Press

Published: Feb 7, 2023

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