A Unique Compensatory Mechanism for Total Pulmonary Vein Occlusion Post Atrial Fibrillation Catheter Ablation Visualized by Multimodality Imaging

Pulmonary vein (PV) stenosis is a rare and serious complication of radiofrequency catheter ablation (RFCA) for atrial fibrillation. However, it can be asymptomatic or mildly symptomatic depending on the severity of the stenosis and the development of compensatory mechanisms. This study provides a detailed description and visualization of a unique type of venous collaterals that bypass the PV stenosis and drain directly in the left atrium alleviating PV stenosis sequelae. This study reports a case of a 61-year-old male who presented with mild dyspnea and fatigue 3 years post atrial fibrillation RFCA. After a thorough evaluation of the case, a redo-ablation was planned. As a part of the preablation workup, a transesophageal echocardiography (TEE), a ventilation-perfusion (V/Q) scan of the lungs, and a chest computed tomography angiogram (CTA) were performed. The TEE revealed total obstruction of the left superior PV, with no color Doppler flow detected. It also showed evidence of multiple collateral flows at the os of the left superior PV. The V/Q scan showed a large perfusion defect involving the entire left upper lobe consistent with a compromised left upper PV flow. The CTA with 3D volume rendering revealed the total occlusion of the left superior PV at its ostium. Moreover, the scan confirmed the pulmonary venous drainage via small collateral channels that was suggested by the TEE.